Every finding on record at Rose Garden of Pana

Based on observation, interview, and record review the facility to manage pain for 1 of 3 (R3) residents reviewed for pain management in a sample of 41. This failure resulted in R3 experiencing unrelieved horrible pain. Findings include:R3's Care Plan, dated 10/16/2026, documents PAIN: The resident has occasional pain r/t (related to) T2DM (type 2 diabetic), heart disease, BPH (benign prostatic hyperplasia), HTN (hypertension), muscle weakness, HLD (Hyperlipidemia), and calcaneal spur to right foot. It also documents Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate pain relief 30-60 minutes after administering analgesics (depending on route).R3's Minimum Data Set, dated [DATE], documents that R3 has pain. R3's Physician order, dated 9/30/2025, documents Heel Protectors on while in bed.On 2/23/2026 at 10:12 AM observed R3 lying on back in bed on his back with heels on mattress. Observed heel protectors in chair next to bed. From 10:30 AM to 2:00 PM using 15 to 30-minute intervals. R3 was observed laying in the bed on his back with both heels pressing against mattress with heel protectors in chair.On 2/23/2026 at 10:12 AM R3 stated that he had sores and blisters to his legs and heels. R3 stated that he was told by the nurse that the areas are closed but not healed. R3 stated that his heels hurt a lot. R3 stated that the pain is horrible. R3 stated that he couldn't get relief because his heels press on the bed. R3 stated that he can't give me a number but is hurts very much and he is unable to get relief.On 2/23/2026 at approximately 11:40 AM R3 stated that his feet feel better. R3 stated that he had been given some pain medication for his stomach earlier, but it didn't help his heels. R3 stated said that since putting on the heel protector the pain is better. R3 stated that it feels like his feet are on air. He feels nothing.On 2/25/2026 at 8:15 AM observed R3 lying on back in bed on his back with heels on mattress. Observed heel protectors in chair next to bed. At 10:16 AM observed R3 lying on back in bed on his back, heels on mattress with heel protectors in chair next to bed. At 11:02 AM observed R3 lying on back in bed on his back, heels on mattress with heel protectors in chair next to bed. At 11:12 AM the heel protectors were applied to R3's feet.On 2/25/2026 at 11:08 AM V3 (Assistant Director of Nursing/ADON), stated that R3 is to always have the heel protectors on when in bed.On 2/25/2026 12:34 PM V5 (Licensed Practical Nurse) stated that R3 is alert. V5 stated that he does have times when he is forgetful. V5 stated that R3 knows when he is in pain and can communicate his pain accurately. V5 stated that R3 has received a new order for pain.The facility's Pain Assessment and Management Level III Purpose policy documents that The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary.

Based on observation, interview, and record review, the facility kitchen staff failed to calibrate a thermometer prior to taking the temperature of the food. This failure has the potential to affect all 71 residents who reside at the facility. Findings Include:On 02/23/26 at 10:55 AM, V7 (Cook) took the temperature (temp) of the food. V7 did not calibrate the thermometer prior to taking the temps. On 02/23/26 at 10:57 AM, V7 was asked how he calibrates the thermometer. He stated, I have no idea let me go ask. V7 talked with V6 (Dietary Manager) and came back and stated V6 said it can't be calibrated. On 02/24/2026 at 10:00 AM, R23, R35, R5, R46, R21 all stated that the food is cold. On 02/26/26 at 11:20 AM, V6 (Dietary Manager) stated that their thermometers are digital and they do not calibrate them and the only way to calibrate it is to put a new battery in it. The facility's Resident Council Concern Report, dated 02/26/26, documents Department: Dietary eggs this morning was cold. The facility's policy Food Preparation and Service, Revision date November 2022, documents Policy Statement Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. It further documents General Guidelines 4. When verifying food temperatures, staff use a thermometer which is both clean, sanitized, and calibrated to ensure accuracy. The facility's CMS 671, dated 02/23/26, documents there is 71 residents in the facility.

Based on observation, interview, and record review, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 88 of the 88 days reviewed for December 2025, January 2026, and February 2026. This failure has the potential to affect all 71 residents that resides in the facility. Findings Include: During this investigation was V4 (Regional Nurse) was the only RN in the building. The facility's working schedules and daily staffing sheets were reviewed and documents the following: December 2025, there was no RN scheduled from 12/01/25 through 12/31/25.January 2026, there was no RN scheduled from 01/01/26 through 01/31/26.February 2026, there was no RN scheduled from 02/01/26 through 02/26/26. On 02/26/2026 at 9:21 AM, V23 (Certified Nursing Assistant/CNA), said V2 (Director of Nursing/DON) and V4 (Regional Nurse) are in the facility, but she did not know if they (V2 and V4) were working the floor as a nurse. On 02/26/26 at 9:25 AM, V22 (CNA) stated V2 and V4 are in the facility but didn't know if they worked on the floor. On 02/26/2026 at 9:45 AM, V4 (Regional Nurse) stated that the facility does not have an RN for 8 consecutive hours a day. The facility's policy Staffing, Sufficient, and Competent Nursing, revision date of August 2022, documents Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. It further documents Sufficient Staff 3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. The facility's CMS 671, dated 02/23/26, documents there is 71 residents in the facility.

Based on observation, interview, and record review the facility failed to properly store medication and discard expired medication. This failure has the potential to affect all 71 residents residing in the facility.Findings include:On [DATE] at 9:51 AM the 200-hall medication cart was inspected. The medication cart contained the following:1 R23's opened and partially used multidose Novolin FlexPen Injection Solution Pen-injector 100 UNIT/ML. No open date.2. R38's opened and partially used multidose Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML. No open date.3. R68's opened and partially used multidose Toujeo SoloStar 300 UNIT/ML Solution pen-injector. No open date.4. R36's opened and partially used multidose Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Vial. No open date.On [DATE] at 9:55 AM V5 (Licensed Practical Nurse/LPN), stated that on the first date the insulin is accessed and used that date is placed on the multidose vials and pens. V5 stated that the insulins have a shortened expiration date. V5 stated that some are 28 days, and some are 30 days after opening. V5 stated that the open dates let them know when the new expiration or use by date is.On [DATE] at 10:02 AM the facility's Medication Room was inspected. The refrigerator inside the medication room contained:5. An opened and partially used multidose vial of Tuberculin inside a plastic bag. No open date on vial or bag. The bag containing the multidose vial of Tuberculin was dated [DATE]. The multidose vial expiration date was [DATE].On [DATE] at 10:04 AM V4 (Regional Nurse) verified that the multidose Tuberculin Vial was open, in use, and no handwritten date on the vial or the bag. V4 verified that the Tuberculin was expired. V4 stated that the multi dose Tuberculin vial should have a handwritten date on the vial or bag when opened. V4 stated that the medication should be disposed of and not in use.On [DATE] at 1:57 PM V5 stated that the multidose Tuberculin vial in the medication room is a stock medication. V5 stated that the medication can be used for all residents as long as they have an order and is not allergic.The facility's Medication Labeling and Storage policy, dated February 2023, Medication Labeling 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.The facility's Medication Administration policy, dated [DATE], documents that Policy Interpretation and Implementation: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.The Facility's Long Term Care Facility Application for Medicare and Medicaid (CMS 671) dated [DATE] documents there are 71 residents living in the Facility.

Based on observation, interview, and record review, the facility failed to implement progressive fall interventions, failed to implement fall reduction interventions in a timely manner, failed to complete post fall assessments per the facility policy, and failed to ensure fall interventions were in place per resident Care Plans for 4 of 10 residents (R7, R34, R64, R86) reviewed for falls in the sample of 35. Findings Include: 1.R7's Face Sheet, print date of 2/25/26, documents R7 has diagnoses including traumatic subdural hemorrhage, dementia, unspecified psychosis, generalized anxiety disorder, chronic myeloid leukemia, osteoporosis, and cerebral infarction. R7's MDS (Minimum Data Set), dated 1/21/26, documents R7 is severely cognitively impaired. R7's Fall Risk Evaluation dated 7/20/23 documents R7 is at risk for falls. R7's Fall Risk Evaluation dated 7/17/25 documents R7 is at risk for falls. On 2/26/26 at 10:53 AM V4 (Regional Nurse) stated R7's fall risk score indicates R7 is at risk for falls. R7's Care Plan, undated, documents resident is at risk for falls related to repeated falls, dementia, incontinence, anxiety, and balance problems. She does not recognize hazardous situation nor her physical limitations. R7's Incident Report dated 6/2/25 documents resident was found in room sitting on bottom in front of bathroom door. Intervention: continue current fall interventions. R7's Incident Report dated 6/7/25 documents resident was ambulating in hallway near a housekeeping cart when she fell. Intervention: housekeeping educated on not leaving carts in walkways. Staff education on making sure resident is wearing proper footwear. R7's Incident Report dated 6/20/25 documents writer was called to unit by CNA (Certified Nursing Assistant) stating that resident had a fall. When writer got to unit to assess resident, resident had gotten up, and started walking around, and when staff tried to approach resident for assessment resident was repeatedly trying to get up and walk. Resident has a laceration above left knee. Steri-strips applied to laceration. It continues, intervention: continue current fall interventions. R7's Incident Report dated 6/26/25 at 8 AM documents resident was ambulating in tv room when she tripped over the leg of another resident's walker. Resident fell to the ground and struck her head. It continues, intervention: resident was sent to (local) ER (Emergency Room) for evaluation and treatment. Resident has a UTI (urinary tract infection) and being treated with oral antibiotics. R7's Incident Report dated 6/26/25 at 3 PM documents resident ambulating in the dining room, then staff seen she was laying on the floor. Resident noted to have purplish discoloration under right eye. Red discoloration on right elbow. Resident c/o (complaint of) facial pain. It continues, resident sent to ER and found to have UTI. R7's Incident Report dated 6/29/25 documents resident found on the hallway floor laying on her stomach with blood coming from open area from bridge of nose and inside nose. Root cause: unaware of safety needs and poor cognition due to advanced dementia. Intervention: medication review and changes as necessary. R7's Incident Report dated 7/2/25 documents resident laying on the floor on her left side. Intervention: continue to monitor effectiveness of ABX (antibiotics) and medication changes. R7's Incident Report dated 7/10/25 at 7:45 AM documents staff seen resident laying in the hallway on her left side. Small purplish discoloration noted to left elbow. Intervention: staff education on keeping walkways clear. R7's Incident Report dated 7/10/25 at 8:05 AM documents R7 was laying on the floor attempting to get up. Intervention: medication review. R7's Incident Report dated 7/15/25 documents staff witnessed resident fall in the dining room. Resident was ambulating when she attempted to walk between a seated resident and her walker. Resident caught the leg of the walker with her foot and fell onto the floor. Resident landed on her left side. Staff went to assess resident and copious amounts of blood loss was coming from resident unable to tell location at this time. Staff log rolled resident on to her back and noted a large laceration on her forehead. Left side of forehead continued to have copious amounts of blood loss, staff applied pressure at this time with a wet towel. Resident continued to stand up while staff attempted to assess her. Staff continued to apply pressure to left forehead. Resident stood herself up and then staff assisted her into a chair. Resident appears to only have forehead laceration, moderate bleeding continued. Resident c/o (complaint of) facial pain. Another nurse was asked to contact EMT'S (Emergency Medical Technicians) for transport to (local) ER. Fall interventions: OT (Occupational Therapy) to evaluate resident for w/c (wheelchair) positioning and use of lap buddy due to decline in resident mobility and safety needs. R7's local hospital record dated 7/15/25 documents diagnosis: 1. Fall, 2. Laceration of head, 3. Dementia. On 2/26/26 at 12:23 PM V4 (Regional Nurse) stated she agrees continue current fall interventions is not a progressive fall intervention. On 2/26/26 at 12:38 PM Surveyor asked V4 if she considers using the same fall intervention for multiple falls acceptable and progressive. V4 replied No. 2. R34's Face Sheet, print date of 02/25/26, documents he has diagnoses of but not limited to congestive heart failure (CHF), paroxysmal atrial fibrillation, muscle wasting and atrophy, multiple sites, and unsteadiness on feet. R34's MDS, dated [DATE], documents R34 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and he requires partial/moderate assistance with sit to stand, transfer chair/bed-to-chair transfer, and toilet transfers. R34's Care Plan, admission date of 12/05/24, documents R34's review shows moderate risk for falls. Risk factors include use of psychotropic medications, diuretics, incontinence, visual impairment, and cognitive impairment. Interventions include but not limited to 01/01/2026: call don't fall sign placed in room by bed to encourage asking for assistance, 01/02/2026: Resident sent to ER (emergency room) for further treatment. Resident noted to have a UTI (urinary tract infection). Will monitor effectiveness of ABX (antibiotics), 01/02/2026: Therapy room to be kept locked when staff not present 01/06/2026: Pressure pad alarm on at all times, 01/25/2026: 15 minute checks, 01/25/2026: Moved to room closer to nursing desk (created on 02/11/2026), 01/01/2026: Physical assessment, neuro assessment, vital signs obtained, assisted patient back into his bed (all created on 01/12/2026), 01/02/2026: Resident assessed from head to toe. Sent to ER (created 01/12/2026), 12/24/2025: Resident educated on walking slow to prevent falls (01/06/2025). R34's Progress Notes were reviewed and documents he had falls on the following dates: On 12/24/2025 at 1:54 PM, R34 was found sitting in the hallway on the floor. On 01/02/2026 at 12:01 AM, R34 was observed on the ground near his bed. He was on his hands and knees. Shoes off and lined up next to bed. 01/02/2026 at 10:28 AM, R34 tried getting on the scale in the therapy room by himself and lost his balance and fell. On 01/03/2026 at 02:42 AM, R34 at 6:19 PM he was found sitting on the floor at the end of his bed with his back against the bed. On 01/25/2026 at 02:41 AM, R34 was noted to be on the floor lying on his right side with his back pressed up against the wall at 01:49 AM. R34 said he was trying to use his urinal and fell forward and hit his head off the ground. Resident's head bleeding. Cut above left eye cleaned and local ambulance was called to transfer to the local hospital. R34's Fall Risk Assessment, dated 12/10/2024, documents R34 is not at risk for falls. R34's Fall Risk Assessment, dated 10/06/2025, documented R34 is at risk for falls. R34's Fall Risk Assessments were reviewed and there was no fall risk assessment completed after his fall on 12/24/25, 01/02/26, 01/03/26, 01/25/26. On 02/25/2026 at 11:40 AM R34 was up and in his wheelchair and there was no pressure alarm on while up in his chair. On 02/26/2026 at 11:51 AM R34's room was inspected and there isn't a call don't fall sign on the wall in his room. 3. R64's Face Sheet, admission date of 12/05/26, documents he has diagnoses of but not limited to localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus and paroxysmal atrial fibrillation. R64's MDS, dated [DATE], documents R64 is severely cognitively impaired with a BIMS of 06 out of 15 and requires substantial/maximal assistance with sit to stand and chair/bed-to-chair transfer. R64's Care Plan, admission date of 12/05/24, documents R64 is at risk for falls related to (r/t) epilepsy, cognitive impairment, hypertension (HTN), type II diabetes mellitus (T2DM), and use of antidepressants. Interventions include but not limited to 11/11/2025: 15 minute checks (create date 11/28/25), 12/23/2025: R64 sent to ER for further evaluation (create date 01/06/2026), 12/30/2025: Bright yellow Call Don't Fall sign placed in resident room by bed (created 02/11/2026), 01/01/2026: Wheelchair not to be left near bedside when resident is not using it (created 02/02/2026), 01/06/2026: Resident moved to room closer to nursing desk (created 02/11/2026). R64's Progress Notes were reviewed and documents he had falls on the following dates: On 11/12/2025 at 1:27 PM, R64 was trying to transfer himself from his wheelchair (w/c) to his bed and fell to the floor. On 12/23/2025 at 5:36 PM, R64 said he was trying to get into his w/c from his bed and slide out of the bed to the floor. On 12/30/2025 at 8:14 PM, R64 was on the floor in his room between the bed and his w/c in a sitting position with his legs out straight. On 12/31/2025 at 01:30 AM, R64 was on the floor in his room. He was lying in the center of the floor halfway between bed and w/c. Hematoma to right eye noted. On 01/01/2026 at 12:55 PM, R64 was found sitting on his floor. He said he was trying to get from his bed into his w/c and his legs gave out. On 01/06/2026 at 10:25 PM, R64 was found on the floor in his room in a sitting position next to his w/c. On 01/07/2026 at 8:00 AM, R64 was found on the floor by staff. He said he was trying to get from his w/c to bed. R64 then fell again at 9:45 AM and was sent to the local hospital for right shoulder pain. R64's Fall Risk Assessment (Admission), dated 12/24/25, documents he is at risk for falls. R64's Fall Risk Assessment (reentry), dated 12/28/25, documents he is not at risk for falls. R64's Falls Risk Assessments were reviewed and there was no fall risk assessment completed after falls on 11/12/25, 12/30/25, 12/31/25, 01/01/26, and 01/07/26. 4. R86's Face Sheet, admission date of 12/23/2025, documents R86 has diagnoses of but not limited to fracture of unspecified part of neck of left femur and malignant neoplasm of unspecified part of unspecified bronchus or lung. R86's MDS, dated [DATE], R86 is cognitively impaired with a BIMS of 06 out of 15 and he is dependent on staff for transfers and sit to stand. R86's Care Plan, admission date of 12/23/2025, documents R86's review shows he is a risk for falls. Risk factors include pain, left femur neck fracture (fx), lung cancer, impaired cognition, psychotropic drug use, and total dependence with activities of daily living (ADLs). Interventions include but are not limited to 01/11/2026: 15-minute checks, 01/12/2026: bed to be kept in low position at all times when in bed and resident moved to room closer to nursing station, 02/22/2026: non-skin cushion add to wheelchair to prevent sliding. Pressure alarm at all times (all created on 02/22/2026). R86's Progress Notes were reviewed and documents he had falls on the following dates: On 01/11/2026 at 5:43 AM, Staff responded to bed alarm and reported R86 was on the floor next to his bed. On 01/12/2026 at 5:28 AM, R86 was noted to be on the floor this morning at 3:59 AM. He was lying on his back with his feet facing the bed. On 02/22/2026 at 1:00 PM, R86 slipped out of w/c in living room by nurse's station. R86's Fall Risk Assessment (admission), dated 12/23/25, documents he is not at risk for falls. R86's Fall Risk Assessment (full assessment), dated 01/11/26, documents he is at risk for falls. R86's Fall Risk Assessments were reviewed and has no fall risk assessments completed after his falls on 01/12/26 and 02/22/26. The facility's Fall and Fall Risk, Managing, revision date of March 2018, documents Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. It further documents Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The facility's policy Assessing Falls and Their Causes, revision date of March 2018, documents Documentation When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). 2.Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4.Notification of the physician and family, as indicated. 5.Completion of a falls risk assessment. 6.Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. The Facility's CMS 671, dated 02/23/26, documents there are 71 residents in the facility.

Based on observation, interview, and record review, the facility failed to add identified problem areas and to update care plans in a timely manner for 4 residents of 35 residents (R7, R34, R64, R86) whose care plans were reviewed in the sample of 35.Findings Include:1. R34's Face Sheet, print date of 02/25/26, documents he has diagnoses of but not limited to congestive heart failure (CHF), paroxysmal atrial fibrillation, muscle wasting and atrophy, multiple sites, and unsteadiness on feet. R34's Minimum Data Set (MDS), dated [DATE], documents R34 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 13 out of 15 and he requires partial/moderate assistance with sit to stand, transfer chair/bed-to-chair transfer, and toilet transfers. R34's Care Plan, admission date of 12/05/24, documents R34's review shows moderate risk for falls. Risk factors include use of psychotropic medications, diuretics, incontinence, visual impairment, and cognitive impairment. Interventions include but not limited to 01/01/2026: call don't fall sign placed in room by bed to encourage asking for assistance, 01/02/2026: Resident sent to ER (emergency room) for further treatment. Resident noted to have a UTI (urinary tract infection). Will monitor effectiveness of ABX (antibiotics), 01/02/2026: Therapy room to be kept locked when staff not present 01/06/2026: Pressure pad alarm on at all times, 01/25/2026: 15 minute checks, 01/25/2026: Moved to room closer to nursing desk (created on 02/11/2026), 01/01/2026: Physical assessment, neuro assessment, vital signs obtained, assisted patient back into his bed (all created on 01/12/2026), 01/02/2026: Resident assessed from head to toe. Sent to ER (created 01/12/2026), 12/24/2025: Resident educated on walking slow to prevent falls (01/06/2025). R34's Progress Notes were reviewed and documents he had falls on the following dates: On 12/24/2025 at 1:54 PM, R34 was found sitting in the hallway on the floor. On 01/02/2026 at 12:01 AM, R34 was observed on the ground near his bed. He was on his hands and knees. Shoes off and lined up next to bed. On 01/02/2026 at 10:28 AM, R34 tried getting on the scale in the therapy room by himself and lost his balance and fell. On 01/03/2026 at 02:42 AM, R34 at 6:19 PM he was found sitting on the floor at the end of his bed with his back against the bed. On 01/25/2026 at 02:41 AM, R34 was noted to be on the floor lying on his right side with his back pressed up against the wall at 01:49 AM. R34 said he was trying to use his urinal and fell forward and hit his head off the ground. Resident's head bleeding. Cut above left eye cleaned and local ambulance was called to transfer to the local hospital. 2. R64's Face Sheet, admission date of 12/05/26, documents he has diagnoses of but not limited to localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus and paroxysmal atrial fibrillation. R64's MDS, dated [DATE], documents R64 is severely cognitively impaired with a BIMS of 06 out of 15 and requires substantial/maximal assistance with sit to stand and chair/bed-to-chair transfer. R64's Care Plan, admission date of 12/05/24, documents R64 is at risk for falls related to (r/t) epilepsy, cognitive impairment, hypertension (HTN), type II diabetes mellitus (T2DM), and use of antidepressants. Interventions include but not limited to 11/11/2025: 15 minute checks (create date 11/28/25), 12/23/2025: R64 sent to ER for further evaluation (create date 01/06/2026), 12/30/2025: Bright yellow Call Don't Fall sign placed in resident room by bed (created 02/11/2026), 01/01/2026: Wheelchair not to be left near bedside when resident is not using it (created 02/02/2026), 01/06/2026: Resident moved to room closer to nursing desk (created 02/11/2026). R64's Progress Notes were reviewed and documents he had falls on the following dates: On 11/12/2025 at 1:27 PM, R64 was trying to transfer himself from his wheelchair (w/c) to his bed and fell to the floor. On 12/23/2025 at 5:36 PM, R64 said he was trying to get into his w/c from his bed and slide out of the bed to the floor. On 12/30/2025 at 8:14 PM, R64 was on the floor in his room between the bed and his w/c in a sitting position with his legs out straight. On 12/31/2025 at 01:30 AM, R64 was on the floor in his room. He was lying in the center of the floor halfway between bed and w/c. Hematoma to right eye noted. On 01/01/2026 at 12:55 PM, R64 was found sitting on his floor. He said he was trying to get from his bed into his w/c and his legs gave out. On 01/06/2026 at 10:25 PM, R64 was found on the floor in his room in a sitting position next to his w/c. On 01/07/2026 at 8:00 AM, R64 was found on the floor by staff. He said he was trying to get from his w/c to bed. R64 then fell again at 9:45 AM and was sent to the local hospital for right shoulder pain. 3. R86's Face Sheet, admission date of 12/23/2025, documents R86 has diagnoses of but not limited to fracture of unspecified part of neck of left femur and malignant neoplasm of unspecified part of unspecified bronchus or lung. R86's MDS, dated [DATE], R86 is cognitively impaired with a BIMS of 06 out of 15 and he is dependent on staff for transfers and sit to stand. R86's Care Plan, admission date of 12/23/2025, documents R86's review shows he is a risk for falls. Risk factors include pain, left femur neck fracture (fx), lung cancer, impaired cognition, psychotropic drug use, and total dependence with activities of daily living (ADLs). Interventions include but are not limited to 01/11/2026: 15-minute checks, 01/12/2026: bed to be kept in low position at all times when in bed and resident moved to room closer to nursing station, 02/22/2026: non-skin cushion add to wheelchair to prevent sliding. Pressure alarm at all times (all created on 02/22/2026). R86's Progress Notes were reviewed and documents he had falls on the following dates: On 01/11/2026 at 5:43 AM, Staff responded to bed alarm and reported R86 was on the floor next to his bed. On 01/12/2026 at 5:28 AM, R86 was noted to be on the floor this morning at 3:59 AM. He was lying on his back with his feet facing the bed. On 02/22/2026 at 1:00 PM, R86 slipped out of w/c in living room by nurse's station. 4.R7's Face Sheet, print date of 2/25/26, documents R7 has diagnoses including traumatic subdural hemorrhage, dementia, unspecified psychosis, generalized anxiety disorder, chronic myeloid leukemia, osteoporosis, and cerebral infarction. R7's MDS (Minimum Data Set), dated 1/21/26, documents R7 is severely cognitively impaired and has a physical restraint. R7's physician order, dated 7/16/25, documents lap restraint when in wheelchair due to frequent falls and decrease in mobility. Off during meals times. Release every 2 hours. R7's restraint Care Plan documents it was created on 9/11/25. This Care Plan documents device in place, lap restraint related to injury, repeated falls, dementia, poor safety awareness, and unsteady gait. Interventions include apply lap restraint when in wheelchair and release every 2 hours and during meals. Document restraint use and release as per facility protocol. R7's fall intervention for the fall R7 sustained on 6/26/25 was not created/added to her Care Plan until 7/7/25. R7's fall intervention for the fall R7 sustained on 7/2/25 was not created/added to her Care Plan until 7/7/25. On 2/24/26 at 2:37 PM V4 (Regional Nurse) stated the initiated date on the resident Care Plan is when the intervention was put into place and the created date is when the care plan was made/created. Survey asked V4 how soon she expects care plans to be created and V4 stated care plan interventions should be created and initiated immediately or the next day after the fall occurred or the restraint was ordered. V4 stated if the IDT (Interdisciplinary Team) decides a resident needs a restraint, then I would expect the care plan to be updated immediately. Surveyor asked V4 what R7's restraint Care Plan creation date was, V4 looked at R7's care plan creation date and stated it was created on 9/11/25. Surveyor asked V4 if that was an acceptable time frame since V4's restraint was implemented/ordered on 7/21/25 and V4 replied no it is not. The Facility's Care Plans, Comprehensive Person-Center Policy dated 3/2022 documents a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The interdisciplinary team (IDT), in conjunction with the resident, family, or legal representative, develops and implements a comprehensive, person-center care plan for each resident. 2. The comprehensive, person-centered care plan is developed within 7 days of the required MDS assessment. It continues, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes, b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. It continues, 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review the facility failed to complete dressing changes and daily skin checks as ordered by the physician for wounds for 1 of 3 residents (R73) reviewed for wounds in a sample of 35. Findings Include: R73's Face Sheet, admission date of 02/24/23, documents R73 has diagnoses of but not limited to rheumatoid arthritis, sepsis, peripheral vascular disease, cellulitis of left lower limb, and atherosclerosis of native arteries of right leg with ulceration of other part of lower leg. R73's Minimum Data Set (MDS), dated [DATE], documents R73 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 15 out of 15 and she is dependent on staff for most of her activities of daily living (ADLs). R73's Care Plan, admission date of 02/24/23, documents R73 has a venous/stasis ulcer of the right medial ankle (08/28/25), non-pressure related blister to left heel. Interventions include but are not limited to document location of wound, amount of drainage, peri-wound area, pain, edema, and circumference measurements weekly, evaluate wound for: Size, depth, margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, monitor/document/report as needed (PRN) for signs and symptoms (s/sx) of infection, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R73's Physician's Orders, dated 09/24/25, documents Daily skin check every day shift. Document: C=Clear; R=Rash, O=Other, P= Pressure, S= Skin Tear, Document CROPs on Treatment Administration Records (TAR) on Friday. R73's Physician's Orders, dated 10/21/25, documents Right Anterior Lower Leg: Cleanse with normal saline/wound cleanser (NS/WC and pat dry. Apply xerform to wound bed. Cover with abdominal pad (ABD). Wrap leg from toes to knee with kerlix then ace bandage. Change daily and PRN. Every night shift. R73's TAR for the month of December 2025 was reviewed and no documentation daily skin check was completed on 12/05/25, 12/19, and 12/26/25. There was no documentation R73's dressing was completed on 12/01/25 and 12/24/25. R73's TAR for the month of January 2026 was reviewed and no documentation daily skin check was completed on 01/16/26 and 01/23/26 and daily dressing change was completed on 01/30/26. R73's TAR for the month of February 2026 was reviewed and no documentation daily skin check was completed on 02/06/26 and 02/20/26 and daily dressing change was completed on 02/06/26 and 02/22/26. On 02/23/2026 at 9:45 AM, R73 is sitting in her wheelchair in her room. The dressing on R73's right lateral ankle has the date of 02/22/26 and there is a moderate amount of yellow/greenish drainage noted to the dressing. On 02/23/26 at 9:40 AM, R73 said her dressing is changed by the night shift usually later in their shift/early in the morning and it wasn't changed last night. She said it was agency staff that was working last night. On 02/24/26 at 4:12 AM, V12 (Licensed Practical Nurse/LPN) said most of the agency nurses don't do their treatments. She said she worked a Saturday night, completed her treatments as ordered, was off Sunday night, then when she worked on Monday night the resident's dressing she applied on Saturday night were still on the residents. On 02/25/26 at 12:38 PM V5 (LPN) stated it's hit or miss if dressings get changed on night shift. She said it depends also if agency staff are working, they are the ones who usually don't do their dressing changes. On 02/26/26 at 3:47 PM, V4 (Regional Nurse) stated she expects dressings to be changed as ordered. The facility's Wound Care Policy, revision date of October 2010, documents Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Further documents: Documentation The following information should b recorded in the resident's medical record: The following information should be recorded in the resident's medical record:1. The type of wound care given.2. The date and time the wound care was given.3. The position in which the resident was placed.4. The name and title of the individual performing the wound care.5. Any change in the resident's condition.6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.7. How the resident tolerated the procedure.8. Any problems or complaints made by the resident related to the procedure.9. If the resident refused the treatment and the reason(s) why.10. The signature and title of the person recording the data.

Based on interview and record review, the facility failed to ensure dignity and respect for 4 of 5 (R23, R21, R35 and R46) residents reviewed for call lights in a sample of 35.Findings include: 1.On 02/24/2026 at 2:00 PM, R23 stated that if they don't answer her call light and she has to go to the bathroom and she has an accident it does not feel good and it embarrasses her.R23's Minimum Data Set (MDS), dated [DATE], documented that her cognition was moderately impaired and that she was frequently incontinent of urine and occasionally incontinent of stool. 2. On 02/24/2026 at 2:08 PM, R35 stated that she takes a water pill, and she is always incontinent but if she has to wait, she is just thinking about the other residents that need help and that are not getting it.R35's MDS, dated [DATE], documented that her cognition was intact and that she was frequently incontinent of urine. 3. On 02/24/2026 at 2:12 PM, R21 stated that it takes a long time for the night shift to answer her call light, but she will just get up and go to the bathroom on her own. R21's MDS, dated [DATE], documented that her cognition was intact and that she was occasionally incontinent of urine. 4. On 02/24/2026 at 2:15 PM, R46 stated that if she has to wait a long time and she has to go to the toilet and if she has an accident, it makes her feel awful. R46's MDS, dated [DATE], documented that her cognition was intact and that she was occasionally incontinent of urine. On 2/24/2026 at 4:12 AM, V12 (Licensed Practical Nurse/LPN) stated they usually staff 2 to 3 Certified Nurse Assistants (CNA) for 100, 200, 400 and 1 CNA for the Memory Care unit on night shift. She also stated that she does not feel it is enough CNAs to get everything done, 1 CNA is not enough on the unit.On 2/24/2026 at 4:28 AM, V14 (CNA) stated management does not answer when staff try to contact them. Not even the call nurse's answer. She stated night shift does not have enough staff and they need 5 CNAs on nights (2 on memory unit). On 02/26/2026 at 9:20 AM, V22 (CNA) stated that they try and answer the call lights as soon as possible but if it was her and if she had urinated on herself, she would feel embarrassed.On 02/26/2026 at 9:25 AM, V20 (CNA) that they try and answer the call lights as soon as possible, but she said if she had urinated on herself while waiting for someone to answer her call light, it would embarrass her.On 02/26/2026 at 9:25 AM, V23 (CNA) stated that they try and answer the call lights as soon as possible, but she said if she had urinated on herself while waiting for someone to answer her call light it would embarrass her. The Long-Term Care Ombudsman Program Residents' Right for People in Long Term Care Facilities, undated, documented, Your facility must provide services to keep your physical and mental health, and sense of satisfaction with yourself, at their highest practical levels.

Based on observation, interview, and record review the facility failed to ensure physical restraints were used to treat a medical symptom, failed to provide evidence of least restrictive methods attempted prior to initiating a physical restraint, failed to identify the amount of time the restraint will be used for, failed to identify risks versus benefits of restraints, failed to provide ongoing monitoring documentation of the restraint, and failed to remove the restraint at meals for 1 of 1 residents (R7) reviewed for physical restraints in a sample of 35. Findings Include: R7's Face Sheet, print date of 2/25/26, documents R7 has diagnoses including traumatic subdural hemorrhage, dementia, unspecified psychosis, generalized anxiety disorder, chronic myeloid leukemia, osteoporosis, and cerebral infarction.R7's MDS (Minimum Data Set), dated 1/21/26, documents R7 is severely cognitively impaired and has a physical restraint.R7's physician order, dated 7/16/25, documents lap restraint when in wheelchair due to frequent falls and decrease in mobility. Off during meals times. Release every 2 hours.R7's Initial/Emergency Use Restraint Evaluation, effective date of 7/17/25, documents lap restraint when in wheelchair d/t (due to) frequent falls and decrease in mobility. Off during mealtimes. Release every 2 hours. This form does not document duration of the restraint application. R7's Care Plan, undated, documents device in place, lap restraint related to injury, repeated falls, dementia, poor safety awareness, and unsteady gait. Interventions include apply lap restraint when in wheelchair and release every 2 hours and during meals. Document restraint use and release as per facility protocol.On 2/24/26 at 9:52 AM R7 was observed sitting in her wheelchair in the Memory Care Unit with a lap restraint on. V19 (Certified Nursing Assistant/CNA) asked R7 to remove/release the lap restraint and R7 did not voice an understanding, nor did she attempt to remove the restraint. V19 then pointed to the lap restraint and asked R7 to remove it. R7 could not release the restraint nor did R7 voice an understanding of the question. On 2/25/26 at 11:50 AM R7 was observed sitting in her wheelchair eating lunch in the memory care unit dining room. R7's lap restraint was observed in use during the meal.On 2/25/26 at 11:55 AM V4 (Regional Nurse) stated restraints are supposed to be removed during meals. On 2/25/26 at 2:56 PM V4 (Regional Nurse) stated she cannot find any restraint reduction attempts nor restraint monitoring documentation for R7.The facility's Use of Restraints policy dated 4/2017 documents restraints shall only be used for the safety and well-being of the resident (s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, reclining wheelchair, lap cushions, and trays that the resident cannot remove. It continues, 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: a. treat the medical symptom, b. protect the resident's safety; and c. help the resident attain the highest level of his/her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. It continues, 9. Restraints shall only be used upon that written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom, and c. The type of restraint, and period of time for the use of the restraint. It continues, 12. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to ensure the least possible discomfort to the resident. b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. It continues, 16. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. It continues, 19. Documentation regarding the use of restraints shall include: a. full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode, b. a description of the resident's medical symptoms, c. how the restraint use benefits the resident by addressing the medical symptom; d. the type of the physical restraint used; e. the length of effectiveness of the restraint time; and f. observation, range of motion, and repositioning flow sheets.

Based on observation, interview, and record review the facility failed to ensure infection control guidelines were in place and implemented for 2 of 3 (R3, R65) residents reviewed for infection control in a sample of 35. Findings include: 1 R3's Care plan, dated 2/9/2026, documents that R3 is on contact isolation; projected time frame start 11/21/2025 r/t (related to) Infection process ESBL to urine. 2/24/2026 Resident is on contact isolation; r/t Infection process in urine. It continues Isolation Precautions: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Educate resident and family on the need of isolation precaution. Educate family and staff regarding the transmission, pathophysiology, etiology, and treatment of infection. Upon gown and glove removal, ensure hands and clothing does not contact potentially contaminated environmental surfaces.R3's Minimum Data Set (MDS), dated [DATE], documents that R3 is cognitively impaired has a catheter and dependent on staff for toileting.R3's sign outside of door documents, Stop Contact precautions everyone must: Clean their hands including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit.On 2/25/2026 at 10:16 AM observed V25 (Certified Nursing Assistant/CNA), and V26 (CNA) entered R3's room. V25 and V26 then washed their hands and applied gloves. V25 and V26 then assisted R3 up in bed. V25 and V26 then removed covers and opened incontinent brief. R3's penis was observed to have a dark red and brown drainage coming from R3's penis and covering the catheter. V25 and V26 then replaced the cover on top of R3. Removed gloves and left room. V25 and V26 did not clean their hands, apply gown and gloves prior to entering room.On 2/25/2026 at 11:02 AM observed V3 (Assistant Director of Nursing/ADON), V25 and V26 applying a gown and gloves outside R3's door. V26 at that time performed catheter care. Using wet wash cloths and foam cleaner V26 cleansed R3's penis and catheter, placing wash cloth on floor then picking it up and handed to V25. V25 then placed the washcloth on the bed. After cleansing the dark red and brown drainage from R3's penis and catheter, using the same soiled gloves V26 applied clean incontinent pad. Using the same soiled gloves V26 assisted R3 with repositioning in bed. Using the same soiled gloves V26 then applied clean sheet over R3, adjusted head of bed touching the remote.On 2/25/2026 at 10:12 AM R3 stated that the staff do not always wear the gowns when providing care for him. R3 stated that the girls clean him but do not wear the gowns. R3 stated that he has an infection in his urine and is on isolation as a result.On 2/26/2026 at 11:15 AM V22 (CNA) stated that gowns, gloves, and mask are worn for residents in isolation and enhanced barrier precautions.2. R65's Care Plan, dated 2/23/2026, documents that Implementation of Enhanced Barrier Precaution due to indwelling medical device are not known to be infected or colonized with any MDRO (Multi drug resistant organism). It also document ensure PPE and alcohol-based hand rub are readily and accessible. Use enhanced barrier protection during high contact care activities, dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting device use central lines, urinary catheter, feeding tube, tracheostomy, wound care.R65's MDS, dated [DATE], documents that R65 is cognitively impaired and totally dependent on staff for toileting.R65's sign outside door documents Stop Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-contact resident care activities. Dressing, Bathing/showering, changing linens, providing hygiene, changing briefs or assisting with toileting.On 2/25/2026 at 2:15 PM observed V25 (CNA) and V19 (CNA) perform incontinent care on R65. R65 was incontinent of urine. V25 and V19 entered R65's room, performed hand hygiene and applied gloves. V25 and V19 did not perform hand hygiene prior to entering R65's room and did not apply gown. V19 then using wash cloths and foam spray performed incontinent care. V19 changed gloves with each wipe and did not perform hand hygiene. V25 assisted with the removal of R65's urine soiled incontinent brief, urine soiled gown and incontinent brief. With the same urine soiled gloves V25 then applied clean gown, clean incontinent brief, and applied clean covers and placed pillow beneath R65's head manipulating R65's head and face. With the same urine soiled gloves V25 then placed television next to bed. V25 then removed her gloves.On 2/26/2026 at 1:50 PM V25 (CNA) stated that when a resident is on contact isolation or enhanced barrier precautions the PPE is applied at the door prior to entry. V25 stated that this includes when providing incontinent care, catheter care, feeding tubing. V25 stated that linen should not be placed on the floor and hand hygiene should be performed after gloves are removed and before reapplied. The facility's Hand Hygiene policy, updated 8/14/23, documents that All staff will comply with current CDC hand hygiene guidelines to reduce the incidence of health-care associated infections. Indications for hand washing- when hands are visibly soiled or contaminated with blood or other bodily fluids, before and after eating and using the restroom. Handwashing can also be used routinely in the following clinic situations: After contact with bodily fluids, excretions, mucous membranes, non-intact skin and wound dressings 1. Before and after direct resident care 2. Before and after inserting invasive devices 3. When moving from contaminated body site to clean body site during resident care 4. After contact with intact skin 5. After removing gloves Indications for Alcohol Based Hand Rub (ABHR)- When hands are not visibly soiled, ABHR may be used for routinely decontaminating hands in the following clinical situations: 1. Before and after having direct contact with residents 2. Before and after inserting invasive devices that don't require a surgical procedure 3. After contact with a residents' intact skin 4. After contact with inanimate objects (including medical equipment) 5. After removing gloves.

Based on interview and record review, the Facility failed to assess a resident with a change in condition for 1 of 3 residents (R2) reviewed for quality of care in the sample of 3. The facility also failed to notify the physician and resident representative of a change of condition. This failure resulted in a delay in hospitalization for R2 for the diagnoses of small bowel obstruction, dehydration, nausea, and vomiting. R2 required nasogastric decompression and endured three attempts at midline catheter placement to achieve intravenous access for fluid resuscitation. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, and congestive heart failure.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was moderately cognitively impaired and required substantial assistance with bed mobility and transfer.On 10/23/25 at 4:35 PM, V9 (R2's Family) stated she came to visit R2 over the weekend of 10/10/25-10/11/25. R2 was asleep in the dining room which was unusual for her. V9 did not see R2 vomit that day, but when she was admitted to the hospital on [DATE], hospital staff told her the Facility reported R2 had been vomiting for three days prior to admission.On 10/24/25 at 12:30 PM, V2 (Director of Nursing/DON), stated R2 did not have a known history of nausea or vomiting.On 10/24/25 at 12:52 PM, V12 (Memory Care Coordinator) stated R2 was vomiting during breakfast on 10/14/25, and V7 (Licensed Practical Nurse/LPN) was notified.On 10/24/25 at 12:59 PM, V10 (Certified Nursing Assistant/CNA), stated R2 vomited during dinner on 10/11/25 and did not eat breakfast or lunch on 10/12/25.On 10/24/25 at 1:55 PM, V13 (CNA) stated R2 was not feeling well on 10/12/25 and was not eating her meals.R2's Progress Note by V7 (LPN) on 10/14/25 at 5:23 PM documents, Resident has had emesis x2 today, food contents mixed with stomach acids. She states she doesnt {sic} feel to {sic} bad. Will put a call into MD (Medical Doctor) in the AMOn 10/24/25 at 1:07 PM, V7 (LPN) stated she had been off work for a few days and had no knowledge of R2 having any gastrointestinal issues. She stated, (Nursing) reports aren't always the greatest because we have agency, and they are not always the best. V7 stated R2 was alert and said she did not feel too bad, so she went on to finish her medication pass. She did not assess R2's abdomen for bowel sounds or distention and was unsure of the time of R2's last bowel movement. She worked until around 6:00 PM and gave report to V6 (LPN) with a plan to call the doctor the next day.R2's Progress Note by V6 (LPN) on 10/15/25 at 2:02 AM documents, Res (resident) had emesis x3 this shift. Vitals still WNL (Within Normal Limits). Bowel sounds present. Res c/o (complained of) LUQ (Left Upper Quadrant) pain upon palpations. Attempted to push fluids this evening, res would feel nauseous after a sip. Res c/o of being light headed. Res has had increased confusion, trying to climb out of the recliner and yelling. R2 was send to (Local Hospital) for further evaluation.On 10/24/25 at 10:53 AM, V6 was unavailable for interview.R2's (Local) Hospital Records dated 10/15/25 R2 was having nausea and vomiting for several days prior to admission and had large protuberant abdomen on examination. Computed Tomography (CT) Scan showed small bowel obstruction. Nasogastric tube was placed for gastric decompression, and midline catheter required three attempts to achieve intravenous access for fluid resuscitation. emergency room physician notes for the assessment/plan documents, 1. Small bowel obstruction. 2. New onset atrial fibrillation. 3. Elevated troponin. 4. Nausea & Vomiting. 5. Hyperkalemia. 6. Dehydration. 7. Chronic kidney disease, stage 3. 8. Urinary tract infection. 9. Lactic acidosis. Discharge Disposition: transferred to (higher level of care hospital name) ICU (intensive care unit).On 10/24/25 at 2:10 PM, V11 (Medical Doctor/MD), stated he would have expected Facility nurses to examine R2's abdomen, listen for bowel sounds, check for distention and tenderness, and call him with any changes in condition.On 10/28/25 at 11:20 AM, V2 (DON) stated nursing staff did what they should have and there was no delay in R2's hospitalization. V2 stated the physician does not need to be contacted just because a resident has emesis. V9 (R2's Family) was in the Facility visiting R2 all weekend and knew she had been doing fine. Staff called V9 when R2 went to the hospital. The Facility does not have a policy specific to gastrointestinal assessment. The Facility's Change in a Resident's Condition or Status Policy dated 2001 documents, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.

Based on interview, observation, and record review the Facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The facility also failed to employ a Director of Nursing (DON). This has the potential to affect all 53 residents in the facility. Findings include: On 10/28/2024 at 9:20 AM V1 (Administrator) stated, We do not currently have a DON and I can tell you we do not have enough RN coverage. We only have one (RN) who works 3 days a week. V1 stated the Facility census was 53. The Facility's Management Team document, undated, documents the DON position is vacant. During this survey 10/28/24-10/31/24, there were no observation of a DON at the Facility. There were also no observations of a RN on duty. On 8/30/2024 at 11:00 AM, V5 (Licensed Practical Nurse/LPN) stated, (Former DON)'s last day was 7/25/2024. We had a DON hired, but she only stayed 2 hours and never completed her (employment) paperwork. (V15 RN) is our only RN and works Fridays, Saturdays and Sundays. V15's Master Schedule documents V15 did not work 10/1/2024, 10/2/2024, 10/3/2024, 10/7/2024, 10/8/2024, 10/9/2024, 10/10/2024, 10/14/2024, 10/15/2024, 10/16/2024, 10/27/2024, 10/21/2024, 10/22/2024, 10/23/2024, or 10/24/2024. This documents the days V15 did not work, there was no RN coverage for 8 hours a day. The CMS 671 Form dated 10/28/2024 documents there are 53 residents residing at the Facility. The Facility's Nurse Staffing policy, undated, documents It is the policy of (Facility's) Health Care to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the Illinois Department of Public Health.

Based on observation, interview and record review, the Facility failed to ensure the daily nursing staff hours were posted and easily visible to residents. This failure has the potential to affect all 53 residents residing in the Facility. Findings include: On 10/28/2024 at 9:20 AM V1 (Administrator) stated the Facility census was 53. On 10/28/2024, 10/29/2024, 10/30/2024 and 10/31/2024 the survey team made observations throughout the Facility. There were no postings observed to document the resident census and the number of licensed nursing staff. On 10/31/2024 at 10:40 AM, V1 stated V1 thought the former Director of Nursing (DON) posted the nurses schedules at the nurses' station. V1 stated she was not aware it was not being posted for the week. On 10/31/2024 at 10:53 AM, V5 (Licensed Practical Nurse/LPN) stated, It used to be posted on the DON's office door, which is now V4's (LPN/Resident Care Coordinator) door. (Former DON) was doing it. It should be done by the person who is doing the schedule. It should be kept current and posted every day. The CMS 671 Form dated 10/28/2024 documents there are 53 residents residing at the Facility.

Based on observation, interview, and record review, the facility failed protect residents' private space from wandering residents for 5 out of 5 residents (R11, R12, R14, R36, and R45) reviewed for resident rights in a sample of 27. Findings include: On 10/28/24 at 1:43 PM, R48 was observed wandering up and down the 100 hallway with no staff supervision. On 10/28/24 at 1:46 PM, R48 was observed wandering on the 100 hallway and was observed going into one of the rooms on the hall. He remained in room for several minutes with no staff attempting to find or check on him. On 10/28/24 at 2:00 PM, R48 was observed wandering back out on the 100 hallway. On 10/28/24 at time unknown R48 attempted to get out the smoker's door. You must have a code to get in and out of the door and it is not a fenced in courtyard. On 10/28/24 at 3:25 PM, R48 was observed wandering down the 400 hallway. On 10/28/24 at 3:56 PM, R48 was observed still wandering the facility. He was observed touching the smoker's door which is located on the 200 hallway. On 10/30/24 at 08:02 AM, R48 was observed ambulating down the hallway unattended and then attempting to open dietary door on 400 hallway. 1. R11's Face Sheet, with a print date of 10/30/24, documented R11 has diagnoses of but not limited to Diastolic congestive heart failure (CHF), acute and chronic respiratory failure with hypoxia, muscle weakness, and other abnormalities with gait and mobility. R11's Minimum Data Set (MDS), dated [DATE], documented R11 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she is independent with all her activities of daily living (ADLs). On 10/30/24 at 12:46 PM, R11 stated R48 wanders up and down the hallways all the time. R11 said one night she woke up at around 12:30 AM to go to the bathroom and as she was standing up, she just happened to look down and seen two feet. She said she knew they were R48's feet that were standing there and it kind of scared her. She said one time he even walked in on her while she was using the bathroom. V11 said she told one of the nurses that if R48 were to hit her it would be over for her due to her being so weak and unsteady on her feet. 2. R36's Face Sheet, print date of 10/30/24, documented R36 has diagnoses of but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hypertension (HTN), major depressive disorder, and anxiety disorder. R36's MDS, dated [DATE], documented R36 is cognitively intact with a BIMS of 14 out of 15 and is independent with most of his ADLs. On 10/30/24 at 1:40 PM, R36 stated R48 came into his room one time and R48 told him to get out because this was his room. There was also a time he came down and was pounding on the door and yelling. R36 said when he sees him wandering down his hallway he will get up and shut the door. On 10/29/24 at 11:15 AM, during resident council, R36 stated R48 came into his bedroom claiming it was his even though R36 told him it was not. R36 stated he had to call staff in to remove R48 but can't remember when this happened. R36 stated R48 wandered up to his dining table and took his tea one time also. 3. On 10/29/24 at 11:13 AM, during resident council, R14 stated about a month ago, R48 came into her room, sat on the spare bed, and started to take off his shoes. R14 stated she told R48 to stop, he was in the wrong place, but he proceeded to take off his shirt. R14 stated she then had to press her call light to get staff to help get him out of her room. 4. On 10/29/24 at 11:18 AM, during resident council, R12 stated R48 has wandered into her room, and she feels like his wandering is getting worse. R12 stated R48 tries to take other resident's food and drinks; he tried taking her water one day. R12 stated R48 doesn't listen to staff even if they are there. R12 continued stating R48 continues to do whatever he wants, there isn't anyone here that is able to take care of him and his sister tries to intervene because she is also a resident here. 5. On 10/29/24 at 2:05 PM, the facility's resident council meeting minutes for the past three months were reviewed and documented on 07/17/24 residents feel uncomfortable with another resident entering their rooms. On 10/29/24 at 2:10 PM, the facility's grievances for the past three months were reviewed and documented on 07/04/24 and 07/07/24 around 7:00 PM another male resident came into his room and would not leave even though R45 asked him to several times. This other resident approached R45 and acted as though he was going to hit R45. R45 stated he drew his fist up and was going to hit this other resident if he hit him. A CNA came into the room and redirected this other resident out. 6. R48's Face Sheet, with a print date of 10/30/24, documented R48 has diagnoses of but not limited to unspecified, dementia, mild, with agitation, chronic obstructive pulmonary disease (COPD), Depression, and anxiety disorder. R48's BIMS is 99- severely cognitively impaired. R48's MDS, dated [DATE], documented R48 is severely cognitively impaired and requires supervision/touching assistance with eating, partial/moderate assistance with sitting to lying, lying to sitting. sitting to standing, transfer, substantial/maximal assistance with oral hygiene, upper body dressing, dependent with toileting hygiene lower body dressing, putting on/taking off footwear, personal hygiene, rolling left/right, and he is always incontinent of bowel and bladder. R48's Care Plan, with an admitted [DATE], documented R48 is/has the potential to be physically aggressive related to (r/t) dementia. Interventions include but are not limited to 15-minute checks in common areas and analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. It also documents R48 is/has the potential to be verbally aggressive r/t dementia. Interventions include but are not limited to Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, assess, and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., monitor behaviors every shift. Document observed behavior and attempted interventions, and when the resident 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. On 10/30/24 at 9:04 AM, V17 (R48's wife) was contacted at this time. She said when R48 was admitted to the facility he was back on the locked unit and he went crazy. She said there wasn't enough room for him to walk and he likes to walk a lot, so they moved him out onto the other hall. V17 said she has suggested they try putting him back on the unit for a few hours a day and then work up to more hours until he is able to stay back there but the facility said they didn't want to be responsible for him hitting anyone because the last time he was back there he did hit someone and urinated on some lady's locker or something. V17 stated R48 should be a 1:1 but they have only made him a 1:1 for a week or two at a time then taken him off. She said the only reason he was a 1:1 yesterday (10/29/24) was because the state surveying agency was in the building, and they made him one after they found him in the therapy room that morning on the floor. She said there has been time they didn't know where R48 was at, and she said one night at 9:00 PM they found him in the kitchen by himself. On 10/31/24 at 1:40 PM, V1 (Administrator) stated she would expect the staff to try and redirect the resident from wandering into another resident's room. She said they will sometimes place the resident 1:1 with activities or even social service if they don't have enough staff to do it. She said they try to give R48 1:1 attention and try to redirect him elsewhere. She said they have had R48 on 1:1 the last couple of days due to medication changes being done. V1 said R48 will get focused on one room, and they will have to put a stop sign across the door. On 10/31/24 at 9:57 AM, V1 (Administrator) and V5 (MDS Coordinator) both stated the facility doesn't have a policy regarding resident rights.

Based on interview, observation, and record review, the facility failed to complete an incident report, failed to investigate, and determine the root cause of the fall, and failed to implement new fall prevention interventions. The facility also failed to provide adequate supervision to prevent resident from wandering into other resident's rooms on multiple occasions for 2 (R47 and R48) of 4 residents reviewed for falls/supervision in a sample of 27. Findings include: 1. R48's Face Sheet, with a print date of 10/30/24, documented R48 has diagnoses of but not limited to unspecified, dementia, mild, with agitation, chronic obstructive pulmonary disease (COPD), Depression, and anxiety disorder. R48's MDS, dated [DATE], documented R48 is severely cognitively impaired and requires supervision/touching assistance with eating, partial/moderate assistance with sitting to lying, lying to sitting. sitting to standing, transfer, substantial/maximal assistance with oral hygiene, upper body dressing, dependent with toileting hygiene lower body dressing, putting on/taking off footwear, personal hygiene, rolling left/right, and he is always incontinent of bowel and bladder. R48's Care Plan, with an admitted [DATE], documented R48 is/has the potential to be physically aggressive related to (r/t) dementia. Interventions include but are not limited to 15-minute checks in common areas and analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. It also documents R48 is/has the potential to be verbally aggressive r/t dementia. Interventions include but are not limited to Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, assess, and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., monitor behaviors every shift. Document observed behavior and attempted interventions, and when the resident 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. It also documented R48 exhibits/has exhibited in past a tendency to seek to leave facility or wander near exits. Specific behavior exhibited, wandering, following staff or resident's, going into other resident's rooms. Interventions include but are not limited to 1:1 close and constant or continuous visual monitoring when resident is agitated and not easily redirected, accompany resident when desires to leave unit, be alert for need of assistance, give verbal cues for direction as needed, guide Resident to safe walking locations away from exits, and intervene as needed to ensure residents/others safety. R48's Progress Notes, dated 9/27/2024 at 11:01 AM, documented Behavior Note: Resident entered a female's resident room and was agitated at staff when being redirected. Female resident was upset that resident would not leave room. Resident left room after multiple attempts by staff. R48's Progress Notes, dated 9/27/2024 at 2:15 PM, documented Behavior Note: Heard a female resident yelling and upon entering her room found R48 in her room while she was using the bathroom. Removed resident from her room. R48's Progress Notes, dated 10/20/2024 at 08:45 AM, documented Behavior Note: Patient restless, wandering facility. Resident has attempted to enter other resident's rooms and urinated on floor. All redirections are met with physical aggression towards staff. Writer was hit during medication administration as well, but pt (patient) did eventually take all medications including as needed (PRN) Lorazepam. On 10/28/24 at 1:43 PM, R48 was observed wandering up and down the 100 hallway with no staff supervision. On 10/28/24 at 1:46 PM, R48 was observed wandering on the 100 hallway and was observed going into one of the rooms on the hall. He remained in room for several minutes with no staff attempting to find or check on him. On 10/28/24 at 2:00 PM, R48 was observed wandering back out on the 100 hallway. On 10/28/24 at time unknown R48 attempted to get out the smoker's door. You must have a code to get in and out of the door and it is not a fenced in courtyard. On 10/28/24 at 3:25 PM, R48 was observed wandering down the 400 hallway. On 10/28/24 at 3:56 PM, R48 was observed still wandering the facility. He was observed touching the smoker's door which is located on the 200 hallway. On 10/30/24 at 08:02 AM, R48 was observed ambulating down the hallway unattended and then attempting to open dietary door on 400 hallway. On 10/29/24 at 11:13 AM, R14 stated about a month ago, R48 came into her room, sat on the spare bed, and started to take off his shoes. R14 stated she told R48 to stop, he was in the wrong place, but he proceeded to take off his shirt. R14 stated she then had to press her call light to get staff to help get him out of her room. On 10/29/24 at 11:15 AM, R36 stated R48 came into his bedroom claiming it was his even though R36 told him it was not. R36 stated he had to call staff in to remove R48 but can't remember when this happened. R36 stated R48 wandered up to his dining table and took his tea one time also. On 10/29/24 at 11:18 AM, R12 stated R48 has wandered into her room, and she feels like his wandering is getting worse. R12 stated R48 tries to take other resident's food and drinks; he tried taking her water one day. R12 stated R48 doesn't listen to staff even if they are there. R12 continued stating R48 continues to do whatever he wants, there isn't anyone here that is able to take care of him and his sister tries to intervene because she is also a resident here. On 10/30/24 at 9:04 AM, V17 (R48's wife) was contacted at this time. She said when R48 was admitted to the facility he was back on the locked unit and he went crazy. She said there wasn't enough room for him to walk and he likes to walk a lot, so they moved him out onto the other hall. V17 said she has suggested they try putting him back on the unit for a few hours a day and then work up to more hours until he is able to stay back there but the facility said they didn't want to be responsible for him hitting anyone because the last time he was back there he did hit someone and urinated on some lady's locker or something. V17 stated R48 should be a 1:1 but they have only made him a 1:1 for a week or two at a time then taken him off. She said the only reason he was a 1:1 yesterday (10/29/24) was because the state surveying agency was in the building, and they made him one after they found him in the therapy room that morning on the floor. She said there has been time they didn't know where R48 was at, and she said one night at 9:00 PM they found him in the kitchen by himself. On 10/30/24 at 12:46 PM, R11 stated R48 wanders up and down the hallways all the time. R11 said one night she woke up at around 12:30 AM to go to the bathroom and as she was standing up, she just happened to look down and seen two feet. She said she knew they were R48's feet that were standing there and it kind of scared her. She said one time he even walked in on her while she was using the bathroom. V11 said she told one of the nurses that if R48 were to hit her it would be over for her due to her being so weak and unsteady on her feet. On 10/31/24 at 1:40 PM, V1 (Administrator) stated she would expect the staff to try and redirect the resident from wandering into another resident's room. She said they will sometimes place the resident 1:1 with activities or even social service if they don't have enough staff to do it. She said they try to give R48 1:1 attention and try to redirect him elsewhere. She said they have had R48 on 1:1 the last couple of days due to medication changes being done. V1 said R38 will get focused on one room, and they will have to put a stop sign across the door. On 10/31/24 at 1:34 PM V5 (MSD Coordinator) stated the facility doesn't have a policy on wandering they have one regarding elopement but not wandering. 49494 2. R47's face sheet dated 10/30/24 documented R47 has diagnoses of Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, and osteoporosis. R47's MDS (Minimum Data Set) dated 9/8/24 documented R47 is severely cognitively impaired. R47's care plan with print date of 10/29/24 documented resident has risk factors for falls that require monitoring and intervention to reduce potential for self-injury. Risk factors include dementia, unaware of safety needs as evidenced by diagnosis. It continues the resident has had an actual fall with no apparent injury. Root cause may be related to cognitive impairment - unaware of safety needs. R47's progress note dated 9/30/24 at 4:30 am documented resident today fell on shift at 0400 while ambulating in hallway. When staff turned around, resident was standing behind staff became startled and spun around tripping over own feet. When falling resident hit her head into the corner of the hand railing on the wall and then fell to the ground. Upon assessment resident was noted to have a small laceration of L (left) brow bone that measured 1.5 cm by 2 cm and two skin tears on L hand. One measure 5.5 cm x 7.5 cm on the top of the hand and a 1 cm x 1 cm on the knuckle. Resident neuro assessment was without abnormalities from baseline. Resident was alert, PERRLA (pupils equal, round, and reactive to light) was present, grips moderate and equal, and opened eyes spontaneously. Manager on call notified with message left at 4:13 am. MD (Medical Doctor) notified of situation at 4:19 am and gave order to be evaluated in ED (Emergency Department), POA (Power of Attorney) made aware of situation at 4:25 am. Vital signs were within normal range, no other injuries present at time. Resident transferred to local hospital via ambulance for evaluation. R47's progress note dated 9/30/24 at 7:30 am documented resident returned from the ER (emergency room ). CT (computed tomography) scan came back negative. Has a laceration above left eye that had steristrips that she was picking off when she returned along with steristrips to skin tears to left hand. R47's EMR (Electronic Medical Record) does not document any post fall neurological assessments for R47's fall on 9/30/24. On 10/30/24 at 12:42 PM V5 (Care Plan Coordinator) stated that she was not aware of R47's fall on 9/30/24 and that she did not update R47's care plan with any new fall interventions after the fall on 9/30/24. V5 stated that the floor nurse did not complete an incident report in the EMR (electronic medical record) risk management program and therefore she was not aware of the fall. V5 stated that she does expect the nurses to always complete an incident report in the EMR risk management program. V5 stated that since R47 hit her head she would have expected the nurses to complete neurological assessments on R47 for 72 hours and that they were not completed on R47 after her fall on 9/30/24. V5 stated that the fall process is supposed to be for the floor nurse to complete the incident report, V4 (Resident Care Coordinator) completes the root cause analysis and interventions, and she updates the care plan with the new interventions. V5 stated that none of these were completed on R47's fall that occurred on 9/30/24. On 10/30/24 at 12:50 pm V1 (Administrator) stated that she expects the nurses to complete an incident report with each fall and that it was not completed for R47's fall that occurred on 9/30/24. 10/30/24 at 1:05 pm V4 (Resident Care Coordinator) stated that she expects the nurses to complete an incident report in the EMR risk management program with each resident fall and that there was not one completed for R47 therefore she did not know she fell , didn't investigate the fall, and did not add any interventions to R47's care plan. On 10/29/24 at 1:42 PM V4 (Resident Care Coordinator) stated they must have missed R47's fall on 9/30/24 because it was not put into the risk management system. V4 stated that R47's fall on 9/30/24 was not investigated to determine the root cause nor was a new intervention put into place to prevent further falls. The facility's Fall Prevention policy dated 11/10/18 documented it is the policy to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: all staff. Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. It continues, 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (Certified Nurse Assistant) assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on interviews, observations, and record reviews the facility failed to label, date, and dispose of food items stored in the refrigerator and freezer with potential to affect 4 out of 4 residents (R2, R7, R18, and R23) reviewed for expired food in a sample of 17. Findings include: On [DATE] at 9:15 AM, during the initial walk through of the kitchen, the following items were found in the refrigerator and freezer: 1. Pears with open date of [DATE]. 2. Opened Thick and Easy Hormel Orange Juice Thickened with no open date or use by date. 3. Opened Thick and Easy Hormel Apple Juice Thickened with no open date or use by date. 4. Mini cinnamon swirls frozen with freezer burn, undated. 5. Sugar snap peas frozen with freezer burn, undated and unlabeled. 6. Bananas for cake or muffins frozen with freezer burn, dated [DATE]. 7. Sugar cookies frozen undated and unlabeled. R23's Physician Orders with a start date of [DATE], documented a diet order of regular food with regular/thin liquid fluid consistency. R2's Physician Orders with a start date of [DATE], documented a diet order of regular food with regular/thin liquid fluid consistency. R18's Physician Orders with a start date of [DATE], documented a diet order of regular with honey/moderately thick fluid consistency. R7's Physician Orders with a start date of [DATE], documented a diet order of regular, pureed texture, and pudding/extremely thick fluid consistency. On [DATE] at 9:15 AM, V3 (Dietary Manager) stated their practice is to usually keep the fruit in the refrigerator for a week. V3 stated the date the thickened juices were received was written but they were unsure if an open date needed to be written also. On [DATE] at 2:08 PM, V3 stated any item found that is undated, without a label or has freezer burn should be thrown away. V3 stated she would have expected this to be done. The facility's Refrigerator and Freezer Storage Policy, with last revision date of ,d+[DATE], documented it is the facility's policy that any item to be placed in the refrigerators and freezers must be covered, labeled, and dated with a date-marking system that tracks when to discard perishable foods. The policy further documented the procedure is to mark each container with name of item and mark the date that the original container is opened or date of preparation. The facility's Storage Policy, with last revision date of ,d+[DATE], documented its procedure is to store leftovers in covered, labeled, and dated containers under refrigeration or frozen.

Based on interview and record review the facility failed to provide Medicare written notice regarding the right to an expedited review of a service termination (Notice of Medicare Non-Coverage/NOMNC) and/or the written notice of the resident's potential liability for a non-covered stay (Skilled Nursing Facility Advance Beneficiary Notice/SNF ABN) for 2 of 3 residents (R17 and R44) reviewed for Beneficiary Protection Notification in the sample of 17. Findings include: 1. R17's EMR (Electronic Medical Record) documented that R17 was originally admitted to the facility on [DATE]. R17's EMR documented R17 was admitted to a local hospital on 2/8/24 with a diagnosis of CHF (congestive heart failure). R17's EMR documented R17 was readmitted to the facility on [DATE] on Medicare Part A for skilled services. R17's EMR documented R17's last day of Medicare Part A coverage was 4/24/24. A review of R17's CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) revealed that R17 was given and signed the SNFABN on 4/24/24 and that R17 was not given at least 2 days' notice of his Medicare Part A coverage ending. 2. R44's EMR documented R44 was originally admitted to the facility on [DATE]. R44's EMR documented that R44 was admitted to a local hospital on 7/5/24 with diagnoses of pneumonia and dehydration. R44's EMR documented that R44 was readmitted to the facility on [DATE] on Medicare Part A for skilled services. The surveyor requested R44's CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the facility was unable to provide a NOMNC for R44's Medicare A coverage that ended on 9/16/24. On 10/30/24 at 12:48 PM V25 (Regional Director) stated that she would expect the residents to be given at least two days' notice before the end of Medicare Part A coverage. On 10/30/24 at 12:50 PM V24 (Social Service Director) stated that she mailed a SNFABN to R44's family but does not have any evidence that this was mailed and received. On 10/31/24 at 10:40 AM V1 (Administrator) stated that the facility does not have a policy for beneficiary notification.

Based on interview and record review the facility failed to ensure residents were free from physical abuse for 3 of 3 residents (R11, R37, and R48) reviewed for abuse in a sample of 27. Findings include: 1. R11's Face Sheet, with a print date of 10/30/24, documented R11 has diagnoses of but not limited to Diastolic congestive heart failure (CHF), acute and chronic respiratory failure with hypoxia, muscle weakness, and other abnormalities with gait and mobility. R11's Minimum Data Set (MDS), dated [DATE], documented R11 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and she is independent with all her activities of daily living (ADLs). R11's Progress Note, dated 10/19/2024 at 5:20 PM, documented Resident informed staff that she was sitting on the seat of her walker when another resident came up to her and started a conversation. Resident states she was talking to them when they got behind her and attempted to push her walker. Resident stated she told the other resident to stop pushing on her walker, states her feet were on the floor & stopping them from moving her. Resident states that the other resident became upset with her and struck her in the middle of her back with his hand. Incident was not witnessed by staff. Staff assessed resident, no discoloration or swelling noted to resident's back. Other resident was re-directed by staff with success. Will continue to monitor. R11's Progress Note, dated 10/20/2024 at 2:49 PM, documented R11 voiced her concern regarding the other resident entering her room. On 10/30/24 at 10:48 AM, R11's Illinois Department of Public Health (IDPH) final report was reviewed and documented an incident that took place between R11 and R48 in the main lobby of the facility on 10/19/24 at 6:45 PM. It documented R11 was cognitively intact with a BIMS of 15 out of 15 and R48's BIMS was 99- severely cognitively impaired. On October 19th, at approximately 5:30 PM 2024, a resident-to-resident altercation happened in the front lobby. According to R11, R48 approached her when she was sitting on the seat of her walker. R48 attempted to push her walker and she told him not to do so. R11 states he then struck her back with his hand. R48 was successfully redirected by staff. Nursing assessment indicted no injury to either resident. R48 was placed on 1:1 observation in common areas for 72 hours. Administrator, PCP, and POA notified of incident. The Interdisciplinary Team (IDT) determined that this event likely occurred to resident R48's, diagnosis of dementia. R48 was recently diagnosed with late stages of dementia and placed on hospice effective Friday, October 18th, 2024. R48's recent U/A (urinalysis) results received on October 19th, 2024; no culture was indicated. Local hospice completed a medication review. New orders received to change Ativan 0.5 MG every 4 hours routinely, in addition to Ativan 0.5 MG every 2 hours PRN. IDT will continue to monitor effectiveness and update care plan as needed. In addition to working close with primary care physician and hospice provider. On 10/30/24 at 12:46 PM, R11 stated R48 wanders up and down the hallways all the time. She said she had an incident that involved R48 a couple of weeks ago. She said she was up front with her walker, and she was sitting down on it. She said she like to go up there after supper just to get out of her room. R11 said R48 came up behind her and grabbed the back of her walker and she told him not to do that. She said R48 then let go of her walker, came around the right side of her walker, and hit her in the right shoulder. R11 said it doesn't hurt now but it did for about two hours after it happened. R11 said she has never feared R48 until he hit her and now R48 scares her. V11 said she told one of the nurses that if R48 were to hit her it would be over for her due to her being so weak and unsteady on her feet. 2. R48's Face Sheet, with a print date of 10/30/24, documented R48 has diagnoses of but not limited to unspecified, dementia, mild, with agitation, chronic obstructive pulmonary disease (COPD), Depression, and anxiety disorder. R48's MDS, dated [DATE], documented R48 is severely cognitively impaired and requires supervision/touching assistance with eating, partial/moderate assistance with sitting to lying, lying to sitting. sitting to standing, transfer, substantial/maximal assistance with oral hygiene, upper body dressing, dependent with toileting hygiene lower body dressing, putting on/taking off footwear, personal hygiene, rolling left/right, and he is always incontinent of bowel and bladder. R48's Care Plan, with an admitted [DATE], documented R48 is/has the potential to be physically aggressive related to (r/t) dementia. Interventions include but are not limited to 15-minute checks in common areas and analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. It also documents R48 is/has the potential to be verbally aggressive r/t dementia. Interventions include but are not limited to Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, assess, and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc, monitor behaviors every shift. Document observed behavior and attempted interventions, and when the resident 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. On 10/29/24 at 2:09 PM, Illinois Department of Public Health (IDPH) final report was reviewed and documented an incident that took place between R36 and R48 on 08/11/24 at 3:45 PM on the 100 hallway. It documented R48's BIMS was 99- severely cognitively impaired and R36's BIMS was 14 out of 15. On August 11th, 2024, at approximately 3:45 PM, resident to resident altercation. R36 and R48 were at nurse's station. While R36 was obtaining water from staff, R48 approached a cart that was nearby containing gardening supplies. R48 was asked to step away from the gardening cart. R48 began verbally arguing back and turned away from the cart, ending up close to R36. R36 stated to R48 get out of the way. Both residents started arguing back and forth with each other at this time. Before the nurse could get around the nurses' station to the residents, R36 pushed R48 with his hip. R48 in turn, grabbed him (R36) and R36 hit R48 in the head with his fist. When the nurse made her way around the nurses' station R36 had both arms around R48 and stated, I'm trying to make sure he doesn't fall. R48's left hearing aid was disheveled. R36 then released R48, and nurse immediately separated residents from each other. Nursing assessment indicated a skin tear to R 38's right hand. Nurse notified V1, administrator, V20, PCP, and POA's of incident. Residents were both placed on 15-minute checks with visuals in common areas. R38's wife (V17) came into facility to sit with him for the evening. The facilty's incident statements documented V21, Licensed Practical Nurse (LPN): R36 and R48 were at nurses' station. R36 was getting water from staff. R48 was wondering when he approached a cart R36 had nearby containing gardening supplies. R48 began to reach into a box on the cart, he was asked to stop by another resident. R48 began verbally arguing with that resident, then turned away and was standing very close to R36. R36 stated get out of the way. R48 responded in an aggressive tone. From where I was at the nurse's desk, I cannot confidently state which resident-initiated contact, but I did see R36's arm near the back of R48's head. Both residents were yelling at each other. When I made my way around the nurses' station to the residents, R36 had both arms around R48 and stated, I'm trying to make sure he doesn't fall. R48's left hearing aid was disheveled. R36 released R48 and R48 was removed from the immediate area. I then removed myself and contacted Admin, MD, and POA's. Other staff remained with both residents. The facility's incident statement documented V22, Certified Nursing Assistant (CNA): R36 was at the nurses' station waiting to go out to water the flowers and R48 came up to him (R36) and R36 said 'get out of my way. R48 didn't move so R36 pushed R48 with his hip. R48 grabbed R36 and R36 hit R48 in the head with his fist. The IDT determined that this event likely occurred due to resident diagnosis of dementia. R48 has a disorganized thought process and is easily over stimulated. He wanders throughout the facility all day and he is impulsive and with poor safety awareness. V20 informed no new orders for either resident but requested phone conference with facility administrator for 8/12/24. A message left for V23, Psychiatric Physician, was also placed. Consults requesting return call with estimated date of next facility visit. R48 remains on 15-minute checks and visuals in common areas at this time. In addition, a medication review was ordered for R36, and resident remained on 15-minute checks for 72 hours. R36's care plan was updated to address physical aggression and behavioral tracking. IDT team will monitor and communicate closely with PCP. R36's Progress Notes, dated 08/11/24 at 6:29 PM, documented Physical aggression initiated by resident. No injuries. Facility administration, Power of Attorney (POA), and medical doctor (MD) aware. On 10/30/24 at 1:40 PM, R36 said R48 came up and grabbed the cart that had water on it, and he thought R48 was going to turn it over, so he reached up and grabbed at it to keep him from turning it over. He said he doesn't remember hitting R48 or R48 hitting him. V1 Administrator stated she would expect the staff to separate the residents immediately if there was a resident-to-resident altercation. They should also notify the nurse so they can do a nursing assessment, and to contact her. She said when R48 first arrived at the facility he was placed back on the locked unit and within eight hours he was involved in a resident-to-resident altercation. She said it was too close of quarters back there for him. V1 stated that hospice is going to get more involved with R48's care and as a team they are going to work together to hopefully make things better. She said hospice is going to have volunteers to come out and sit 1:1 with R48. 40701 3. On 10/28/24 at 3:51 PM, R17 stated, (R48) has hit (R37) and (R11). He threw a soda bottle at me, but it didn't hit me. On 10/30/24 at 9:51 AM, R37 stated, (R48) head butt me. It hurt. He has a hard head. I wasn't expecting it. (V19) heard and turned so fast. She got him away from me. I didn't do anything to him, but I wanted to. My grandsons wanted me to as well after hearing about it. I just told him not to put his fingers in the milk glass. I didn't raise my voice or anything. He has come into my room but now I have a sign up. He followed me everywhere I would go. I sat with him for 3 hours, 2 hours the next day and 1 hour the next day just to keep him occupied while they (staff) did whatever. I don't get paid for it. On 10/30/2024 at 11:20 PM, V19, Housekeeping, stated, It was my third day here (employed at the facility). I was cleaning the dining room. I heard (R37) tell (R48) to 'back off'. I turned around and he started (did an elbowing motion) going like this a couple times. She (R37) said, 'stop I'm going to fall. I fall easy'. I told (R48) to 'come here'. I told the CAN (unknown Certified Nursing Assistant) (R48) hit (R37) so she told the nurse. She was very upset. I think it hurt her arm but not enough to cause her to be sent out to the hospital or anything. The Facility's IDPH (Illinois Department of Public Health) Notification Form dated 9/29/2024 at 8:00 AM documents, Unwitnessed resident on resident altercation. The Facility's Final Investigation dated 10/3/2024 documents R37 is alert, oriented x's 3 (person, place, time) and has independent decision-making skills. It further documents R48 has severe cognitive impairment. It continues, On September 29th, 2024 at approximately 8:00 AM, a staff member was alerted to (R37), who was getting ice from the ice machine in the main dining area. (R37) and (R48) were observed side by side at the ice cooler by staff member, (V19). (R37) stated he (R48) had elbowed her shoulder 3xs. [NAME] was redirected away from the area and nurse was notified. (R37) reported to nurse that (R48) elbowed her 3xs on her right upper arm. It continues to document, Staff Statements: (V19) (Housekeeper): I was cleaning the dining room and heard (R37) raise her voice at (R48) telling him to stop or she was going to fall. I went to redirect resident and saw (R48) nudging (R37) in her right arm with his elbow. I guided (R48) away from (R37) and alerted the nurse. and (V26) (CNA): I was feeding in the dining room. Resident, (R37) reported to me she was hit by (R48). I asked the resident if she was ok, she stated I am fine, he just shoved me but it scared me. I helped assist (R48) from the dining room. A couple of hours later I checked on (R37), to make sure she was doing ok. (R37) stated she was doing ok but her forearm is sore. I reported this to nurse. The Facility's Abuse Prevention Program policy, revised 11/28/16, documented Policy This facility affirms the rights of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of out residents. This will be done by: Dementia management and resident abuse prevention. Immediately protecting residents involved in identified reports of possible abuse: implementing systems to investigate all reports and allegations of mistreatment, exploitation, neglect, abuse of residents and misappropriation of resident property; promptly and aggressively and making the necessary changes to prevent future occurrences. It further documented V. Protection of residents. Residents who allegedly mistreat or abuse another resident or misappropriate resident property will be removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement considering his or her safety, as well as the safety of other residents and employees of the facility.

Based on interview, observation, and record review, the facility failed to update R47's care plan with new fall prevention interventions for 1 resident (R47) of 14 residents whose care plans were reviewed in the sample of 17. Findings Include: R47's face sheet dated 10/30/24 documented R47 has diagnoses of Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, and osteoporosis. R47's MDS (Minimum Data Set) dated 9/8/24 documented R47 is severely cognitively impaired. R47's care plan with a print date of 10/29/24 documented the resident has had an actual fall with no apparent injury. This care plan does not address R47's fall with injury that occurred on 9/30/24 including a root cause analysis and new fall prevention interventions. R47's progress note dated 9/30/24 at 4:30 am documented resident today fell on shift at 0400 while ambulating in hallway. When staff turned around, resident was standing behind staff became startled and spun around tripping over own feet. When falling resident hit her head into the corner of the hand railing on the wall and then fell to the ground. Upon assessment resident was noted to have a small laceration of L (left) brow bone that measured 1.5 cm by 2 cm and two skin tears on L hand. One measure 5.5 cm x 7.5 cm on the top of the hand and a 1 cm x 1 cm on the knuckle. Resident neuro assessment was without abnormalities from baseline. Resident was alert, PERRLA (pupils equal, round, and reactive to light) was present, grips moderate and equal, and opened eyes spontaneously. Manager on call notified with message left at 4:13 am. MD (Medical Doctor) notified of situation at 4:19 am and gave order to be evaluated in ED (Emergency Department), POA (Power of Attorney) made aware of situation at 4:25 am. Vital signs were within normal range, no other injuries present at time. Resident transferred to local hospital via ambulance for evaluation. R47's progress note dated 9/30/24 at 7:30 am documented resident returned from the ER (emergency room ). CT (computed tomography) scan came back negative. Has a laceration above left eye that had steristrips that she was picking off when she returned along with steristrips to skin tears to left hand. R47's EMR (Electronic Medical Record) does not document any post fall neurological assessments for R47's fall on 9/30/24. On 10/30/24 at 12:42 PM V5 (Care Plan Coordinator) stated that she was not aware of R47's fall on 9/30/24 and that she did not update R47's care plan with any new fall interventions after the fall on 9/30/24. V5 stated that the floor nurse did not complete an incident report in the EMR (electronic medical record) risk management program and therefore she was not aware of the fall. V5 stated that she does expect the nurses to always complete an incident report in the EMR risk management program. V5 stated that since R47 hit her head she would have expected the nurses to complete neurological assessments on R47 for 72 hours and that they were not completed on R47 after her fall on 9/30/24. V5 stated that the fall process is supposed to be for the floor nurse to complete the incident report, V4 (Resident Care Coordinator) completes the root cause analysis and interventions, and she updates the care plan with the new interventions. V5 stated that none of these were completed on R47's fall that occurred on 9/30/24. On 10/30/24 at 12:50 pm V1 (Administrator) stated that she expects the nurses to complete an incident report with each fall and that it was not completed for R47's fall that occurred on 9/30/24. 10/30/24 at 1:05 pm V4 (Resident Care Coordinator) stated that she expects the nurses to complete an incident report in the EMR risk management program with each resident fall and that there was not one completed for R47 therefore she did not know she fell , didn't investigate the fall, and did not add any interventions to R47's care plan. The facility's Comprehensive Care Planning policy dated 7/20/22 documented it is the policy of the facility to comprehensively assess and periodically reassess each resident admitted to this facility. The results of the resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person center comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental, and psychosocial well-being. It continues, 5. Program Plan - A structured program designed to change a specific need/problem. The Program Plan consists of, at minimum: a. Statement of the targeted problem/need. b. Goal stating the expected outcome of the reduction of the targeting problem. C. Interventions/Approaches aimed at reducing the causative factors of the targeted problem. It continues, 9. The resident care plan may be kept electronically or in hard copy printed format. a. Problems, goals and interventions should include the date initiated for ease of reference. b. All intervention entries should include the date the care intervention was initiated by the staff as well as the date the intervention was added to the care plan if added after the original care plan date. The facility's Fall Prevention policy dated 11/10/18 documented it is the policy to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Responsibility: all staff. Procedure: 1. Conduct fall assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. It continues, 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (Certified Nurse Assistant) assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on observation, interview, and record review, the facility failed to ensure there was sufficient supervision to prevent falls and ensure care plan interventions were appropriately in place for 2 out of 3 (R28, R36) reviewed for falls in a sample of 31. This failure resulted in R28 being sent to local emergency room with an acute to subacute right lateral 9th rib fracture, subacute to acute right anterolateral 3rd rib fracture and also had multiple healed rib fractures from other falls. Findings include: 1. R28's Face Sheet, print date of 11/16/23 documents R28 has the following diagnose Type II diabetes mellitus with hyperglycemia, multiple fractures of ribs, Alzheimer's disease, dementia, Hypertension. R28's Minimum Data Set (MDS), dated [DATE], documents R28 is severely cognitively impaired and requires substantial/maximal assistance with transferring, oral hygiene, toileting hygiene, shower/bath, dressing, and personal hygiene, he is frequently incontinent of bladder, and always continent of bowel. R28's Care Plan, not dated, documents the resident has had an actual fall. Root cause may be related to (r/t) Cognitive Impairment- Does not understand limits, Cognitive Impairment- unaware of safety needs, poor Balance, and unsteady gait. Interventions include but are not limited to for no apparent acute injury, determine and address causative factors of the fall, Major injury- Pressure alarm under buttocks and under torso while in bed, and Major injury- signage posted in room to use call light for assist. R28's Physician's Orders, dated 05/10/23, documents pressure pad alarm at all times. R28's Incident Audit Report, dated 10/06/23 at 5:38 AM, documents R28 had an unwitnessed fall. He was found face down on the floor beside his bed. R28 attempted to get up to the bathroom without calling for assistance. He had a hematoma noted to the top of his scalp. It further documents in the notes section root cause of this fall noted to be resident attempting to get out of bed to toilet self without assistance. Resident had shut off pressure alarm. Intervention is to place a pressure alarm under resident's bottom and another under his torso. R28's Progress Notes, dated 10/06/23 at 8:57 AM, documents the writer received in report R28 had and unwitnessed fall in his bedroom. He was found in the prone position attempting to roll over and get his self-up. He was noted to have a hematoma on his forehead above his left eye and he complained of pain and discomfort to his right arm/shoulder when the writer was assessing and doing range of motion. Neuro checks were in place due to it being an unwitnessed fall. His blood pressure at 6:25 AM was 158/101 and his pulse was 98. He was able to recall the fall to writer without difficulty he agreed to be sent out to the local hospital to be evaluated and treated, and doctor and his power of attorney was notified. R28's Hospital Report, dated 10/06/23 at 9:24 AM, documents Computed Tomography (CT) scan report impression: Acute to subacute right lateral 9th rib fracture. Subacute to acute right anterolateral 3rd rib fracture. Multiple healed rib fractures. On 11/14/23 at 1:43 PM, R28 is up and in his wheelchair. Tab alarm noted to be attached to the back of his shirt. No pressure pad alarm noted in his wheelchair. On 11/15/23 at 1:20 PM, R28 is lying in bed with his eyes open. Fall mat beside his bed, bed in low position, there was a tab alarm observed hooked to his shirt and the other end lying in his bed. There were no pressure pad alarms observed by this surveyor. On 11/15/23 at 1:22 PM, this surveyor went and asked V2 (Director of Nursing/DON) if R28 was supposed to have pressure pad alarms under him while he was in bed and she stated, yes. This surveyor asked V2 if she could please come down to R28's room. This surveyor and V2 went down to R28's room and V2 checked under R28 to see if he had pressure pad alarms under him and there wasn't any noted at this time. On 11/15/23 at 1:24 PM, V2 stated she would expect for the pressure pad alarms to be placed under R28 when he was in bed. On 11/16/23 at 10:00 AM, V4 (MDS Coordinator) stated they discontinued R28's tab alarm on 06/28/23, due to him taking it off and carrying it and then they ordered him the one pressure pad alarm. She said after the fall on 10/06/23, is when they ordered the second pressure pad alarm for him. V4 stated R28 should not have a tab alarm on. On 11/16/23 at 10:05 AM, this surveyor and V4 went down to R28's room together. R28 was observed to be sitting up in his wheelchair with a tab alarm placed on the back of his wheelchair and hooked to the back of his shirt. There was no pressure pad alarm noted to be under him at this time. V4 stated R28 should have a pressure pad alarm placed in his wheelchair and she said they are supposed to put it on R28 every time they change his position. On 11/16/23 at 10:35 AM, V4 stated she was just made aware the pressure pad alarms are broken and will be fixed and here within the next couple of hours. She said until the new/fixed pads get here they are using the pull tab alarm and doing 15-minute visual checks on R28. She said she isn't sure how long the pressure pad alarms have been broken she was just made aware of it today when she questioned staff about them. She said she would expect the Certified Nursing Assistants (CNAs) to notify the nurses and the nurses to notify management about the pressure alarms being broken so they could rectify the situation. 49494 2. R36's face sheet documents that R36 was admitted to the facility on [DATE] with a diagnosis of right hip fracture, C5 compression fracture and L1 compression fracture resulting from a fall at home. R36's other medical diagnosis includes Unspecified Dementia, Anxiety Disorder, Major Depressive Disorder, Hypertension, and Hyperlipidemia. R36's Minimum Data Set (MDS), dated [DATE], documents R36 is severely cognitively impaired and is totally dependent on at least two staff members for bed mobility and transfers. The facilities incidents by incident type report, dated 11/13/2023, documents R36 has had a fall on 7/21/2023, 9/4/2023, 9/13/2023, 9/14/2023, and 10/19/2023. R36's Care Plan, dated 7/5/2023, documents the resident has had an actual fall. The root cause may be related to cognitive impairments as she does not understand limits, unaware of safety needs, poor balance, poor communication/comprehension and has an unsteady gait. Interventions: bed to be in low position, fall mat placed beside bed, bed against wall, foam positioning aids on both sides, staff educated on safe resident positioning, and continue interventions on the at-risk plan. R36's progress notes dated 7/21/2023 at 9:28 AM, documents, during breakfast resident rolled out of bed, no injuries from fall, and the right hip incision had nothing to do with the fall. The facility Incident Audit Report, dated 7/21/1023, documents the root cause of this fall was resident was not positioned in the center of the bed and rolled off edge of bed into floor. Intervention is staff education of safe positioning of residents. R36's progress notes, dated 9/4/2023, documents on doing rounds, CNAs found resident on the floor beside her bed, lying on her left side, head was rested up against bedside table and bleeding noted from right ear. Ambulance was called and resident was transported to the local emergency room . R36's ear injury was treated with medical glue and R36 returned to the facility. The facility Incident Audit Report, dated 9/4/23, documents the root cause of this fall was resident fell out of bed. Intervention is a fall mat on floor beside bed. Bed also to be in lowest position. R36's progress notes dated 9/13/2023 at 8:20 PM, documents resident noted on floor in her room. Laying on left side beside bed. Clothes and linens saturated with urine. Bed not in low position. Floor mat not in place. Small skin tear to left elbow. Cleansed and band aid applied. Resident assisted back to bed and care given. The facility Incident Audit Report, dated 9/14/2023, documents R36's bed was not in low position, floor mat was not in place and R36 was saturated with urine. Root cause of this fall was resident rolled out of bed. Intervention is foam positioning aids on each side of resident's bed while resident is in bed. R36's progress notes dated 9/14/2023, documents resident was on the floor next to her bed, nurse checked resident over, she was fine and voiced no complaints of pain. Fall was unwitnessed. The facility Incident Audit Report, dated 9/14/2023, documents the root cause of R36's fall was resident rolled out of bed. Mattress changed to better fit foam positioning aids. R36's progress notes dated 10/19/23 at 4:11 AM, resident found on the floor beside her bed face down and on right side. Noted to have a large goose egg above her right eye and facial bruising noted. The floor mat was on the opposite side of the bed and the foam positioning aid was slid off the bed on the floor also. The facility Incident Audit Report, dated 10/19/2023, documents the root cause of R36's fall was that resident rolled out of bed. Intervention will be a bolstered mattress. R36's fall risk assessment, dated 8/10/2023, documents R36 was high risk for falls with a score of 13. A score of 10 or more equals high risk. On 11/13/2023 at 9:10 AM, R36 was observed to have light blue/green bruising to the right side of her face near the temporal region. V12 stated the bruising was from a previous fall. On 11/14/2023 at 6:21 PM V10 (Licensed Practical Nurse) stated she (R36) did not have her bed in low position and her mat was not on the floor when she fell on [DATE]. On 11/15/2023 at 1:40 PM V2 (Director of Nursing) stated she would expect fall interventions to be in place according to the care plan. The Facility's Fall Prevention Policy, dated 11/10/18, documents To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. 1. Conduct Fall Assessments on the day of admission, quarterly, and with a change in condition. 2. Identify, on admission, the resident's risk for falls. All staff must observe residents for safety. If residents with a high-risk code are observed up or getting up, help must be summoned, or assistance must be provided to the resident. 3. Assessments of Fall Risk will be completed by the admission nurse at the time of admission. Appropriate interventions will be implemented for residents determined to be at high risk at the time of admission for up to 72 hours. 5. Immediately after any resident fall, the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. 6. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new interventions deemed to be appropriate at the time. The unit nurse will also place any new interventions on the CNA assignment worksheet. 7. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on interview and record review, the facility failed to ensure timely treatment for a change in condition for 1 of 3 residents (R2) reviewed for quality of care in the sample of 6. This failure resulted in a delay in treatment for left femur fracture around a previous left knee replacement. Findings include: 1. R2's Fall Risk Assessment, dated, 4/27/23 prior to fall incident date of 5/10/23, documented R2 was at High Risk for falls. R2's Minimum Data Set, dated dated , 4/27/23, documented mild impaired mental cognition. R2's Nurse's Notes, dated 5/10/23 (Wednesday) at 9:00PM, documents, resident lowered to floor in sit to stand (partial mechanical lift for transfers), no apparent injury. R2's Quality Care Reporting Form, dated 5/10/23 at 9:00PM, documented R2's fall location was in R2's room and reported by V7 (Certified Nurse Assistant/CNA) to V13 (Licensed Practical Nurse/LPN), with pain located to the left leg and knee with slight bruising to left knee. Physician notified on a date of 5/12/23. R2's Investigation Report for Falls, undated, documented R2 was transferred from a shower chair to bed using a partial standing mechanical lift (sit to stand), the lift belt buckle was not secure and R2 was barefoot after returning from a shower during the transfer. R2's Nurse's Note, dated 5/11/23 (Thursday) at 1:30AM, documents, resident c/o (complained of) left leg pain. Light bruising noted to left knee. Res (resident) yelling out in pain when left leg straightens. R2's Fax Transmittal Form to V14 (R2's physician), dated 5/11/23 at 1:19 PM, documents (R2) had to be lowered to the ground from the sit to stand machine and is c/o left knee and left leg pain-can we get an X-ray (radiology imagining)? with V14 documenting OK with a stamp date of 5/12/23 when re-faxed back to the facility. Also, a handwritten note from unknown nurse, documents, Xray needs scheduled Sat AM (Saturday morning-5/13/23). R2's Nurse's Note, documented by V6 (LPN), dated 5/13/23 (Saturday) at 8:00 AM, documented Xray scheduled for left knee and leg and residents was yelling out before breakfast. R2's Nurse's Note, dated 5/13/23 at 6:00 PM, documented R2 yells out in pain at times when moved or touched, outside Xray company is scheduled to come for Xray of left lower extremity. R2's Nurse's Note, dated 5/13/23 at 10:30 PM, documented, outside Xray company arrived at the facility to perform the Xray. R2's Radiology Report, for date of service 5/13/23 and faxed 5/14/23 at 01:?? AM (time cut off), documents, left knee replacement is identified. A fracture is noted involving the distal femur (lower part of thigh). The posterior lateral (back of knee on the outer side) displacement of fracture fragment is noted. R2's Nurse's Note, dated 5/13/23 [sic] at 2:30AM, documented report received of a left fracture of distal femur and faxed to the physician. R2's Nurse's Note, dated 5/14/23 at 6:30 AM, V6 documents, slight bruising to knee area noted. R2's Nurse's Note, dated 5/14/23 at 7:00 AM, documents, writer (V6) called Doctor, left message for the doctor to call the facility. At 7:05 AM, continues to document, V1 (Administrator) was made aware of Xray report. Nurse's Note continues to document at 8:15AM, a telephone physician order was received to send R2 to emergency department for evaluation and treatment and at 9:00 AM, R2 was transferred to Emergency Department. R2's Hospital consultation, dated 5/14/23 at 6:03PM, documented, left knee pain, Xray acute fracture of distal supracondylar femur around the femoral component of the replacement hardware acute comminuted fracture of the supracondylar distal fracture above the cemented femoral knee replacement. It also documents a preop assessment was done and R2 was cleared for surgical repair. On 5/18/23 at 1:50PM, V6 (LPN) stated she was scheduled to work on 5/13/23 (Saturday) morning at 6:00 AM, at 6:30 AM, had noticed a physician fax order for a Xray to be done, dated 5/11/23 on R2 which was located in a filing basket at the nursing station. V6 stated she went through R2's medical records Nurse's Notes and noticed R2 had a fall on 5/10/23 at 9:00PM and documentation on 5/11/23 early morning that R2 complained of left leg pain with bruising and no documentation on 5/12/23. V6 stated that she identified there was no treatment provided or if a nurse followed-up with the fax transmittal order that was submitted on 5/11/23 to V14 (Physician). V6 stated she notified V14 immediately at 8:00 AM, to receive an order that R2 receive a Stat (immediate) Xray due to visible bruising on the left knee and left inner thigh with decrease range of motion to that left leg. V6 continues to state, R2's Xray was not performed till 5/13/23 late at 10:30 PM, with results received on 5/14/23 around 1:00 AM in the morning that identified a fracture to the left femur and was not sent out for treatment till the morning of V6's shift at 8:00 AM. On 5/24/23 at 4:15 PM, V2 (Director of Nursing), stated the physician was notified on 5/11/23 for the Xray. V2 also stated this situation is subjective to the individual nurse. The facility's Notification for Change in Resident Condition or Status policy and procedure, dated 12/7/17, documents, The facility staff shall promptly notify physician of changes in the resident's medical/mental condition and/or status, further documents, a discovery of injuries, abnormal complaints of pain, a need to transfer the resident to a hospital/treatment center.

Based on observation, interview and record review, the facility failed to provide safe transfers for 2 of 3 residents (R2, R6) reviewed for falls in a sample of 6. This failure resulted in R2's fall during a transfer sustaining a left leg fracture requiring surgical repair. Findings include: 1. R2's Fall Risk Assessment, dated 4/27/23 prior to fall incident date of 5/10/23, documented R2 was at High Risk for falls. R2's Minimum Data Set (MDS), dated [DATE], documented mild impaired mental cognition. R2's Physical Therapist Progress and Discharge Summary, dated 2/18/22, documents, Discharge summary, patient progressed in muscle strength from start of care but was with limited progress due to poor safety with use of mechanical sit to stand Lift. Ultimately it was decided that patient is safer transferring with (full mechanical transfer lift) versus sit to stand (partial transfer lift) and CNAs (Certified Nurse Assistants) were instructed to continue to use (full mechanical transfer lift) with resident. R2's Physician Order Sheet (POS) dated 4/25/23, documented, may use (full mechanical lift) for transfers. R2's Nurse's Notes, dated 5/10/23 (Wednesday) at 9:00PM, documents, resident lowered to floor in sit to stand no apparent injury. R2's Investigation Report for Falls, undated, documented transfer from shower chair to bed using a standing mechanical lift, the lift belt buckle was not secure and R2 was barefoot after returning from a shower during the transfer. R2's Nurse's Note, dated 5/11/23 (Thursday) at 1:30AM, documents, resident c/o (complained of) left leg pain. Light bruising noted to left knee. Res (resident) yelling out in pain when left leg straightens. R2's Radiology Report, dated 5/13/23 and faxed 5/14/23 at 01:?? AM (time cut off), documents, left knee replacement is identified. A fracture is noted involving the distal (lower part of thigh) femur. The posterior lateral (back of knee on the outer side) displacement of fracture fragment is noted. R2's Hospital consultation, dated 5/14/23 at 6:03PM, documented left knee pain, Xray acute fracture of distal supracondylar femur around the femoral component of the replacement hardware acute comminuted fracture of the supracondylar distal fracture above the cemented femoral knee replacement. It also documents a preop assessment was done and R2 was cleared for surgical repair. R2's Care Plan, dated 1/13/22, documents, assist to transfer resident using mechanical device of (full mechanical lift device) and 2 staff members, and a revised handwritten, date of 1/25/23, documents, may use sit to stand for toileting and shower transfers, as needed. On 5/23/23 at 11:15AM, V8 (MDS Coordinator) stated the Interdisciplinary Team decided that R2 could use a Sit to Stand for transfers, as R2 requested the facility to use. V8 also stated there is no documented assessment of this change in R2's mode of transfer, however, R2 at times does well with a sit to stand but most the times she cannot. On 5/18/23 at 1:50PM, V6 (Licensed Practical Nurse/LPN), stated that R2 is not able to bear weight to her lower legs and requires the use of a full mechanical lift for all transfers. On 5/18/23 at 2:10PM, V7 (Certified Nurse Assistant/CNA), stated R2 had received a shower and was brought back to her room to be placed in bed, using a sit to stand. At this time, R2 was at the edge of the shower chair when being raised with sit to stand and her legs became weak and was lowered down to the floor with the sit to stand. On 5/23/23 at 1:40PM, V9, V10, and V11 (all CNAs) stated that R2 cannot stand, both of her feet are bowed outward, she cannot straighten her feet, she cannot bear weight with her legs, R2 requires a full mechanical lift for transfer. On 5/23/23 at 11:00AM, R2 was lying in bed, the left leg was propped up on a pillow with the leg wrapped in a support brace with dressings. R2's left and right feet were angled out away from her body and was unable to straighten her feet. On 5/23/23 at 4:20PM, V1 stated, so a re-assessment of R2's transfer status needs to be completed. 2. R6's POS, dated 4/27/23, documented high back wheelchair, may use (full mechanical transfer lift) as needed. R6's Care Plan dated 05/3/23 documented, dependent with transfer using (full mechanical transfer lift) and 2 staff members. On 5/23/23 at 2:38PM, V7 and V15 (CNAs) transferred R6, from the bed using a full mechanical lift. During the transfer, R6's bed was not locked and R6's high back wheelchair also was not locked when R6 was being lowered into the chair. The facility's Full Mechanical Lift Operating Instructions, dated 7/2014, documented to lift the patient while in bed, ensure the bed brakes are in locked position and lowered into a wheeled chair, ensure the chair wheels are locked. The facility's Fall Prevention policy and procedure, dated 11/18, documented, to provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility.

Based on interview, observation and record review, the facility failed to provide supervision, investigate falls thoroughly to develop a root cause and analysis and implement progressive interventions to prevent falls for 2 of 5 residents (R1, R31) reviewed for falls. This failure resulted with R1 dislocating his shoulder multiple times, receiving 2 staples for a [CONDITION(S)] and hematomas. Findings include: 1. R1's Admission Profile, undated, documents R1 was admitted on [DATE]. R1's September 2022 Physician Orders documents that R1 has diagnoses of Depression, Anxiety, and unspecified neuro cognitive disorder. R1's Minimum Data Set (MDS), dated [DATE], documents that R1 has moderately impaired cognition and is totally dependent on one staff member for locomotion on the unit using a wheelchair. R1's Care Plan, with start date of 2/18/22 documents Resident has risk factors that require monitoring and intervention to reduce potential for self-injury. (Consider medical conditions, sensory altercations, balance, gait, assistive devices, cognition, mood/behavior, safety awareness, compliance, medication, restrictions, restraints. Risk factors include poor safety awareness, dementia, agitation, anxiety, weakness as evidence by related diagnoses/ condition/history. R1's Goal for this problem documents Resident will follow safety suggestions and limitations with supervision and verbal reminders for better control of risk factors thru next 90 days. The following are R1's Care Plan Approaches/Interventions all dated 2/18/22: Review quarterly and prn (as needed) resident's ADL (activities of daily living), mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary team) review of changes and needs with Resident and/or responsible party (when choose to attend) during care plan. Discuss fall related (information to review and revise plan as needed; Review quarterly and as needed during daily care and services of resident's plan for safety, giving verbal cues as needed to gain resident participation in minimizing risk factor and injury, encourage and assist placement of proper non-skin footwear; Attempt to anticipate needs-toileting, hydration, hunger and provide care before resident attempt to fulfill on own; observe for unsteady/unsafe transfer or ambulation and provide stand by or balance support as needed; Fall risk assessment quarterly and as needed with change in condition or falls status; IDTG review of ADL status and fall potential changes in condition or fall status. Report significant finding to MD for follow up; Monitor for changes in condition such as appetite, sleep patterns, balance, ADL assist level, swelling, muscle weakness, less socialization. Report to nurse for follow up assessment and MD notification. An intervention, dated 2/11/22 documents Low bed. R1's Nurse's Note, dated 4/4/22 at 11:30 PM, documents, Res (Resident) fell in living room with injuries noted to Lt (left) temporal area and shoulder deformity. Sent to ER (emergency room ). R1's Nurse's Note, dated 4/4/22 at 12:45 PM, documents, Res returned from ER (emergency room ) with dx (diagnosis) of Anterior Dislocated of L shoulder, contusion to face, COVID 19, Broken collarbone. R1's emergency room documentation, dated 4/4/22, documents, Assessment/Plan: 1. Anterior dislocation of left shoulder. 2. Clavicle fracture. 3 Head contusion. 4. Neck Strain. Procedure: Attempted to reduce left shoulder dislocation multiple times without any success. Transfer to (regional) hospital. On 9/15/22 at 1:48 PM, surveyors were unable to view the fall investigations independently. At that time, V2 Regional Nurse, reviewed the investigation from 4/4/22 with the surveyor and stated, (R1) got up from his recliner. He had fallen asleep, and the aide went to clean the dining room. (R1's) alarm sounded and by the time the aide got to him he was on the floor. The emergency room could not do a closed reduction. He came back with both of his arms in a sling and a follow up appointment to the orthopedic doctor. (R1's) investigation showed that he woke up and was disorientated and tried to self-transfer and he fell . (R1's) new intervention was to not leave (R1) asleep in the lounge unattended. R1's Care Plan was reviewed and there was no documentation that this intervention was implemented to prevent R1 from future falls. R1's Nurse's Note, dated 4/5/22 at 1:30 PM, documents, Res is alert with confusion noted. Res constantly trying to get up on his own. R1's Nurse's Note, dated 4/5/22 at 7:30 PM, documents, Res (resident) observed on floor in room 121. Res laying on abdomen with arms outstretched and legs outstretched. Res noted to have large s/t (skin tear) to lt (left) arm probably from ER (emergency room ) visit from previous night. Res has laceration on Rt (right) brow with some slow to respond answers to questions. Res appears to be confused beyond his norm (normal). sent out to ER. R1's ED (Emergency Department) Physician note, dated 4/5/22, documents, History of Present Illness: [AGE] year-old man with a history of dementia brought to the emergency department after a fall in which he injured his head and his left shoulder per EMS (Emergency Medical Services). Witnessed fall from a standing position. No loss of consciousness. Patient was seen yesterday for a similar presentation and found to have a right clavicle fracture, left anterior shoulder dislocation and scalp contusions. Transferred to (regional) hospital for shoulder dislocation after several unsuccessful attempts were made here. There were abrasions and contusions on his face and forehead on the right last night. There are 2 new contusions today. R1's Nurses Note, dated 4/6/22 at 2:30 AM, documents, Res returned to via transport. Orders to see ortho r/t dislocation of lt. (left) shoulder from fall on 4/4/22. On 9/19/22 at 11:00 AM, V2, stated that she was unaware of this fall. There was no fall investigation for the fall on 4/5/22 for review. R1's Care Plan was not revised after this fall on 4/5/22, with progressive interventions to prevent him from future falls. R1's Nurse's Note, dated 4/27/22 at 8:00 PM, documents, Res fell in LR (living room) with gash to Rt side of head. Unable to assess fully r/t (related to) sending res out with head trauma. R1's Nurses Note, dated 4/27/22 at 10:00 PM, documents, ER called and sending res back res has 2 staples to Rt (right) side of head no other injuries. R1's ED (Emergency Department), dated 4/27/22, documents, Procedure: Scalp laceration right forehead 2 cm (centimeter) x (by) 0.5 cm no active bleeding local [MEDICATION(S)] 1% 5 cc (cubic centimeters) stapled with 2 closed the wound. On 9/15/22 at 2:15 PM, V2, reviewed the investigation and stated that R1 was resting in the recliner. V2 stated R1 tried to stand, and he fell . V2 stated that the new fall intervention is to always wear shoes because he only had on gripper socks. R1's Care Plan was not revised after this fall to prevent R1 from future falls. R1's Nurse's Note, dated 4/29/22 at 2330, documents, Resident was in low bed, alarm on alarm was sounding, resident on floor by bed. hematoma above L eye noted. On 9/19/22 at 11:55 AM, V2, Regional Nurse, stated, (R1) got out of bed and bumped head on foreign object. (R1's) intervention is to ensure to continue use of low bed. R1's Nurse's Note, dated 5/2/22 at 12:25 PM, Resident in w/c (wheelchair) in dining area. Resident attempted to stand out of w/c and fell to floor on L side. Hitting left side of head on floor 3 x 2 cm (centimeter) s/t noted to LFA (left forearm). Cleansed with (wound cleanser) dry dressing applied scant amount of serosanguinous drainage noted to L forehead. On 9/15/22 at 2:35 PM, V2, stated, (R1's) root cause for the fall on 5/2/22 was he attempted to self-transfer and 15-minute checks were initiated. R1's Care Plan was not revised after his fall on 5/2/22 with progressive interventions to prevent him from future falls. R1's MDS, dated [DATE], documents, R1 is moderately cognitively impaired and requires supervision of 1 staff member for ambulation and transfers. R1's Nurse's Note, dated 8/12/22 at 12:35 AM, documents, Writer called to resident room. Res is sitting in floor 1 cm skin tear noted to R elbow unable to reapproximate. area cleansed with (wound cleanser) steri-strips applied, thumb swollen and purple in color. Res c/o (complaint of) pain to Left finger and LFA, unable to perform pronation / supination to L arm. no other injuries apparent. Res sitting in chair at this time. R1's Nurses Note, dated 8/12/22 at 11:45 AM, Res returned to facility per facility van. L shoulder back in place. L thumb severely fractured and L pinky fx. (fracture) Splint in place to L hand and arm and ace wrap. R1's Hospital Emergency Department Discharge Instruction, dated 8/12/22, documents, Diagnosis: 1. Anterior dislocation of left shoulder. 2. Fracture of fifth metacarpal bone of left hand. On 9/15/22 at 2:36 PM, V2, stated, On 8/12/22 (R1) was found on the floor at 12:35 AM, just prior to this he was walking in the hallway to go back to his room. He stated that he got his foot caught on an extra cover and he fell . The new intervention for this fall is to ensure that blankets are not touching the ground and extra blankets are taken off the bed. On 9/19/22 at 12:15 PM, V20, Medical Director, was questioned about all R1's falls. V20 stated, It is obvious (R1) should be on one to ones (supervision). The facility made me aware of all of the fractures, but I was never made aware of the big picture that he had fallen that many times. On 9/19/22 at 3:10 PM, V8, Licensed Practical Nurse, stated, I am not sure what was going on with (R1) when he kept falling. They were using a wheelchair for him, and he just kept standing up and trying to walk. He then went out to (Behavioral Health) and when he came back, they just let him walk and he has been doing better. 2. R31's Admission Sheet documented R31 was admitted to the facility on [DATE]. R31's Nurse's Note documented Res (Resident) arrived @ (at) facility per facility van into room (Room #)-see assessment. R31's Nursing Admission Assessment, dated 6/2/22, documented R31's admitting diagnosis was brain hemorrhage. R31's Fall risk assessment, dated 06/02/2022, documented that she was a high risk for falls. R31's Baseline Care Plan, dated 06/02/2022, documented, High Risk Fall Assessment, Poor Safety awareness, Fall history and 15 (minute check). R31's 15 Minute Observation checklist, dated 06/02/2022 from 5:30 PM until 7:30 PM, documented that R31 was in her room, sitting in a chair and was anxious. No interventions for R31's anxiousness was documented. There was nothing in R31's Nurse's Notes regarding R31s anxious behaviors and what staff were doing to address her anxious behaviors while she was alone in her room. R31's Nurse's Note, dated 06/02/2022 at 7:30 PM, documented, (Resident) attempted to get up (without) assistance (and) was alerted to staff per call light. Staff found her on the floor (at) foot of bed, sitting on bottom. Top of head was rested up against the foot board, blood all over head (and) hands. (Small) pool of blood on the floor (and) (resident) states I fell headfirst. Able to answer all nurses questions correctly but due to recent bleeding in brain (resident) will be sent to (local hospital emergency room ) for (evaluation) (and) (treatment). Administrator and (V18, Care Plan and MDS) aware. (Power of Attorney) (phone number) is not in chart. (Regional Hospital) was called (and) they would not give nurse any (information). (Administration) notified. R31's Investigation Report for falls, dated 06/02/2022, documented that she was seen at 7:25 PM and that she had a tab alarm in place. On 09/15/2022 at 02:10 PM, V2, Regional Nurse stated that R31's tab alarm was not sounding because it was in her hand when she fell . Report sent to the Illinois Department of Public Health, dated 06/09/2022, documented, .Tabs monitor was in resident's right hand. R31's Minimum Data Set (MDS), dated [DATE], documented that R31 required extensive assistance with transferring, frequently incontinent of bladder and occasionally incontinent of her bowels. R31's History of Present Illness from Trauma Center, dated 06/03/2022, documented, (R31) is a [AGE] year old female brought in by (Emergency Medical Service), ground transfer from outlying facility and was in cervical collar and boarded on presentation. The patient was involved in a fall from standing. Per report, (R31) was discharged earlier today after being admitted from 2/18 to 6/2/2022, patient was discharged to a nursing home. Patient was admitted for an intracranial hemorrhage, (Urinary Tract Infection) Hypertensive emergency, metabolic [CONDITION(S)], and A-fib who was on [MEDICATION(S)] which was stopped at time of discharge. Upon being discharged and admitted to the nursing home, patient was reported to be found lying on the floor on her back after an unwitnessed fall. It continues, At the (Outside Service Hospital), patient was reported confused and moaning. Imaging reported at the (Outside Service Hospital) found a C1-C2 fracture. Upon arrival to the trauma center, there was no (Outside Service Hospital) records to review. Patient is noted to have a small scalp laceration and surrounding hematoma. R31's Trauma CT Cervical Spine report, dated 06/03/2022, documented, Findings: Acute, mildly displaced type 3 fracture of the odontoid process. Mild dorsal subluxation of the lateral masses of C1 relative to C2. Moderate multilevel cervical spondylosis . It continues, Impression: Acute type 3 fracture of the odontoid process. On 09/14/2022 at 1:30 PM, V17, Assistant Director of Nurses (ADON), stated that when a resident falls, the nurses fill out the form and then the Interdisciplinary team (IDT) will meet and discuss the fall and then they will fill out the rest of Quality Care Reporting Form, the investigation. On 09/14/2022 at 2:00 PM V18, Minimum Data Set/Care Plan Coordinator, stated that R31 had a baseline care plan and it addressed her being a high risk for falls and that she should have been on 15-minute checks. On 09/15/2022 at 2:10PM, V2, Regional Nurse stated that she would expect the nurses and CNAs to do the 15-minute checks if it was on the care plan. She continued to state that the Investigation Report for Falls was an internal document, and that the facility would not give a copy to the state surveyor but was able to review the document. The Fall Prevention Policy, dated 11/10/18, documents, Policy: To provide for resident safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Procedure: 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. It continues, Report all falls during morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan.

Based on observation, interview and record review, the facility failed to provide nursing care/services and implement care in accordance with residents' plan of care to attain residents' highest practicable physical and psychosocial well-being for 7 of 13 residents (R1, R2, R3, R6, R7, R8, R12) reviewed for quality of care in the sample of 13. These failure resulted in an Immediate Jeopardy which was identified to have begun on 6/27/22 for numerous situations observed upon the arrival of the state agency as follows: When it was found the nursing staff failed to assess and monitor R8's peripherally inserted central catheter (PICC) line and provide care to prevent ongoing urinary tract infections, failed to provide incontinent care/service to prevent R3's non-pressure ulcer skin injury in accordance with R3's Plan of Care, when it was found R1, R2, R3, R6, R7, R8 and R12 did not receive supervision and timely care to prevent urinary tract infections, non-pressure related skin injuries and psychosocial harm. The facility failed to provide timely incontinent care/services for R1, R2, R6, R7 and R12 in accordance with their Plan of Care to prevent potential Urinary tract infections, incontinent related skin injury and psychosocial harm. Due to R1, R2, R3, R6's, R7, R8's and R12's vulnerabilities and comorbidities related to their diagnoses, this failure increased their likelihood for risk of decline to overall health and psychosocial harm. Using the reasonable person approach for R1, R6, R7, and R12 because these residents were unable to articulate/verbalize the impact of sitting in soiled incontinent briefs for extended periods of time, a reasonable person would have feelings of shame, embarrassment, humiliation, anxiety, hopelessness and dehumanization. The IJ was identified on 8/3/22. On 8/3/22 at 12:16 PM, V2, Assistant Administrator and V4, Minimum Data Set/Care Plan Coordinator were notified of the Immediate Jeopardy. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on 8/3/22 but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1. R8's Face Sheet, undated, documents R8 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/27/22 from 9:30 AM-1:30 PM, based on 15-20 minutes observation intervals, R8 was up in her wheelchair without being provided toileting, checks or incontinent care. At approximately 11:30 AM, R8 self-propelled and then staff assisted her to the dining room for lunch and then back to her room at approximately 12:15 PM where she remained until 1:20 PM. On 6/28/22 at 10:45 AM, R8 stated she needs assistance with toileting and has incontinent episodes at times because she goes frequently and has to wait for staff to change her. When asked about how waiting makes R8 feel, R8 stated I really don't like it. R8 states she has urinary tract infections frequently and has recently received antibiotics through a midline catheter, which was still intact in R8's upper left arm with a date of 6/13/22 on the dressing. R8 continued and stated she wanted her midline site removed but they don't have anyone who knows how to do it and pointing to her right upper arm midline access. R8 stated its itchy and she has been asking to get it removed and they say they don't have anyone to do it. R8's Care Plan, dated 1/5/22 documents Problem of alteration in bladder elimination as related to incontinent; approach/intervention of pad appropriately for dignity and comfort, toilet and/or change padding and give proper hygiene before/after meals, upon arising, upon request, before retiring for the evening, after napping and as needed. R8's Care Plan was not revised to address the voiding schedule that includes V19's orders/recommendation for waiting 30 seconds and void again to optimize bladder emptying. R8's Minimum Data Set (MDS), dated [DATE] documents R8 is cognitively intact and does not refuse care. The MDS documents R8 requires extensive assistance of one staff member for transferring, toileting, and personal hygiene. The MDS further documents R8 is occasionally incontinent of urine and has a current toileting program in place which has decreased wetness. The Facility's April 2022 Infection Control and Antimicrobial log documents R8 had a Urinary Tract Infection ([CONDITION(S)]) with organism of E. Coli and was treated with [MEDICATION(S)] twice daily from 4/18/22-4/29/22. R8's Infectious Disease Progress note dated 4/14/22 written by V19, R8's Infectious Disease Physician, documents: To reduce the risk of recurring urinary tract infections, both hydration and vaginal health are critical. The ability to flush the urinary tract depends upon adequate hydration and bladder emptying. The ability of the vagina to establish its own flora, with acidification, and resist contamination with bowel flora, protects periurethral areas. To accomplish this, (R8) needs to implement the following plan of care: Implement a voiding schedule to begin in the morning upon awakening, before lunch, before dinner and before bedtime (and otherwise as needed) to encourage flushing of the urinary tract as a defense mechanism to prevent urinary tract infections. Upon completion of voiding, wait 30 seconds and void again for optimize bladder emptying. Hydration as feasible given her medical history. Drink 6-8 glasses of water per day to encourage and flushing of the urinary tract. (R8) reports difficulty with frequent urination, leakage of urine and dysuria. Nursing Notes dated 6/6/22 documents R8 was found on floor of R8's bathroom holding right shoulder and stated, I fell trying to go potty. R8's Doctor here and ordered Xray of right shoulder/humorous. New order received for [MEDICATION(S)] (antibiotic) 1gram daily x 10 days for [CONDITION(S)]. R8 has been in bed all evening with low grade fever. The Facility's June 2022 Infection Control and Antimicrobial log documents R8 had a [CONDITION(S)] with organism of E. Coli and was treated with [MEDICATION(S)] (antibiotic) IV (intravenously) once daily for 10 days for 10 days from 6/6/22 - date resolved is blank. R8's June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Nurse's Notes dated 6/9/22 documents: ambulance service able to obtain IV access to left hand for antibiotic. R8's Nurse's Note, dated 6/10/22 documents ambulance service placed IV access on 6/9 after multiple failed attempts by nurses, current IV site infiltrated and attempted to restart IV and R8 stating she was in pain. The Nurse's Note documented staff contacted V19, Infectious Disease Physician, and scheduled midline placement. Contacted three area hospitals and were unable to place, instructed to call vascular surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Nurse's Note, 6/12/22 documents continue to complain of pain to IV sites. R8 complains of burning in peri (external) vaginal area. R8's Nurse's Note dated 6/13/22 documented placing Midline today at 1 PM. R8's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR further documents R8 only received one day of the ordered [MEDICATION(S)] 100mg and [MEDICATION(S)] until midline placed on 6/13/22. R8's Final Report of Midline Catheter insertion dated 6/13/22 documents: Your midline will need some care to keep it clean and working. This care includes changing the dressing, flushing the catheter with fluids and changing the cap on the end of the catheter. Homecare: change the dressing over the site as directed. This is usually once a week. Change it sooner if the dressing gets wet or soiled. Check the dressing daily. Sterile technique must be used for Midline dressing change. R8's June 2022 Treatment Administration Record (TAR) documents: 6/13/22 keep dressing on midline right upper arm dry and intact, check daily for signs and symptoms of infection. Change midline dressing once weekly on Mondays and as needed. Flush midline with 10cc (cubic centimeters) of saline every 12 hours that is crossed out and handwritten cannot do. The June 2022 TAR is blank and there is no documentation on the June TAR that R8 received any dressing changes or monitoring of her right upper arm midline site. R8's Current Bowel and Bladder assessment dated [DATE] documents R8 is continent, has dribbling and history of urinary tract infection. The assessment documents R8 would benefit from incontinent training program with no further instruction and restorative need and recommended interventions are left blank. R8's Nurse's Note, dated 6/22/22 document V19 will not be rechecking u/a (urinalysis) post antibiotic. Midline may be removed. On 6/28/22 at 9:29 AM, V6, Licensed Practical Nurse (LPN), stated R8 had an IV (intravenous catheter) that kept blowing and then she had to get a PICC (peripherally inserted central catheter). R8 stated We don't have an RN (Registered Nurse) here to do that, so they had someone coming from another facility, I guess. R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/28/22 at 11:00 AM, V3, LPN, stated she wasn't sure when R8's midline catheter would be discontinued or who would take it out since the facility did not have any RNs on staff. V3 stated she would work on it. On 6/29/22 at 9:15 AM, V3 stated R8 has chronic history of urinary tract infections and had Midline catheter inserted for antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated R8 sees infectious disease physician for her chronic UTIs. V3 stated R8 toilets frequently and facility tried a toileting program every 2 hours, but it didn't work because R8 toilets too frequently with her urgency and frequent requests to toilet. V3 stated R8 requires 1 assist to toilet and the expectation is to toilet R8 when she requests it. V3 stated R8 is at risk and prone to infection given her history of chronic UTIs. V3 stated R3 has suffered a fall self-transferring to the toilet because of her frequency and urgency. On 6/29/22 at 10:37AM, V2, Assistant Administrator, stated there is no RN coverage for 8 hours a day and there has not been a DON (Director of Nursing) for about the last 2 months. V2 stated to her knowledge they have enough staff, but she doesn't determine staffing needs, the Resident Care Coordinator handles the schedule. V2 stated they are not using agency and haven't requested agency. V2 stated she can't recall the last time a PICC/Midline catheter was in the facility-- not sure when one was in the building and couldn't give a time frame of when the last one was without looking. On 7/5/22 at 9:06 AM, V13, Medical Director, stated he expects residents who are incontinent or need toileting assistance to be done every 1-2 hours and as needed. V13 stated geriatric residents are at an increase for urinary tract infections when incontinent and are not provided care timely. V13 stated if any resident was sent out to the hospital or checked for urinary tract infection, they would most likely have it, but not everyone is treated and is based upon clinical presentation. V13 stated he could not comment on individual residents' clinical status without looking at their chart. V13 stated he wouldn't know if the facility was short staffed and stated they know to call him if needed. On 7/6/22 at 1:30 PM, V11, Certified Nursing Assistant (CNA), stated We try to take (R8) potty and try our best to keep her dry, but our staffing is just bad-we only have 1 CNA for 2-10PM today. V11 stated she was unaware if there was a toileting program for R8. 2. R3's Face Sheet documents R3 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS dated [DATE] documents R3 is cognitively intact and is mildly depressed and does not reject care. The MDS documents R3 requires total dependance of two staff members for bed mobility, transfer, and toileting. The MDS further documents R3 is frequently incontinent of bowel and bladder. R3's Braden Scare for Predicting Pressure Ulcer Risk dated 4/13/22 documents R3 is a high risk for pressure ulcers. The Assessment documents R3's Moistures as: very moist with linens must be changed at least once a shift and chairfast. R3's Bowel and Bladder assessment dated [DATE] documents R3 is incontinent both day and night, has dribbling with history of [CONDITION(S)] in the last 6 months. R3's restorative need is scheduled toileting. R3's June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS documents treatments to coccyx apply barrier cream twice daily, and abdominal/groin folds apply inter dry moisture-wicking fabric as needed. R3's Care Plan dated 9/29/21 documents R3 requires assist of 2 staff for mechanical device transfers and a focus area of: alteration in bladder elimination as related to incontinence with approaches/interventions of: pad appropriately for dignity and comfort, toilet and or change padding and give proper hygiene before/after meals, upon arising, upon request, before retiring for the evening after napping and PRN (as needed) for incontinence, apply house stock barrier cream with every incontinent care, report to nurse in charge for any skin conditions. R3's Care Plan further documents a focus area of: R3 may display alterations in psychosocial wellbeing, observe and report changes in behavior, psychosocial status or condition to nurse. Altered Mood state (anger/easily upset) potential for altered social reaction with approach/intervention of assess residents strength and positive coping skills and encourage resident to utilize them in present situation, encourage, invite and praise involvement in activities assist as necessary, encourage resident to vent feelings through active listening, validate feelings, restate comments to allow resident to hear and understand self-expressions, assess for changes in sleep patterns, appetite, mood interest in self-care and leisure activities- if resident is expressing anger with self or others, attempt to determine source of anger and encourage appropriate outlets for expression. Attempt to anticipate needs-toileting hydration, hunger and provide cares before Resident attempts to fulfill on his own, keep call light within reach at all times, answer promptly and notify resident help is on the way. On 6/27/22 at 10:15AM, R3 stated he is up in his wheelchair all day and would like to be laid down during the day. R3 stated at his previous facility he laid down twice a day and he liked that, but he doesn't lay down here. R3 stated he has an incontinent brief he goes to the bathroom in and doesn't get up to the toilet. R3 stated staff have to clean him up and states he had to wait 2-3 hours last week to get changed after he s*** my pants! R3 stated staff scrubbed him so hard and it hurt. R3 stated his skin is rubbed raw and he told staff to leave him some skin, but they said they had to get the poop off because it had been on so long. R3 stated it doesn't make him feel good when he s**** all over and it stings his skin because his skin is so raw and he sits in the wheelchair all day on the mechanical lift sling. On 6/27/22 from 8:30AM- 2:18 PM, based on 15-20-minute observation intervals, R3 was up in his wheelchair without being provided incontinent care or checks. At approximately 11:35 AM, R3 self-propelled his wheelchair to the dining room for lunch and then back to his room where he remained until staff laid him down. On 6/27/22 at 1:47 PM, R3 was sitting in his wheelchair in his room waiting to be laid down. V11, CNA, stated she had to wait on another staff member to get here so she could lay R3 down. At 2:18PM, V11, CNA, and V18, CNA, used a mechanical transfer to transfer R3 in bed and provided incontinent care to R3. V11 stated the facility had no clean washcloths so she grabbed a hand towel. R3 was heavily soaked with urine through his pants. R3 states I'm wet! My butts sore! Careful! R3's incontinent brief was heavily saturated with urine and smelled of strong odor. R3's scrotum, peri area and inner thighs and buttock had deep creases of heavy lines from where the mechanical lift sling had been in place all day. R3's peri area, scrotum, inner thighs and buttock were deep red, maroon in places that had a mushy, boggy appearance with maceration (occurs when the skin comes in contact with moisture for a long period of time). R3 grimaced when V11 and V18 wiped scrotum and groin. There was dark yellow residual on R3's hand towel that was used for incontinent care after cleaning R3's groin and scrotum. V11 and V18 did not continue to clean R3 after noting the yellow residual on R3's hand towel being used to clean R3. No barrier cream was applied to R3. On 6/27/22 at 2:25 PM, V11 confirmed that R3 had not been provided incontinent care all day and had urine soaked through his pants. V11 stated there are 2 staff members (V11 and V7, CNA) taking care of approximately 27 residents with 7 mechanical lifts. V11 stated it takes both to transfer residents and they do not have time during the day. V11 stated R3 gets changed in the morning and then again after lunch when they can get to R3. V11 states R3 is red and very sore and gets skin breakdowns. On 6/27/22 at 9:20 AM, V6 (LPN) stated the CNAs work really hard to try and make sure residents don't sit for over 3 hours. V6 stated residents don't get toileted or checked or changed (incontinent residents) until after lunch unless a resident asks. V6 stated residents have to stay in bed sometimes because they don't have enough staff to get them up, and mechanical lift transfer residents are the most often left in bed. On 6/27/22 at 8:25 PM, V14, LPN, stated she doesn't feel like there is enough staff. V14 visibly upset describing trying to provide care to residents without enough staff. V14 stated residents are sitting 3-4-5 hours soiled from being incontinent and are left in bed at times because there isn't enough staff to get them up. On 6/29/22 at 9:15 AM, V3, Resident Care Coordinator/LPN stated R3 does get gaulded (reddened and irritated) and has a barrier cream and that usually resolves it. V3 stated she would expect staff to keep R3 clean and dry to prevent skin breakdown and expect barrier cream to be applied. 3. On 6/27/22 with intermittent observations of approximately 15-20 minutes from 8:30AM- 2:18PM, R1 was up in his tilt back geriatric chair parked in front of the television without being provided incontinent care, checks, or repositioning. At approximately 11:45 AM, R1 was wheeled to the dining room for lunch and then back out to the television area at approximately 12:15 PM where he remained until 2:18 PM. R1 appeared anxious and was scooting back and forth in his chair without staff intervention. At 2:10 PM, V11, Certified Nurse's Assistant (CNA) stated R1 always tries to scoot in his chair and is fidgety. V11 stated R1 has not been laid down or provided incontinent care since breakfast. On 6/28/22 at 9:27 AM V8, CNA and V9, CNA transferred R1 by mechanical lift to R1's bed to provide incontinence care. R1's incontinent brief was saturated with urine and has heavy creases in R1's groin and buttock. V8 and V9 did not have Peri Wash, soap/cleanser or washcloths and provided peri-care with water only. R1's bilateral buttock area was both pinkish red and R1 had an open area to his right buttock. V8 and V9 did not dry R1 off upon completion of incontinent care or apply barrier cream. V8 said further stated sometimes they don't have enough washcloths, or towels to do complete peri care and she just forgot to get the towels and didn't dry (R1) off because she forgot the towel. V8 further stated they don't have enough staff here to do the care that needs done. V8 stated We have so many mechanical lifts like 8 lifts, that takes two people, and sometimes we've had to use only one staff to transfer a resident with a mechanical lift. R1's Current Face Sheet documents R1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS), dated [DATE], documents R1 has severe cognition impairments and does not resist care. The MDS documents R1 requires extensive assistance of 2 staff members for activities of daily living. The MDS further documents R1 is at risk of developing pressure ulcers and has one or more unhealed pressure ulcers. The MDS documents R1 is frequently incontinent of urine and occasionally incontinent of bowel. R1's Bowel and Bladder assessment dated [DATE] documents R1 is incontinent day and night and has history of urinary tract infections and is totally dependent to transfer to toilet. R1 would not benefit from an incontinence training program and no explanation or restorative need marked. R1's Care Plan dated 7/21/21 documents: Altercation in Bladder elimination as related to incontinence. Interventions: Toilet riser to assist with transfers on and off toilet. The Care Plan further documents R1 is morbidly obese and attempt to anticipate needs- toileting, hydration, hunger, and provider cares before R1 attempts to fulfill on own. Assist of 2 staff members for mechanical lift bearing assist and or mechanical device to place resident on toilet upon rising and at bedtime, after all meals and as tolerated. Place brief on when up, pad on bed, changed every 2 hours and as needed when repositioning. Assist resident with cleansing peri area after each incontinent episode. Barrier cream as needed upon cleansing (7/20/21). Assist to transfer resident using mechanical device and 2 staff members. Total assist of transfer on and off toilet (10/1/21). Unable to position self without assist of 2 staff. Scheduled repositioning program. Scheduled to be repositioned every 2 hours and as needed to maintain comfort, pressure reducing mattress on bed and pressure reducing cushion in chair when up. 4. R2's Face Sheet documents R2 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS dated [DATE] document R2 is mildly cognitively impaired and is mildly depressed and does not reject care. The MDS further documents R2 requires total dependance of two staff members for bed mobility, transfer, and toileting. R2's MDS documents R2 is always incontinent of bowel and bladder. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Current Braden Scare for Predicting Pressure Ulcer Risk dated 4/14/22 documents R2's Moistures (skin) as very moist with linens must be changed at least once a shift, and chairfast. R2's Current Bowel and Bladder assessment dated [DATE] documents R2 is frequently incontinent of both day and night, has dribbling and current medication of [MEDICATION(S)] (diuretic) which could affect the resident's continence status. The assessment documents R2 would not benefit from incontinent training program with no explanation of why not and restorative need not marked. R2's June 2022 POS documents R2 required [MEDICATION(S)] 20mg (diuretic, increases urination to reduce [CONDITION(S)]) once a day an activity: up as tolerated; may use mechanical lift for all transfers. R2's Care Plan dated 7/20/21 documents R2 is morbidly obese and attempt to anticipate needs- toileting, hydration, hunger and provider cares before R1 attempts to fulfill on own. Assist of 2 staff members for mechanical lift bearing assist and or mechanical device to place resident on toilet upon rising and at bedtime, after all meals and as tolerated. Place brief on when up, pad on bed, change every 2 hours and as needed when repositioning. Assist resident with cleansing peri area after each incontinent episode. Barrier cream as needed upon cleansing (7/20/21). Assist to transfer resident using mechanical device and 2 staff members. Total assist of transfer with transfer on and off toilet (10/1/21). On 6/27/22 at 10:05AM, R2 states she has to sit in her wheelchair all day and would like to lay down sometime through the day. On 6/27/22 from 8:30AM-1:00PM, based on 15-20 minutes observation intervals, R2 was up in her wheelchair without being provided incontinent care or checks. At approximately 11:40 AM, R2 was taken to the dining room for lunch and then back out to the television area at approximately 12:15PM where she remained until 1:00PM when staff laid R2 down. On 6/27/22 at 1:00PM, V7 and V11 transferred R2 to bed using a mechanical lift and provided incontinent care to R2. R2's incontinent brief was heavily saturated with yellow urine. V7 stated R2 is a heavy wetter. R2's buttock, peri area and groin were reddened and heavily creased in multiple areas from mechanical lift sling R2 was sitting on all day. V11 confirmed R2 was last changed around 8AM. On 6/27/22 at 1:15PM, V5, LPN stated R2 is a heavy wetter and needs changed frequently. On 6/28/22 at 10:45 AM, R2 was in TV room and was pleasant and smiling and engaged in conversation. R2 stated staff assist her with toileting and then added You know I have a diaper on and then was very reserved, looked down to floor and got quiet. When asked how it made her feel, R2 did not respond and continued looking down at the floor. R2 did not look up and was no longer smiling or engaged in conversation. On 7/6/22 at 6:30 PM, V23, CNA stated she was getting residents for bed and is the only CNA out here on main hall. At 7:18PM, V23 stated she's just waiting for help to put R2 to bed and stated, There's a lot of things I can't do until there is another person. V23 stated she is not going to lie, and she does transfer residents with a mechanical lift that requires two people by herself because she just can't wait on the other CNA on the unit to come help. The nurse is busy passing meds and doing what they need to do. V23 stated she knows it is not safe but sometimes she is the only one in the building and has to provide care to the residents. V23 stated there are 2 mechanical lifts on the locked unit and sit to stand transfer and its common practice to do it by yourself on evenings and nights. V23 stated it is not always feasible to have nurse to assist and they (facility) are running 2 CNAs on evening and nights daily and sometimes just 1 aide for the building and it has been happening for 1-2 months. V23 stated she works full time and does approximately 10 hours of overtime a week. At 7:47 PM, V3 had returned to the facility and was in street clothes of jean shorts and a t-shirt came to assist V23 with a mechanical lift transfer and V23 exclaimed Finally! R2 has been waiting for approximately 25 minutes for staff to transfer her to bed. 5. R7's Face Sheet documents R7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's MDS dated [DATE] document R7's cognition is cognitively intact and does not reject care. R7's MDS documents R7 requires total dependance of two staff members for bed mobility, transfer, and toileting and extensive assistance. The MDS documents R7 is frequently incontinent of bladder and is at risk of developing pressure ulcer/injuries with interventions of pressure reducing device for chair and bed, turning and repositioning program, application of ointments/medications. R7's Braden Scare for Predicting Pressure Ulcer Risk dated 4/19/22 documents R7's moistures: very moist with linens must be changed at least once a shift and is chairfast. R7's Bowel and Bladder assessment dated [DATE] documents R7 is incontinent both day and night. The Assessment documents R7 would not benefit from incontinent training but does not explain why. R7's June 2022 POS documents R7 requires [MEDICATION(S)] ([MEDICATION(S)]) 40mg daily, activity up as tolerated, assist as needed, may use mechanical lift for transfers; treatment: peri/groin folds, apply [MEDICATION(S)] (anti-fungal) twice daily as needed, apply barrier cream as needed. R7's June 2022 Treatment Administration Record documents affected area apply barrier cream as needed and is not marked as given for the month of June. The TAR further documents Peri/groin folds apply [MEDICATION(S)] twice daily as needed is not marked for the month of June. R7's Care Plan dated 1/13/2022 documents R7 requires assist of 2 staff for mechanical device: place brief on when up. Pad on bed, change every 2 hours and as needed when repositioning. Assist resident with cleansing peri area after each incontinent episode. Barrier cream as needed upon cleansing. The Care Plan further documents: Alteration in Bladder elimination, pad appropriately for dignity and comfort, toilet and or change padding and give proper hygiene before and after meals, upon arising upon request and before retiring for evening, after napping and as needed for incontinence; apply house stock incontinent barrier cream to peri area with every after incontinent episodes and as needed. Toilet/change when brief when wet and upon ring, at bedtime and after meals, maintain clean, dry wrinkle free linens. On 6/27/22 from 9:30AM- 1:55PM, based on 15-20 minute observation intervals, R7 was up in his wheelchair without being provided incontinent care or checks. At approximately 11:30 AM, R7 was wheeled to the dining room for lunch and then back to hallway at approximately 12:15 PM where she remained until 1:55PM when staff laid R7 down. On 6/27/22 at 1:55PM, V7 and V11, transferred R7 to bed using a mechanical lift and provided incontinence care to R7. R7's upper thighs had dry skin, and deep creases on buttocks and upper thighs where the mechanical lift sling had been all day. R7's incontinent brief was wet and a small light discolored area on R7's bilateral buttock of old pressure area was noted. V11 confirmed R7 got up around 9:30AM today and had not been provided incontinence care since before R7 had gotten up. On 7/6/22 at 8:10 PM, R7 was in bed watching a basketball game. R7 stated she did not want to be in bed and had been all day. R7 stated she was not ready to go to bed but states she had to and I guess that's just how it is. R7 stated she like to go to bed around midnight. 6. R6's Face sheet documents R6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's MDS dated [DATE] document R6 is moderately cognitively impaired and does not reject care. The MDS further documents R6 requires total dependance of two staff members for bed mobility, transfer, and toiletings. R6's MDS documents R6 is always incontinent of bowel and bladder. R6's Braden Scare for Predicting Pressure Ulcer Risk dated 4/11/22 documents R6's moisture as very moist with linens must be changed at least once a shift and is chairfast. R6's Bowel and Bladder assessment dated [DATE] documents R6 is incontinent both day and night. The assessment documents R6 would not benefit from incontinent training program with no explanation of why not and restorative need not marked. R6's Care Plan dated 7/21/2017 documents R6 has impaired cognition with approach to give resident adequ

Based on observation, interview and record review, the facility failed to provide treatments as ordered, and implement interventions including pressure relief and timely turning and repositioning to prevent pressure ulcers for 7 of 8 residents (R1, R2, R3, R6, R7, R8, and R12) reviewed for pressure ulcers in the sample of 13. This failure resulted in the deterioration of R1's left heel and buttock resulting in the need for multiple debridement. Findings include: 1. R1's Current Face Sheet documents R1 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Care Plan, dated 7/20/21, documents: (R1) unstageable pressure ulcer to left heel (2/20/22), stage 1 to bilateral buttocks (3/11/22), stage two right gluteal fold (3/28/22). Risk factors include Alzheimer's need for assist with bed mobility and transfer. Interventions: apply house stock incontinent barrier cream to peri area with after every incontinent episode. Turn and reposition every two hours and PRN (as needed). Dressing to left heel as ordered. (2/20/22, float heels while in bed. Dressings to bilateral buttocks per MD order. (3/11/22). Dressing as ordered to right gluteal fold (3/28/22). R1's Care Plan further documents R1 is morbidly obese and interventions to attempt to anticipate needs-toileting, hydration, hunger and provide cares before R1 attempts to fulfill on own. Assist of 2 staff members for mechanical lift bearing assist and or mechanical device to place resident on toilet upon rising and hs (hour of sleep) and after all meals as tolerated. Place brief on when up, pad on bed, change every 2 hours and as needed when repositioning. Assist resident with cleansing peri area after each incontinent episode. Barrier cream as needed upon cleansing (7/20/21). Assist to transfer resident using mechanical device and 2 staff members. Total assist of transfer with transfer on and off toilet (10/1/21). Unable to position self without assist of 2 staff. Scheduled repositioning program. Scheduled to be repositioned every 2 hours and as needed to maintain comfort, pressure reducing mattress on bed and pressure reducing cushion in chair when up. R1's Minimum Data Set (MDS) dated , 04/13/2022, documents R1 has severe cognition impairments and does not resist care. The MDS documents R1 requires extensive assistance of 2 staff members for activities of daily living (ADL). The MDS documents R1 is frequently incontinent of urine and occasionally incontinent of bowel. The MDS further documents R1 is at risk of developing pressure ulcers and has one or more unhealed pressure ulcers with interventions of pressure reducing device for chair and bed, turning and repositioning program, application of ointments/medications. R1's Bowel and Bladder assessment dated [DATE] documents R1 is incontinent day and night and has history of urinary tract infections and is totally dependent to transfer to toilet. R1's Braden Score for Predicting Pressure Ulcer dated 4/19/22 documents R1 does not have any unresolved pressure ulcers, and pressure ulcers in last 90 days is left blank. The Braden Score documents R1 requires pressure reducing mattress for bed and turning and positioning program. The Braden Assessment had no documentation that the following were needed: barrier cream/ointment, occasional moist, chair fast and pressure reducing cushion for chair is left blank. R1's Shower Sheets, dated 2/28/22 documented R1 had a sore on his heel that was not new. Interventions of briefs, float heels and turning and repositioning. On 6/27/22 with intermittent observations of approximately 15-20 minutes from 8:30AM through 2:18PM, R1 was up in his tilt back geriatric chair parked in front of the television without being provided incontinent care, checks, or repositioning. At approximately 11:45 AM, R1 was wheeled to the dining room for lunch and then back out to the television area at approximately 12:15PM where he remained until 2:18 PM. R1 appeared anxious and was scooting back and forth in his chair without staff intervention. V11, Certified Nurse Assistant, CNA, stated at 2:10 PM that R1 always tries to scoot in his chair and is fidgety. V11 stated R1 has not been laid down or provided incontinent care since breakfast. On 6/28/22 at 9:27 AM V8 and V9, CNAs, transferred R1 by mechanical lift to R1's bed to provide incontinence care. R1 did not have any pressure reducing device in his tilt back wheelchair. R1's incontinent brief was saturated with urine and had heavy creases in his groin and buttock. V8 and V9 did not have Peri Wash, soap/cleanser or washcloths and provided peri-care with water only. R1's bilateral buttock area was pinkish red and R1 had an opened pressure area to his right buttock. R1 did not have a dressing in place. V8 and V9 did not dry R1 off upon completion of incontinence care or apply barrier cream. V8 and V9 did not float R1's heels, apply heel protectors or offer hydration/fluids when care was completed. R1's heels were lying directly on the mattress. V8 stated at this time that the nurses put a patch on R1's open area. V8 stated she forgot to bring the barrier cream in the room with her, and doesn't have any in her pocket, where I usually keep it. V8 stated sometimes they don't have enough washcloths, or towels to do complete peri care and she didn't dry R1 off because she forgot the towels. V8 further stated they don't have enough staff here to do the care that needs done. V8 stated We have so many mechanical lifts (residents that require two assist with lift machine), like 8 lifts, that takes two people, and sometimes we've had to use only one staff to transfer a resident with a mechanical lift. On 6/29/22 at 11:00 AM, V6, Licensed Practical Nurse (LPN) provided wound treatment to (R1), with assistance of V11, CNA. R1's left heel pressure ulcer was open with red beefy tissue. V6 stated the pressure ulcer size was approximately 3 centimeters (cm) x (by) 2.5 cm and open and red. V6 further stated R1's left heel pressure ulcers has a brownish/black area within the left heel wound that is approximately 1.5 cm x 1 cm in size. V6 did not measure R1's left heel pressure ulcer but gave approximate size. R1's left ankle had a red area on the underside of the lateral malleolus (ankle). V6 stated R1's ankle is always pretty angry looking. V6 then cleansed R1's left heel with wound cleanser, applied collagen and an island dressing, wrapping with gauze. V6 then provided pressure ulcer treatment to R1's right buttock and cleansed with wound cleanser, applied calcium alginate with silver and Duoderm (provides a bacterial and [CONDITION(S)] barrier when the dressing remains intact and without leakage, adhesive dressing). V6 stated R1's right buttock was approximately 1.2 cm x 1 cm. R1's right buttock pressure ulcer was open with yellow slough and buttocks were reddened. At the completion of care, V6 and V11 did not apply heel protectors to R1. V11 stated at this time, that it's hard to find heel protectors because we don't have enough. R1's heels were laying directly on the mattress. R1's March 2022 Shower Sheets were reviewed. R1's Shower Sheet, dated 3/14/22 documents R1 had an old area on left heel. R1's Shower Sheet dated 3/16/22 documented R1 had opened sores on left heel and bottom of both butt cheeks which were not new. R1's Shower Sheet, dated 3/21/22, documented R1 had an opened sore on left heel not new, skin tear on right elbow not new, new blister on top of right foot not new, raw on top/side of right foot, with interventions of briefs, float heels, seat cushion and turning and repositioning. R1's Shower Sheet dated 3/23/22 documents area on heel. R1's Shower Sheet, dated 3/28/22, documents circled areas on coccyx, right buttock and right heel. R1's Shower Sheet, dated 3/31/22, documents raw spot on back of testicles. R1's Telephone Orders dated 3/11/22 document an order to apply Duoderm to areas to left and right buttocks and change every 72 hours and as needed. R1's March 2022 Treatment Administration Record (TAR) documents Duoderm to left and right buttocks and changed every 72 hours and as needed. The TAR was not signed off that R1 received treatment on 3/17 and 3/20/22. R1's Telephone Orders dated 3/17/22 document an order to apply collagen then calcium alginate with silver, cover with ABD (Abdominal dressing/Army Battle Dressing, sterile and absorbent dressing) and roll gauze but doesn't indicate what area to receive treatment. Heel protectors while in bed. R1's March 2022 TAR documents apply collagen then calcium alginate with silver cover with ABD (absorbent dressing) and roll gauze daily but doesn't indicate what area to receive treatment. Reviewed with V3 on 7/7/22 at 11:00AM and confirmed the order doesn't document where the treatment is indicated and V3 does not know what area was being treated with this order. R1's March 2022 TAR documents skin prep three times daily and as needed to right heel, float right heel and apply heel protectors while in bed and is not signed off as received on 3/30, 3/31. R1's March 2022 TAR documents daily skin checks that were done only on 5 days 3/1, 3/8, 3/15, 3/22, 3/29/22. R1's Nurse's Note, dated 03/28/22, documents, at 11:00AM Resident has new pressure area to right gluteal fold. Called (V12) Wound Physician, ordered apply calcium alginate and cover with island dressing daily (dressing applied to a wound to promote healing and also to prevent any further harm to the wound. The wound dressing is sterile, breathable and is considered most conducive for a moist healing) and PRN (as needed). Area 3 cm x 2 cm with slough (dead tissue separating from living tissue) noted to wound bed. Surrounding skin slightly red. (V12) Wound Physician will assess at next visit, family aware. R1's Telephone Orders dated, and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Reviewed order with V3 on 7/7/22 at 11:00AM and confirmed that the order did not get transcribed on to the April 2022 TAR. V3 Stated the April TAR would have been printed when the 3/28/22 order was written, and the nurses should have transcribed it on the TAR. V3 stated there is no documentation that R1 received this treatment. V3 confirmed there were no orders transcribed for R1's 3/28/22 order for April, May and June for right gluteal fold. V3 stated there is no documentation that R1 ever received this treatment. R1's April 2022 Shower Sheets were reviewed. R1's Shower Sheet, dated 4/4/22 document circled old area, coccyx, left heel, old area. R1's Shower Sheet, dated 4/7/22 documents left skin tear back of left elbow, open areas on bottom area and heel, bruising to arm. R1's Shower Sheet dated 4/11/22 documents area on heel (circled right heel), left arm sore on forearm and skin tear back elbow and 2 open areas on bottom. R1's Shower Sheet, dated 4/14/22 document no findings. R1's Shower Sheet, dated 4/18/22, documents area of right buttock circled and left heel old area. R1's Shower Sheet, dated 4/20/22, documents an open area on bottom, area on heel and red in abdominal fold, cream applied. R1's Shower Sheet, dated 4/25/22, documents circled areas on coccyx and left heel. R1's Shower Sheet, dated 4/28/22, documents no new findings. R1's Wound Physician (V12) notes dated 4/7/22 document: At the request of the referring provider, (V13, R1's Physician), a thorough wound care assessment and evaluation was performed today. (R1) has a stage 4 pressure wound to the left heel for at least 31 days duration with moderate serous exudate (drainage). Support surface: chair: pressure reduction cushion, feet: pillow. Appearance: Obese. Site #1: Stage 4 pressure wound of the heel full thickness: 4x5x0.4 with moderate serous exudate, 30% eschar, (A slough or piece of dead tissue that sheds off from the surface of the skin after an injury). 20% devitalized necrotic tissue, 20% slough, 30% granulation tissue: Wound progress: deteriorated. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing: gauze roll 4.5' apply once daily for 23 days, tape (retention) apply once daily for 23 days; abd (abdominal) pad apply once daily for 9 days. Recommendations: elevate legs; float heels in bed; offload wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; sponge boot. Site 1 surgical excisional debridement (procedure to remove debris or infected/dead tissue from a wound) procedure: indications for procedure-remove necrotic tissue and establish the margins of viable tissue. The indicated debridement was discussed with V13 on 3/6/22 and its necessity was mutually agreed upon. Procedure Note: Surgical excise 14 cm of devitalized tissue and necrotic tendinous and aponeurotic fibers (sheet of pearly-white fibrous tissue) the slough and biofilm were removed at a depth of 0.6 cm. The Wound Physicians Note further documents: Site #2: Stage 3 pressure wound of the right, inferior buttock full thickness: 4.2x3.9x0.2cm. with moderate serious exudate, 20% devitalized necrotic tissue, 20% slough, 60% granulation tissue. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing: gauze island with bdr (border) apply once daily for 30 days. Recommendations: elevate legs; float heels in bed; offload wound; reposition per facility protocol; turn side to side and front to back every 1-2 hours if able. Site 2 surgical excisional debridement procedure: indications for procedure- remove necrotic tissue and establish the margins of viable tissue. The indicated debridement was discussed with V13 on 4/7/22 and its necessity was mutually agreed upon. Procedure Note: Surgical excise 6.55cm of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissue with slough and biofilm at a depth of 0.3cm. Summarized Wound Care assessment and Individualized treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure: surgical excisional debridement was performed today on this wound. Site 2 stage 3 pressure wound of the right inferior buttock- initial evaluation full thickness. Procedure: surgical excisional debridement performed today on this wound. R1's Wound Physician notes dated 4/21/22 document: R1 has a stage 4 pressure wound to the left heel for at least 44 days duration with moderate serous exudate. Support surface: chair: pressure reduction cushion, feet: pillow. Appearance: obese. Site #1: Stage 4 pressure wound of the heel full thickness: 4x5x0.3 with moderate serous exudate, 20% slough, 70% granulation tissue: Wound progress: improved. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing: gauze roll 4.5' apply once daily for 9 days, tape (retention) apply once daily for 9 days; abd pad apply once daily for 30 days. Recommendations: elevate legs; float heels in bed; offload wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able; sponge boot. Site 1 surgical excisional debridement procedure: indications for procedure- remove necrotic tissue and establish the margins of viable tissue. Procedure Note: Surgical excise 6 cm of devitalized tissue including slough and biofilm and non-viable tendinous and aponeurotic fibers were removed at a depth of 0.4 cm. The Wound Physicians Note further documents: Site #2: Stage 3 pressure wound of the right, inferior buttock full thickness: 2.6x3.2x0.2 with moderate serious exudate, 20% slough, 80% granulation tissue. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary dressing: gauze island with bdr apply once daily for 16 days. Recommendations: elevate legs; float heels in bed; offload wound; reposition per facility protocol; turn side to side and front to back every 1-2 hours if able. Site 2 surgical excisional debridement procedure: indications for procedure- remove necrotic tissue and establish the margins of viable tissue. Procedure Note: Surgical excise 1.66 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.2. Summarized Wound Care assessment and Individualized treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Site 2 stage 3 pressure wound of the right inferior buttock; Procedure: surgical excisional debridement performed today on this wound. R1's Nurse's notes dated 4/23/22 at 10:20AM, documents R1 has new pressure area to right outer distal foot from where (R1) crosses his feet. Calcium alginate with silver and cover with island dressing daily per (V12) Wound Physician, family and appropriate staff aware. R1's Telephone Orders date 4/23/22 document apply calcium alginate with silver to right outer distal foot cover with border gauze daily. R1's April 2022 TAR documents apply collagen, thin calcium alginate with silver, abd, roll gauze and a brand name (self-adherent elastic wrap that functions like tape, but sticks only to itself), change daily to right heel with start date of 4/14/22. The treatment was not documented as completed on 4/22, 4/25, 4/26, 4/27, 4/28. 4/29, and 4/30/22. R1's April 2022 TAR continues to document a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR did not document R1 did receive this treatment on 4/25, 4/27, 4/28, 4/29 and 4/31/21. R1's TAR further documents apply collagen, then calcium alginate with silver ABD, roll gauze and self-adherent elastic wrap and change every day to right heel with a start date of 4/14/22. The TAR did not document R1 received the treatment on 4/22, 4/25, 4/26, 4/27, 4/28, and 4/29/22. R1's TAR documents collagen then calcium alginate silver cover with ABD and roll gauze daily to left heel. There are 8 days R1 did not receive treatment. The TAR further documents daily skin checks were not completed on 4/2, 4/3, 4/16, 4/22, 4/25, 4/27, 4/28, and 4/29/22 for both skin checks and left heel treatment. R1's April 2022 TAR documents float heels and apply heel protectors while in bed: on day shift there are 10 days not completed, on evenings shift: 11 days not completed, and on night shift: 26 times not completed. R1's May 2022 Shower Sheets were reviewed. R1's Shower Sheet, dated 5/2/22 documents old areas to coccyx and left heel. R1's Shower Sheet, Dated 5/5/22, documents area on buttocks and circled coccyx and area on right heel. R1's Shower Sheet, dated 5/9/22, documents areas on bottom, areas on heel. R1's Shower Sheet, dated 5/11/22, documents no new findings. R1's Shower Sheet, dated 5/16/22, documents left heel wound, right foot next to pinky toe wound, and 3 open spots on buttock, none are new. R1's Shower Sheet, dated 5/19/22, documents old area on coccyx, old area right heel. R1's Shower Sheet, dated 5/22/21, documents sores on heel and buttocks not new. R1's Shower Sheet, dated 5/25/22, documents no new findings. R1's Shower Sheet, dated 5/30/22, documents new skin tear on right knee, old open wound left heel and top of left foot. R1's Hospice admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's May 2022 TAR documents calcium alginate with silver to right outer distal foot, cover with bordered gauze daily. There are 6 days R1 did not receive treatment to right foot. R1's TAR further documents daily skin checks were not completed for 6 days. The TAR documents the ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Shower Sheets, dated 6/6/22 documents nothing new, 6/9/22 documents none, 6/13/22 documents no new findings, 6/17/22 is blank, 6/27/22 is blank. R1's June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS further documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's June 2022 TAR documents a treatment to the left heel, apply dry dressing daily until healed from 2/25/22. This order had previously been crossed out and had a handwritten order of collagen then calcium alginate with silver, cover with ABD and roll gauze daily written in. R1's Tar documents R1 did not receive treatment to left heel except for two days (6/1 and 6/4) in the month of June. R1's TAR further documents R1 did not receive a treatment to R1's right outer distal foot of calcium alginate silver and cover with border gauze daily for two days (6/1 and 6/4). The TAR also documents R1's daily skin checks were not done for the month of June with the exception of 2 days (6/1 and 6/4). On, 06/28/2022 at 1:41 PM V4, Licensed Practical Nurse, (LPN), MDS Coordinator, stated I don't see where the Treatment Assessment Record (TAR), has been documented for treatments, and a lot of holes. V4 stated, Looks like the ball got dropped on transferring orders to (TAR) for R1. V4 stated, R1 is now on Hospice Care, and Wound Physicians no longer see R1 for wounds because R1 was admitted to Hospice. V4 stated she thought hospice was going to see R1. V4 stated the last time R1 was seen was in April 2022. V4 stated it looks like an order changed in March but, I don't know to what, there is nothing on TAR. V4 said, if area heals or resolves, there should be an order to discontinue it and put on TAR. On 6/29/22 at 9:15AM, V13, R1's Medical Doctor/Medical Director, stated residents with wounds see the wound physician, that is their specialty. V13 stated he thinks he was aware that the wound physicians have not been coming to see residents since May, but unsure and the nurse can call him if needed. V13 stated he could not comment on individual residents without reviewing their individual records. On 06/30/2022 at 10:28 AM V12, Wound Physician stated via phone interview I haven't seen any residents at the facility for at least 5 weeks. V12 stated he retired and doesn't think anyone is doing wounds at the moment. V12 stated like anywhere else there is staff shortages in wound physician group and also the facility. V12 stated he would expect the facility to coordinate with the Primary physician of any resident with wounds to be contacted for orders or changes if they are not seeing wound physicians. R1's July 2022 shower sheet, dated 7/4/22 documents no new findings. On 7/5/2022 at 9:56AM V4, Licensed Practical Nurse/MDS Coordinator stated The TARs should not have new written orders without the old order being discontinued, then new order written in a new box on the TAR. On 7/5/22 at 10:30 AM V5, LPN stated, I made round's with (V12) when he was here. V5 stated V12 did the measuring when he was here. V5 stated V3 (LPN) is supposed to do the wound measurement when V12 isn't here to do measurements. V5 stated the last time V12 made rounds was probably a month ago or longer, not really sure when measurements were done, I can't say really. On 7/7/22 at 11:00 AM, V3 (Resident Care Coordinator/Licensed Practical Nurse, LPN), confirmed that the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 stated the dry dressing order from 2/25/22 is an old one that was never discontinued and replaced with the current order. V3 further stated it was just handwritten month to month and the nurses do that and they do not have any documentation that R1 received the right treatment or any treatment. V3 stated the wound physician had retired and R1 is now in hospice care, and think orders are from them. When asked how the nurses would know the correct treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 confirmed there were no orders transcribed for R1's 3/28/22 buttock treatment order for April, May and June 2022. R1's March 2022 Weekly Wound tracking documents as follows: Area 1: blank, Date onset: blank, Admit/Acquired: blank, date: 3/22, type: pressure, stage: blank, L (length) x (by) W (Width): 2 cm x 2 cm, drainage: minimal Area 2: blank, date: 3/28/22, type: Pressure, stage: blank, LxW: 3cmx2, drainage: none Area 3: blank, date: 3/11/22, type: pressure right buttock, LxW: 0.5x illegible, drainage: minimal Date: 3/11/22: type: pressure: left buttock, LxW 0.5 x illegible, drainage: minimal The March 2022 Weekly Wound tracking does not document where the pressure ulcers are located for area 1 or area 2. The March 2022 Weekly Wound tracking does not document when the pressure ulcer developed for area 1. R1's April 2022 Weekly Wound tracking documents as follows: Area 1: blank, date 4/7, type D left heel wound stage 4, LxW: 4x5x0.4, drainage: minimal, odor: yes Date: 4/21, typed left heel, stage 4, LxW: 4x5x0.3, drainage: minimal, odor: yes Area 2: blank, date: 4/21, type pressure right butt, stage 3, LxW 2.6x3.2x0.2 with tunnel time: 8.32, drainage: minimal, odor: yes Area 3: bank, dated 4/23, pressure right foot, stage: blank, LXW 2.0x illegible, drainage: minimal. The Weekly Wound tracking does not document what D stands for. R1's May 2022 Weekly Wound tracking document as follows: Area 1: left heel, date 5/12/22, type: pressure, stage 4, LxW: 3.9x4.8 x 0.3, drainage: minimal, odor: yes Date: 5/26/22, type: pressure, stage 4, LxW: 3.9x4.9x0.3, draining: minimal, odor: yes Area 2: R butt, date: blank, type: pressure, stage bank, LxW blank, drainage: bank, odor: blank. healed Area 3: R foot, date: blank, type: pressure, stage: blank, LXW blank, drainage: blank, odor: blank healed R1's June Weekly Wound tracking document as follows: Area 1: left heel, date 6/2/22, type: D, stage 4, LxW: 3.8x4 x 0.3, drainage: moderate, odor: yes Date: 6/09/22, type: D, stage 4, LxW: 3.8x4x3, drainage: moderate, odor: yes Date: 6/16/22, type: D, stage 4, LxW: 3.7x3.9, drainage: moderate, odor: yes Date: 6/23/22, type: D, stage 4, LxW: 3.8x3.9, drainage: moderate, odor: yes Date: 6/30/22, type: D, stage 4, LxW: 3.8x3.8, drainage: moderate, odor: yes Area 2: R outer distal foot, date: 6/2/22, type: pressure, stage 2, LxW: 0.5x1x0.1, drainage: moderate, odor: yes Date: 6/9/22, type: pressure, stage 2, LxW: 0.4x0.9x0.1, drainage: moderate, odor: yes Date: 6/16/22, type: pressure, stage 2, LxW: 0.4x0.9x0.1, drainage: moderate, odor: yes Date: 6/23/22, type: pressure, stage 2, LxW: 0.4x0.9x0.1, drainage: moderate, odor: yes Date: 6/30/22, type: pressure, stage 2, LxW: 0.4x0.9x0.1, drainage: moderate, odor: yes On 7/7/22 at 11:00 AM, V3 stated there is no documentation of any other assessments, measurements, or areas the facility was monitoring, and this is all they have. On 7/7/22 at 1:10 PM, V3 stated she did not know where R1's location of pressure ulcers are from the March 2022 Weekly wound log. V3 stated she did not know what the D stood for because she was not doing wounds and wasn't for sure if R1 was diabetic or not. V3 stated V20, LPN/Unit Coordinator was doing the wound logs in March. On 7/7/22 at 1:15 PM, V20, Licensed Practical Nurse, LPN, stated the D meant deteriorating on the April 2022. V20 stated she didn't think R1 was diabetic and marked D for deteriorating in the second legend at the bottom of the page. 2.R3's Face sheet documents R3 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS, dated [DATE], documents R3 is cognitively intact and is mildly depressed and does not reject care. The MDS documents R3 requires total dependance of two staff members for bed mobility, transfer, toiletings, and extensive assistance/physical help of 2 staff members for bathing. The MDS further documents R3 has impairments on upper and lower extremities, uses a wheelchair for mobility, is unable to ambulate and is frequently incontinent of bowel and bladder, at risk of developing pressure ulcer/injuries with interventions of pressure reducing device for chair and bed, turning and repositioning program, application of ointments/medications. R3's Braden Scare for Predicting Pressure Ulcer Risk dated 4/13/22 documents R3 is a high risk for pressure ulcers. The Assessment documents R3's skin as: very moist with linens must be changed at least once a shift and chairfast. R3's Bowel and Bladder Assessment, dated 4/14/22, documents R3 is incontinent both day and night, has dribbling with history of [CONDITION(S)] in the last 6 months. The Assessment document R3's restorative need is scheduled toileting. R3's June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS documents treatments to coccyx apply barrier cream twice daily, and abdominal/groin folds apply dry moisture-wicking fabric as needed. R3's Care Plan dated 9/29/21 documents R3 requires assist of 2 staff for mechanical device transfers and a focus area of: alteration in bladder elimination as related to incontinence with approaches/interventions pad appropriately for dignity and comfort, toilet and or change padding and give proper hygiene before/after meals, upon arising, upon request, before retiring for the evening after napping and PRN (as needed) for incontinence, apply house stock barrier cream with every incontinent care, report to nurse in charge for any skin conditions. R3's Care Plan further documents a focus area of: R3 may display alterations in psychosocial wellbeing, observe and report changes in behavior, psychosocial status or condition to nurse. Altered Mood state (anger/easily upset) potential for altered social reaction with approach/intervention of assess residents strength and positive coping skills and encourage resident to utilize them in present situation, encourage, invite and praise involvement in activities assist as necessary, encourage resident to vent feelings through active listening, validate feelings, restate comments to allow resident to hear and understand self-expressions, assess for changes in sleep patterns, appetite, mood interest in self-care and leisure activities- if resident is expressing anger with self or others, attempt to determine source of anger and encourage appropriate outlets for expression. Attempt to anticipate needs-toileting hydration, hunger and provide cares before Resident attempts to fulfill on his own, keep call light within reach at all times, answer promptly and notify resident help is on the way. R3's Care plan does not document actual skin impairments. R3's 6/24/22 Shower Sheet document a red open area on buttocks. On 6/27/22 at 10:15 AM, R3 stated he is up in his wheelchair all day and would like to be laid down during the day. R3 stated at his previous facility he laid down twice a day and he liked that, but he doesn't lay down here. R3 stated he has an incontinent in his brief and doesn't get up to the toilet. R3 states staff have to clean him up. R3 stated he had to wait 2-3 hours last week to get changed after he s*** my pants! R3 stated staff scrubbed him so hard and it hur

Based on observation, interview and record review 1) the facility failed to provide supervision to prevent resident to resident incidents for 9 of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, R10) reviewed for incidents in the sample of 10. 2) the facility failed to provide supervision to prevent elopement (exit seeking behaviors) for 1 resident (R9) reviewed for elopement in the sample of 10. This failure resulted in a resident to resident altercation in which R3 attacked R2 in her own room. R2 sustained bruises and scratches from R3, is now fearful of further attacks by R3, has withdrawn to her room and will only come out with staff escort. Findings include: 1. On 8/17/2021 at 9:10 AM, R2 who is a [AGE] year old alert female stated, I was sitting in my recliner and (R3) entered my room and began yanking at my dresser drawer. R2 stated that she told R3 to Get out! R2 stated that R3 then grabbed her walker and began shoving the walker into her legs which caused her to lose her balance and she landed on her bed. R2 stated, I began to scoot across my bed so I could use my call light because no staff had responded to cries for help. R2 stated, I then screamed out 'Help me!' about 5-6 times because (R3) began throwing full cans of soda at me striking my arm and I am becoming agitated. R2 stated, (R3) used the F word stating 'F*** You'. R2 stated, Yes, I am afraid of (R3), now I stay in my room. R2 stated, I don't feel safe anymore and this is my home and I have been here about 8 years. R2 stated, It's like having a rapist living next door. R2 stated, I wait for staff to walk me into the dining room and activities because I am fearful of (R3). R2 stated if staff is not available then she eats in her room or misses activities. R2 stated, (V6, Licensed Practical Nurse/LPN) and (V2, Director of Nursing/DON) responded on 8/09/21 and removed (R3) from her room. R2 stated, (V6) took my vitals and I think made some phone calls. R2 stated, I am getting anxious just talking about it, because I am reliving it. R2 stated that R3 had been in her room before. R2 stated there were soda cans under my bed and out in the hallway. R3's Face Sheet documents that R3 is a [AGE] year old male that was admitted to facility on 7/10/2021 with a diagnosis to include: Severe Alzheimers, Congestive Heart Failure, A-Fib, Hypertension and BPH (Benign prostatic hyperplasia). On 8/17/2021 at 8:08 AM, R3 stated, I never threw a soda can at anybody. R3 stated, I will go to jail first. R3 stated, I am very hard headed about things I didn't do. On 8/17/2021 at 9:23 AM, R3 opened the closed dementia unit door setting off the alarm. On 8/17/2021 at 9:28 AM, R3 wheeled himself down the hallway with no staff interaction or intervention. On 8/17/2021 at 11:07 AM, R3 fed himself lunch sitting by himself at lunch table. On 8/17/2021 at 9:56 AM, V2, DON, stated, (R3) was just wheeling around in his wheelchair, then we heard 'Help' and I saw (R3) wheeling himself from (R2's) room. V2 stated that, (R2) stated that (R3) had busted into her room. V2 stated, I knew something had happened, (R2's) words were rushed, not making complete sentences, her eyes were big and she was scared. V2 stated, We also saw dented cans. V2 stated, No, (R3) was not sent out for a psych evaluation because (R3) is on hospice and they would not accept him. On 8/17/2021 at 1:07 PM, V1, Administrator, stated, I believe a additional medication was added for intervention. V1 stated, (V9, Hospice Nurse) was going to address it through hospice. V1 stated, (R3) was not sent out for psych eval due to being on hospice, they would not accept. R3's Physician orders dated 8/9/2021 documents; [MEDICATION(S)] 5mg/ml vial give 2mg intramuscular x 1 dose. On 8/18/2021 at 10:17 AM, V9, Hospice Nurse, stated, I called (V13, Hospice Medical Director) and he ordered medications for (R3). V9 stated, I advised (V13) that (R3) was being combative and physically aggressive. V9 stated, I believe (V13) ordered [MEDICATION(S)]. On 8/17/2021 at 11:53 AM, V4, Certified Nursing Assistant (CNA), stated, I am walking (R2) back to her room from the dining room, because she is afraid of (R3). On 8/18/2021 at 10:35 AM, V4 stated, I found (R3's) shirt on (R6's) floor when I went inside her room today. V4 stated, (R6) stated that (R3) came into her room and took off his shirt. On 8/18/2021 at 10:45 AM, R6, who is a [AGE] year old alert and oriented female stated, (R3) has come into my room several times and I am scared to death of him. R6 stated, Last night (R3) came into my room and took his shirt off. R6 stated, One evening (R3) was in my room going through my night stand drawer. R6 stated, I am scared to death of (R3). On 8/17/2021 at 10:10 AM V5, CNA, stated, (R3) wanders a lot in his wheelchair. V5 stated, It gets rough trying to watch him, by the end of the day you're dead. V5 stated, Don't have enough help. V5 stated, We don't have any behavior tracking for (R3). On 8/17/2021 at 10:20 AM, R4 an alert and oriented [AGE] year old male stated, I'm scared of (R3) because he has hit people. R4 stated, (R3) comes into my room all the time without permission. On 8/17/2021 at 10:48 AM, R5 an alert and oriented [AGE] year old, stated, (R3) comes into my room all the time. On 8/17/2021 at 11:00 AM, V4, CNA, stated, When it comes to (R3), we just redirect. V4 stated, No, (V10, Maintenance) is not always watching (R3) like he is today. On 8/17/2021 at 11:05 AM, R1 an alert and oriented [AGE] year old, stated, (R3) is kinda demented. R1 stated, (R3) comes into my room, he's a nuisance. R1 stated, (R3) he doesn't know what he is doing. R1 stated, (R3) is all the time trying to get out of the building and staff try to keep him in. On 8/17/2021 at 2:07 PM, R8, a [AGE] year old alert and oriented male, stated, I am aggravated, someone in charge lets him loose. R7 (R8's wife), a [AGE] year old alert and oriented female stated, One time (R3) entered our room and (R8) was in the bathroom and (R3) blocked the bathroom door to where (R8) couldn't come out, until staff arrived. On 8/17/2021 at 2:18 PM, V7, CNA, stated R3 has been violent with her many times. V7 stated, I try snacks, TV and take outside and nothing works. On 8/18/2021 at 9:54 AM, V6, LPN, stated, (R2) started screaming, so I started running down to her room (located at the end of the hallway next to exit doors) and saw (R3) propelling out of (R2)'s room. V6 stated, (R2) was a panic mess, red marks on her arm and sodas on the floor. V6 stated, Yes, it changed (R2) she is more withdrawn now and (R2) is not wanting to come out of her room alone anymore. R3's Progress note dated 8/9/2021 documents, (R3) has been exit seeking, hitting staff, another resident states (R3) hit him but it was not witnessed, cursing and being very hard to keep under control. Family was notified. Hospice was notified. awaiting return call from hospice. R3's Progress note dated 8/13/2021 documents; (R3) has been trying all afternoon to get outdoors-refusing to take meds- threatening to knock staff out-all staff. Keeps going in other residents rooms and trying to take their stuff. R3's Progress note dated 8/15/2021 documents; Hospice continues. (R3) up in wheelchair propelling self; exit seeking, talking about events in distant past. Talking a lot about guns and killing of animals and people. R3's Care Plan dated 7/10/2021 documents; (R3) known to wander may seek to leave home. Interventions start date 7/20/2021; Validate residents need to complete task and assist resident to find what/who is being sought, eventually redirecting Resident back to unit/facility/room. 15 minutes checks Start date 8/17/2021. There is no documentation there were any new interventions implemented after the incident (altercations between resident to resident) on 8/11/2021 or the other incident which occurred on 8/9/2021 which involved (R3) hitting. On 8/18/2021 at 11:30 AM, V1, Administrator, stated, There is no policy and procedure for supervision. Facility's Final investigation involving R3 and R10 dated 8/16/2021 documents; On 8/9/2021 at 3:30 PM, staff reported an alleged resident to resident altercation. During the investigation, R10 stated that resident (R3) hit him. (R10) stated that he and resident (R3) were in hallway near nurses' station when resident (R3) hit him. On 8/19/2021 at 1:40 PM, V1, Administrator, stated, We are working on trying to find a way to supervise (R3). V1 stated, We are looking at his medications, and a way to have (R3) be seen for his behavioral health. V1 stated, We are doing visual checks but don't know when it started. V1 stated, We are constantly revaluating. 2. R9's Care Plan dated 8/4/2020 documents; (R9) known to wander may seek to leave the home. (R9) specific information Wandering worse in the evening. Interventions: Seek alternative/diversional activities for exit seeking behaviors. Share successful strategies with others as needed. No new interventions have been added since 8/4/2020. R9's Progress note dated 6/17/2021 documents; (R9) exited building 2nd time. Was assisted by CNA and redirected back. R9's Progress note dated 6/19/2021 documents; (R9) exited building on 200 hall trying to go home. (R9) redirected back inside building. R9's Progress note dated 6/20/2021 documents; (R9) has exited the facility numerous times. R9's Progress note dated 7/16/2021 documents; (R9) exited the building times one, redirected back inside. R9's Progress note dated 7/31/2021 documents; (R9) redirected back into building. On 8/17/2021 at various times between 9:00 AM-12:30 PM, R9 observed walking to the end of hallway and exiting out of building without staff intervention stopping resident from exiting. On 8/18/2021 at various times between 9:00 AM-1:00 PM, R9 observed walking to end of hallway unsupervised and exiting out the building. On 8/19/2021 at various times between 8:00 AM-9:00 AM, R9 observed walking to end of hallway and exiting out building without staff supervision. On 8/19/2021 at 12:40 PM, R9 observed walking out the exit doors with no staff stopping R9 before she got outside the facility. On 8/19/2021 at 09:25 AM, V14, MDS/LPN, stated, The floor nurses are responsible to update Care Plans after an incident, then I believe it's V2, DON, responsiblity to check Care Plans. V14 stated, When I receive the Care Plans, I add all the written interventions and print out the new Care Plan. On 8/19/2021 at 1:45 PM, V2, DON, stated that V14, MDS/LPN, is responsible for updating the residents care plan with new interventions. The Facility's Abuse Prevention Program Policy and Procedure dated 11/28/2016, documents; This facility affirms the right of out residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, exploitation, neglect or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, exploitation, neglect, and abuse of residents. Dementia management and resident abuse prevention.

Based on observation, record review, and interview, the facility failed to assess for contractures; implement interventions based on the assessment; and thoroughly investigate a fracture for 1 of 3 residents (R1) in the sample of 3. This failure resulted in R1 sustaining a fracture to her right ankle. Findings include: R1 was originally admitted to the facility on [DATE] with diagnoses, in part, of Cerebral Artery Occlusion, Cerebrovascular Accident with right [DIAGNOSES REDACTED] and Severe Osteoarthritis. Hospital History & Physical dated 3/26/07 documents in part, R1's history includes severe osteoarthritis. The Facility "Final Investigation Report" documents: "Account: On 11/27/13, it was reported that during morning care, R1 complained of ankle pain. E7, Licensed Practical Nurse (LPN) assessed R1's right foot and noted abnormalities. E7 notified the Administrator, Physician and called for a stat x-ray. Stat x-ray was then cancelled due to time frame to get portable x-ray to Facility and R1 was sent to the emergency room for the x-ray. X-ray results indicated diffuse osteopenia and fracture involving the distal right tibia and fibula. Investigation: E4, Certified Nurses Aide (CNA) stated that she and E8, CNA, were in the room getting R1 dressed and ready to get up. E4 was on the side of the bed near the wall and E8 was by the night stand. E4 had the mechanical lift sling rolled and ready to place under R1's buttocks while E8 turned her. As E8 started to turn R1 screamed and stated "my ankle". E4 told E8 to let R1 go. R4 stated R1's ankle was up underneath of her (R1 does have contractures of the lower extremities). R1 then complained of knee pain when they moved her leg. R1 then again stated that her ankle hurt. As E4 and E8 were coming out of R1's room, the day shift CNA's, E6 and E5, were waiting for report from the two night shift CNA's. The day shift CNA's immediately reported R1's complaint of ankle pain to the nurse. E8 stated she was by the night stand and she had hold of the pad to turn R1 towards her. R1 started yelling. R1 stated "my ankle, my ankle" as E8 went to lay her back. E8 stated that they noticed R1's foot was curled under her after turning her. E8 stated that before R1 was turned she did move her foot down a little bit. E8 stated she did not notice R1 had curled her ankle back up under her. E8 stated that she did report the incidents to the day shift CNA's as incident did occur right at shift change. E5 stated E4 told her R1's foot was under her bottom when they rolled her over and she hollered out. E5 and E6 then went in to get R1 up. The lift sling was already under her and they went to fix the pad under R1. E6 started to roll R1 to her side and she screamed. They immediately stopped and noted that R1's right ankle stayed flat on the bed and her leg came up. E5 immediately reported the incident to E7. Conclusion: The Facility is unable to determine the exact cause of the fracture. Upon interview with R1's primary care physician, he stated that he believed the fracture could have occurred while she was being turned because her bones are so brittle. The Facility is unable to determine any willful intent by either staff member". The Facility investigation into this incident does not document the potential causative factors for R1's ankle fracture nor is there documented corrective actions to prevent further injury to R1. During an interview with E1, Administrator, on 12/2/13 at 2:30 PM, it was stated that she thought she could not put conclusions in an investigation. R1's emergency room record, dated 11/27/13, documents, in part, R1's "knee contracted bilateral, unable to straighten right knee". The Diagnostic X-Ray Imaging of R1's right lower leg and ankle, also dated 11/27/13, documents "the bones are diffusely osteopenic. There is a fracture through the distal metaphysis of the right tibia which appears to be comminuted. There is some impaction of the fracture as well. There is apparent distal right fibular fracture as well. There is some medial angulation of the medial lateral malleolar fracture fragments on the cross-table view." R1 was readmitted to the facility from the hospital on [DATE] at 11:00 AM, with a cast on her right leg and foot. R1's right lower leg is contracted at a 90 degree angle and drawn up to her knee level. R 1's Minimum Data Set (MDS), dated [DATE] documents, in part, that R1 is unable to complete the Brief Interview of Mental Status (BIMS); is totally dependent on two or more staff for transferring, dressing, hygiene, tolieting, and bathing; unable to ambulate; and has severe limitations of both upper and lower extremity range of motion. R1's Care Plan dated 8/2/13, documents, in part, that R1 is dependent on staff for Activities of Daily Living (ADL's) and is "totally dependent on staff for transfers D/T (due to) leg contractures". The Care Plan does not address how to transfer, turn or reposition R1 due to her right leg contracture. On 12/2/13, at 1:45 PM, in an interview with E6 (CNA), when asked how she (E6) knows how to turn and reposition R1, E6 stated she is trained by nursing staff and CNA's who have been at the facility longer. On 12/2/13, at 2:20 PM, during a telephone interview with E5, when asked how she (E5) knows how to turn and reposition R1, E5 stated by working with residents and seeing what works best. The most recent assessment of R1's functional skills dated 3/25/11, documents R1's right lower extremity as "right knee contracted". On 12/5/13, at 1:00 PM, during an interview, E2 (DON) stated that this is the most current assessment of R1's functional abilities. During an interview with R1 on 12/2/13, at 1:17 PM, R1 stated she did not know what happened to her right leg or why she has a cast. When R1 was asked about her recent hospitalization she stated "I didn't know......". On 12/4/13, at 2:20 PM, in a telephone interview with E8 (CNA), E8 stated that E4 (CNA) and E8 were dressing R1 on 11/27/13 at around 5:30 or 6:00 AM when R1 was rolled to the left and R1 yelled out "my ankle!" E8 stated she noticed R1's foot was tucked underneath her buttocks. E8 stated she did not report the incident or have R1's right foot assessed by nursing staff, but "mentioned it to oncoming CNA's." During an interview with E1 and E2 on 12/5/13 at 1:40 PM, E1 stated "If the CNA's think there is something wrong they should tell a nurse as soon as they can but there is no time frame". On 12/2/13, at 3:40 PM, in a telephone interview with E4 (CNA), E4 stated that on 11/27/13 at 5:50 AM, E8 and E4 were dressing R1 when R1 screamed out "my ankle!" when rolled to side. E4 stated that day shift CNA's were told to watch R1's ankle because R1 was complaining of pain. E4 further stated that R1 had her right ankle caught in her geri-chair the previous day, 11/26/13. E5 stated that R1's right foot was caught where the geri-chair folded up and R1 had complained of pain to her right foot on 11/26/13. E4 stated that E5, CNA told E4 about this incident the on 11/26/13. E4 stated she did not report this to anyone and stated that E8 "told E1(Administrator) what she needed to know." When asked E4 how she knows how to turn and reposition R1, E4 stated "I've been a CNA for [AGE] years." On 12/4/13, at 11:00 AM, in a telephone interview, Z1 (Medical Doctor) stated that R1 has "really osteoporotic bone and rigidity of the knee." Z1 further stated that the ankle fracture could have resulted from turning. Z1 stated that R1 has probably had osteoporosis ever since R1 has had the arthritis. On 12/3/12, at 8:30 AM, in an interview, E2 (Director of Nursing) stated she was unaware of any incident that occurred with R1 on Tuesday 11/26/13 regarding her right foot being caught in the geri-chair. On 12/3/12, at 8:35 AM, in an interview, E1, Administrator, stated she was aware of R1's right foot being caught in her geri-chair on Tuesday 11/26/13. E1 further stated that she did not know of the incident until after the investigation of R1's ankle fracture was initiated. E1 stated E5 did not report the incident to any staff or have R1's right foot assessed after being caught in the geri-chair.

Based on observation, record review and interview, the facility failed to prevent the development of new pressure ulcers, assess and provide the appropriate interventions and treatment for two, (R2, R7) of five residents identified with pressures ulcers. This failure resulted in the development of a Stage II pressure ulcer to R7's right ankle and three unstageable ulcers to the toes. This failure also resulted in the development an unstageable necrotic pressure ulcer to R2's coccyx; an unmeasured, unstageable area to the right malleolus; and a Stage II pressure sore to R2's left heel. Findings include: 1. R2's physician's orders [REDACTED]. The Minimum (MDS) data set [DATE], assessed R2 as moderately impaired with cognition, dependent on staff for bed mobility and all activities of daily living, and is incontinent of bowel and bladder. The Braden Scale dated 10/12/10 assesses R2 as a high risk for the development of pressure ulcers. The Nursing Admission Assessment of 9/30/10 documents R2 returned to the facility from the hospital with an unmeasured red area to the coccyx. The Nursing Admission Assessment of 10/12/10 documents R2 was readmitted to the facility from the hospital with a shearing to the coccyx, measuring 2 inches X 1/2 inch, and excoriation of both upper legs and bilateral buttocks. A black spot was documented as a vascular ulcer to the left third toe. During tour of the facility on 11/08/10, at 10:37 AM, R2 was laying in bed on her back. R2 had been incontinent of a large amount of liquid stool. Both feet had egg crate type heel protectors applied, and were resting on a pillow. A dressing dated 11/05/10 was on the right outer malleolus. R2's left heel was open and draining into the heel protector. Some drainage was noted on the pillow case. R2 was turned to the right side. A large foul smelling, draining, necrotic pressure ulcer containing fecal material was noted to R2's coccyx. No dressing was on the coccyx. On 11/08/10, at 10:40 AM, staff had provided incontinent care. E6, Registered Nurse, (RN) entered the room. E6 stated, "I don't know why there is no dressing on her (coccyx) wound." E6 failed to cleanse the coccyx wound of the fecal matter before applying the prescribed ointment and a large dressing to R2's coccyx. E6 had not brought wound cleanser into the room with the other wound treatment supplies. Two open and bleeding areas the size of a quarter were noted to R2's left lower buttock, and a open area was noted to the left upper buttock. No dressing were noted or applied to these areas by E6. E6 reported only skin prep was being applied to the left heel, with no dressing. E6 did not reassess R2's left heel. On 11/09/10 at 9:30 AM, Z1, Physician entered R2's room. Z1 was asked if he was aware of the condition of R2's pressure ulcers. Z1 replied, "Yes, but the family wants comfort measures only........" On 11/09/10, at 9:50 AM, R2 was incontinent of a large amount of liquid stool. A large dressing soiled with feces was on R2's coccyx. Both buttocks were red, excoriated. The right buttock had numerous discolored and open areas. After incontinent care, E6 entered the room with dressing supplies, but no wound cleanser. E6 removed the soiled dressing. The pressure ulcer to R2's coccyx remained foul smelling and necrotic, also containing fecal material. The wound was draining purulent fluid. E6 used a wash cloth and applied the no rinse liquid soap, used for incontinent care, to the cloth. E6 wiped R2's coccyx with the washcloth containing soap across the wound. On 11/09/10, at 10: AM, R2 was positioned on the right side, with the right malleolus directly on the mattress. R2's left foot was floated on a pillow. No heel protector or dressing was on the left heel. E6 stated R2 is turned and repositioned every two hours. A review of the physician's orders [REDACTED]. Apply CA (calcium alginate) and Santyl ointment. Cover with dry dressing daily and PRN (as needed)." The physician's orders [REDACTED]. [MEDICATION NAME] ointment PRN to all red excoriated areas." A review of the physician's orders [REDACTED]. The Treatment Administration Record (TAR), for November 2010 was reviewed. The area for skin check daily revealed no documentation the skin check had been done for 11/02, 11/03, 11/05, and 11/07/10. The treatment ordered for daily cleansing and treatment of the coccyx with NS was not documented as completed for 11/06 and 11/07/10. The treatment ordered for the right malleolus every shift lacked documentation as completed on the day shift 11/06 and 11/07/10, and the evening shift on 11/02,11/03, 11/05, and 11/07/10. No treatment for the large Stage II to the left heel was documented on the TAR. R2's Care Plan, dated 11/05/10, failed to address R2's coccyx ulcer, the right malleolus, the left heel, or the open areas and excoriation of the buttocks. The Care Plan's plan of approach for R2 reads, in part, "Treatment as ordered, skin check as ordered, administer meds (medication) as ordered, and turn and position and incontinent care every two hours and as needed. No interventions are addressed for prevention for R2's heels. 2. R7's Minimum Data Set (MDS), dated [DATE], documented an alert resident, with diagnoses, in part, of [MEDICAL CONDITION] who was dependent on tube feeding for nutrition, received treatments of, in part, [MEDICAL CONDITION] care and ventilator/respirator, totally dependent on two plus persons physical assistance with mobility and transfer and no pressure sores. R7's Care Plan, goal date of 1-11, documented R7 was a bedfast resident who was to have heel boots and elbow protectors on at all times. It was also noted that R7 was at risk for skin impairment with a treatment to his right ankle dated 1-22-10. During observation of R7's bilateral toes and right ankle,on 11-8-10 at 11:00a.m., R7's right ankle did not have a dressing on, and active drainage was observed on his right ankle E6, Licensed Practical Nurse (LPN), stated, on 11-8-10 at 11:00a.m., that R7 did not have a treatment or dressing on his right ankle and he should have. R7's Treatment Record, dated 11-1-10 to 11-30-10, documented "Treatment Right Outer Ankle Apply Skin Prep>Cover With Dry Drsg (dressing) Daily & PRN (as needed)." It was also observed that R7 had raised reddened areas, some with drainage, on the right foot great toe, second toe and fourth toe. R7's Treatment Record did not have a treatment documented for his toes. R7's toes were also observed without treatment or dressings. R7 did not have his heel boots on his feet were laying on a pillow. R7 did have a right elbow protector on. R7's record did not have an assessment and/or measurements of the opened areas on R7's toes. During observation of R7's feet, on 11-9-10 at 9:15a.m., multiple open areas some with active drainage were observed on R7's right foot great toe and second toe and his left foot second toe. Again, R7's toes did not have treatments and/or dressings. R7's right outer ankle was dressed. R7 did not have his boots on and his feet were laying on a pillow. E3, Licensed Practical Nurse (LPN), provided, on 11-10-10 at 11:15a.m., two Newly Acquired Skin Conditions forms, dated 11-9-10, that documented the physician was notified of a "1.0cm x 0.5cm x 0.25cm re-opened right outer ankle abrasion" and "two right 0.5cm x 0.5cm scabs and one left second toe scab 0.3cm x .0.3cm." E3 also provided a copy of an updated Care Plan, dated 9-10, which documented R7's abrasion on right outer ankle and scabs on R7's toes with interventions documented. Skin Assessments, dated 10-4-10, 10-11-10, 10-12-10 and 10-25-10, that R7 was timely reposition and that his skin was intact and a Dietary Notes, dated 7-12-10, 8-19-10 and 10-14-10, that R7 had no pressure skin breakdown were also provided on 11-10-10. E3 stated, on 11-10-10 at 11:15a.m., that the physician was not notified of R7's right outer ankle area and toes until 11-9-10. The facility's Decubitus Care/Pressure Areas policy and procedure, dated 5-07, documented that the facility staff were to "ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer...2) Pressure area will be assessed and documented on the treatment Administration Record" and "3) Complete all areas of three TAR (Treatment Administration Record)."

Based on observation, interview and record review, the facility failed to develop, implement, monitor and/or modify a pain management plan for pain related to movement, chronic diarrhea, and treatment of [REDACTED]. This failure resulted in R2 repeatedly complaining of pain, crying out and moaning in pain, and asking for help as her condition continued to decline. Findings include: The physician's orders [REDACTED]. The Minimum (MDS) data set [DATE], assessed R2 as moderately impaired with cognition, dependent on staff for bed mobility and all activities of daily living, and is incontinent of bowel and bladder. The Pain Assessment for R2, dated 10/12/10, assesses R2 with a pain intensity of "10", with 0 being no pain and 10 as the worst pain. The Pain Assessment documents R2's with severe pain daily, with pain indicators of crying, moaning, verbal complaints of pain, facial expressions of pain, and protective body movements. During tour of the facility on 11/08/10, at 10:37 AM, R2 was laying in bed on her back. R2 had been incontinent of a large amount of liquid stool. Both feet had egg crate type heel protectors applied, and were resting on a pillow. A dressing dated 11/05/10 was on the right outer malleolus. R2's left heel was open and draining into the heel protector. Some drainage was noted on the pillow case. R2 was turned to the right side. R2 cried out in pain with every movement. A large foul smelling, draining, necrotic pressure ulcer containing fecal material was noted to R2's coccyx. No dressing was on the coccyx. On 11/08/10, at 10:40 AM, staff had provided incontinent care. R2 cried when her excoriated buttocks were cleansed and dried by E4 and E8, Certified Nurses Aides. E6, Registered Nurse, (RN) entered the room. E6 stated, "I don't know why there is no dressing on her (coccyx) wound." E6 failed to cleanse the coccyx wound of the fecal matter before applying the prescribed ointment and a large dressing to R2's coccyx. E6 had not brought wound cleanser into the room with the other wound treatment supplies. Two open and bleeding areas the size of a quarter were noted to R2's left lower buttock, and a open area was noted to the left upper buttock. No dressings were noted or applied to these areas by E6. E6 reported only skin prep was being applied to the left heel, with no dressing. E6 did not reassess R2's left heel. R2 cried and moaned during the wound treatment to the coccyx. When asked if R2 had any [MEDICATION NAME] prior to the treatment to her coccyx, E6 confirmed R2 had no oral pain medication since 7:00 AM that morning. E6 stated, "She (R2) is not due again until 1:00 PM." When asked if R2 was receiving an antidiarrheal medication E6 replied, "No, only pain medication for comfort care." A review of the Medication Administration Records (MAR) for October and November 2010 revealed R2 had not received any medication for the [DIAGNOSES REDACTED]. R2's previous physician's orders [REDACTED]. A review of the MAR, dated November 2010, documents R2 was given [MEDICATION NAME] at 7:00 AM on 11/08/10 and 1:00 PM. The PRN MAR for 11/10 repeatedly documents R2 has "pain all over" with some relief one hour later. R2 was not reassessed for break through pain management. A review on 11/08/10 of the physician's orders [REDACTED]. A physician's orders [REDACTED]." On 11/06/10, new physician's orders [REDACTED]. On 11/09/10 at 9:30 AM, R2 repeatedly cried out and moaned with pain, stating, "Help me." R2 complained of pain in the right arm. Z1, Physician entered the room as R2 was crying out in pain. Z1 was asked if he was aware of the condition of R2's pressure ulcers. Z1 replied, "Yes, but the family wants comfort measures only. I medicate her for pain. I want to increase the [MEDICATION NAME] in a few days." When Z1 was asked by the surveyor if he thought R2 was comfortable, Z1 instructed E3, Licensed Practical Nurse to give her a dose of [MEDICATION NAME] immediately. The MAR indicated [REDACTED]. On 11/09/10, at 12:45 PM, a new [MEDICATION NAME] was noted to her left clavicle, dated 11/09/10. At 3:30 PM, R2 was asked if she was in any pain now. R2 replied, "Not anymore." R2's Care Plan, dated 11/05/10, reports a problem of complaints of severe pain and end of life care. Plans of Approach reads, in part, "Administer pain meds as ordered, reposition for comfort, and one on one for comfort/pain control." The Care Plan fails to address R2's chronic diarrhea, only incontinence of bowel and bladder. The facility's policy and procedure entitled, 'Pain Prevention & Treatment', reads, in part, "To assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize ADL (activities of daily living) functioning and enhance quality of life...A Pain Assessment will be completed at the time of the MDS (Minimum Data Set), completion, if pain has been recorded, when warranted by changes in resident's condition or treatment plan that indicate pain, self reporting of pain or evidence of behavioral cues indicative of the presence of pain and as necessary to identify and monitor there level of pain and/or the effectiveness of treatment modalities."