Every finding on record at Silver Foxes SR Living & Rehab

Based on interview and record review the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for 1 (R1) of 3 residents reviewed for indwelling catheters in the sample of 4. This failure resulted in R1 being sent to a local hospital emergency department, flown to an out of state hospital and admitted with diagnoses including Sepsis and Complicated UTI.Findings Include:R1's admission Record documented that R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Unspecified Dementia, aortic valve stenosis, dysphagia, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit, and pain.R1's MDS (Minimum Data Set) quarterly assessment with an Assessment Reference Date of December 12, 2025, documented a Brief Interview for Mental Status (BIMS) score of 06 indicating R1 had severe cognitive impairment. R1's Care Plan with an initiation date of 09/12/2025 has a Focus Area of I have an indwelling catheter due to diagnosis of urinary retention, and benign prostatic hyperplasia with lower urinary tract symptoms. Interventions listed include monitor and document intake and output as per facility policy, monitor/record/report to medical doctor signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.R1's Order Summary Report with a print date of 01/07/2026 documented that R1 had the following orders: Urinary catheter, irrigate with 30 milliliters of normal saline for blockage as needed with an order date of 9/12/25, urinary output every shift related to retention of urine dated 9/12/25, and urinary catheter 18 fr (French) coude with 10 cc (cubic centimeter) balloon, change every 30 days on night shift with an order date of 09/12/2025.R1's Treatment Administration Record with a date range of 12/01/2025 - 12/31/2025 documented that R1 did not have an indwelling catheter change during that time frame. The same TAR documents that R1's urinary catheter was irrigated with 30 cc of Normal Saline on 12/26/25 and documents R1's daily urinary output as:12/19/2025 -1150 milliliters,12/20/2025 - 1150 milliliters,12/21/2025 - 900 milliliters12/22/2025 - 925 milliliters12/23/2025 - 650 milliliters12/24/2025 - 700 milliliters12/25/2025 - 200 milliliters12/26/2025 - No urine output documentedR1's Progress Note dated 12/08/2025 authored by V13 (Registered Nurse) documented the resident is experiencing a change in condition. The change in condition the resident is currently experiencing is Urine dark amber in color with white sediment in catheter tubing No distress noted. No c/o voiced. Afebrile. Fluids encouraged. Message to D.O.N. (Director of Nursing).R1's Progress Note dated 12/09/2025 authored by V13 documented Resting in bed. No distress noted. No complaints voiced. Urine a dark yellow at this time, improved in color.R1's Progress Note dated 12/16/2025 authored by V6 (Licensed Practical Nurse) documented return from doctor visit. Catheter wasn't changed. New order to change monthly.R1's Progress Note dated 12/19/2025 authored by V2 (Director of Nursing) documented new order received today from V10 (Urologist) to change catheter order to an 18Fr. coude with 10cc balloon change monthly. May change when catheter supplies are received. A January 7th appointment was made in case catheter needs changed in office.R1's Progress Note dated 12/25/2025 at 7:26 A.M. authored by V9 (Licensed Practical Nurse) documented when CNA went to get R1 out of bed for breakfast, dried emesis of undigested food in bed and R1 was incontinent of a large bowel movement. Taken to shower and laid down. Afebrile. R1 clinches teeth when staff tried to assist with feeding or when medications are attempted. Negative for COVID.R1's Progress Note dated 12/25/2025 at 1:00 P.M. authored by V9 documented R1 was up for lunch in wheelchair. Staff attempted to feed and resident clinches teeth together.R1's Progress Note dated 12/26/2025 at 11:00 A.M. authored by V5 (Licensed Practical Nurse) documented call placed to V8 (Medical Doctor) office due to resident has had no urine output from indwelling catheter. Resident lethargic and lower abdomen is distended and rigid. New order from V8 to send R1 to local hospital emergency department for evaluation and treatment.R1's Emergency Department (ED) Provider Notes dated 12/26/25 from the local hospital documents R1 presents to ED with c/o (complaints of) lethargy and urinary retention with current foley catheter. On arrival patient is responsive to painful stimuli and groans when moved. R1's bladder distended with no drainage in bag. Bladder scan shows >1570ml. 18 fr coude removed and replaced with 18 fr straight tip foley cath (catheter) placed. When foley bulb was deflated, brown urine started flowing out around the catheter. R1 had 1850ml out of bladder, very malodorous, nearly brown in color with large amount of sediment present. R1's abdomen no longer distended. R1's ED Progress Notes document a clinical impression of hypotensive episode, hydronephrosis with ureteropelvic junction obstruction, sepsis with acute renal failure and septic shock, and unspecified acute renal failure type and documents that R1 was accepted at an out of state hospital. Photos of R1's urine in the hospital records dated 12/26/25 shows three graduated cylinders with dark brown, cloudy urine with large amounts of sediment visibleR1's out of state hospital records document that R1 was admitted on [DATE] and discharged on 12/31/25 with admitting and discharge diagnoses including Sepsis, complicated UTI, chronic indwelling catheter, and AKI (Acute Kidney Injury) on CKDIIIB (Chronic Kidney Disease Stage 3B). The hospital records further document that R1 was seen in the ICU (Intensive Care Unit) and R1's family elected comfort care and was discharged to a hospice facility.On 01/02/2026 at 1:35P.M. V2 (Director of Nursing / Registered Nurse) stated she was the nurse for R1 the night before he was sent to the hospital. V2 stated she came in on 12/25/2025 at 7:00 P.M .and worked until 06:00 A.M. on 12/26/2025. V2 stated R1 was in bed when she came on shift. V2 stated she had received in report that R1 had been sick all day and had not eaten or drank anything. V2 stated R1 had vomited earlier that day and the wife felt like it was because R1 had eaten too much when he was out with family on 12/24/2025. V2 stated she had not notified the physician because she thought he was sick from overeating the day before. V2 stated she had been told in report that day shift had flushed / irrigated R1's indwelling catheter without any issue so she did not attempt to. V2 stated she let the day shift nurse that came on 12/26/2025 know R1 had not had any urine out put all night and keep an eye on him.On 01/02/2026 at 3:09 P.M., V5 (Licensed Practical Nurse) stated she was the nurse for R1 on 12/26/2025 for about 30 minutes. V5 stated she took report from V7 (Licensed Practical Nurse) around 10:00 A.M. V5 stated when she got report she went in an assessed R1 and sent him to the hospital. On 01/07/2026 at 9:58 A.M. V5 (Licensed Practical Nurse) stated on 12/25/2025 she assumed care of R1 around 10:00 A.M. V5 stated V7 let her know in report that R1 had not taken his medications, had no urine output, and had not eaten. V5 stated she went in and assessed R1. V5 stated she attempted to flush / irrigate R1's indwelling catheter but had no success. V5 stated she then notified the physician, and R1 was sent to the local hospital. V5 stated R1 was lethargic, had a distended abdomen and had not taken his medication that helped keep his blood pressure up. V5 stated R1's baseline was alert and oriented at times.On 01/02/2026 at 3:15 P.M., V7 (Licensed Practical Nurse) stated she was here to pass the medications on 12/26/2025 from 0600-1000 A.M. V7 sated it was reported that R1 had been sick, had emesis and loose stools. V7 stated that R1 did not eat or drink that morning. V7 stated she obtained vital signs and must not have charted them. V7 stated she did not notify the physician of R1's condition. V7 stated she does not remember being told that R1 had no urine output. V7 stated she provided no care for the foley catheter on 12/26/2025. On 01/02/2026 at 10:34 A.M., V3 (Registered Nurse at local hospital) stated she was the nurse working the day R1 came into the emergency department. V3 stated she was told the facility had tried to irrigate R1's catheter because he was not having any output. V3 stated R1 was hypotensive upon arriving to the emergency department with blood pressures averaging 80's over 40's. V3 stated that R1's indwelling catheter balloon was deflated and dark foul urine started to immediately pour out around the catheter. V3 stated she had done a bladder scan on R1, and the outcome was R1 had greater than 1500 Milliliters (ML) of urine in the bladder. V3 stated she took R1's indwelling catheter out and replaced it. V3 stated there was greater than 1800 ml of urine with a lot of sediment in it. V3 stated R1's urine was very brown in appearance and had a foul odor. V3 stated that R1 was septic and had to be placed on intravenous vasopressors for his blood pressure. V3 stated R1 was flown via helicopter to an out of state hospital. V3 stated when she spoke to R1's wife, she was told that on 12/24/2025, R1 went home for Christmas dinner. R1 must have eaten too much because he ended up vomiting. V3 stated that on 12/25/2025 when the wife came to visit, R1 was not acting like himself. On 01/07/2026 at 10:49 A.M., V9 (Licensed Practical Nurse) stated she was the nurse caring for R1 on 12/25/2025. V9 stated she was made aware early that morning that R1 had vomited. V9 stated they got R1 up, gave him a shower and laid him back in bed. V9 stated she notified R1's wife and was told that he had overeaten while out of the facility on 12/24/2025 and she was not surprised that he threw up. V9 stated R1 was out of bed for lunch but did not eat. V9 stated R1 took his medications with water but refused eating and drinking. V9 stated his vitals were with in normal range for her and she was not concerned about R1 at that time. V9 stated there was a small amount of urine in R1's catheter bag and the urine in the drainage tube was amber in color. V9 stated there were times that R1's urine would get darker, and the staff would encourage fluids. V9 stated her shift ended around 4:00 P.M. and R1 had a low-grade temperature of 99.5. V9 stated at that time R1 was given Tylenol. V9 stated she did a COVID test on R1 when he vomited, and it was negative. V9 stated besides vomiting and having loose stools there was nothing that she was concerned about and contributed the vomiting to R1 overeating while out with family.On 01/07/2026 at 10:10 A.M., V8 (Medical Doctor) stated he reviewed the medical records for R1 and doesn't see anything bad, the staff called after he went greater than 8 hours without urine output. V8 stated 8 hours is a reasonable amount of time for R1 to go without urine output before the physician was notified. V8 stated R1's catheter was flushed with no issues or return output. V8 stated he felt like there was an issue with the catheter and that is why R1 was sent to the emergency department. V8 stated he feels that the catheter had to have some type of obstruction causing the urine to not flow. V8 stated R1 had been declining for a period of time before this happened. V8 stated R1 had been having issues with the indwelling catheter and had been following with the urologist in the weeks prior. V8 stated R1 is on hospice now and he honestly was not surprised. V8 stated with 100 out on the prior two shifts and vital signs stable the entire day waiting until there was no urine output was acceptable. V8 was shown the pictures of R1's urine from the hospital records and stated that looks infected. V8 stated looking over the facts, R1 could have been sent out and hour or two earlier but it would not have changed the fact that R1 was declining in health. On 01/08/2026 at 2:26 P.M., V1 (Administrator) stated she expects the nursing staff to provide the proper care required for all residents and to document the care that was provided. V1 stated it is also her expectation for the nurses to follow the physician orders.On 01/07/2026 at 11:57 A.M. V12 (Urology Nurse) stated with R1's diagnosis, previous issues with his indwelling catheter and decreasing urine output, something should have been done immediately and before he had no urine output. V12 stated R1 had to feel miserable with that much urine in his bladder. V12 stated they nurse should have attempted something at the point they knew there was no urine and not wait another 4 hours.On 01/07/2026 at 11:57 A.M., V10 (Urologist) was unavailable for a phone call. V12 took down this surveyors' questions for V10. On 01/07/2026 at 12:08 P.M., V12 stated in V10's professional opinion was when it was noticed R1 had no urine out put something should have been done at that point, not waiting additional hours. With R1's diagnosis, decrease in urine output, having an indwelling catheter, the facility should have attempted to change the catheter or flush it at the time there was no urine output observed. V12 stated that V10 said with the decrease in urine out put it should have been flushed or changed before there was no urine output.The facility policy titled Output, Measuring and Recording with a revision date of October 2010 documented Purpose: the purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period. The policy goes on to document Reporting: 3. Report to the primary care physician abnormal output within 24 hours.The facility policy titled Catheter Care, Urinary with a revision date of September 2014, under Input/Output documents 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Under Complications documents I. Observe the resident for complications associated with urinary catheters. e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.

Based on interview and record review the facility failed to notify the physician of a change in condition timely for 1 (R1) of 3 residents reviewed for change in condition in the sample of 4.Findings Include:R1's admission Record documented that R1 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Unspecified Dementia, aortic valve stenosis, dysphagia, retention of urine, benign prostatic hyperplasia with lower urinary tract symptoms, cognitive communication deficit, and pain.R1's MDS (Minimum Data Set) quarterly assessment with an Assessment Reference Date of December 12, 2025, documented a Brief Interview for Mental Status (BIMS) score of 06 indicating R1 had severe cognitive impairment. R1's Care Plan with an initiation date of 09/12/2025 has a Focus Area of I have an indwelling catheter due to diagnosis of urinary retention, and benign prostatic hyperplasia with lower urinary tract symptoms. Interventions listed include monitor and document intake and output as per facility policy, monitor/record/report to medical doctor signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.R1's Treatment Administration Record (TAR) with a date range from 12/01/2025 - 12/31/2025 documented under urinary output, R1 had 0 urinary output from 10 P.M. on 12/25/2025 to 6 A.M. on 12/26/2025. R1's TAR also documented on 12/25/2025 R1's oral intake for day shift was 10 milliliters, evening shift was 240 milliliters and night shift was 0. Under the section titled Amount Eaten for 12/25/2025 it is documented 0 for all three meals.R1's Progress Note dated 12/25/2025 at 7:26 A.M. authored by V9 (Licensed Practical Nurse) documented when CNA went to get R1 out of bed for breakfast, dried emesis of undigested food in bed and R1 was incontinent of a large bowel movement. Taken to shower and laid down. Afebrile. R1 clinches teeth when staff tried to assist with feeding or when medications are attempted. Negative for COVID.R1's Progress Note dated 12/25/2025 at 1:00 P.M. authored by V9 documented R1 was up for lunch in wheelchair. Staff attempted to feed and resident clinches teeth together.R1's Progress Note dated 12/26/2025 at 11:00 A.M. authored by V5 (Licensed Practical Nurse) documented call placed to V8 (Medical Doctor) office due to resident has had no urine output from indwelling catheter. Resident lethargic and lower abdomen is distended and rigid. New order from V8 to send R1 to local hospital emergency department for evaluation and treatment.R1's Emergency Department (ED) Provider Notes dated 12/26/25 from the local hospital documents R1 presents to ED with c/o (complaints of) lethargy and urinary retention with current foley catheter. On arrival patient is responsive to painful stimuli and groans when moved. R1's bladder distended with no drainage in bag. Bladder scan shows >1570ml. 18 fr coude removed and replaced with 18 fr straight tip foley cath (catheter) placed. When foley bulb was deflated, brown urine started flowing out around the catheter. R1 had 1850ml out of bladder, very malodorous, nearly brown in color with large amount of sediment present. Photos of R1's urine in the hospital records dated 12/26/25 shows three graduated cylinders with dark brown, cloudy urine with large amounts of sediment visible.On 01/02/2026 at 1:35P.M. V2 (Director of Nursing / Registered Nurse) stated she was the nurse for R1 the night before he was sent to the hospital. V2 stated she came in on 12/25/2025 at 7:00 P.M .and worked until 06:00 A.M. on 12/26/2025. V2 stated R1 was in bed when she came on shift. V2 stated she had received in report that R1 had been sick all day and had not eaten or drank anything. V2 stated R1 had vomited earlier that day and the wife felt like it was because R1 had eaten too much when he was out with family on 12/24/2025. V2 stated she had not notified the physician because she thought he was sick from overeating the day before.On 01/02/2026 at 3:15 P.M. V7 (Licensed Practical Nurse) stated she was there to pass the medications on 12/26/2025 from 6:00-10:00 A.M. V7 sated it was reported that R1 had been sick, had emesis and loose stools. V7 stated that R1 did not eat or drink that morning. V7 stated she obtained vital signs and must not have charted them. V7 stated she did not notify the physician of R1's condition. V7 stated she does not remember being told that R1 had no urine output. V7 stated she provided no care for the foley catheter on 12/26/2025.On 01/07/2026 at 10:10 A.M. V8 (Medical Doctor) stated 8 hours is a reasonable amount of time for R1 to go without urine out put before the physician was notified. V8 stated R1's catheter was flushed with no issues or return output. V8 stated he felt like there was an issue with the catheter and that is why R1 was sent to the emergency department. V8 stated he feels that the catheter had to have some type of obstruction causing the urine to not flow. V8 stated R1 had been having issues with the indwelling catheter and had been following with the urologist in the weeks prior. V8 was shown the pictures of R1's urine from the hospital and stated that looks infected. V8 stated looking over the facts R1 could have been sent out and hour or two earlier but it would not have changed the fact that R1 was declining in health.On 01/07/2026 at 11:57 A.M. V12 (Urology Nurse) stated with R1's diagnosis, previous issues with his indwelling catheter and decreasing urine output, something should have been done immediately and before he had no urine output.On 01/07/2026 at 11:57 A.M., V10 (Urologist) was unavailable for a phone call. V12 took down this surveyors' questions for V10. On 01/07/2026 at 12:08 P.M., V12 stated V10's opinion was when it was noticed R1 had no urine out put something should have been done at that point, not waiting additional hours. On 01/08/2026 at 10:18 A.M. V1 (Administrator) stated it is her expectation for staff to follow the change in condition policy.The facility policy titled Change in a Resident's Condition or Status with a revision date of October 2010, documented Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical /mental condition and or status.The facility policy titled Catheter Care, Urinary with a revision date of September 2014, under Input/Output documents 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Under Complications documents I. Observe the resident for complications associated with urinary catheters. e. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.

Based on interview, observation and record review the facility failed to implement fall prevention interventions for 1 of 5 residents (R35) reviewed for falls in a sample of 24. Findings include: R35's Admission Record documents R35 was admitted to this facility on 10/12/2024 with diagnoses of fractured right femur, dementia, weakness and reduced mobility among others. R35's MDS (Minimum Data Set) dated 10/19/2024 documented in Section C, Cognitive Patterns, that R35 is never understood, has short and long term memory problems and due to this, R35 could not participate in a BIMS (Brief Interview for Mental Status) test. The same MDS documents in section J, Health Conditions, that R35 has had 2 falls with no injury since her admission or prior assessment. A form titled Illinois Department of Public Health documented on 10/18/24, R35 fell out of her wheelchair while being transported by staff in the dining room. According to the form, R35 put her foot down and lunged forward out of the wheelchair and onto the floor. R35 was hospitalized and returned to the facility on [DATE]. R35's care plan was reviewed and new interventions put into place. R35's Care plan, with initiation date of 10/11/2024 documented the focus area of: I am (at) risk for falls due to gait/balance problems, unaware of safety needs and hx (history) of actual fall with fx (fracture) . Planned fall intervention with a start date of 10/18/2024, documented R35 will have her foot pedals on her wheelchair. Another fall intervention with a start date of 10/16/2024 documented R35 will remain within staff's line of sight when out of bed. On 11/13/2024 at 8:30am, R35 was observed in the facility's dining room in her wheelchair, with staff but without foot pedals on her wheelchair. On 11/13/2024 at 11:10am, R35 was observed siting in her wheelchair at the nurse's station with V3 (Licensed Practical Nurse) and V5 (Certified Nursing Assistant). R35 did not have foot pedals on her wheelchair. V3 was asked about R35's missing foot pedals and replied, I didn't know she (R35) was supposed to have foot pedals on her wheelchair. V5 then transported R35 from the nurse's station to the group room down the hallway without foot pedals on R35's wheelchair. When asked about the missing foot pedals, V5 said she did not know if R35 was supposed to have on foot pedals. On 11/13/2024 at 12:15pm, R35 was observed in the same group room, in her wheelchair and without foot pedals on her wheelchair. On 11/14/2024 at 9:22am, R35 was observed in her room up in her wheelchair and not in the line of sight of staff. No staff were observed in the hallway near R35's room. On 11/14/2024 at 10:35am, V2 (Director of Nursing) said R35 is supposed to have foot pedals on at all times and especially when staff are transporting her in a wheelchair. V2 agreed R35 should not have been in her room in her wheelchair without staff present. A facility policy titled Fall and Fall Risk, Managing, with revision date of March 2018, documented the following in part: When a resident is found on the floor, a fall is considered to have occurred. Staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling.

Based on interview and record review, the facility failed to offer pneumococcal vaccinations for 3 of 5 residents (R20, R31, R29) reviewed for immunizations in a sample of 24. Findings include: 1. R20's Admission Record documents an admitted [DATE] with diagnoses including: chronic obstructive pulmonary disease, peripheral vascular disease, hypertensive heart disease with heart failure, asthma, chronic viral hepatitis C and aneurysm of artery of lower extremity. R20's documented date of birth indicates that R20 is [AGE] years of age. R20's most current Influenza and Pneumococcal Vaccine Consent/Declination dated 09/28/23 documents yes for the statement: Please mark YES or NO for permission to administer the Pneumococcal (PVC15-Pneumococcal Conjugate Vaccination 15) vaccine, yes for the statement: Please mark YES or NO for the permission to administer the Pneumococcal (PCV20- Pneumococcal Conjugate Vaccination 20) vaccine, and Yes to the statement: Please mark YES or NO for permission to administer the Pneumococcal (PPSV23- Pneumococcal Polysaccharide Vaccine 23) vaccine. R20's Immunization Report does not document any pneumococcal vaccinations given. R20's Order Summary Sheet documents active orders as of 11/14/2024 does not document an order for any pneumococcal vaccinations. 2. R31's Admission Record documents an admitted [DATE], a date of birth indicating that R31 is [AGE] years of age, and diagnoses including: hypertensive heart disease without heart failure, disorder of kidney and ureter, benign prostatic hyperplasia with lower urinary tract symptoms, and gastro-esophageal reflux disease without esophagitis. R31's Influenza and Pneumococcal Vaccine Consent/Declination dated 05/10/24 documents yes for the statement: Please mark YES or NO for permission to administer the Pneumococcal (PVC15) vaccine, yes for the statement: Please mark YES or NO for the permission to administer the Pneumococcal (PCV20) vaccine, and Yes to the statement: Please mark YES or NO for permission to administer the Pneumococcal (PPSV23) vaccine. R31's Immunization Report does not document any pneumococcal vaccinations given. R31's Order Summary Sheet documents active orders as of 11/14/2024 does not document an order for any pneumococcal vaccinations. 3. R29's Admission Record documents an admitted [DATE], a date of birth indicating that R29 is [AGE] years of age, and diagnoses including: dementia, chronic kidney disease stage 3, peripheral vascular disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and hypertensive heart disease without heart failure. R29's Influenza and Pneumococcal Vaccine Consent/Declination dated 01/09/24 documents yes for the statement: Please mark YES or NO for permission to administer the Pneumococcal (PVC15) vaccine, yes for the statement: Please mark YES or NO for the permission to administer the Pneumococcal (PCV20) vaccine, and Yes to the statement: Please mark YES or NO for permission to administer the Pneumococcal (PPSV23) vaccine. R29's Immunization Report does not document any pneumococcal vaccinations given. R29's Order Summary Sheet documents active orders as of 11/14/2024 does not document an order for any pneumococcal vaccinations. The Centers for Disease Control website (https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html), Pneumococcal Vaccine Recommendations (dated October 26th, 2024) documents that the recommendation for adults [AGE] years or older for routine vaccination as Administer PCV15, PCV20, or PCV21 (Pneumococcal Conjugate Vaccination 21): who have never received any pneumococcal conjugate vaccine and whose previous vaccination history is unknown .If PCV15 is used, administer a dose of PPSV23 one year later, if needed. Their pneumococcal vaccinations are complete. On 11/14/24 at 2:10 PM V1 (Administrator) stated, they do not have any documentation for R20's, R31's or R29's pneumococcal vaccinations. She stated, she does not know if the residents need the vaccination or which vaccination. V1 stated R20, R31, and R29 have signed consent forms documenting they would receive the pneumococcal vaccination. The facility policy dated 08/2016 titled, Pneumococcal Vaccine documents in part: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series with thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 4. Pneumococcal vaccines will be administered to resident (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions to prevent falls for two (R2 and R11) of three residents at risk for and reviewed for falls in the sample of twenty three. Findings include: 1. On 07/10/22 at 10:32am, R2 was observed lying in his bed asleep. Gripper strips were noted to be adhered to the floor beside R2's bed. R2's Care Plan with a review date of 05/11/22 documented a problem area of (R2) is at risk for falls, with a corresponding intervention, (Staff) educated on replacing nonskid strips to floor after waxing floor. R2's Fall Investigations documented the following: 03/17/22: Resident was sitting on bathroom floor in front of toilet. Injuries: None noted. Conclusion: Replaced gripper strips in front of the toilet as an intervention. 04/07/22: (R2) was on the edge of the bed when he slid to the floor. No apparent injuries. Conclusion: We will replace the nonskid appliques on the floor beside the bed . 04/24/22: Resident had an unwitnessed fall, found in floor of resident room. Injuries: Hematomas left forehead, left shoulder, left upper arm. Conclusion: Residents room was just recently waxed and nonskid strips were not in place. (V1 Administrator) educated staff on ensuring that fall interventions are properly in place (for) all residents. 2. R11's Care Plan with a review date of 06/15/22 documented a problem area,(R11) is at risk for falls, with a corresponding intervention, Nonslip strips to the floor at the bedside. R11's Fall Investigations document the following: 10/14/21:Resident was (found) on floor against bed on her buttocks. Injuries: None noted. Conclusion: Floor recently waxed by maintenance, gripper strips not intact, staff reeducated on the importance of fall interventions. A Fall Prevention Policy (S.A.F.E.) with a revision date of February 2014 documented, Definition: The S.A.F.E. Program promotes Safety Assessment, fall prevention, and Education of both staff and residents .Residents found to be at high risk for falls are placed on the SAFE Program and specific interventions are implemented to meet individual need. On 07/13/22 at 9:11am, the above referenced falls of R2 and R11 were reviewed with V1. V1 stated it is V6's (Maintenance Director) job to replace the gripper strips after the floors have been waxed. V1 also stated V6 is to be checking all gripper strips at least monthly and replacing them as needed. On 07/13/22 at 1:42pm, V6 stated he is the staff member responsible for replacing gripper strips after the floors are waxed. V6 stated it is possible he forgot to replace the above referenced strips, but he could not remember specifically. V6 stated he does daily environmental rounds and checks items in resident rooms including gripper strips and replaces them when they appear worn. V6 stated it is possible at the time of R2's falls, he did not realize the strips in R2's room were worn enough to need replacement, but they have since been replaced.

Based on observation, record review, and interview, the facility failed to provide aseptic catheter care for one (R31) of one resident at risk for and reviewed for [CONDITION(S)] (Urinary Tract Infections) in the sample of twenty-three. Findings include: On 07/12/22 at 9:52am, V7 and V8 (both Certified Nursing Assistants/CNAs) were observed providing catheter care to R31. After handwashing and donning gloves,V8 grasped the distal end of the catheter tubing, and wiped the tubing back and forth from meatus to distal end without changing the position of the washcloth or using a clean washcloth for each wipe. R31's Care Plan with a review date of 07/12/22 listed a problem area, (R31) has a (trade name indwelling) catheter, with a corresponding intervention, Catheter care prn (as needed) and every shift. Monitor/Report/Record to MD (Medical Doctor) for signs and symptoms of [CONDITION(S)]. R31's 6/26/22 Urinalysis documented, Clarity-cloudy. Blood: Small amount (present). Leukocytes (white blood cells): Large (amount present). Bacteria-4 plus. Comment-(obtain) urine culture. A Catheter Care Policy with a revision date of January 2017 documented, Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. On 07/13/22 at 1:51pm, V2 (Director of Nurses/DON) confirmed the above observation did not represent aseptic technique during catheter care. V2 stated CNA staff would be re- educated regarding proper technique for catheter care.

Based on interview, and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the development and worsening of pressure ulcers for 1 of 4 residents (R2) reviewed for pressure ulcers in a sample of 4. This failure resulted in R2 to developing a left heel pressure wound with a limb threatening infection which required a hospital admission, antibiotics, and surgical debridement of R2's left heel immediately after being discharged from this facility. Findings include: On 1/10/2022 at 8:30am, V3 (Family Member) said R2 was admitted to this facility on 11/29/2021 for short term rehabilitation after an acute illness and hospitalization . V3 said R2 developed a sore on the back of R2's left heel about two weeks after being admitted . V3 said R2 and R2's family was dissatisfied with the care R2 was receiving at this facility and decided to transfer R2 to another local long term care facility on 1/5/2022. V3 said when R2 was transferred, R2's family became aware of R2's left heel wound and was very surprised to discover the wound because they were told the area was healed long ago. V3 said R2's family thought R2's left heel wound was severe and took R2 to R2's regular family physician (V6) the next day (1/6/2022) for evaluation. V3 said V6 (Family Physician) had R2 immediately admitted to the local hospital for IV (Intravenous) antibiotic therapy and surgical consult for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Brand name treatment) right heel, every shift preventative, Active, Order date 12/9/21, Start date 12/9/21. R2's care plan dated 11/30/2021 lists a goal with an initiation date of 12/7/2021 and further documents (R2) SDTI (Severe Deep Tissue Injury) to left heel will be healed by next review date but no interventions were added or implemented to address R2 ' s left heel wound. The care plan lists the following summarized intervention with implementation dates of 11/30/2021. 1.) Administer medications, 2.) administer treatments as ordered, 3.) avoid scratching, 4.) avoid damaging skin when assisting with repositioning, 5.) assist with repositioning, 6.) pressure relieving cushion to wheelchair, 7.) pressure relieving mattress, 8.) good nutrition. R2's Hospital Records document R2 was admitted to the hospital on 1/6/22 by V6 (Family Physician). V6's H & P (History and Physical) dated 1/6/22 documents in part, (R2) is brought to the office today by (R2's) son and daughter. The patient has recently been in a nursing home getting rehab after hospitalization . Unfortunately, it was recently discovered that the patent has an ulcer on (R2's) left heel. It has recently stated looking deep in bad according to family. The patient states (R2) has had some degree of heel pain for several months, but just recently did it start to look like and ulcer. (R2) has had rather significant pain . The patient was examined in the office in found to likely have a diabetic foot versus early [CONDITION(S)]. (R2) will require IV antibiotics and aggressive wound care. (R2) will be admitted to the hospital for further evaluation and treatment. R2's Hospital Records dated 1/6/22 by V6 documents in part, Skin: Definite large ulcer noted on left heel. Extremities: Large heel ulcer on bottom of left heel. R2's Hospital Records further document on 3:13pm by V6, Plan: admit to the hospital as the patient definitely has a limb threatening infection. (R2) appears to have a diabetic foot and will need aggressive interventions given (R2's) multiple risk factors to include long-term history of diabetes, stage 4 [CONDITION(S)], chronic malnourishment, and history of peripheral artery disease consult (V6) for wound care and potential debridement start [MEDICATION(S)] and [MEDICATION(S)]. R2's Hospital Records dated 1/6/22 by V9 (Wound Specialist Physician) document in part, left heel with an open wound 4 x 3.2 x.2 cm (centimeters) with dry intact eschar covering 80% of the area Assessment and plan- pressure injury left heel, unstageable agree with plan to do arterial dopplers, CT scan, antibiotics, bed side debridement after the eschar is softened up with Santyl. On 1/11/2022 at 9:00am, V1 (Administrator) said R2 medical records did not include any information about a pre-existing left heel pressure area when R2 was admitted to this facility. V1 said R2 developed the left heel wound after being admitted to this facility on 11/29/2021. On 1/12/2022 at 11:30am, V4 (Assistant Director of Nursing/Treatment Nurse/Registered Nurse) said she was responsible for managing the facility's wound care program. V4 said this included weekly assessment of all wounds, measuring, weekly documentation and notifying the physician of any changes in the wounds. V4 said R2 was not admitted to this facility with a left heel wound but developed it after R2 was admitted on [DATE]. V4 said R2 ' s left heel pressure wound was identified on the evening of 12/6/2021 and the next morning she (V4) requested a treatment from R2 ' s physician of [MEDICATION(S)] to be swabbed onto both heels one time, every shift (every 8 hours). V4 said R2 was assessed for pressure wound risk and presented a facility document titled Braden Scale for Predicting Pressure Sore Risk, in which R2 was scored a total of 16 indicating R2 is At Risk for developing pressure sores. V4 said she only measured R2 ' s left heel pressure wound when it was discovered, and it measured 3.5cm (Centimeters) by 4.0cm. and did not re-measure the wound during R2 's 5-week stay at the facility. V4 was asked how R2 ' s wound progression was being measured for improvement and replied she did not know. V4 said except for the [MEDICATION(S)] swabbing treatment she did not discuss other treatment option with R2 ' s physician. V4 said R2 did not sleep in R2's bed and preferred to sit up in R2's bedside recliner to sleep during the night. On 1/12/2022 at 11:30am, V4 said she expected R2 ' s care plan to include pressure relieving interventions to be implemented as soon as R2 was scored to be at risk for pressure sores. V4 said she definitely expected R2 ' s care plan to be updated after R2 was found to have a pressure wound. V4 said she could not find where R2's care plan was updated with pressure relieving interventions after R2 was found to have a pressure wound on R2's left heel on 12/6/2021. After reviewing R2's care plan, V4 said R2's care plan was not properly updated after R2's left heel pressure wound was identified but should have been. On 1/12/2022 at 11:30am, V4 (Assistant Director of Nursing/Wound Treatment Nurse/Registered Nurse) said a pressure ulcer/pressure injury worksheet was never completed for R2's in house acquired pressure wound and thus R2's physician (V5) was not notified of the worksheet's findings. V4 could not reproduce documented evidence of R2's left heel pressure wound being assessed on a weekly basis and the nursing staff had not collaborated with the therapy department. V4 could not reproduce documented evidence of the facility's Dietician being notified of R2 ' s left heel pressure wound and thus R2 was not given nutritional supplements to support wound healing during R2's admission to this facility. V4 said R2's wound did not show improvement and had not progressed in a positive manner during the 5 weeks of admission to this facility. V4 said she nor the nursing staff notified R2's physician to request alterative treatment options. On 1/11/2022 at 12:30pm, V8 (Physical Therapy Assistant) said she has been contracted to provide therapy services to the residents of this nursing home since September 2021 and the therapy department has not been asked to consult for residents to prevent pressure related issues, including pressure wounds. V8 said therapy staff are specially trained to look at and make recommendations for pressure relieving services to prevent or improve healing for pressure wounds. V8 said it is unusual for a nursing home to not utilize their therapy department to assess for ways to prevent pressure that causes wounds. On 1/10/2022 at 11:30am, V5 (Nursing Home Physician/Medical Director), said he came into the facility every week on Wednesday to see R2 during R2's 5-week stay at this facility. V5 said his weekly nursing home visit note did not including information about R2's left heel wound because he was not aware R2 has such a wound. V5 said when a resident develops redness on their heels from pressure, he expects the nursing staff to treat this type of area with a [MEDICATION(S)] swabbing every shift. V5 said the nursing staff had done this as he ordered, however if the area does not improve after a week or so of this treatment then the nursing staff should notify him and then he would refer the patient to a wound physician for further specialized treatment. V5 said it is his expectation for the nursing staff at this facility to bring any new or worsening issue with R2 skin integrity to his attention when he came into the facility to see R2, but they did not. V5 said he was not aware of R2's worsening left heel wound until he was contacted by V6 (Family Physician) on 1/7/2022 and V6 notified him of the worsening wound. On 1/12/2022 at 9:37am, V9 (Wound Specialist Physician) said he has been managing R2 ' s wound care since R2 was discharged from the nursing home and admitted to the local hospital on 1/6/2022 for left heel wound necrosis and a limb threatening infection. V9 said R2's left heel wound was a pressure sore that was caused by pressure and not by R2 ' s comorbidities. V9 said R2 ' s left heel wound could have been prevented with proper medical/nursing care and pressure relieving interventions. V9 said it was his professional opinion that R2 ' s left heel wound began about 4 weeks prior to R2 ' s hospital admitted [DATE]. V9 said when R2 was admitted to the hospital, R2's left heel wound needed to be surgically debrided meaning surgically cutting dead, necrotic tissue from the wound so the wound can heel. V9 said R2 will need additional hospitalization s and debridement treatments in the near future to treat the left heel pressure wound. A facility policy titled Wound Care System Requirements (revision date of 3/2021) documents in part .A pressure ulcer/pressure injury worksheet will be completed each time an in house acquired pressure ulcer/pressure injury is identified. The physician will be notified of the finding from the Pressure Ulcer Pressure Injury Worksheet. Ulcer and skin conditions are assessed and documented weekly. Collaborate with therapy to initiate therapeutic interventions to prevent occurrence or progression of the pressure ulcer/wound. Treatments are to be completed as ordered and are changed if no progress is noted within two weeks.

Based on interview and record review the facility failed to identify the root cause of each resident fall and failed to develop and implement effective interventions that are consistent with professional standards in an effort to reduce future falls for 2 of 5 (R5, R24) residents reviewed for falls in a sample of 21. Findings include: According to R5's EHR (Electronic Health Record), R5 was admitted to this facility on 08/06/2013 with the [DIAGNOSES REDACTED]. R5's EHR shows R5 was mentally assessed for cognitive ability on 01/08/2021 at her quarterly MDS (Minimum Data Set) assessment and received the score of 00, which indicates R5 has very poor mental cognition. 1. On 4/7/2021 at 1:00 pm, V2 DON (Director of Nursing) and V4 MDS-C/CP-C (Minimum Data Set-Coordinator/Care Plan-Coordinator) both verified R5 fell at the facility on 2/9/2021 at approximately 8:45 am in which R5 was sent to the local emergency room for evaluation and treatment due to a left eye brow laceration that required stitches. A facility document titled Confirmation: Report has been submitted, You can investigate this occurrence by clicking here was presented as the facility's documentation of the facility's fall investigation. This document summarizes the fall's details as Resident was ambulating in hallway when she began yelling out for help. She (R5) then started leaning forward with her feet planted and fell forward hitting her head on the floor causing a laceration and stated she was dizzy prior to falling. This same document under the title Fall Detail Report--Occ# 7 under the heading of Preventative Measures at time of fall shows N/A (not applicable) or None answered for each of the 13 preprinted preventative measures listed. When asked what interventions the IDT's (Interdisciplinary Team) put in place after R5's fall, V4 said the only intervention was sending R5 to the local emergency room for evaluation and treatment. V4 said R5 was sent to the local emergency room for evaluation and treatment and thus V4 resolved R5's one fall intervention from R5's care plan at that time. V2 (DON) said and verified per R5's fall report (dated 2/9/2021) the only IDT recommendation listed on R5's fall report was Physician to do a chart review during rounds in order to determine root cause of dizziness. When asked, V2 could not provide any documentation showing R5's physician had performed a chart review during rounds in order to determine the root cause of R5's fall or that the IDT attempted to determine the root cause of R5's fall. V2 verified R5's physician did not see R5 after her 2/9/2021 fall until 3/3/2021 and could not find any documentation of R5' physician performing a chart review and a root cause analysis of R5's fall at that time or show the IDT performing a root cause analysis of R5's fall. V2 verified R5's physician's visit note dated 03/03/2021 mentioned R5's fall which occurred in November 2020 but did not mention R5's fall on 02/09/2021. On 4/7/2021 at 1:20 pm, V2 (DO and V4 (MDSC/CPC) both verified R5 fell at the facility on 11/27/2020 at approximately 8:30 am in which R5 was sent to the local emergency room and found to have a fractured first Cervical Vertebrae and a scalp laceration. When asked about the facility's investigation into the root cause of R5's 11/27/2020 fall, V2 said R5's fall was so unusual that the root cause of the fall was never looked into. V4 said the only intervention put into place to reduce the chances of R5 falling in the future was to measure R5's orthostatic blood pressure for 3 days and once completed, V4 resolved R5's fall from her care plan. When asked about the IDT's (Interdisciplinary Team) assessment of the effectiveness of this intervention, V2 said, We don't do that here. When asked for further explanation, V2 said the IDT doesn't re-evaluate interventions for effectiveness and does not follow up on the IDT post fall investigation recommendations. V2 said she was not aware that R5's physician had not completed the recommended chart review and root cause analysis for R5's fall and said she did not feel the IDT needed to chase after a grown doctor to ensure he completed his chart reviews. 2. According to R24's EHR (Electronic Health Record), R24 was admitted to this facility on 11/18/2019 with the [DIAGNOSES REDACTED]. R24 's EHR shows R24 was mentally assessed for cognitive ability on 03/15/2021 at her quarterly MDS (Minimum Data Set) assessment and received the score of 06, which indicates R5 has poor mental cognition. On 04/07/2021 at 1:35 pm, V2 DON (Director of Nursing) and V4 MDSC/CPC (Minimum Data Set Coordinator/Care Plan Coordinator) both verified R24 fell at the facility on 12/04/2020 at 10:25 am in which R24 was sent to the local emergency room for evaluation and treatment. When asked what interventions were developed and implemented after R24's fall, V4 said R24 was referred for a physical therapy evaluation and no further interventions were put into place. V4 could not produce evidence of R24 being evaluated by physical therapy for her fall on 12/04/2020 as recommended by the IDT and said she resolved this intervention off R24's care plan without the IDT ensuring the intervention was actually in place or completed.

Based on observation, interview and record review the facility failed to wear appropriate Personal Protective Equipment (PPE) into resident rooms or place signage specifying the type of transmission based precautions for two of two residents reviewed for transmission based precautions (R1, R4) in a sample of 4. The findings include: On 3/9/21 at 2:20 PM, surveyor observed V4 Housekeeper/laundry aide coming out of R1's room without a gown or N95 face mask. There was no signage on R1 and R4's door indicating what type of transmission-based precautions were in place or signage in the area around their doors. R1 had a container hanging on the outside of her door with gloves, and 4 empty holes with nothing in them. There were no gowns noted to be in the container on the door. Inside R1's room were two black barrels that contained biohazard bags labeled linen and trash. On 3/9/21 at 2:22 PM, V4 said she would wear gloves, a surgical mask and a face shield into R1's room to clean the room. On 3/9/21 at 2:41 PM, V3 Registered Nurse was asked what type of PPE should be worn into R1 and R4's rooms. V3 said all of it and specified mask, face shield, gown and gloves. When questioned as to what type of mask V3 said surgical. V3 said residents are placed in quarantine every time they have symptoms of COVID. R1 had been placed in quarantine due to having a cough on 3/8/21. V3 was asked what type of precautions R1 and R4 were on. There was no signage on R1's and R4's doors. V3 said she had been off on 3/8/21 and would have to check to find out. On 3/10/21 at 2:46 PM, V7 Certified Nurse Aide was standing behind R1's wheelchair without a gown, and wearing a surgical mask, and face shield. V7 did not have a gown, N95 or gloves on at the time. On 3/10/21 at 2:48 PM, V7 said she realized she needed a gown, and had just taken it off prior to my entry into R1's room. On 3/10/21 at 3:28 PM, V2 Director of Nursing (DON) said R1 was on transmission-based precautions due to having respiratory symptoms similar to COVID and was on droplet and contact transmission-based precautions. V2 also said R1 and R4 are in rooms she called transition rooms and a resident was placed in those rooms due to having symptoms similar to COVID or was a new admission into the building and had not tested positive for COVID. She said she expected the staff to wear a gown, gloves, an N95 face mask, and face shield into those rooms when caring for the residents. On 3/11/2021 at 9:30 AM, V2 DON said she was disappointed in the staff not dealing with the isolation precautions as seriously as they needed to be. The facility document entitled Action Plan - COVID 19 dated 12/10/2020 page 16 says Preventing the Spread of COVID-19, Transition Area: Each community will develop a plan that includes an identified area or group of rooms that will be utilized for all residents that meet the following: 1. Newly admitted or readmitted to the community and their COVID-19 status is negative or unknown. And 3. Current resident that had a sudden onset of respiratory/COVID-19 symptoms, but have not tested positive for COVID-19. On page 18 of this same document lists steps for residents in the transition areas and step number 2. Immediately place on droplet precautions. 3. Isolation set up with gowns, facemasks and shield or goggles, gloves and door signage (an N95 or higher-level respirator is required while in this area) and 4. Maintain core principles of infection control every time you enter or exit the Transition area d) Appropriate use of PPE: eye protection, gowns and gloves.

Based on interview, record review and observation, the facility failed to ensure residents and/or resident representatives were provided the facility's bed hold policy at the time of transfer for 2 of 2 (R13 and R19) residents reviewed for hospitalization in the sample of 27. Findings Include: 1. Review of R13's MDS (Minimum Data Set) dated 4/29/19 documents that R13 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates R13 is cognitively intact. R13 said she does not remember being given a notice of the facility's bed hold policy when she was transferred to a local hospital on [DATE] for [MEDICAL CONDITION]. A form titled Notice of Transfer/Discharge documents R13 was transferred to a local hospital on [DATE], and again on 5/20/19. Review of R13's medical record revealed no evidence of documentation that the facility's bed hold policy was provided to R13 in writing. 2. R19's MDS dated [DATE] documents a BIMS score of 9, indicating R19 has moderate cognitive impairment. A form titled Notice of Transfer/Discharge documents that R19 was discharged to a local hospital on [DATE], and again on 5/22/19. Review of R19's medical record revealed no evidence of documentation that the facility's bed hold policy was provided to R19 or the resident representative in writing. On 7/10/19, at 2:49 PM, V3 (Business Office Manager) stated that they can't charge for a bed hold on Medicaid residents, but the private pay/Medicare resident/resident representatives are phoned to see if they want the bed held, and they give them the rate. V3 then stated No they do not send a notice to Medicaid residents for bed hold. V1 (Regional Nurse Consultant) also added that the policy is in their admission agreement, so the resident and/or resident representative should know. The facility's Bed Hold Policy and Agreement form lists the following under Procedure: a telephone call may be documented as notification on the Bed Hold Agreement. Review of page 6 from the admission packet under Bed Hold Policy indicates that this bed hold policy will be provided to Resident or his or her Authorized Representative at the time of the transfer or discharge from the facility.

Based on interview and record review, the facility failed to provide adequate nursing staff to meet resident needs for 3 (R4, R25, R42) of 45 residents reviewed for staffing. This failure has the potential to effect all 45 residents who reside in the facility. The Findings Include: 1. On 07/09/19 at 11:23 AM, R25 stated there isn't enough staff to tend to resident needs on night shift. R25 said that call lights take an excessive time to answer, and added she has had to wait for greater than 30 minutes at times. R25 stated she has at times experienced incontinence episodes while having to wait for staff to answer her call light, and describes those events as embarrassing and frustrating. R25 said they need more staff at night. R25 stated she has expressed her staffing shortage concern to staff and said they agree, but she was unable to give a specific name as to who she reported this concern. R25's Admission Record documents an original admitted to the facility as 3/23/16. R25's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating she is cognitively intact. This same MDS documents R25's Toilet use as requiring Total Dependence, by Two+ persons physical assist. This same MDS also documents R25 Urinary Continence status as occasionally incontinent with a Bowel Continence status as frequently incontinent. 2. On 7/10/19 at 2:15 PM, R4 stated that the midnight shift does not have enough staff to care for residents, and it takes prolonged periods of time for the staff to get them up for the restroom when call lights are on. R4 stated she has had an incontinence episode in the past waiting for her call light to be answered. A document titled Grievance Report Form dated 4/10/19 documents a grievance filed by R4, which states the nature of the grievance as, After dinner, call lights are slow to be answered because CNA's are in the dining room. The same document asks what actions or recommendations do you feel need to be taken, with a response of R4 stating, I think you need more help. R4's Admission Record documents an original admitted to the facility as 5/14/18. R4's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 9, indicating she is moderately cognitively impaired. R4's MDS documents Toilet use as requiring Extensive assistance, by Two+ persons physical assist. This same MDS also documents R4's Urinary Continence status as frequently incontinent with a Bowel Continence status as always continent. On 7/11/19 at 1:37 PM, V10 (Certified Nurse Assistant/CNA) stated that R4 is cognitively intact and able to recall and answer questions appropriately. The Resident Council meeting minutes dated 4/10/19, under the new business section of Nursing documents the Issues/Concerns area of Slow on call lights. On 7/11/19 at 12:31 PM, V8 (Licensed Practical Nurse/LPN) states that she works as a nurse on night shift. V8 states that there have been times when residents have had to wait an excessive amount of time to have their call light answered due to staff tending to other residents' needs. V8 states the normal staffing for 3rd shift is one nurse and two certified nurse assistants. V8 states she helps aides answer call lights to the best of her ability. V8 states that if a resident requires a two person assist, that resident's needs will occupy the only two available aides. V8 states that they apologize to residents and explain to them that they will be with them as quickly as possible. On 7/11/19 at 1:16 PM, V9 (CNA) states she works 1st shift. V9 states she has received complaints from residents and other staff regarding being short staffed, specifically on 3rd shift. V9 states she has observed the effects of not having enough staff on 3rd shift to meet the needs of residents by seeing evidence of residents who are scheduled to be toileted and/or up and dressed for the day, are still in bed at the time of 1st shift arrival. V9 states night staff will express to 1st shift that they were unable to fulfill the duties of having those people up and ready for the day due to tending to other residents' needs. On 7/11/19 at 1:37 PM, V10 (CNA) states she is assigned to 1st shift, but works 3rd shift overtime at times. V10 states she last worked 3rd shift approximately 2 weeks ago. V10 states she does not feel 2 CNA's and a nurse are adequate staff coverage on 3rd shift. V10 states the demands of the residents' needs is too high for two aides and a nurse to fulfill. V10 states when a resident who requires a two person assist needs assistance, that leaves the other residents waiting for services for an unacceptable amount of time, due to both aides being tied up with one resident. V10 states she has received complaints specifically from R4, R25, and R42 regarding waiting for their call light to be answered for an unacceptable amount of time during 3rd shift. V10 states she has witnessed both R4 and R25 experience urinary incontinence episodes on 3rd shift, due to having to wait for their call light to be answered. V10 describes R4 and R25 as being both embarrassed and apologetic after experiencing their incontinence episodes. V10 states she, along with other staff have expressed their staffing concerns, specifically on 3rd shift to V11 (Administrator), V2 (Director of Nursing/DON), and V12 (Assistant Director of Nursing/ADON). V10 states V11, V2, and V12 tell them they are working on it. On 7/11/19 at 12:30 PM, V2 (DON) states the normal staffing coverage for 3rd shift, which is 10:00 PM - 6:00 AM, is 1 nurse, and 2 nurse aides. V2 states that although staff may be mandated to fill staffing needs on 3rd shifts, or herself and V12 (ADON) cover scheduled shortages/call ins, V2 states the count of 2 aides and 1 nurse are met. On 07/12/19 at 09:07 AM, V2 states the facility determines staffing levels based on the facility census. V2 states V11 (Administrator) provided her a staffing ratio document that states how many staff to utilize based on the facility census. On 7/11/19 at 2:23 PM, V11 acknowledges she has had residents complain to her regarding the amount of time it takes staff to answer call lights. V11 states the facility initiated a performance improvement plan, and met with the union to implement a staff mandate program to cover staff shortages. The resident census and condition form dated 7/11/19 documents the facility census as 45.

Based on observation, interview and record review, the facility failed to implement fall prevention interventions as identified in the Care Plan for 1 of 27 residents (R38) reviewed for Care Plans in the sample of 27. Findings include: R38's current Care Plan includes a Focus area initiated on 3/14/19, which identifies R38 as being at risk for falls. Interventions for prevention of falls listed on this same document, include: Anti - rollbacks on wheelchairs, initiated on 3/30/19; and Body Pillow, initiated on 3/18/19. On 7/11/19 at 11:14 AM, V14 (Care Plan Coordinator), accompanied the surveyor to R38's room, and viewed R38's wheelchair. V14 confirmed that anti - rollback devices were not in place on R38's wheelchair, and added that they would be put in place on this date. On this same date and time, a standard-sized pillow was noted on R38's bed, as opposed to the Body Pillow that was listed on the care plan. On 7/12/19 at 9:10 AM, a large, blue, rectangular pillow was noted on R38's bed. R38 stated at this time, that this was the first time she has seen this pillow and is not sure what it's for.

Based on observation, interview and record review, the facility failed to ensure controlled medications were appropriately disposed of for 1 (R16) of 1 resident reviewed for controlled medication disposal in the sample of 27. The Findings Include: On [DATE] at 11:25 AM, V7 (Licensed Practical Nurse/LPN) was observed preparing and attempting to administer R16 her prescribed medication. Included in the prepared mediation was a [MEDICATION NAME] 0.25 MG (Milligram) tablet which was observed as being stored under double locked conditions in the medication cart. Upon R16's refusal to take her medication, V7 was observed disposing of R16's medication by dumping the cup of pills in the red, biohazard sharps container attached to the side of the medication cart. R16's current physician's orders [REDACTED].*Controlled Drug* Give 0.5 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED. The United States Drug Enforcement Administrator documents via website, https://www.dea.gov/drug-scheduling, [MEDICATION NAME] is considered a class IV Scheduled medication. A document titled Controlled Substance Policy with a revision date of (MONTH) (YEAR) states, Controlled Substances in Schedules II, III, and IV are subject to special handling, storage, disposal and record-keeping requirements. Such drugs are to be accessible only to authorized nursing and pharmacy personnel. The Director of Nurses is responsible for the control of such drugs. The same policy goes on to state, Drugs listed in Schedules II, III, and IV are to be stored under double-lock conditions. A policy titled Disposal/Destruction of Expired or Discontinued Medication with a most recent revision date of [DATE] states, Wasted medications are defined as medication contaminated or refused that require disposal. The same policy goes on to state, Wasted controlled medications should be destroyed by two licensed nurses employed by Facility, and the disposal should be documented on the accountability record on the line representing that dose. This procedure should apply to the disposal of unused doses (whole tablets, partial tablets, unused portions of single dose [MEDICATION NAME] and doses of controlled substances) wasted for any reason. The same policy also goes on to state, Wasted single doses of medication for disposal should disposed of in a manner that limits access to them by unauthorized personnel or residents. On [DATE] at 10:26 AM, V6 (Registered Nurse/RN) stated narcotic medication destruction is done in the presence of 2 nurses. V6 states the controlled medication is crushed and mixed with cat litter and water for the destruction process. On [DATE] at 10:00 AM, V2 (Director of Nursing/DON) stated it would not be her expectation that nurses would dispose of controlled medications in the biohazard sharps container upon resident refusal of their medication. V2 states nurses would be expected to proceed through the normal controlled substance destruction procedure, which would include having a second nurse witness/document observation of the destruction of the medication with cat litter.

Based on record review and interview the facility failed to notify the resident representatives in writing of the hospital transfers for 3 of 3 residents (R3, R37, R40) reviewed for hospitalization s in a sample of 29. The Findings Include: 1. R37's Echart lists a primary responsible party as V12 (family) and Physician (V6). R37 was admitted to the facility on [DATE] with primary [DIAGNOSES REDACTED]. On 6/16/18, R37's health status notes document that R37 was sent to the hospital per V6 for evaluation related to change in condition. These changes included coarse crackles heard in all lung fields and the resident was tired and not herself. R37 was admitted to the hospital and stayed through 6/20/18. On 8/20/18 R37's health status notes document that R37 was sent to the hospital per V6 for respirations at 32, chest muscle breathing and appearing to be pale in color and skin cool to touch. R37 was admitted to the hospital with [REDACTED]. On 9/14/18, R37's health status notes document that R37 was sent to the emergency room for evaluation for oxygen saturation levels at 84% while on oxygen at 2.5 liters/minute. R37 was diagnosed with [REDACTED]. No indication of the resident or the resident family representative being notified in writing was found in the clinical document. 2. R40 was sent to the hospital on 6-23-18 at 5:35 AM with complaints of chest pain and remained until 7/5/18 as noted in the Nurse Progress Notes. Section C of the Minimum Data Set assessment tool with a date of 3-26-18 documents R40 with moderate cognitive impairment. As noted in the clinical record, neither R40 nor R40's resident representative were notified in writing of the transfer and the reason for the transfer. 3. R3's face sheet dated 9/21/18 documents R3 was admitted to the facility on [DATE] and R3's [DIAGNOSES REDACTED]. R3 has a BIMS (Brief Interview for Mental Status) score of 7, which indicates R3 has a severe cognitive impairment. R3's hospital Physician Clinical Report dated 7/15/18 documents R3 was evaluated at the local hospital for complaints of chest pain and diagnosed with [REDACTED]. R3's hospital Physician Clinical Report dated 7/23/18 documents under, History of Present Illness; Chief complaint: vomiting and diarrhea. The patient has had nausea, vomiting, and diarrhea Clinical Impression: Acute [MEDICAL CONDITION] gastroenteritis. No rotavirus gastroenteritis or norovirus gastroenteritis .Discharge instructions reviewed with caregiver and understanding verbalized. On 9/19/18 at 2:47 PM, V1, Administrator, stated that the resident family representatives are notified prior to or at the time of the transfer of residents to the hospital over the phone. There is nothing in writing provided to the resident or the family representatives regarding the transfers.

Based on observation, interview, and record review, the facility failed to develop and implement a personalized plan of care for 2 (R7 and R33) of 15 residents reviewed for comprehensive care planning in the sample of 29. Findings include: 1. Review of R7's Order Summary Report dated 9/20/18 documents an admitted to the facility of 10/6/17. [DIAGNOSES REDACTED]. Review of the Patient Report from the local hospital dated 1/24/18 documents R7 has a Large, large ventral hernia that has been present for many, many years. It still remains the size of a basketball. A document titled Assessment of (R7) dated 10/05/17, completed by V16 (Pre Admission and Resident Review Screener) states, He eats cigarettes off the floor. (Nursing Facility) was notified that I had done the screening and the above information. A Pre-Admission Screening, Level 1 Summary dated 10/11/17 documents Staff at (local shelter care) state he is not a behavior problem, but does eat cigarettes off the floor. An Admission History and Physical dated 10/3/17 completed by the local hospital and noted in R7's Clinical Record documents, Patient also has a history of eating tobacco. On 09/18/18 at 01:54 PM, 3 cigarette butts were observed lying on a bookshelf in R7's room. On 09/19/18 at 01:50 PM, R7 states the nurses store his smoking supplies for him. R7 states he will on occasion smoke a cigarette, but prefers to eat them. R7 describes breaking the cigarette off at the point of the filter, and will sometimes keep them to chew on. R7 laughs, and states he will find the butts on his bed, on a shelf, or he will throw them away. R7 states he does have a history of ingesting cigarette filters and states that V1 (Administrator) has told him in the past not to eat them. R7 states he is allowed to smoke / take his smoking supplies to the corridor smoking area independently, without supervision. On 09/19/18 at 02:42 PM, R7 was observed chewing on cigarette without the filter attached. R7 states he uses the cigarette as chewing tobacco, and then swallows the tobacco. 4 cigarette filters were observed on his book shelf at this time. R7 states he does get stomach discomfort, along with diarrhea at times, but states he is unsure of the cause. On 09/20/18 at 10:07 AM, R7 was observed in his room with a cigarette in his pocket. R7 voluntarily demonstrated the process in which he broke off part of the tobacco end of the cigarette, tore off the paper dumping the tobacco in his hand, and placed the tobacco in his mouth. R7 states he will chew on it for a while, then swallow it. R7 was observed placing the remaining part of the cigarette back in his pant pocket. R7 states he chews and eats approximately 9-10 cigarettes daily. As listed on Merriam-Webster (https://www.merriam-webster.com/dictionary/pica), PICA is defined as An abnormal desire to eat substances (such as chalk or ashes) not normally eaten. On 9/20/18 at 09:25 AM, V1 states R7 was admitted to the facility from a shelter care with a history of eating cigarette butts. V1 states at times he has been seen, since at the facility messing with the cigarette butts, but states she spoke with him about not eating them and they have had no further concerns. V 1 states if R7 was eating cigarettes, she would see that as being a concern. V1 states she would expect a current PICA concern, or history of PICA to be included in the resident's Care Plan, and also tracked as a behavior. On 09/20/18 at 09:55 AM, V2 (Director of Nursing, DON) states if a resident did have a [DIAGNOSES REDACTED]. On 09/20/18 at 11:54 AM, V6 (Physician) states he would expect the facility to have a plan of care in place to address R7's PICA behavior. On 09/20/18 at 12:40 PM, V13 (Advanced Practice Registered Nurse-Certified Nurse Practitioner-Psychiatric Mental Health Nurse Practitioner, APRN-CNP, PMHNP) states she would expect R7 to have a plan of care in place to address his PICA behavior. On 09/20/18 at 12:45 PM, V2 states she would expect R7's hernia to be addressed on his care plan. Review of R7's most recent Care Plan as provided by the facility, does not list any plan of care for R7's current, or history of PICA behavior, nor does it address a plan of care for his very large ventral hernia. 2. R33's admission Minimum Data Set (MDS) indicates that R33 has a [DIAGNOSES REDACTED]. R33's Order Summary Report for (MONTH) (YEAR) has an order for [REDACTED]. R33 returned to facility on the same day with a health status note entered by nursing staff at the time 3:32 PM, and that he returned with a bandage on his face and daily dressing orders along with insertion of a port and orders regarding the treatment prior to use. A current copy of the R33's care plan with most recent revision date of 9/5/18, has no focus area related to R33'[MEDICAL CONDITION], treatment of [REDACTED]. On 9/19/18 at 2:30 PM, V2 (Director of Nursing) stated that it would be her expectation for new care concerns and treatments to be updated and added to the care plans for all staff to be aware of current needs.

Based on observation, interview, and record review the facility failed to identify and treat pressure ulcers acquired at the facility for 2 of 3 (R3 and R9) residents reviewed for pressure ulcers in the sample of 29. Findings Include: 1) R3's face sheet dated 9/21/18 documents R3 was admitted to the facility on [DATE] and R3's [DIAGNOSES REDACTED]. R3 has a BIMS (Brief Interview for Mental Status) score of 7, which indicates R3 has a severe cognitive impairment. On 09/18/18 at 10:05 AM R3 stated, I have a sore on my bottom. When asked if there was a dressing on the sore R3 stated, No, just a cream. R3's Braden scale assessment dated [DATE] documents R3 has a score of 21 which indicates she is not at risk for pressure ulcers. R3's weekly skin assessments dated 8/1/18 through 9/5/18 do not document skin impairment to R3's buttocks. R3's order summary report with active orders as of: 9/20/18 does not document a treatment for [REDACTED]. R3's care plan documents, R3 has potential for skin impairment r/t (related to) needing assist with bed mobility. Date initiated 11/6/15, Revision on 11/16/15. There is not a skin breakdown focus area documented on R3's current care plan. On 09/20/18 at 1:30 PM, R3 was observed in her bathroom with V2 (Assistant Director of Nursing-ADON) present. R3 had an open area on her right buttock and on her left buttock with discolored tissue surrounding the area on her left buttock. R3 stated the area on the right side had been there about a week but she wasn't aware of the area on the left side. R3's pressure ulcer weekly wound evaluation dated 9/20/18 documents a Stage 2 pressure ulcer on R3's left inner buttock measuring 0.3 by 0.2 with an unknown depth, acquired during stay (in house). R3's pressure ulcer weekly wound evaluation dated 9/20/18 documents a Stage 2 pressure ulcer on R3's right buttock measuring 0.5 by 1.3 cm (centimeters), acquired during stay (in house). On 9/20/18 at 1:30 PM V2 (ADON) stated she did not think R3 had a skin assessment for the last eight days or so and was not aware of the pressure areas. 2) R9's face sheet dated 9/21/2018 documents an admission date of [DATE] and R9's [DIAGNOSES REDACTED]. R9 has a BIMS score of 06, which indicates R9 has a severe cognitive impairment. On 09/19/18 at 10:26 AM, R9 stated she had a sore on her bottom. On 09/19/18 at 3:07 PM, R9 was observed in bed, V2 (ADON), V14 and V15 (Certified Nursing Assistants-CNA) were present during the observation. R9 was observed to have an open area on her right buttock. R9's Braden scale for predicting pressure sore risk dated 7/6/18 documents R9 has a score of 14 which indicates she is at a moderate risk for acquiring a pressure sore. R9's skin check weekly and PRN (as needed) dated 8/1/18 through 9/12/18 does not document a wound to R9's buttocks. R9's monthly skin check dated 9/19/18 documents, open area to right lower buttocks. R9's weekly wound evaluation dated 9/19/18 documents a Stage 3 pressure ulcer measuring 0.4 by 0.5 by 0.05 on R9's right lower buttock, acquired during stay (in house). R9's order summary report active orders as of: 9/20/18 documents an order dated 9/19/18 to clean scabbed area on inner right buttock, pat dry, apply calazyme cream until healed. R9's order report continues to document an order dated 9/20/18 to clean area, pat dry, apply therahoney to open area only and cover with border gauze every shift for pressure ulcer. R9's care plan documents, R9 has a potential for skin impairment r/t (related to) immobility. Date initiated 05/25/16 Revision on: 05/25/16. R9's care plan continues to document, R9 has a pressure ulcer on right buttock. Date initiated: 09/20/18, Revision on: 09/20/18. On 9/19/18 at 3:07 PM, V2 (ADON) stated apparently R9 had the open area on her right buttock prior to the observation on 09/19/18, but she had not been made aware of it. When asked if R9 had the open area prior to the skin assessment that was completed this morning at 5:20 AM by the facility nursing staff, V2 stated, They must have missed it. When asked where the measurements of the area were documented V2 stated it was on another assessment that she had not completed yet. The facility Pressure Ulcer/Pressure Injury Prevention policy dated 04/2018 documents, A pressure ulcer/injury (PU/PI) can occur whenever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter: Evaluate resident specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PI's. The first step in the prevention of PU/PI's, is the identification of the resident at risk for developing PU/PI's. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. On 09/20/18 at 3:37 PM, V2 (ADON) stated when a certified nursing assistant identifies an open area they should notify the nurse and the nurse should do an assessment and notify the family, the Director of Nurses, and the Physician for orders to treat the area. V2 (ADON) confirmed she had not been made aware of the open areas on R3 or R9. V2 also confirmed, R3 and R9 did not have assessments completed on their wounds, family was not notified, and the physician was not notified of the wounds prior to the observations with the surveyor. V2 (ADON) confirmed both R3 and R9's pressure areas were acquired in the facility.

Based on observation, interview, and record review, the facility failed to provide adequate smoking supervision for 1 (R7) of 1 resident reviewed for smoking in the sample of 29. The Findings include: A Physician's Report dated 1/26/18, and completed by V6 (Physician) documents R7 requires supervision with smoking and appropriate disposal of cigarette filters with education not to eat them. On 09/18/18 at 01:54 PM, 3 cigarette butts were observed lying on a bookshelf in R7's room. On 09/19/18 at 01:50 PM, R7 states the nurses store his smoking supplies for him. R7 states he will on occasion smoke a cigarette, but prefers to eat them. R7 describes breaking the cigarette off at the point of the filter, and will sometimes keep them to chew on. R7 laughs and states he will find the butts on his bed, on a shelf, or he will throw them away. R7 states he does have a history of ingesting cigarette filters and states that V1 (Administrator) has told him in the past not to eat them. R7 states he is allowed to smoke / take his smoking supplies to the corridor smoking area independently, without supervision. On 09/19/18 at 02:42 PM, R7 was observed chewing on cigarette without the filter attached. R7 states he uses the cigarette as chewing tobacco, and then swallows the tobacco. 4 cigarette filters were observed on his book shelf at this time. R7 states he does get stomach discomfort, along with diarrhea at times, but states he is unsure of the cause. On 09/20/18 at 10:07 AM, R7 was observed in his room with a cigarette in his pocket. R7 voluntarily demonstrated the process in which he broke off part of the tobacco end of the cigarette, tore off the paper dumping the tobacco in his hand, and placed the tobacco in his mouth. R7 states he will chew on it for a while, then swallow it. R7 was observed placing the remaining part of the cigarette back in his pant pocket. R7 states he chews and eats approximately 9-10 cigarettes daily. R7's Care Plan with an initiation date of 11/03/17 states resident can Smoke Independently. On 09/19/18 at 02:39 PM, V7 (Registered Nurse, RN) showed this surveyor R7's smoking supplies. V7 states that R7 receives 1 cigarette, anytime he requests, with no lighter due to his preference to chew the cigarette, rather than smoke them. V7 states R7 signs in and out on a sheet when he goes to sit in the smoking area of the court yard to engage in his tobacco activities. V7 states that R7 is allowed to use his tobacco independently, without supervision. On 9/20/18 at 09:25 AM, V1 states that R7 uses his tobacco by method of smoking. V1 states that R7 has been assessed as an independent smoker, and he signs in and out when going outside to smoke. V1 states R7 came from a shelter care facility with a history of eating cigarette butts. V1 states at times since his admission to the facility, R7 has been seen messing with cigarette butts, but states she spoke with him about not eating them, and they have had no further concerns. V1 states if R7 was eating cigarettes, she would concern that a concern. V1 states she would expect any PICA concerns to be included in the resident's Care Plan, and also tracked as a behavior. V1 also states if a physician recommended a resident be supervised for smoking, she would expect those recommendations to be followed. V1 states Social Services meets with resident's to discuss behaviors, or concerns along with creating behavior tracking documentation sheets. On 09/20/18 at 9:30 AM, V9, (Certified Nurse Assistant, CNA) states she has only worked at the facility for approximately 3 weeks. V9 states to her understanding R7 is a smoker, and has a behavior of unraveling his cigarettes in his room. V9 states staff clean up tobacco pieces on the floor in his room frequently. V9 states she personally is not sure how R7 uses his tobacco, as she does not see him go outside to smoke. V9 states she is not aware if R7 ingests his cigarettes. V9 states R7 has never complained to her of abdominal pain, or concerns with bowel movements. On 09/20/18 at 09:45 AM, V10 (Registered Nurse, RN) states to her understanding, R7 Eats and chews the tobacco, but leaves the butts. V10 states R7 doesn't smoke the cigarettes, and states R7 doesn't even have a lighter. V10 states R7 has never complained to her of any abdominal concerns. V10 states that the amount of cigarettes R7 uses daily varies. V10 states some day she may give him 1 on her shift, while other days it may be 3. V10 states that from her understanding, R7 had a behavior of eating cigarette butts prior to his admission to the facility. V10 states R7's cigarettes are kept by nursing staff, and they are given to him 1 cigarette at a time. V10 states that R7 uses his cigarettes independently, without constant supervision. V10 states that she is not aware of any PICA history, other than R7's history with cigarettes. V10 states that she has noted tobacco being scattered on the floor in his room, in which she states she documents in progress notes, and reports to V11 (Social Services), and V2 (Director of Nursing, DON). V10 states that R7 is a very private person. V10 states that she is aware R7 places the tobacco in his mouth, as she states R7 has asked her before if she's ever tried it. On 09/20/18 at 09:55 AM, V2 states R7 hasn't smoked tobacco for a while. V2 cannot give an exact date of when he stopped, but does state R7 doesn't even have a lighter. V2 states she is unaware if R7 is purposefully swallowing tobacco. V2 states she is not aware of any PICA history R7 has. V2 states R7 was admitted to them from a shelter care home, and the history they received regarding R7 was very limited. V2 states if a resident did have a [DIAGNOSES REDACTED]. involved smoking materials. V2 states smoking assessments are completed quarterly by nursing staff. V2 states R7 has not expressed to her any abdominal pain / concerns. On 09/20/18 at 10:10 AM, V11 states R7 is currently being tracked for the behaviors of being an elopement risk, and auditory hallucinations. V11 reports she meets with R7 at least weekly to discuss any concerns / behavior's R7 is having. V11 states R7 receives psychiatric services from an outpatient center, and states she is not aware of any new behavior R7 has had since his admission to the facility. V11 states R7 was initially scheduled for a psychiatric appointment for routine care. V11 states she does notice that R7 does not go outside to smoke as much as he used to. V11 states she was told by the shelter care facility that R7 previously resided at that R7 would seek out cigarette butts. V11 states she was under the impression R7 would seek out the butts though to smoke any tobacco left on them. V11 states if R7 did have a history, or current PICA [DIAGNOSES REDACTED]. On 09/20/18 at 11:54 AM, V6 (Physician) states R7 should not be eating cigarettes, and states he maintains his statement made in his Physician's Report dated 01/26/18 that R7 should be supervised while smoking due to his history of eating cigarettes. Dr. Parks states he was contacted by V2 this AM regarding R7 eating his cigarettes presently. V6 states as he discussed with the V2, eating cigarettes is terrible, but with R7's psychiatric diagnoses, taking the cigarettes away so he cannot eat them may also pose a problem. V6 states he would expect the facility to have a plan of care in place to address this behavior. On 09/20/18 at 12:40 PM, V13, (Advanced Practice Registered Nurse-Certified Nurse Practitioner-Psychiatric Mental Health Nurse Practitioner, APRN-CNP, PMHNP) states that she has seen R7 in her office for psychiatric services. V13 states she was not aware R7 is currently eating his cigarettes, but was aware of his history of ingesting them. V13 states that purposeful ingestion of a cigarette would be considered PICA. V13 states that she would expect R7 to be supervised with his smoking materials due to his history and present PICA behavior. V13 states she would also expect R7 to have a plan of care in place, and behavior tracking to address his PICA behavior. On 09/20/18 at 12:45 PM, V2 states R7 is on 15 minute checks, only when he is outside for safety due to his history of sitting outside in inclement weather. On 09/19/18 at 08:10 PM, V8 (Certified Specialist in Poison Information, RN) from the Illinois Poison Center (1-800-222-1222) states, Ingestion of tobacco in cigarettes has the potential to cause nicotine poisoning which may result in nausea, vomiting, tremors, etcetera, and the need for emergency room Evaluation if symptomatic. As listed on the Merriam-Webster website (https://www.merriam-webster.com/dictionary/pica), PICA is defined as An abnormal desire to eat substances (such as chalk or ashes) not normally eaten. On 09/19/18 at 08:30 PM, Review of an article titled, Tobacco and cigarette butt consumption in humans and animals, listed on the National Center for Biotechnology Information, United States National Library of Medicine (https://www.ncbi.nlm.gov/pmc/articles/PMC 60) states: Cigarettes contain at least 4000 chemicals, with about 50 of these being carcinogenic. Although a typical cigarette contains from 9 milligrams (mg) to 30 mg of nicotine, inhalation through smoking is only about 0.5 - 2 mg per cigarette. Nicotine in tobacco products is rapidly absorbed by oral and intestinal mucosa, and alkalinisation enhances absorption; nicotine-related symptoms develop rapidly (less than 4 hours) after ingestion. These may represent a wide variety of symptoms including nausea, vomiting, salivation and diaphoresis; with severe poisoning, there may be convulsions, [MEDICAL CONDITION] with [MEDICAL CONDITION], cardiac arrhythmias and respiratory depression.

Based on observation, interview, and record review the facility failed to provide appropriate care for 2 of 4 (R18 and R34) residents in the sample of 29 reviewed for urinary catheter/incontinent care. Findings Include: 1) R34's annual MDS-Minimum Data Sets dated 8/27/18 documents R34 has severely impaired cognitive skills and R34's [DIAGNOSES REDACTED]. R34's MDS continues to document R34 has an indwelling catheter. On 9/20/18 at 9:46 AM, V5 (LPN-Licensed Practical Nurse) provided catheter care for R34. V5 washed her hands and asked R34 if it was ok to provide care to him. Once she received his consent for care V5 removed the dressing from R34's suprapubic catheter insertion site. V5 then washed her hands and put on clean gloves. V5 used a clean wet wash cloth and washed down the catheter tube towards the insertion site. V5 then got a clean wash cloth and washed down the catheter tube towards the insertion site again. V5 dried the catheter tube and surrounding skin with a clean towel then reapplied a dressing to the insertion site. V5 confirmed she had used the wash cloth and washed down the tube towards the insertion site. The facility Catheter Care, Urinary policy dated 01/2017 documents under, 12. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site outward. On 09/20/18 at 3:37 PM, V2 (Director of Nurses-DON) stated she would expect to see the nurse wipe away from the insertion site not towards the insertion site when providing catheter care. 2. On 9-20-18 at 11:31 AM an observation was made of R18 receiving incontinence care after having been found to be soiled with urine. V17, Certified Nurse Aide (CNA) cleaned R18, wiping down thru the inner upper thighs and downwards thru the peri-area. V17 and V18, CNA turned R18 to her left side. V18, Certified Nurse Aide (CNA), then continued cleaning R18, wiping from the coccyx area and down thru the rectum and towards the vaginal area. The wash cloth was noted soiled with a light brown discoloration after V18 had wiped this area. V18 obtained a fresh washcloth and again wiped in the same downward motion thru the rectal area and this time the cloth was noted to contain a small amount of soft formed stool. V18 used clean washcloths twice more and was noted to wipe correctly from the vaginal area then back towards rectum. R18's buttocks and back of thighs were not cleaned. V17 and V18 were asked if R18 had been incontinent of urine and V18 stated yes she (R18) was wet. V5, Licensed Practical Nurse (LPN) was present during the incontinence care. After completion of the care, V5 verified that the incontinence care was not performed appropriately. The facility policy for Perineal Care, with a revision date of (MONTH) 2010, states that the perineal area should be wiped from the front labia area downward and after turning resident to her side, the rectal area should be washed thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to address PICA behavior for 1 (R7) of 2 resident reviewed for behavioral health needs in the sample of 29. The findings include: 1. As listed on the Merriam-Webster website (https://www.merriam-webster.com/dictionary/pica), PICA is defined as An abnormal desire to eat substances (such as chalk or ashes) not normally eaten. Review of R7's Order Summary Report dated 10/20/18, documents an admitted to the facility as 10/06/17, with current psychiatric [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R7 has a Brief Interview for Mental Status (BIMS) score of 13. This score of 13 would make R7 considered as being cognitively intact. A document titled Assessment of (R7) dated 10/05/17, which was completed by V16 (Pre Admission and Resident Review Screener) states, He eats cigarettes off the floor. (Nursing Facility) was notified that I had done the screening and the above information. A Pre-Admission Screening, Level 1 Summary dated 10/11/17 documents Staff at (local shelter care) state he is not a behavior problem, but does eat cigarettes off the floor. An Admission History and Physical dated 10/3/17, which was completed by the local hospital states, Patient also has a history of eating tobacco. On 09/18/18 at 01:54 PM, 3 cigarette butts were observed lying on a bookshelf in R7's room. On 09/19/18 at 01:50 PM, R7 states the nurses store his smoking supplies for him. R7 states he will on occasion smoke a cigarette, but prefers to eat them. R7 describes breaking the cigarette off at the point of the filter, and will sometimes keep them to chew on. R7 laughs, and states he will find the butts on his bed, on a shelf, or he will throw them away. R7 states he does have a history of ingesting cigarette butts and states that V1 (Administrator) has told him in the past not to eat them. R7 states he is allowed to smoke / take his smoking supplies to the corridor smoking area independently, without supervision. On 09/19/18 at 02:42 PM, R7 was observed chewing on cigarette without the filter attached. R7 states he uses the cigarette as chewing tobacco, and then swallows the tobacco. 4 cigarette filters were observed on his book shelf at this time. R7 states he does get stomach discomfort, along with diarrhea at times, but states he is unsure of the cause. On 09/20/18 at 10:07 AM, R7 was observed in his room with a cigarette in his pocket. R7 voluntarily demonstrated the process in which he broke off a portion of the tobacco end of the cigarette, tore off the paper dumping the tobacco in his hand, and placed the tobacco in his mouth. R7 states he will chew on it for a while, then swallow it. R7 was observed placing the remaining part of the cigarette back in his pant pocket. R7 states he chews and eats approximately 9-10 cigarettes daily. Review of R7's current Behavior Tracking monitoring forms document no behavior tracking for PICA. Review of R7's most recent Care Plan as provided by the facility, does not list any plan of care for R7's current or history of PICA behavior. R7's Care Plan with an initiation date of 11/03/17 states resident can Smoke Independently. A Physician's Report completed by V6 (Physician), and dated 01/26/18 documents R7 requires supervision with smoking and appropriate disposal of cigarette filters with education not to eat them. On 09/20/18 at 11:54 AM, V6 states R7 should not be eating cigarettes, and states he maintains his statement made in his Physician's Report dated 01/26/18 that R7 should be supervised while smoking due to his history of eating cigarettes. Dr. Parks states he was contacted by V2 this AM regarding R7 eating his cigarettes presently. V6 states as he discussed with the V2, eating cigarettes is terrible, but with R7's psychiatric diagnoses, taking the cigarettes away so he cannot eat them may also pose a problem. V6 states he would expect the facility to have a plan of care in place to address this behavior. On 09/20/18 at 12:40 PM, V13 (Advanced Practice Registered Nurse-Certified Nurse Practitioner-Psychiatric Mental Health Nurse Practitioner, APRN-CNP, PMHNP), verifies she has seen R7 in her office for psychiatric services. V13 states she was not aware R7 is currently eating his cigarettes, but was aware of his history of ingesting them. V13 states that purposeful ingestion of a cigarette would be considered PICA. V13 states that she would expect R7 to be supervised with his smoking materials due to his history and present PICA behavior. V13 states she would also expect R7 to have a plan of care in place, and behavior tracking to address his PICA behavior. A Psychiatric Initial Evaluation dated 7/31/18, and completed by V13 documents R7 has had multiple past psychiatric hospitalization s. This document states resident information was obtained from R7 himself, and also from V1. This document states R7 Has occasional outburst which involve yelling and PICA of cigarette butts. On 09/19/18 at 02:39 PM, V7 (Registered Nurse, RN) showed this surveyor R7's smoking supplies. V7 states that R7 receives 1 cigarette, anytime he requests, with no lighter due to his preference to chew the cigarette, rather than smoke them. V7 states R7 signs in and out on when he goes to sit in the smoking area of the court yard to engage in his tobacco activities. V7 states that R7 is allowed to use his tobacco independently, without supervision. On 9/20/18 at 09:25 AM, V1 states that R7 uses his tobacco by method of smoking. V1 states that R7 has been assessed as an independent smoker, and he signs in and out when going outside to smoke. V1 states R7 came from a shelter care facility with a history of eating cigarette butts. V1 states at times since admission to the facility R7 has been observed messing with cigarette butts, but states she spoke with him about not eating them, and they have had no further concerns. V1 states if R7 was eating cigarettes, she would consider that a concern. V1 states she would expect any PICA concerns to be included in the resident's Care Plan, and tracked as a behavior. V1 also states if a physician recommended a resident be supervised for smoking, she would expect those recommendations to be followed. V1 states Social Services meets with resident's to discuss behaviors or concerns, along with creating behavior tracking documentation sheets. On 09/20/18 at 9:30 AM, V9, (Certified Nurse Assistant, CNA) states she has only worked at the facility for approximately 3 weeks. V9 states to her understanding, R7 is a smoker and has a behavior of unraveling his cigarettes in his room. V9 states staff clean up tobacco pieces on the floor in his room frequently. V9 states she personally is not sure how R7 uses his tobacco, as she does not see him go outside to smoke. V9 states she is not aware if R7 ingests his cigarettes. V9 states R7 has never complained to her of abdominal pain, or concerns with bowel movements. On 09/20/18 at 09:45 AM, V10 (Registered Nurse, RN) states to her understanding, R7 Eats and chews the tobacco, but leaves the butts. V10 states R7 doesn't smoke the cigarettes, and states R7 doesn't even have a lighter. V10 states R7 has never complained to her of any abdominal concerns. V10 states that the amount of cigarettes R7 uses daily varies. V10 states some day she may give him 1 on her shift, while other days it may be 3. V10 states that from her understanding, R7 had a behavior of eating cigarette butts prior to his admission to the facility. V10 states R7's cigarettes are kept by nursing staff, and they are given to him 1 cigarette at a time. V10 states that R7 uses his cigarettes independently, without constant supervision. V10 states that she is not aware of any PICA history, other than R7's history with cigarettes. V10 states that she has noted tobacco being scattered on the floor in his room, in which she states she documents in progress notes, and reports to Social Services and the V2 (Director of Nursing, DON). V10 states that R7 is a very private person. V10 states that she is aware R7 places the tobacco in his mouth, as she states R7 has asked her before if she's ever tried it. On 09/20/18 at 09:55 AM, V2 states R7 hasn't smoked tobacco for a while. V2 cannot give an exact date of when he stopped, but does state R7 doesn't even have a lighter. V2 states she is unaware if R7 is purposefully swallowing tobacco. V2 states she is not aware of any PICA history R7 has. V2 states R7 was admitted to them from a shelter care home, and the history they received regarding R7 was very limited. V2 states if a resident did have a [DIAGNOSES REDACTED]. involved smoking materials. V2 states smoking assessments are completed quarterly by nursing staff. V2 states R7 has not expressed to her any abdominal pain / concerns. On 09/20/18 at 10:10 AM, V11 (Social Services) states R7 is currently being tracked for the behaviors of being an elopement risk, and auditory hallucinations. V11 reports she meets with R7 at least weekly to discuss any concerns / behavior's R7 is having. V11 states R7 receives psychiatric services from an outpatient center, and states she is not aware of any new behavior R7 has had since his admission to the facility. V11 states R7 was initially scheduled for a psychiatric appointment for routine care. V11 states she does notice that R7 does not go outside to smoke as much as he used to. V11 states she was told by the shelter care facility that R7 previously resided at that R7 would seek out cigarette butts. V11 states she was under the impression R7 would seek out the butts though to smoke any tobacco left on them. V11 states if R7 did have a history, or current PICA [DIAGNOSES REDACTED]. On 09/20/18 at 12:45 PM, V2 states R7 is on 15 minute checks only when he is outside for safety due to his history of sitting outside in inclement weather. On 09/19/18 at 08:10 PM, V8 (Certified Specialist in Poison Information, RN) from the Illinois Poison Center (1-800-222-1222) states, Ingestion of tobacco in cigarettes has the potential to cause nicotine poisoning which may result in nausea, vomiting, tremors, etcetera, and the need for emergency room Evaluation if symptomatic. On 09/19/18 at 08:30 PM, Review of an article titled, Tobacco and cigarette butt consumption in humans and animals, listed on the National Center for Biotechnology Information, United States National Library of Medicine (https://www.ncbi.nlm.gov/pmc/articles/PMC 60) states: Cigarettes contain at least 4000 chemicals, with about 50 of these being carcinogenic. Although a typical cigarette contains from 9 milligrams (mg) to 30 mg of nicotine, inhalation through smoking is only about 0.5 - 2 mg per cigarette. Nicotine in tobacco products is rapidly absorbed by oral and intestinal mucosa, and alkalinisation enhances absorption; nicotine-related symptoms develop rapidly (less than 4 hours) after ingestion. These may represent a wide variety of symptoms including nausea, vomiting, salivation and diaphoresis; with severe poisoning, there may be convulsions, [MEDICAL CONDITION] with [MEDICAL CONDITION], cardiac arrhythmias and respiratory depression. R7's Clinical Record documents the following Progress Notes made by V10: 9/12/18 at 08:30 AM- Resident has a behavior of eating the cigarettes instead of smoking them and states that he has done this for a long time. V11 and V2 notified. 9/14/18 at 1:11 PM- Reminded not to leave cigarette butts laying around. Resident states, I eat the tobacco, have you ever tried it? 9/19/18 at 10:47 AM- Continues to eat his cigarettes. Laughs at this nurse when asked if he has any abdominal issues then states, no, I've done that for years, better than smoking them.

Based on record review and interview, the facility failed to ensure that a resident was free from unnecessary [MEDICAL CONDITION] medications used for the treatment of [REDACTED]. The Findings Include: R19's current Physician order [REDACTED]. R19's care plan with a date initiated/revision date of 8/15/18 has a focus area of R19 has anxiety as evidenced by crying when faced with tasks. R19 takes an anti-psychotic. R19 has behavior tracking for (MONTH) and (MONTH) with a behavior of anxiety with non-pharmalogical interventions listed if the behavior exists. Behavior tracking does not start until (MONTH) 15, (YEAR). For 8/15/18-8/31/18 R19 has 7 episodes of anxiety behavior tracking on the evening shift between 2 PM-6 PM, and 1 episode from 10 PM-6 AM. (MONTH) 1-20th behavior tracking has only 1 episode on the night shift reported of anxiety on the evening shift. A consultation report from Omnicare, dated (MONTH) 21, (YEAR)- (MONTH) 14, (YEAR) has a comment section from the pharmacist reporting that R19 receives an antipsychotic with an unapproved indication and/or target behavior. The report then recommends that if this therapy is to continue to document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual and resident-specific reason why a dose reduction is clinically contraindicated at this time and that the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. The physicians response section is dated 8/22/18 by V6 (physician) stating to look at previous progress note. V6's physician progress notes [REDACTED]. R19 sees a psychiatrist, they don't know the name but we will confirmation and I am not going to stop the Risperadol. No other documentation is found in the clinical record on follow up determine if a proper [DIAGNOSES REDACTED]. V4 (Assistant Director of Nursing) stated on 09/20/18 at 1:30 PM, that R19 does not have any behaviors that she is aware of and doesn't display any anxiety issues. V4 will look more into the [DIAGNOSES REDACTED]. A health status note dated 9/20/18 at 3:10 PM that R19 stated that she does not wish to share anything regarding visits with the psychiatrist that's confidential. V2 then 'explained to her that she has the that right, and we respect her wishes' in this health status note. V2 (Director of Nursing) stated on 9/20/18 at 3:35 PM that R19 refuses the facility to contact the prescribing physician for the Risperadol, stating that its confidential. V2 stated at this time that the only [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to follow identified safety interventions and protocols, care plan interventions and facility policy and procedures to prevent falls and injuries for 4 residents (R1-4) in a total sample of 4 reviewed for accidents and injuries. This failure resulted in R2 sustaining a right hip fracture that caused the resident to go from a stand-by ambulatory status to a partial weight bearing status and reduced activity because of pain. Findings include: According to R2's Plan of Care with initiation date of 5/5/15 and target goal date of 11/17/15, R2 is a risk for falls related to falls prior to admission. High risk per fall assessment. Fall 6/20/15, Fall 7/9/15, Fall 7/16/15, fall 8/7/15. The goal is the resident will be free of falls thru the review date (11/17/15). The initiation of this goal is 5/5/15. R2 was also identified as an elopement risk/wanderer as evidence by history of attempts to leave facility unattended and this focus area was initiated on 8/3/15. R2's noted intervention: assess for fall risk, staff to monitor R2's location every 30 minutes and document wandering behavior and attempted divisional interventions in behavior log R2's Health Status Note dated 8/7/15 at 1:27 AM shows that at 12:50 AM, the nurse was sitting being nurse station and heard a loud noise and went in to check on resident in room and found resident sitting upright in the floor between her bed and her recliner. Resident stated, I thought that it was time to get up to go down to eat for breakfast. I tried to get up on my own and tripped on my recliner. The nurse noted resident ' s recliner was close to bed with chair in reclining position. The nurse moved chair away from bed and pushed lever down to remove chair from reclining position. During assessment found 4 cm x 2 cm skin tear to right elbow. The nurse cleansed sit with skin integrity and applied 7 steri strips. Nurse found another skin tear measuring 2 cm x 1 cm to lower back. The nurse cleansed with skin integrity and applied 4 steri strips. Another skin tear noted to anterior right lower extremity measuring 4 cm x 2 cm. The nurse cleansed site with skin integrity and applied 6 steri-strips. Resident denied having any pain or discomfort. Resident was laughing and stated I'm Fine. I didn ' t hurt anything except for my elbow. I didn't hurt my head. I just thought it was time to get up for the day. Complete skin assessment performed and helped to transfer resident back into bed. Applied body alarm underneath resident while in bed. Applied derma savers to upper extremities to protect site. Called and notified Z8 (POA #1) about incident. Faxed and notified doctor. Will continue to monitor. No documentation was found where R2's range of motion was assessed after fall on 8/7/15. There were also no documentation of neurological checks initiated per facility policy and procedure for this residents fall incident. On 9/3/15 at 11:40 AM E2 DON (Director of Nursing) stated with any fall staff should all assess range of motion and should document what it is and if it was not documented it did not happen. E2 stated the nurse on duty when R2 fell on [DATE] should have initiated a neurological check because it was an unwittnessed fall and the facility policy was to initiate with unwittnessed falls. E2 also stated with the neurological checks the resident is checked on more often by the nurse of should be. On 9/8/15 at 10:00 AM E2 DON stated E11 RN(Registered Nurse) that had been on duty the night of R2's fall had since resigned and she had been unable to speak to her regarding what had actually occurred or not occurred the night R2 had fall. On 9/3/15 at 11:40 AM, E2 DON was unable to answer why the doctor was faxed instead of actually contacted regarding R2's fall when there was actual injuries with treatments provided. On 9/3/15 at 11:40 AM, E2 DON stated R2 had been on 30 minute checks for safety and supervision. E2 confirmed when staff did these checks they should also be checking for any hazards within the vicinity of the resident. E2 stated that she did not know why R2's recliner what up and out and this is something staff should be checking during the safety checks. E2 confirmed that had the recliner foot rest not been out R2 would not have fallen or the risk would have been greatly decreased. E2 stated the footrest could certainly have contributed to the increase in the injury to R2. On 9/3/15 at 12:10 PM, E2 DON stated that R2's 30 minute checks are to be done as marked at those intervals. E2 could not explain why on the night R2 fell (8/7/15) that three hours of 30 minute checks where all documented at the same time, then two hours at the same time. E2 stated there was no way to determine if R2 was actually being monitored every 30 minutes or not. E2 stated there was no way to determine or confirm that R2's safety checks were actually done per the facility policy and procedure E2's statement of review dated 9/8/5 shows R2's first visit to emergency room has no documentation of notification of POA(Power of Attorney) upon arrival back to facility. No documentation of notification over weekend of continued pain. No neurological checks on R2's fall initiated. On 9/8/15 at 9:30 AM, Z3(Therapist) stated she was familiar with R2 and had treated her off and on since her admission. Z3 stated at the time of her fall on 8/7/15 she was ambulatory with stand by assist but knew there had been issues with her trying to leave the facility so they had been monitoring her every so often because of this. Z3 stated that as of this time R2 was now in a wheel chair and partial weight bearing due to the fracture of her hip that occurred with her fall on 8/7/15. l. On 9/3/5 at 9:30 AM, Z4 (Therapist) stated the last time she saw R2 she was in bed and she could not bear weight and any time they tried to move her she was in pain and was having facial grimacing. Z4 stated any time a person had a fracture or a fractured hip then they're going to have a lot of pain for a while. Z4 stated that before R2 fell and fractured her right hip she was up and walking around the facility with a walker. Z4 stated at this time R2 was unable to do any type of therapy and was only partial weight bearing on her right leg due to her fractured hip. Z4 stated anytime she went into a room as a therapist she tried to asses for hazards and a chair with a footrest out with definitely be a cause for a concern for her. Z4 stated if she went into a room and a recliner had a footrest up she would go put it down and move it away from the bed making sure the resident had a safe path to walk to the doorway in. According to emergency room X-ray report dated 8/7/15 impression shows: lucency right greater trochanter, favored to be artifactual, with nondisplaced fracture not entirely excluded. Recommended correlation with radiography right hip or CT(computed tomography) for further evaluation. Doctor aware and wants R2 sent back to nursing home and monitor and do CT if not better in two days. R2's Health Status Note dated 8/10/15 at 10:25 AM shows reported resident continues to complain of pain to right hip and leg. Resident is not bearing weight on right leg during transfers. R2's document titled CT right hip without contrast dated 8/10/15 stated under impression mildly displaced fracture of the right hip. According to R2's Health Status Note dated 8/14/15 at 12:19 PM, R2 to orthopedic appointment and does have a right hip fracture, no surgery needed but very painful break, may pivot for transfers, partial weight bearing as tolerated to right foot. According to document titled Neuromuscular Orthopedic institute dated 8/14/15 shows she has she has a fracture of her right hip. Healing will take 6-12 weeks. Will allow her to be partial weight bearing on her right lower extremity as tolerated. She is going to be at reduced activity level for a while because of the pain. On 9/3/15 at 10:20 AM, E9 CNA (Certified Nursing Assistant) was in R2's bathroom and had her on the toilet. E9 had no gait belt on R2. E9 stated R2 had gotten herself out of her bed and put herself in her wheelchair and because she had had a bowel movement on herself. E9 stated that when she entered R2 ' s room her body alarm was going off and had been going off but she had been assisting another resident and did not want to leave them unattended and had responded as soon as possible but, R2 had managed to transfer self from bed to wheelchair in that time. E9 then proceeded to transfer R2 from the toilet to the wheelchair with no gait belt. R2 was noted to bear weight on her right leg and had facial grimacing. E9 then transferred R2 from her wheelchair to her bed without the use of a gain belt. R2 again was noted to bear weight on her right leg and had facial grimacing. On 9/3/15 at 10:35 AM, E9 CNA stated she should not have transferred R2 without a gait belt and there is a great change for injury to the resident. E9 gave no indication she was aware of facial grimacing and indications of pain during transfers and weight bearing. On 9/3/15 at 11:00 AM , E5 LPN(Licensed Practical Nurse) stated that any time a staff transfers a residents a gait belt should be used and any staff that hears an alarm whether it ' s a bed, chair or door alarm should respond. E5 stated even if they ' re not nursing they can at least try to make sure the resident is safe. E5 stated that if an alarm is going off long enough for a resident to make it from the bed to a chair or a chair to bed then it probably is going off to long and staff should be responding quicker. E5 stated R2 was partial weight bearing status to right leg due to her recent fractured hip. E5 stated the last time she had a Norco pain pill was 8/16/15. At this time survey made E5 aware R2 had been transferred by E9 without gait belt and was in bed asked if pain assessments need to be done. E5 stated pain assessment is done every shift and she can tell you if she is hurting. On 9/3/15 at 12:40 PM, E2 DON, stated if alarm is going off long enough for resident to transfer self from bed to chair or chair to bed then staff is not responding quickly enough and any staff can respond to any alarm and should respond for resident safety. E2 stated E9 should not transfer without gait belt for resident safety. E2 stated facial grimacing is an indicator of pain and should be assessed. E2 stated R2 is at increased risk for pain due to recent fracture and should be assessed for pain on on-going basis. E2 stated at this time R2 is only to be partial weight bearing on right leg due to fracture. According to R's Health Status Note dated 9/6/15 at 8:20 PM shows at 7:55 PM resident found sitting in floor beside her bed. She had apparently put herself to bed and was attempting to get back up into her wheelchair and the brakes were not locked. She states that she does not hurt anywhere, but she has a 3 cm scratch behind her ear on the left side of her head. R2's occurrence report dated 9/6/15 at 7:55 PM stated R2 ' s alarm was turned off. R2's Restorative note dated 9/5/15 at 5:44 shows R2 continues with active range of motion, ambulates to dining room in the evening with gait belt and one assist, she is compliant with exercise and walking. On 9/8/5 at 3:00 PM, E2 stated R2 was still partial weight bearing to right leg due to fracture when questioned about being walked on 9/5/15 was unable to answer. 2.According to R1's Occurrence report dated 8/8/15 at 8:40 AM, shows R1 was in dining room lying on ground face down and had fallen forward. Under miscellaneous at 1:3 shows R2 's chair alarm was not on. Under conclusion dated 8/9/15 at 7:49 PM shows R1 continues to lean forward in her wheelchair, R1 sustained a bruise to her face and small skin tear to her cheek. Bruise to face has increased in size. On 9/3/15 at 12:10 PM E2 stated she had spoken to the POA the past weekend (9/1/15) and made them aware that after her follow up to R1's fall that she had determined it was the facility staff 's fault that R1 had fallen out of her chair on her fall that occurred on 2/13/15 as well as 8/8/15. E2 stated that according to R1 's care plan she is to have her alarm on while in her wheelchair and it was not on. R2 stated she made the POA aware of this. According to R1's care plan with initiated date of 5/13/15, R1 is risk for falls related to impaired mobility with falls on 2/13/15 and 8/9/15. Under intervention is to have alarms to bed and chair. R3 3.According to R3's Care Plan with date initiated of 4/30/15, R1 is at risk for falls related to unaware of safety needs, gait/balance problems with falls on 5/9/15 and 5/13/15. Interventions stated R3 is to have wedge cushion to wheelchair for positioning. On 9/1/15, 9/3/15 & 9/8/15, R3 was seen in various areas throughout the facility and did not have designated wedge cushion in her wheelchair. On 9/8/15 at 9:30 AM, R3 was in the physical therapy room and Z3 (therapist) was with her and was sitting in same cushion previously noted. Z3 stated that the cushion R3 was on was not a wedge cushion but a standard cushion and that R3 was not positioned well because she was at the edge of her seat and this would make her more like to slide out of her chair. R4 4. According to R4's Care Plan with initiated of 3/16/15 shows R4 is at risk for falls related to hip fracture with falls on 3/21/15, 5/18/15, 6/1/15, 6/8/16, 6/11/15, 7/1/15, 8/21/15 and 8/30/15. Intervention for R4 to use a bed/chair electronic alarm and ensure the device is in place as needed and working correctly with initiation date of 7/10/15. On 9/3/15 at 10:11 AM R4's chair alarm started sounding. No staff responded to R4's alarm until 10:16 AM. When staff responded R4 had transferred herself from her bed to her wheelchair. According to the facilities policy titled Falls-Clinical Protocol dated 5/13 under treatment and management it shows that based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff, with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall According to the facility policy titled Pain-Clinical Protocol dated 5/13 shows the nursing staff will assess each individual for pain whenever there is a significant change in condition and when there is onset of new or worsening of existing pain. The staff will identify the nature and characteristic such as location, intensity, frequency, pattern, etc. as well as severity of pain. The staff will observe the resident (during rest and movement) for evidence of pain: for example, grimacing while being repositioned. The staff will identify any situations or interventions where an increase in the resident's pain may be anticipated: for example ambulation or reposition. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complications such as gait disturbance, social isolation and falls According to the facility policy titled Charting and Documentationdated 5/08 shows all services provided to the residents, or any changes in the residents medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident clinical records. All incidents, accidents, or changes in the residents condition must be recorded.

Based on observation, interview and record review the facility failed to notify the physician of change and new onset of pain and manage pain for one resident (R2) in a total sample of 4 residents reviewed for pain. This failure resulted in R2 experiencing pain at a voiced level of excruciating and 4-8 on a scale of 1-10, over a three day period and not being medicated regularly for pain after a [MEDICAL CONDITION] with anticipating healing of 6-12 week period. Findings include: R2's Health Status Note dated 8/7/15 at 1:27 AM shows that at 12:50 AM, the nurse was sitting being nurse station and heard a loud noise and went in to check on resident in room and found resident sitting upright in the floor between her bed and her recliner. During assessment found 4 cm x 2 cm skin tear to right elbow. The nurse cleansed sit with skin integrity and applied 7 steri strips. Nurse found another skin tear measuring 2 cm x 1 cm to lower back. The nurse cleansed with skin integrity and applied 4 steri strips. Another skin tear noted to anterior right lower extremity measuring 4 cm x 2 cm. The nurse cleansed site with skin integrity and applied 6 steri-strips. Resident denied having any pain or discomfort. Resident stated I'm Fine. Faxed and notified doctor. Will continue to monitor. No documentation was found where R2's range of motion was assessed after fall on 8/7/15. No documentation of neurological checks initiated per facility policy and procedure for this residents fall incident could be found. E2's statement of review dated 9/8/5 shows R2's first visit to emergency room has no documentation of notification of POA (Power of Attorney) upon arrival back to facility. No documentation of notification over weekend of continued pain. No neurological checks on R2's fall initiated. On 9/3/15 at 11:40 AM E2 DON (Director of Nursing) stated with any fall staff should all assess range of motion and should document what it is and if it was not documented it did not happen. E2 stated the nurse on duty when R2 fell on [DATE] should have initiated a neurological check because it was an unwittnessed fall and the facility policy was to initiate with unwittnessed falls. E2 stated this is to help assess a residents pain level also On 9/8/15 at 10:00 AM E2 DON stated E11 RN(Registered Nurse) that had been on duty the night of R2's fall had since resigned and she had been unable to speak to her regarding what had actually occurred or not occurred the night R2 had fall of how or if R2's pain was actually assessed On 9/8/15 at 9:30 AM, Z3 (Therapist) stated she was familiar with R2 and had treated her off and on since her admission. Z3 stated at the time of her fall on 8/7/15 she was ambulatory with stand by assist but knew there had been issues with her trying to leave the facility. Z3 stated that as of this time R2 was now in a wheel chair and partial weight bearing due to the fracture of her hip that occurred with her fall on 8/7/15. Z3 stated any time a person has a fracture it will be painful. Z3 stated she had come in the morning or 8/7/15 to do therapy for R2's roommate around 7:00 AM. Z3 stated R2 was in bed and was complaining to her of having excruciating pain in her right hip and thigh area. Z3 stated this was very unusual for R2 as she had never complained of pain before this. Z3 stated she got the physical therapy assistant and they both assessed R2. Z3 stated that R2 was complaining of pain in her back, right hip and upper leg. Z3 said at that point she went and immediately notified the day shift nursing staff. Z3 stated she did not know how R2 was assessed on nights but as soon as she tried to do anything as far as range of motion R2 complained of excruciating pain and had facial grimacing. Z3 stated she was unable to even really turn and reposition R2. Z3 stated any [MEDICAL CONDITION] is going to be painful. On 9/3/5 at 9:30 AM, Z4 (Therapist) stated she had been called to R2's room by other therapist(Z3) because she was concerned about her complaints. Z4 stated that R2 was complaining of a lot of pain. Z4 stated at the time she saw Z4 she was in bed and she could not bear weight and any time they tried to move her she was in pain and was having facial grimacing. Z4 stated any time a person had a fracture or a [MEDICAL CONDITION] then they're going to have a lot of pain for a while. Z4 stated that before R2 fell and fractured her right hip she was up and walking around the facility with a walker. Z4 stated at this time R2 was unable to do any type of therapy and was only partial weight bearing on her right leg due to her [MEDICAL CONDITION]. According to emergency room X-ray report dated 8/7/15 impression shows: lucency right greater trochanter, favored to be artifactual, with nondisplaced fracture not entirely excluded. Recommended correlation with radiography right hip or CT (computed tomography) for further evaluation. Doctor aware and wants R2 sent back to nursing home and monitor and do CT if not better in two days. R2's MAR (Medication Administration Record) for August 2015 shows resident complaining of pain on a scale of 4 & 8 on a scale of 1-10 for 8/7/15 (Friday), 8/8/15 (Saturday), 8/9/15 (Sunday). No documentation can be found were doctor was made aware of increase in resident's pain level after fall on 8/7/15. Review of R2's MAR for June, July and 8/1-7/15 has her normal pain level of 0. R2's Health Status Note dated 8/10/15 at 10:25 AM shows reported resident continues to complain of pain to right hip and leg. R2's document titled CT right hip without contrast dated 8/10/15 stated under impression mildly displaced [MEDICAL CONDITION] hip. According to R2's Health Status Note dated 8/14/15 at 12:19 PM, R2 to orthopedic appointment and does have a right [MEDICAL CONDITION], no surgery needed but very painful break, may pivot for transfers, partial weight bearing as tolerated to right foot. According to document titled Neuromuscular Orthopedic institute dated 8/14/15 shows she has she has a fracture of her right hip. Healing will take 6-12 weeks. Will allow her to be partial weight bearing on her right lower extremity as tolerated. She is going to be at reduced activity level for a while because of the pain. On 9/3/15 at 12:05 AM, E2 DON stated she did not know why the nursing staff over the weekend of 8/7/15 to 8/9/15 did not make the doctor aware of R2's increase and change in pain after her fall on Friday 8/7/15. E2 stated that the nursing staff should not have waited all weekend and allowed R2 to have been experiencing pain at such a high level. E2 stated that she did not feel R2's order for [MEDICATION NAME] was going to be effective for R2 type of pain considering R2 probably had a [MEDICAL CONDITION] at that time. E2 stated she had questioned her nursing staff as to why they had not notified the physician and had not been given and answer. E2 stated this was obviously a problem and she was trying to resolve it and pain should always be treated and treated with a medication that is most effective and the doctor should be notified immediately of any change as soon as needed. E2 stated a [MEDICAL CONDITION] can be very painful and stronger pain medication than [MEDICATION NAME] would be needed to alleviate the pain. E2 stated that is why she had made sure the physician was called on 8/10/15 for an order for [REDACTED]. E2 stated at this time R2 was mobile with a wheelchair and partial weight bearing to her right leg and not to ambulate and no therapies at this time and to have assist with all transfers. On 9/3/15 at 10:20 AM, E9 CNA (Certified Nursing Assistant) was in R2's bathroom and had her on the toilet. E9 had no gait belt on R2. E9 stated R2 had gotten herself out of her bed and put herself in her wheelchair. E9 stated that when she entered R2's room her body alarm was going off and R2 had managed to transfer self from bed to wheelchair in that time. E9 then proceeded to transfer R2 from the toilet to the wheelchair with no gait belt. R2 was noted to bear weight on her right leg and had facial grimacing. E9 then transferred R2 from her wheelchair to her bed without the use of a gait belt. R2 again was noted to bear weight on her right leg and had facial grimacing. On 9/3/15 at 10:35 AM, E9 CNA stated she should not have transferred R2 without a gait belt and there is a great change for injury to the resident. E9 gave no indication she was aware of facial grimacing and indications of pain during transfers and weight bearing. On 9/3/15 at 11:00 AM , E5 LPN(Licensed Practical Nurse) stated that any time a staff transfers a residents a gait belt should be used. E5 stated R2 was partial weight bearing status to right leg due to her recent [MEDICAL CONDITION]. E5 stated the last time she had a [MEDICATION NAME] pain pill was 8/16/15. At this time survey made E5 aware R2 had been transferred by E9 without gait belt and was in bed asked if pain assessments need to be done. E5 stated pain assessment is done every shift and she can tell you if she is hurting. On 9/3/15 at 12:40 PM, E2 DON, stated E9 should not transfer without gait belt for resident safety. E2 stated facial grimacing is an indicator of pain and should be assessed. E2 stated R2 is at increased risk for pain due to recent fracture and should be assessed for pain on on-going basis. E2 stated at this time R2 is only to be partial weight bearing on right leg due to fracture. According to R2's Health Status Note dated 9/6/15 at 8:20 PM shows at 7:55 PM resident found sitting in floor beside her bed. She had apparently put herself to bed and was attempting to get back up into her wheelchair and the brakes were not locked. She states that she does not hurt anywhere, but she has a 3 cm scratch behind her ear on the left side of her head. On 9/8/15 at 2:00 PM, E2 DON stated that she had just started her investigation to this fall when she had come in this morning. E2 also stated that when she asked about R2's pain management that the nurse on duty E8 RN (Registered Nurse) stated that R2 was just having her regular pain . E2 stated she asked E8 why R2 was having any pain let alone regular pain when the nursing staff was to be assessing R2 for pain every shift and R2 had pain medication available. E2 stated E8 was unable to answer her question. When questioned E2 was not aware that R2 had not received any pain medication since 8/16/15. E2 stated R2 should have been receiving some kind of pain relief per the orthopedic doctors recommendations and that's why she (E2) had gotten the [MEDICATION NAME] order but apparently after the incident with R2 on 9/3/15 and 9/6/15 the staff do not understand how pain needs to be addressed and obviously education needs to be done with all staff. E2 stated R2's pain is not being managed at this time. On 9/8/15 at 1:00 PM reviewed R2's MAR (Medication Administration Record) and progress noted regarding her pain management and assessment. No documentation was found where resident was assessed or medication for indicators of pain after facial grimacing with improper transfer on 9/3/15 and staff was made aware. Review shows last [MEDICATION NAME] was given on 8/16/15. R2's Health Status Note dated 8/14/5 states R2 went to orthopedic appointment at 9:10 AM, review of R2's MAR indicated [REDACTED]. On 9/8/5 at 2:00 PM, E2 stated nursing staff should have medicated R2 with the pain medication [MEDICATION NAME] prior to her appointment for pain management. On 9/8/15 at 2:00 PM E2 stated nursing staff should have medicated R2 for pain after her fall on 9/6/15. R2's Restorative note dated 9/5/15 at 5:44 shows R2 continues with active range of motion, ambulates to dining room in the evening with gait belt and one assist, she is compliant with exercise and walking. On 9/8/5 at 3:00 PM, E2 stated R2 was still partial weight bearing to right leg due to fracture when questioned about being walked on 9/5/15 was unable to answer. According to the facilities policy titled Falls-Clinical Protocol dated 5/13 under treatment and management it shows that based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff, with the physician ' s guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall According to the facility policy titled Pain-Clinical Protocol dated 5/13 shows the nursing staff will assess each individual for pain whenever there is a significant change in condition and when there is onset of new or worsening of existing pain. The staff will identify the nature and characteristic such as location, intensity, frequency, pattern, etc. as well as severity of pain. The staff will observe the resident (during rest and movement) for evidence of pain: for example, grimacing while being repositioned. The staff will identify any situations or interventions where an increase in the resident's pain may be anticipated: for example ambulation or reposition. The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, including complications such as gait disturbance, social isolation and falls According to the facility policy titled Charting and Documentation dated 5/08 shows all services provided to the residents, or any changes in the residents medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident clinical records. All incidents, accidents, or changes in the residents condition must be recorded.