Every finding on record at Silvis Center for Nursing Rehab & Care

Based on observation, interview and record review the facility failed to administer medications as ordered, at ordered times for 5 of 8 residents (R1, R2 R3, R4 and R5) reviewed for medication administration in the sample of 8.The findings include:1. On 6/12/26 at 9;30 AM, V3 (Registered Nurse-RN) said she's to pass meds in the skilled unit.On 6/12/26 at 9:40 AM, R1 was sitting in her recliner. R1 said she was waiting for her lidocaine patch for her hip pain, it just aches there V3 (RN) applied R1's lidocaine patch to her right hip. (An hour and 40 minutes late.)R1's Medication Administration Record (MAR) dated 6/26 shows an order to administer Lidocaine Patch to R1's right hipbone every 8AM; remove at bedtime.2. On 6/12/26 at 10 AM, V3 administered R2's Eliquis 5 milligrams for atrial fibrillation. V3 also administered R3's insulin Lispro 3 units for blood sugar of 193 for diabetes. (2 hours late)R2's MAR dated 6/26 show an order to administer Eliquis 5 mg two times a day with morning dose to be given at 8AM. R2's regular insulin according to sliding scale with morning dose to be administered at 8AM3. On 6/12/26 at 10:25 AM, R3 was in bed. R3 was alert and said she had already finished her breakfast. V3 administered R3's Omeprazole capsule for ulcer. R3's medication was administered late and after breakfast. R3's MAR show an order to administer Omeprazole delayed release 40 mg, 30 minutes before breakfast.4. On 6/12/26 at 10:20 AM, R4 was sitting in her recliner. V3 administered R4's antibiotics for urinary tract infections of: Nitrofuratoin100 mg 1 capsule and Cephalexin 500 mg 1 capsule. (An hour and 20 minutes late.)R4's MAR show an order to administer R3's Nitrofurantoin 100 mg 1 capsule two times a day with morning dose given at 8AM and Cephalexin 500 mg give 1 capsule by mouth 4 times a day with morning dose given at 8AM. 5. On 6/12/26 at 10:15 AM, R5 was in bed. V3 administered R5 her Tylenol. R5 showed this surveyor her contracted left hand and said she takes Tylenol for discomfort to her contracted hand. R5 said she has been waiting for her Tylenol extra strength which was due since 8AM. R5's MAR shows an order of Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) TID for contracted hand with morning dose to be given at 8AM.On 6/12/26 at 10:30 AM, V3 (RN) said those were the medications due at 8AM which were all late. V3 said she was just informed to work the floor and cover for a Nurse when this surveyor arrived. Medications should be administered an hour before and an hour after it was due.On 6/12/26 at 1PM, V2 (Director of Nursing-DON) said Nurse coverage has been a challenge. Medications should be administered timely.The Facility Policy Medication administration data 2/12/25 shows Drug Administration shall be defined as an act in which a single dose of a prescribed drug or biological is given to a resident by an authorized person in accordance with all laws and regulation governing such act. Medications must be prepared and administered within one hour of the designated time or as ordered.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for residents, failed to treat a resident (R44) with dignity and respect, failed to ensure a resident (R7) had rights to a dignified existence. These failures have the potential to affect all residents in the facility.The findings include:1. The resident census & condition report dated 5/19/26 showed 69 residents residing in the facility. Observations of breakfast meals and lunch meals were conducted from 5/19/26-5/21/26. All residents in the building were served their meals in Styrofoam containers with plastic silverware and Styrofoam cups. On 5/19/26 at 9:57 AM, R141 stated, I have been here for several weeks now, and I have yet to eat off of a real plate, the food is always in a Styrofoam container. It doesn't even feel like a home-cooked meal, it feels like take-out. On 5/20/26 at 9:04 AM, R99 stated, I don't like the Styrofoam containers, it's been like that for a long time, and I feel like I'm eating out of a fast-food container. I would like real plates and silverware to make it feel more like a meal. You can't even cut the meat because of the plastic silverware. On 5/20/26 at 10:07AM, R2 stated, I typically eat oatmeal every morning and for the past several weeks I have to eat my oatmeal out of a paper bowl and my other meals out of a Styrofoam container. It's so odd and I hate it; it's like eating fast food but it's not even good when it comes in those containers. I want to feel like I'm eating a real meal on a real plate. On 5/20/26 at 3:35 PM, V32 (R22's Power of Attorney) stated, We spoke with (V1-Administrator) about the Styrofoam dishes and food concerns. (V1) said the dishwasher has been down and they are working on trying to get it fixed. They are not able to give a date when it will be fixed. (V1) said the new dietary manager was hired and she is trying to improve the meals. R22 stated she does not like to eat out of Styrofoam. On 5/21/26 at 9:08 AM, R94 was sitting in his room with his breakfast meal in a Styrofoam container. R94 stated, If I wanted take-out food I wouldn't come to a nursing home. I don't know why they put it in these containers. On 5/21/26 at 10:51 AM, V1 (Administrator) stated, Styrofoam containers are being used because the dishwasher is down. Something is wrong with the wiring; the other one can't keep up and the whole kitchen area needs to be redone. Styrofoam has been used for a couple weeks I think, and we have no idea how long this kitchen project is going to take. We can't afford to get our food from the hospital anymore like we did with the last company, so nothing is going to change. I get it that it's not ideal but there's nothing I can do to change it or make it better; it is what it is. The facility's policy titled, Dignity dated 8/9/23 showed, Dining: 7) Only use plastic/Styrofoam plates, cups, and utensils when extremely necessary with a good, documented rationale . 2. R44's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include stroke, gastric ulcer, and partial paralysis. R44's 2/24/26 Quarterly Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status score of 14 out of 15. On 5/20/26 at 10:10 AM, a resident meeting was held. During the meeting, R24 and R99 described and incident involving R44 and a staff member and a Certified Nursing Assistant (CNA) approximately two months ago. R24 and R99 stated R44 requested a drink to which the CNA replied, I don't care. R24 and R99 declined to identify the CNA. On 5/21/26 at 8:48 AM, R44 stated he recalled an incident during a meal when he requested a drink. R44 stated the CNA replied, A please and a thank you helps. R44 stated, due to his medical condition, he has difficulty controlling the tone of his voice and it may sound demanding. R44 said, I felt like she was talking down to me. I have a resident's rights brochure in my top drawer, and it says I should be treated with respect, and I don't feel like I was treated with respect. R44 did not know the CNA. On 5/21/26 at 10:27 AM, V2 (Director of Nursing) stated a staff member should not say, A please and a thank you helps. It is very disrespectful. The facility's Dignity policy (dated 8/9/23), showed, 1.) Staff will be polite and respectful at all times-and will be positive in their approach to residents to include residents who make repetitive requests and residents who are demanding or who use inappropriate language towards staff. These types of behaviors will be addressed by SSD and the appropriate clinical team members, but will not affect timeliness or appropriateness of care delivery. 2.) Staff will not speak in a manner that could be interpreted as even minimally condescending/critical or argumentative nor in a volume any louder than is absolutely necessary as this can be interpreted as meeting criteria for abuse. 3. On 5/19/26 at 10:14 AM, R7 was sitting in a padded wheelchair in the common area next to the nurses' station. R7's shorts were down around his ankles. R7's incontinence brief was open with his penis and scrotum exposed. Two female residents were in wheelchairs near R7. Staff were in the nurses' station and observed walking by the common area. V21 (Registered Nurse/other facility Director of Nursing) was in the area and asked to go over to R7 to observe and help. V21 stated she was at this facility helping them today. V21 went over to R7 and stated she did not know who he was and left to get someone to assist him. V21 did not cover R7 up or remove him from the common room. At 10:22 AM, V21 came back over to R7, covered him with a sheet and took him to his room. V21 stated R7 should not have been in a common area like that and stated it was a dignity issue. On 5/9/26 at 10:30 AM, V21 (Certified Nursing Assistant – CNA) and V23 (CNA) were in R7's room to provide care due to R7 being in the chair and groin area exposed. V21 stated they are supposed to give R7 fidget toys because it helps him keep his hands out of his pants. On 5/20/26 at 2:23 PM, R7 was sitting in his padded wheelchair in the common area by the nurses' station. R7's shorts were off, incontinence brief was open, and he was touching his penis. V5 (Licensed Practical Nurse – LPN) and V28 (Registered Nurse – RN) were sitting at the nurses' desk in front of him going over shift change report. V5 and V28 were asked to provide R7 assistance; they stated they were not aware that he was like that. V28 stated it was not appropriate for that to happen for R7 to be out there like that. V28 stated R7 has fidget items he is supposed to have so he doesn't do this. R7 did not have these items in his chair or hands. The Face Sheet dated 5/21/26 for R7 showed diagnoses including cerebral infarction, encounter for palliative care, ventricular tachycardia, disorientation, transient ischemic attack, gastro-esophageal reflux disease, anxiety disorder, and insomnia. The Care Plan dated 1/23/26 for R7 showed he uses anti-anxiety medication related to an anxiety disorder with behaviors of anxiety, agitation, depression, refusal of cares, and removal of clothing. The facility's Dignity policy (no date) showed residents will have all aspects of their dignity maintained by staff regardless of the resident's cognitive level or ability to realize or understand what is being said or done by others.

Based on observation, interview, and record review the facility failed to ensure residents received all items on the menu and received correct portion sizes. This failure has the potential to affect all residents residing in the facility.The findings include:The facility census dated 5/19/26 showed 69 residents reside in the facility.On 5/19/26 at 9:26 AM, V1 (Administrator) stated the facility does not have a full-service kitchen. V1 stated the facility is attached to a hospital and prior to being sold, the hospital kitchen prepared the resident meals. V1 stated resident meals are currently prepared at their sister facility, 2.5 miles away, and transported to the facility.On 5/19/26 at 11:00 AM, V9 (facility's Dietary Manager) arrived at the sister facility to transport the noon meal. V9 stated this was her first day transporting food and it was her first day as dietary manager. V7 (sister facility Cook) and V9 loaded a pan of scalloped potatoes with ham as well as a pan of cooked broccoli into an insulated transport cooler. V7 and V9 also loaded pans of puree vegetables and pureed scalloped potatoes with ham. V9 loaded them into the back of her personal vehicle and left the sister facility. No tomato soup was transported.On 5/19/26 at 11:53 AM, V10 (Cook) began the noon meal service at the facility. The portion size of scalloped potatoes with ham appeared small. No tomato soup was present at the steam table or provided to the residents. On 5/19/26 at 12:05 PM, V10 said, I don't know what is for lunch until it shows up. I don't have a menu for what is to be served today. V10 said she knows what portion sizes to provide resident based on her experience. V10 also pointed to documentation on the wall regarding portion sizes; however, none of the documents she references showed the portion size for the scalloped potatoes with ham. On 5/19/26 at 12:15 PM, R101 and R99 requested second helpings.On 5/19/26 at 12:37 PM, V10 showed the scoop that was used to serve the scalloped potatoes with ham. Engraving on the ice-cream style scoop showed it was a number six scoop.On 5/19/26 at 1:40 PM, V8 (sister facility Dietary Manager) provided a portion guide showing scoop size definitions. The guide showed a number six scoop was two-thirds (2/3) of a cup.The facility's Recipe for the Ham and Potato Casserole showed the portion size is a cup (33 percent more than what was provided).The facility's menu for 5/19/26 showed the residents should have been given the casserole, mixed vegetables, and tomato soup.On 5/20/26 at 10:47 AM, a resident meeting with R22, R24, R28, R99, and R100 was held. All the residents stated, regarding the noon meal on 5/19/26, the portion sizes were tiny.On 5/20/26 at 1:36 PM, V13 (Licensed Dietitian) stated menus and portion sizes are developed to ensure residents receive adequate calories, protein, and nutrients. V13 stated she expects residents to be given the correct portion sizes and all menu items.On 5/20/26 at 1:59 PM, V8 stated the facility should have used a number 8 scoop. V8 stated he was aware tomato soup was not prepared, and he said he had asked V7 why it was not made. V8 said V7 replied that she had not made the soup due to a lack of pans.

Based on observation, interview, and record review, the facility failed to ensure food was served at an appetizing temperature for all residents, and failed to ensure 3 residents (R60, R94, R125) received foods that conserved flavor. These failures have the potential to affect all residents in the building.The findings include: 1. The resident census & condition report dated 5/19/26 showed 69 residents residing in the building. On 5/19/26, R1, R15, R24, R66, and R100 were interviewed regarding meals at the facility. All residents agreed when they eat meals at the facility, they are lukewarm at most all meals and unappetizing. All residents stated their appetite declines when foods are not served at a warmer temperature due to staff being unable to warm the food up for them. On 5/19/26 at 9:57 AM, R141 stated, The food is terrible. There is no flavor and it's not warm, several times it seemed right out of the refrigerator, so I just didn't eat. On 5/19/26 at 10:20 AM, R102 stated, The food is cold quite often. It's brought here from another facility and by the time they get it here it's cold. On 5/20/26 at 10:08AM, R12 stated, The food is not warm and when it's not warm, I don't eat, and they just take my tray away and don't offer me anything else to eat so I wait for the next meal and hope it's hot. On 5/21/26 at 10:51 AM, V1 (Administrator) stated, We don't want residents being served cold food because then they won't eat or could get sick. There are a number of reasons why you don't serve cold food but those are the 2 most important in my opinion. The facility's policy titled, Monitoring Food Temperatures for Meal Service dated 2020 showed, Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures .h. all room trays are sent to the room with meal card and documentation of the time the meals was delivered and when it should be served by to assure the tray is delivered to the correct resident and to assure that is not held longer than needed for food palatability and safety. 2. The facility's dietary report showed R60, R94, and R125 were on pureed diets. On 5/19/26 at 9:26 AM, V1 (Administrator) stated the facility does not have a full-service kitchen. V1 stated the facility is attached to a hospital and prior to being sold, the hospital kitchen prepared the resident meals. V1 stated resident meals are currently prepared at their sister facility, 2.5 miles away, and transported to the facility. On 5/19/26 at 10:33 AM, the pureed broccoli for the noon meal was tasted while still at the sister facility. The broccoli tasted sweet and had a vinegar taste. The pureed broccoli had red tinged chunks scattered throughout. V7 (sister facility Cook) stated she had added leftover pureed green beans to the broccoli. On 5/19/26 at 11:00 AM, V9 (Dietary Manager) began the process of transporting the noon meal from the sister facility to her facility's kitchen. On 5/19/26 at 12:19 PM, V11 (R125's Spouse) approached V10 (Cook) who was serving the noon meal. V11 asked V10 what was in the pureed vegetable. V10 pointed to the broccoli and told V11 just pureed broccoli. V11 said, It tastes like they put sugar in it. On 5/19/26 at 12:21 PM, surveyor requested V10 taste the pureed broccoli. V10 stated, Oh wow, that is sweet and there's something else there too. V10 was asked if it tasted like vinegar, V10 replied, Yes that's it, it tastes like vinegar. On 5/20/26 at 12:40 PM, V7 stated, regarding the pureed broccoli, It was just green beans and broccoli. It was just regular green beans from the day before. I didn't put anything sweet in it. It came from the day before. I'm not for sure where the sweetness came from, I just know it was there from the night before. On 5/20/26 at 1:59 PM, V8 (sister facility Dietary Manager) stated the broccoli should not have a vinegar and sweet taste to it. V8 said that would not be appetizing. V8 stated the cook should not be mixing left over puree. V8 stated, he believed V7 had mixed three bean salad, which would explain the red chunks he had witnessed, as well as the taste profile. V8 stated three bean salad is a cold salad and would not be appetizing warm, and it would not be appetizing mixed with broccoli. The facility's menu for 5/19/26 showed mixed vegetables were to be served. (Broccoli was substituted.) The facility's Pureed Vegetable Blend recipe (report date 4/16/26) showed, Prepare according to regular recipe . The puree recipe does not mention mixing left over purees. The facility's Pureed Food Preparation policy (2020) showed, .The flavor of pureed foods will be assessed. The pureed food should have the same desirable flavor as the menu item.

Based on observation, interview, and record review the facility failed to monitor walk-in cooler temperatures, failed to monitor dishwasher sanitization temperatures, failed to store dry food properly, and failed to maintain kitchen cleanliness. This failure has the potential to affect all residents residing in the facility.The findings include:On 5/19/26 at 9:26 AM, V1 (Administrator) stated the facility does not have a full- service kitchen. V1 stated the facility is attached to a hospital and prior to being sold, the hospital kitchen prepared the resident meals. V1 stated resident meals are currently prepared at their sister facility, 2.5 miles away, and transported to the facility. V1 stated the sister facility is currently washing the facility's dishes. On 5/19/26 at 9:45 AM, V6 (sister facility Dishwasher) stated she was not certain what process was used to sanitize the dishes, either high temperature or chemical. V6 said she did not have temperature or chemical test strips for the dishwasher. On 5/19/26 at 9:48 AM, V7 (sister facility Cook) stated, We don't have a log for monitoring the dishwasher sanitization. It used to be on this clipboard, but we haven't had one for a while. (V7 pointed to an empty clipboard on the wall near the dishwasher.)On 5/19/26 at 9:57 AM, the sister facility's two walk-in coolers and freezer had no thermometers inside the units. The thermometers outside the coolers showed no calibration stickers. Outside the two coolers and the freezer were clipboards. The clipboards had no papers on them.On 5/19/26 at 9:58 AM, V8 (sister facility Dietary Manager) stated, I'm in the process of making logs walk-in temp logs. We've not been logging temps; not in the week since I've started. This is my seventh day here. V8 said he does not know what type of dishwasher the facility has, whether it is chemical or heat sanitizer.On 5/19/26 at 10:00 AM, the sister facility's can opener showed dried black pieces directly above the cutting blade.On 5/19/26 at 10:08 AM, the sister facility's dry stores showed boxes of gelatin and cornbread mix on the floor. V8 stated the last food delivery was on Friday (5/15/26). On 5/20/26 at 1:59 PM, V8 stated I'm fairly certain it's a high heat sanitizer dishwasher. In my experience, we would use a thermometer in the machine to temp the stages. We don't have one, but we are ordering one. That is the most accurate way to measure the sanitizer temperature because it measures the temp on the plate. Our maintenance man said the external thermometer on the dishwasher is broken. V8 said the sanitizer temperature should be checked after every meal service and then documented. V8 said the purpose of monitoring the dishwasher is to ensure it as the proper temperature to kill any bacteria on the plates, flat wear, and pots or pans. V8 said there should be a thermometer in the coolers and freezers. V8 said the temperatures should also be documented and reviewed. V8 said the purpose of the thermometers is to ensure the temperatures are cool enough to prevent or slow bacterial growth. V8 stated, food should be stored 6 inches off the floor. V8 said this is to prevent rodents from getting into the food. V8 said the gelatin and corn bread had been delivered the Friday prior and had not been put on the shelves. The facility's Dishwashing: Machine Operation (2020) policy showed, .Record log documents twice daily for either final rinse temperature (High temperature dishwashing machine) or sanitizer concentration (Low-temperature dishwashing machine with chemical sanitizer).The facility's Food Storage (Dry, Refrigerated, and Frozen) policy (2020) showed, .Store deliveries as soon as they have been inspected. Place a thermometer in the warmest part of the refrigerator to monitor the air temperature in the refrigerator. Check freezer temperature regularly.Store dry food on shelves two inches away from walls to allow ventilation, six inches off the floor to allow for proper sanitation, and 18 inches from the ceiling to ensure fire safety.

Based on interview and record review the facility failed to provide notification of transfer to the residents and their representative. The facility failed to provide the written bed hold policy to the residents or their representative prior to transfer. This applies to 5 of 5 residents (R120, R124, R11, R15, & R104) reviewed for transfer/discharge communication in the sample of 47.The findings include: 1. On 5/19/26 at 11:34 AM, R120 sat in a padded high back wheelchair and V25 (R120's son/power of attorney) was visiting the resident. V25 stated in April 2026, R120 was not as responsive as she should be and was sent to the emergency room from the facility. V25 stated R120 was admitted to the hospital for a urinary tract infection and pneumonia and was there for 4 days. On 5/19/26 at 1:15 PM, V25 stated he was not sure if he received the notification of transfer or the bed hold policy when R120 went to the hospital in April 2026. V25 stated he would let the surveyor know if he received them; he has papers in a backpack. The surveyor was never notified that he had the paperwork. On 5/21/26 at 10:07 AM, V5 (Licensed Practical Nurse – LPN) stated when a resident is sent to the hospital, the bed hold paper and the notice of transfer is filled out, but it is not always given to the resident and/or their representative. V5 stated they had been told by management they were not doing it, and it needs to be done. When R120 was sent to the hospital she was sent out by the third shift agency nurse, so it probably did not happen. V5 stated she was there the day R120 was sent out and tried to help. V5 looked in R120's medical record and did not see copies of the notice of transfer or bed hold form. On 5/21/26 at 10:50 AM, V1 (Administrator) stated the bed hold policy and notice of transfer is supposed to be done when the resident is sent out. It is given to the residents if they are alert and oriented and then to the power of attorney. V1 stated they talked about this at the morning meeting and the staff know that this should be done. V1 stated if the copies of the forms are not uploaded into the electronic medical record, then she cannot prove that this is being done. 2. On 5/21/26 R124's medical record was reviewed related to transfers and discharges. The Note for a change in condition on 12/15/25 at 2:21 PM for R124 showed he was evaluated for abdominal pain. The Nurse's Note dated 12/15/25 at 10:10 PM for R124 showed he was admitted to the hospital for a twisted sigmoid colon and was having emergency surgery. There wasn't a notification of transfer or bed hold paper scanned into R124's medical record. On 5/21/26 at 1:05 PM, R124 was sitting in wheelchair in room and was asked if he was given any paperwork when he was sent to the hospital; he stated no. The bed hold and notification of transfer paperwork was explained to R124 and he confirmed he never received this information the last time he was sent to the hospital. 3. R11's admission Record, provided by the facility on 5/21/26, showed she had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction (stroke) affecting her right dominant side, type II diabetes mellitus with diabetic chronic kidney disease, a non-pressure chronic ulcer of abdomen, chronic systolic congestive heart failure, stage 3A chronic kidney disease, iron-deficiency anemia, and hereditary and idiopathic neuropathy. On 5/20/26, at 10:42 AM, V3 (Assistant Director of Nursing-ADON/Wound Nurse) was getting ready to provide wound care for R11. R11 told V3 that her left side was hurting. V3 looked at R11's left side. R11 had a large, reddened area over her left hip and upper outer leg. V3 touched the area with her gloved hand and said it was warm to touch. V3 told R11 the nurse practitioner was in the building, and she would ask the nurse practitioner to look at it. R11's progress note dated 5/20/26 showed R11 was sent out to the hospital by ambulance around 4:30 PM, due to having a temperature and her hands shaking uncontrollably. The progress notes show R11 was admitted to the hospital. On 5/21/26 at 12:03 PM, V3 (ADON) was asked if a bed hold notice was given to R11 when she was sent to the hospital on 5/20/26 (the previous afternoon). V3 said it may not have been scanned into R11's electronic medical record yet. V3 said it may still be in V2's (Director of Nursing-DON) inbox. At 12:10 PM, V2 (DON) provided R11's bed hold notice for 5/20/26 and said the bed hold notice also serves as the facility's written notice of transfer. The bed hold notice does not specify the reason R11 was sent out, the location R11 was sent to, a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the bed hold notice does not contain the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. 4. R15's admission Record, provided by the facility on 5/21/26, showed she had diagnoses including, but not limited to right tibia fracture, fracture around internal prosthetic right knee joint, fracture of shaft of right fibula, chronic respiratory failure with hypoxia, congestive heart failure, thoracic aorta aneurysm without rupture, anemia, muscle wasting and atrophy, low back pain, gastrointestinal hemorrhage, pain in right shoulder, polyosteoarthritis, and anxiety disorder. R15's electronic medical record only showed a bed hold for June 20, 2025. R15's medical record did not show a written notice of transfer was provided to R15 or her power of attorney (POA). R15's census document showed she was sent to the hospital on 6/20/25, 11/25/25, and on 12/29/25. On 5/21/26 2:18 PM, V3 (Assistant Director of Nursing) said she only sees the bed hold in R15's electronic medical record for June of 2025. V3 was asked to provide copies of any bed holds or written notices of transfer for R15 in June, November, and December of 2025. On 5/21/26 at 2:20 PM, R15 said she does not recall getting any bed holds and is not sure if her son got one. She said she would be upset and would not know what to do if the facility did not allow her to come back after going to the hospital. On 5/21/26 at 2:36 PM, V33 (R15's POA) said the facility is good at calling him when R15 is being sent to the hospital, but he had never received any bed hold notice, or any paperwork from the facility whenever she was sent out. 5. R102's nursing progress notes dated 5/18/26 showed R104 was sent to a local hospital for a change in condition. R102's progress notes did not show that a written transfer of notice or bed-hold policy was given to R102 or her Power of Attorney. On 5/19/26 at 10:20AM, R104 and her husband were sitting in her room. R104's husband stated, She has gone to the hospital recently, just yesterday actually but they didn't keep her. I didn't know there was any paperwork she was supposed to get or anything and I don't receive anything when she goes to the hospital. That must be something new because I have never heard of it. The facility's Bed-hold and Return to Facility Policy and Procedure (2025) showed the purpose was to ensure that residents being transferred to a hospital or placed on therapeutic leave are informed as to the facility's bed-hold and return policy. The facility will notify residents or their resident representatives of this policy in accordance with provisions below. Procedure: Before a resident is transferred to a hospital or the resident goes on therapeutic leave, the facility must provide written information to the resident or the resident representative regarding the facility's bed hold and return policy. No other policy related to notification of transfer was received.

Based on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS (Minimum Data Set) data to the CMS System for 11 of 12 residents (R4, R16, R29, R58, R66, R68, R75, R96, R109, R120, R124) reviewed for resident assessments in the sample of 47.The findings include:R4's quarterly MDS assessment showed, In progress and was due on 3/20/26. R16's discharge MDS assessment showed, In progress and was due on 3/13/26. R29's quarterly MDS assessment showed, In progress and was due on 3/18/26. R58's quarterly MDS assessment showed, In progress and was due on 4/7/26. R66's quarterly MDS assessment showed, In progress and was due on 4/3/26. R68's quarterly MDS assessment showed, In progress and was due on 4/6/26. R75's quarterly MDS assessment showed, In progress and was due on 4/2/26. R96's annual MDS assessment showed, In progress and was due on 3/24/26. R109's quarterly MDS assessment showed, In progress and was due on 4/15/26. R109's death in facility MDS showed, In progress and was due on 4/29/26. R120's quarterly MDS assessment showed, In progress and was due on 3/25/26. R120's quarterly MDS assessment showed, In progress and was due on 4/22/26 R120's discharge MDS assessment showed, In progress and was due on 4/29/26. R120's entry MDS assessment showed, In progress and was due on 5/2/26. R120's medicare-5 day MDS assessment showed, In progress and was due on 5/8/26. R120's end of part A stay showed, In progress and was due on 5/12/26. R124's annual MDS assessment showed, In progress and was due on 4/3/26. On 5/21/26 at 12:08 PM, V20 (MDS Nurse) stated, I'm newer in this position. I'm part-time and the other nurse is full time. Our plan is I'm working on the past due ones, and she is working on the current ones. We know they are late and are working to get everything caught up. On 5/21/26 at 12:22 PM, V4 (Regional Nurse) stated, We knew MDS was going to be an issue because this building went without an MDS nurse for a few months, so nobody was doing them. The 2 new MDS nurse's are getting them caught up as fast as they can. On 5/21/26 1:06 PM, V1 stated, Regarding MDS submissions, we follow the guidelines for the specific payer sources and timing as defined by CMS guidance. I don't have a specific policy.

Based on observation, interview, and record review the facility failed to double lock a controlled substance. This applies to 1 of 1 resident (R85) reviewed for controlled substances in the sample of 47. The findings include:R85s Order Summary Report showed an order for alprazolam (anxiety treatment medication) 0.25 milligrams to be given every day for anxiety. On 5/20/26 at 8:58 AM, V5 (Licensed Practical Nurse-LPN) was passing medications to residents. Prior to this time, V5 had been away from her cart, in resident rooms, administering medications. In the top drawer of the medication cart was an unlabeled medication cup with a medication tablet. V5 stated it was R85's alprazolam. V5 stated R85 had refused the medication, and she was holding the medication to reapproach at a later time.On 5/21/26 at 10:27 AM, V2 (Director of Nursing) stated she was aware of the incident regarding R85's alprazolam. V2 stated alprazolam is a controlled substance and it should be double locked to prevent misappropriation. V2 stated V5 should have disposed of the medication per the facility's policy.The facility's Controlled Substances policy (dated 6/4/25) showed, Schedule II drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may be used for safe keeping. (Alprazolam is a Schedule IV medication.) The policy showed, .The drugs in other schedules deemed necessary for control are placed under the same restrictions as Schedule II drugs by the pharmacist. The nurse and the pharmacist will discuss the potential abuse or drugs that are being abused and decide on proper controls. The policy continued, If a resident refuses a dose of a controlled drug, or it is not given for any reason, the medication dose must be destroyed. The dose must be destroyed in the presence of two (2) Licensed Nurses and documented on the disposition sheet as destroyed.

Based on observation, interview, and record review the facility failed to ensure a resident that requires assistance was having his facial hair shaved for 1 of 1 residents (R10) reviewed for activities of daily living in the sample of 47.The findings include: On 5/19/26 at 9:40 AM, R10 was sitting up in his bed with his tray table in front of him. R10 had longer facial hair present but not a full mustache and beard. R10 stated he needed to be shaved but can't get it done and would like to have it done. R10 stated he must have someone do it, not because he can't do it but because he was told that someone had to do it. R10 stated this was not how he normally looks, and he has been shaved once since he has been at the facility.On 5/20/26 at 10:33 AM, R10 was in his room with V27 (Certified Nursing Assistant - CNA) and V26 (CNA). The aides provided incontinence care, dressed the resident and transferred R10 to the recliner using 2-person standby assist with a gait belt and wheeled walker. R10 still had facial hair present. R10 asked if the surveyor found out anything about when he was going to be shaved. V27 and V26 did not respond to R10's question. The aides were asked by the surveyor when R10 would be shaved. V27 stated she was waiting for his razor to be brought in by his daughter. R10 stated that his razor was there and had been there and he was waiting for someone to help him. R10 stated two students did it one day and no one has helped him since then.On 5/20/26 at 11:08 AM, V5( Licensed Practical Nurse) stated the CNAs should shave the resident when growth appears, when the resident prefers, or with the shower and/or and regular hygiene regimen unless they refuse. V5 stated it has been discussed with them. Basic needs of care are not being met. V5 stated she notice that R10 needed to be shaved, and the aides were talked to about it.The Face Sheet dated 5/21/26 for R10 showed diagnoses including gastrostomy, chronic obstructive pulmonary disease, chronic respiratory failure, fall, muscle weakness, muscle wasting and atrophy, dysphagia, unsteadiness on feet, cognitive communication deficit, hypertrophic cardiomyopathy, peripheral vascular disease, peripheral vascular disease, hypertension, malignant neoplasm of prostate, dyspnea, dependence on supplemental oxygen, syncope and collapse. The Minimum Data Set, dated [DATE] for R10 showed no cognitive impairment.The facility's Shaving - Male or Female policy (no date) showed resident will be free of facial hair - male and female. If the resident is alert and oriented and requests not to be shaved, this will be noted in the care plan.

Based on observation, interview, and record review, the facility failed to perform a pressure ulcer assessment for a resident (R104) with a reopened pressure ulcer, failed to ensure pressure ulcer prevention measures were in place for a resident (R120). These failures apply to 2 of 3 residents reviewed for pressure ulcers in the sample of 47.The findings include: 1. R104's electronic face sheet dated 5/21/26 showed R1 has diagnoses including but not limited to type 2 diabetes, type 1 diabetes, hypertensive heart disease, and gastroesophageal reflux disease. R104's facility assessment dated [DATE] showed R104 has mild cognitive impairment and has 1 unstageable wound. R104's care plan dated 5/10/26 (revised 5/20/26) showed, The resident has potential for pressure ulcer development r/t (related to) Immobility 1/13/26: L (left) heel pressure wound 1/28/26: Right gluteus pressure wound. On 5/19/26 at 10:20 AM, R104 stated, There's something wrong with my bottom. I can tell that's something isn't right, and it feels like there is a sore there. R104's husband was present and stated R104 used to have a wound to her buttocks, but it healed a few weeks ago. On 5/19/26 at 11:19 AM, V17 (Certified Nursing Assistant-CNA) assisted R104 to the bathroom. V17 pulled R104's incontinence brief down and bright red blood was noted on the incontinence brief. V17 stated, This is where she just had an open area that had a scab on it so the scab must have come off. V17 left the room and obtained a bottle of zinc oxide cream and applied it to R104's buttocks. V17 stated she informed V14 (Licensed Practical Nurse) that R104's wound had reopened, and she instructed her to apply cream, and she would come assess it later in the shift. R104's progress notes dated 5/21/26 showed, Assessed reopened pressure area to right medial buttock. Wound had been resolved on 4/28/26 with preventative zinc cream remaining as a treatment. CNA informed floor nurse on 5/20/26 that area had reopened. Area was cleansed and bandage was applied, Treatment placed. This nurse assessed wound. Wound in same area as previously resolved wound. Wound is 3.2x1.5x0.1cm (centimeters). Wound bed is 100% granulation tissue with mild erythema to peri-wound. Some scarring noted to buttocks from healed wound. Area cleansed, bandage placed and treatment plan updated . R104's electronic medical record showed no assessment of R104's wound and no treatment orders in place until 5/21/26 (2 days after R104's wound reopened). On 5/21/26 at 11:28 AM, V3 (Assistant Director of Nursing/Wound Nurse) stated, (R104's) wound did reopen and it was assessed yesterday by the floor nurse and treatment was started. The assessment would be documented in progress notes, and the order should be in, but if it's not there then I can't confirm she did it if she didn't document it. No assessment was done on 5/19 when it was originally identified by the CNA. It should have been done at that time but sometimes I think when I am in the building the nurses just assume I will be doing it. Treatment should start immediately for wounds to give the best chance at healing them. The facility's undated policy titled, Decubitus Care/Pressure Area policy showed, It is the policy of this facility to ensure a proper treatment program has been instituted and is closely monitored to promote the healing of any pressure ulcer .1) Upon notification of skin breakdown, the Newly Acquired Skin Assessment will be completed. 2) The pressure area will be assessed and documented in the Treatment Administration Record or the Wound Documentation Record . 2. On 5/19/26 at 11:34 AM, R120 was sitting up in a padded wheelchair in the common area. R120's heels were resting on the footrest. V25 (R120's son/power of attorney) was sitting in a chair next to her. V25 stated R120 was in the hospital, and he was notified that she had a pressure ulcer to her tailbone and to her right heel. V22 (hospice Registered Nurse – RN) arrived and stated R120 has offloading boots, and they are to be on as much as tolerated. V22 stated R120 has a deep tissue injury to her right heel. On 5/20/26 at 9:24 AM, R120 was sitting in her padded wheelchair, and her heels were not offloaded. On 5/20/26 at 11:08 AM, V5 (Licensed Practical Nurse) stated R120 has a deep tissue injury to her heel. V5 stated the offloading boots are for prevention and to help with the healing process. On 5/21/26 at 10:36 AM V3 (Assistant Director of Nursing/Wound Care Nurse) stated R120's wound developed in the hospital during her stay. V3 stated R120 should have the offloading boots on when she is up in the chair and that R120 spends a lot of time up in her chair. On 5/21/26 at 11:27 AM, wound care to R120's right heel was provided by V3. R120 had a small purple area to her right heel; the heel was closed. V3 applied skin prep to the area. The Wound Documentation for R120 dated 5/14/26 showed she has an unstageable pressure injury presenting as a deep tissue injury to her right heel. R120's Physician Orders for May 2026 showed, apply heel protectors at all times. If guest refused, float heels on pillow. The Minimum Data Set, dated [DATE] for R120 showed dependence on staff for all activities of daily living. The facilities Decubitus Care/Pressure Areas policy (no date) showed when a pressure ulcer is identified additional intervention must be established and noted in care plan in an effort to prevent worsening or re-occurring pressure ulcers.

Based on observation, interview, and record review the facility failed to ensure catheter tubing was not on the floor for 1 of 2 residents (R124) reviewed for catheters in the sample of 47.The findings include: On 5/19/26 at 10:43 AM, R124 was sitting in a wheelchair in his room. R124 had an indwelling urinary catheter drainage bag under his chair and the catheter tubing was on the floor. R124 was able to propel his wheelchair in the room and the tubing was dragging on the floor. On 5/21/26 at 10:07 AM, V5 (Licensed Practical Nurse) stated catheter tubing should not be on the floor for contamination prevention.The Face Sheet dated 5/21/26 for R124 showed diagnoses including anxiety disorder, dysphagia, muscle weakness, muscle wasting, benign prostatic hyperplasia, Ogilvie syndrome, epididymo-orchitis, hyperlipidemia, gastroesophageal reflux disease, acute atopic conjunctivitis, insomnia, bullous pemphigoid, unspecified intestinal obstruction, person history of urinary infections, depressive episodes, hypertension, hypo-osmolality and hyponatremia, and unspecified intellectual disabilities. The May 2026 Physician Orders for R124 showed he has a 16 French 10ml (milliliter) bulb urinary catheter. Catheter care every shift. R124's Care plan dated 4/17/26 showed the resident has indwelling catheter for obstructive uropathy. The facility's Indwelling Catheter Use and Removal policy (6/2025) showed if an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures.

Based on observation, interview, and record review the facility failed to provide privacy during care for 1 of 1 residents (R10) reviewed for privacy in the sample of 47.The findings include:On 5/20/26 at 10:33 AM, V26 (Certified Nursing Assistant - CNA) and V27 (CNA) were at R10's bedside providing incontinence care. R10's penis, scrotum, anus and buttocks were exposed during the care. The window blind was open; his room was on ground level and visible from the driveway and parking area at the facility. V26 and V27 stated the blinds should have been closed during care for R10's privacy.On 5/20/26 at 11:08 AM, V5 (Licensed Practical Nurse - LPN) stated the blinds were to be closed when providing care for a resident for their personal privacy.The Minimum Data Set (MDS) dated [DATE] for R10 showed no cognitive impairment; frequently incontinent; dependence for toileting hygiene.The Face Sheet dated 5/21/26 showed diagnoses including gastrostomy, chronic obstructive pulmonary disease, chronic respiratory failure, fall, muscle weakness, muscle wasting and atrophy, dysphagia, unsteadiness on feet, cognitive communication deficit, hypertrophic cardiomyopathy, peripheral vascular disease, peripheral vascular disease, hypertension, malignant neoplasm of prostate, dyspnea, dependence on supplemental oxygen, syncope and collapse. The facility uses the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet as their policy on resident's rights. The booklet showed the residents' medical and personal care is private. The facility staff must respect privacy when the resident is being examined or given care.

Based on observation, interview, and record review the facility failed to provide puree foods in a texture to meet resident needs. This applies to 3 of 3 residents (R60, R94, and R125) reviewed for pureed diets in the sample of 47. The findings include:The facility's dietary report showed R60, R94, and R125 were on pureed diets.R60, R94, and R125's admission Record (Face Sheets) all showed a diagnosis of dysphagia (difficulty swallowing).R60's 1/8/26 Speech Therapy plan of treatment showed he was being treated for swallowing dysfunction.R94's 2/27/26 Speech Therapy evaluation showed he was being treated for swallowing dysfunction.R125's 4/15/26 Speech Therapy note showed he was being treated for swallowing dysfunction.On 5/19/26 at 9:26 AM, V1 (Administrator) stated the facility does not have a full-service kitchen. V1 stated the facility is attached to a hospital and prior to being sold, the hospital kitchen prepared the resident meals. V1 stated resident meals are currently prepared at their sister facility, 2.5 miles away, and transported to the facility.The facility's 5/19/26 menu showed ham and potato casserole as well as mixed vegetables were to be served.On 5/19/26 at 10:33 AM, V7 (sister facility Cook) stated she was going to measure the temperature of the menu items prior to sending them to the facility. V7 measured the temperature of the purees and stated they were ready to be sent to the facility. Prior to being sent to the facility, the pureed ham (pureed ham was to be ladled over mashed potatoes) was tested. The pureed ham was not pureed; it was small but separate individual pieces floating in cooking liquid. The pieces ranged in size from a grain of rice up to the size of pea. The ham pieces required chewing in order to be swallowed. Broccoli was substituted for mixed vegetables. The pureed broccoli was tested next. The broccoli also had pea-sized and larger chunks which required chewing to swallow. On 5/19/26 at 10:45 AM, it was requested that V8 (sister facility Dietary Manager) test the texture of the pureed ham and broccoli. V8 visually observed the purees and stated, without testing them, There are way too many chunks to send this over. We will have to run this again.On 5/20/26 1:59 PM, V8 stated the purees looked like mechanical ground texture instead of puree. V8 stated puree texture is most often prescribed for residents with dysphagia. V8 stated if a puree is not the correct texture it can be a choking risk for the resident. The Puree Ham Potato Casserole recipe and the Pureed Vegetable recipe (both dated 4/16/26) both showed, .blend until smooth.The facility's Pureed Food Preparation policy (2020) showed .Pureed foods will be the consistency of applesauce or smooth, mashed potatoes. A food processor is preferred; however, a blender may be used to make pureed foods.

Based on observation, interview, and record review, the facility failed to store medications in a locked compartment for 1 of 1 residents (R149) reviewed for medication storage in the sample of 47.The findings include:On 5/21/26 at 10:32 AM, a medication cart was located on R149's hallway. The medication cart had 11 medication cards with R149's name on them with medications enclosed, a medication cup with medications inside of it located on the top of the cart. The medication cart was unlocked with no nurse present. A housekeeper was observed cleaning a room down the hall from the medication cart. Due to safety concerns, surveyor continued continuous observations of the medication cart until V19 (Licensed Practical Nurse) returned to the medication cart. At 10:40 AM, V19 emerged from a room down the hall from the medication cart where the door had been closed and she was not visible to this surveyor. At this time, surveyor questioned V19 as to why the medications were unattended and V19 abruptly picked up the medication cards, opened the drawer, threw the medication cards in the cart and stated, Well they aren't now, are they? Surveyor reported V19's actions and responses to V3 (Assistant Director of Nursing) at 10:48 AM.On 5/21/26 at 12:21 PM, V2 (Director of Nursing) stated, All medications should be in a locked compartment or in direct eyesight of the nurse at all times. Someone could've taken those medications or gotten into the medication cart and taken other medications. This is a major safety issue and is not tolerated at our facility. (V19) is an agency nurse and will not be allowed to return to our facility based upon this practice. The facility's policy titled, Procurement and Storage of Medications dated 8/12/25 showed, 8. All medications, except those requiring refrigeration, shall be kept in the locked medicine room or locked medication cart.

Based on observation, interview, and record review, the facility failed to ensure the filter for an oxygen concentrator was cleaned and the oxygen tubing and humidifier were changed weekly for 2 of 2 residents (R146, R10) reviewed for respiratory care in the sample of 47.The findings include:1. R146's admission Record, provided by the facility on 5/21/26 showed he was admitted to the facility on [DATE] with diagnoses including, but not limited to amyotrophic lateral sclerosis (ALS is a progressive, fatal neurological disorder that destroys motor neurons-the nerve cells in the brain and spinal cord that control voluntary muscle movement. As these cells die, muscles weaken, waste away, and eventually leave patients unable to move, speak. Eat, or breathe), bipolar II disorder, polyneuropathy (simultaneous damage to multiple peripheral nerves throughout the body causing numbness, tingling, weakness, or burning pain), myelopathy in diseases (spinal cord compression), and fasciculation (muscle twitching). On 5/20/26 at 12:00 PM and again at 3:44 PM, R146 was observed lying in bed with the head of bed up. The oxygen concentrator next to R146's bed was running at 2 liters per minute. The tubing for the nasal cannula on both observations had a piece of tape attached to the tubing dated 5/11/26. (This date was prior to R146's admission to the facility on 5/13/26.) The other end of the tubing was in R146's nose to provide oxygen. The humidification unit on the concentrator was dated 5/13/26. R146's Order Summary Report, provided by the facility on 5/21/26, showed an order for Hospice dated 5/13/26. The report showed an order dated 5/13/26 to change oxygen tubing and humification unit weekly on Sunday during the night shift. Please date tubing and humidifier. R146's May 2026 medication administration record (MAR) showed the nurse working on the night shift marked the tubing and humidifier as being changed on 5/17/26. On 5/21/26 at 10:16 AM, V2 (Director of Nursing-DON) said oxygen tubing and the humidifiers are changed weekly. V2 said the order is listed on the residents' MAR and the night nurses usually change them. At 10:21 AM, V2 said it is important to change the oxygen tubing weekly for infection prevention because bacteria can get in the tubing. V3 (Assistant Director of Nursing-ADON) was present during the conversation and was asked to go to R146's room with this surveyor. At 10:23 AM, V3 verified the date on the nasal cannula tubing was 5/11/26 and the date on the humidifier was 5/13/26. V3 said R146 was admitted to the facility on [DATE] and said the tubing must be from before R146 was admitted to the facility. V3 said that is not acceptable. It should have been changed on 5/17/26 on the night shift. V3 said the humidifier is the one she put on when R146 was admitted . V3 said it is important to change them weekly for infection control because R146 is immunocompromised. The facility's policy and procedure titled Oxygen Safety Guidelines, with a revision date of June 2025 showed It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment.3. Staff, residents, and families will be educated on oxygen safety precautions in accordance with their roles and responsibilities related to the use and storage of oxygen.6. a. Licensed staff using oxygen equipment will be trained in its operation, safety precautions, and manufacturer's instructions for using the equipment. Training will occur upon hire and periodically for review of safety guidelines and usage requirements. 2. On 5/19/26 at 9:40 AM, R10 was sitting up in bed and had oxygen on via a nasal cannula. The nasal cannula was attached to an oxygen concentrator that had a dirty filter with thick white fuzzy debris in it. The oxygen tubing was not labeled. On 5/21/26 at 10:07 AM, V5 (Licensed Practical Nurse) stated if they see a dirty oxygen filter they clean it. There isn't one specific person that does it. V5 stated she will clean the ones that are able to be cleaned. V5 stated she was not sure that everyone realizes that the filters can be cleaned. V5 stated it is night shift that changes the nasal cannula and tubing and they usually label them that it was done. The May 2026 Treatment Administration Record (TAR) for R10 showed changed oxygen tubing and humidification unit (if applicable) weekly every night shift every Saturday and date the tubing. The TAR showed on 5/16/26 (Saturday) no one signed off that this was completed. The Face Sheet dated 5/21/26 for R10 showed diagnoses including gastrostomy, chronic obstructive pulmonary disease, chronic respiratory failure, fall, muscle weakness, muscle wasting and atrophy, dysphagia, unsteadiness on feet, cognitive communication deficit, hypertrophic cardiomyopathy, peripheral vascular disease, peripheral vascular disease, hypertension, malignant neoplasm of prostate, dyspnea, dependence on supplemental oxygen, syncope and collapse.

Based on observation, interview, and record review, the facility failed to wear personal protective equipment for 2 residents (R10, R89) on transmission-based precautions, and failed to prevent cross-contamination for 1 resident (R10). These failures apply to 2 of 2 residents reviewed for transmission-based precautions in the sample of 47.The findings include: 1. R89's electronic face sheet dated 5/21/26 showed R89 has diagnoses including but not limited to acute osteomyelitis, type 2 diabetes, and sepsis due to methicillin resistant staphylococcus aureus (MRSA). R89's physician's orders dated 5/19/26 showed, Contact Isolation for MRSA of wound every shift for 7 days. R89's care plan dated 5/19/26 showed, The resident requires contact isolation related to wound infection with MRSA present. On 5/19/26 at 9:56 AM, R89's door had a sign showing, Contact Precautions: everyone must clean their hands before entering and when leaving the room, put on gloves before room entry, discard gloves before room exit, put on gown before room entry, discard gown before room exit, use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 5/20/26 at 9:26AM, V15 (Registered Nurse) was inside R89's room administering medications with only gloves on. V15 administered R89's oral medication with gloves on, exited R89's room and went to her medication cart, obtained an insulin pen for R89, re-entered R89's room to administer insulin, returned to her medication cart to put the insulin away, obtained a blood pressure cuff from her cart, re-entered R89's room, obtained R89's blood pressure all with the same pair of gloves on. V15 put the blood pressure cuff used for R89 on top of her medication cart and proceeded to go into R104's room with the contaminated blood pressure cuff and obtained R104's blood pressure. V15 stated, I didn't do any extensive care with him, so the gloves were fine. He is on contact isolation for MRSA on his foot I believe. I did not use anything to clean the blood pressure cuff or the other equipment because his wound is covered. On 5/21/26 at 11:28 AM, V3 (Assistant Director of Nursing) stated, Staff should be wearing gowns and gloves in contact precaution rooms; (there is) no reason why they shouldn't be. If any of the staff take equipment into an isolation room, it should be sanitized appropriately when removed from the room prior to being taken into another resident room to prevent cross-contamination. On 5/21/26 at 12:21 PM, V2 (Director of Nursing) stated, For all residents on contact precautions, you wear all of the PPE (personal protective equipment) when you enter the room; that is our expectation. There is a 50/50 chance I might come into contact with them being a nurse, even if you're just going in there to pass medications there is a high likelihood that you will be doing more than just that because you want to make sure all of their needs are met before you leave the room. Any reusable equipment should be sanitized between residents due to the chance to spread bacteria from one resident to another. The facility's policy titled, Contact Precautions reviewed 12/7/18 showed, In addition to Standard Precautions, use Contact Precautions, or the equivalent for specified residents known or suspected to be colonized with epidemiologically important microorganisms that can be transmitted by direct contact or indirect contact with the resident .2. Gloves: wear gloves when entering the room, during the course of providing care for the resident .Remove gloves before leaving the residents environment and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent .Gown. Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident .5. Resident Care Equipment: when possible, dedicate the use of non-critical resident care equipment to a single resident to avoid sharing between residents. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another resident . 2. On 5/20/26 at 10:33 AM, V26 (Certified Nursing Assistant-CNA) and V27 (CNA) were at R10's bedside to provide incontinence care. V26 and V27 put gloves on but not gowns and there was an enhanced barrier precaution (EBP) sign posted on the entrance to his room. V26 took a disposable wipe from a package on the tray table and wiped his groin and left the wipes between his legs. V26 and V27 had him turn on his left side and V26 removed the wet brief. V26 grabbed wipes and cleaned his buttocks and grabbed the wipes between his legs and discarded them. V26 grabbed another wipe and cleaned his anus and buttocks and discarded the wipe. V26 grabbed another wipe to clean under buttocks and discarded. V26 grabbed the cream from the tray table, put some on her glove, put the cream back on the table, and applied it to his buttocks. V26 never changed her gloves when going from dirty to clean. V26 put a clean brief under R10. V26 she then touched the resident to help him turn on his back and a little to his other side to position the brief. V26 and V27 fastened the brief closed. V26 and V27 removed their gloves. They both applied new gloves and got R10 dressed. R10's dressing was hanging off him from around the feeding tube. They used a gait belt and transferred him to the chair. V27 stated they change gloves when going from dirty to clean so they don't touch clean stuff with dirty gloves for infection control. They were asked about the enhanced barrier precautions sign, and they stated that it should not be up for him. V26 asked if it was for R10's feeding tube. They denied needing to do anything because of it. They both stated they had been asking if the sign needed to be up anymore for him. On 5/20/26 at 10:51 AM, V5 (Licensed Practical Nurse) stated R10 has EBP because of his feeding tube and then stated it was for the wound on his back and not the feeding tube. V5 stated a gown is only worn when the dressing to R10's back is changed. On 5/20/26 at 11:01 AM, V5 went to R10's room, put gloves on, did not put a gown on and provided site care and a dressing change to his feeding tube. On 5/20/26 at 2:14 PM, V3 (Assistant Director of Nursing) stated the enhanced barrier precaution policy should be followed and residents on EBP have signs posted. The Face Sheet dated 5/21/26 for R10 showed diagnoses including gastrostomy, chronic obstructive pulmonary disease, chronic respiratory failure, fall, muscle weakness, muscle wasting and atrophy, dysphagia, unsteadiness on feet, cognitive communication deficit, hypertrophic cardiomyopathy, peripheral vascular disease, peripheral vascular disease, hypertension, malignant neoplasm of prostate, dyspnea, dependence on supplemental oxygen, syncope and collapse. May 2026 Physician Orders for R10 showed enhanced barrier precautions related to feeding tube/wound. The Care Plan dated 3/8/26 for R10 showed he is on enhanced barrier precautions for feeding tube, wounds, or skin opening that requires a dressing. Follow Enhanced Precaution Guidelines when providing care and coming in direct contact with potentially infected material or devices that put me at risk. Direct care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting and incontinence care, device use, catheter, trach/ventilator, central lines, feeding tube, wounds care or any skin opening requiring a dressing. The Enhanced Barrier Precautions Guidelines policy (6/2025) showed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High contact resident care activities include dressing, bathing, transferring, providing hygiene, device care or use. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. The facility's Removing Gloves policy showed the procedure for removing gloves but not when to do it or why it is important. Disposable gloves (non-sterile) act as a barrier between the resident and you. To protect employee from pathogens in the resident's blood, body fluids, and body substances. Protection for the resident from microorganisms the employee may have on their hands.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion and contractures had her hand splints applied for 1 of 4 residents (R120) reviewed for splints in the sample of 47.The findings include:On 5/19/26 at 11:34 AM, R120 was sitting in a padded wheelchair in the common area. R120's right arm was twisted inward, and both of her hands were turned inward. R120 did not have any splints in place. V25 (R120's son/power of attorney) was sitting in a chair next to her. V25 stated he was concerned about R120's flexibility and contractures. V25 stated R120 has splints that are supposed to be in place to both hands and arms. V25 stated the facility staff were using them and then would say they could not find them. V25 stated he sees the splints at intervals and usually finds them in R120's room in a drawer. R120 stated she tells the staff to put them on and stated her hands and arms sometimes hurt when they are turned in like that.On 5/19/26 at 12:31 PM, R120 was in her wheelchair with V25 sitting next to her. V22 (hospice Registered Nurse) was at the facility and applying the splints to R120's hands/arms. V25 stated the splints were located on a shelf in R120's room.On 5/20/26 at 11:08 AM, V5 (Licensed Practical Nurse) stated staff know that R120's splints are to be applied when they get her up. V5 stated the staff have been notified over and over about it. R120's Face Sheet dated 5/21/26 showed diagnoses including metabolic encephalopathy, urinary tract infection, pneumonia, altered mental status, depressive disorders, vitamin D deficiency, polyneuropathy, chronic obstructive pulmonary disease, hypertension, benign neoplasm of meninges, spinal stenosis, cerebral infarction, and neuromuscular dysfunction of the bladder.The Minimum Data Set, dated [DATE] for R120 showed dependence on staff for all activities of daily living.The facility's Splints/Appliances policy (no date) showed a resident who has a contracture, or has a likelihood of developing a contracture, caused by a physical condition and requires further evaluation will be assessed by the occupational therapist for splint/appliance as ordered by the resident's physician. The occupational therapist will provide nursing with a schedule for the application and removal of the splint, subject to physician order. The program will be identified on the resident's care plan including the problem, approaches, and goals.The Care Plan dated 1/23/26 that was revised 5/13/26 for R120 showed bilateral resting hand splints to be applied each morning and taken off at bedtime as tolerated 6-7 days per week to prevent hand contractures.

Based on observation, interview, and record review the facility failed to post accurate shift based nurse and certified nursing assistant (CNA) ratios. This failure has the potential to affect all residents in the facility. The findings include:The facility's daily census on 5/19/26 showed 69 residents reside in the facility.On 5/20/26 at 9:00 AM, the Daily Staffing showed, the date, the current census, then RN (Registered Nurse): 5; LPN (Licensed Practical Nurse): 3; CNA (Certified Nursing Assistant): 22.19. This daily staffing was posted on the receptionist's desk. The daily staffing sheet was not broken down by shift.On 5/21/26 at 11:42 AM, V18 (Scheduler) stated she posts the Daily Staffing. V18 stated she counts the number of RNs, LPNs, and CNAs on duty for the 24-hour period and that is the number documented. V18 stated the partial hours for CNAs is related to CNAs working a partial shift. V18 said she was not aware staffing needed to posted on a shift by shift basis.On 5/21/26 at 1:18 PM, V1 (Administrator) stated, via email, she does not have a policy related to the posting of Daily Staffing.

Based on Interview and Record Review, the facility failed to ensure a resident with declining mobility and signs and symptoms of a urinary tract infection was started timely on antibiotic treatment and was care planned for urinary tract infection monitoring and an increase in care needs for one of three residents (R1) reviewed for urinary tract infections in the sample of nine. These failures resulted in R1 suffering suprapubic pain and burning with urination, blood and odor in the urine and waiting seven days to receive treatment for a contagious bacterial urinary tract infection.Findings Include:The facility's Algorithm for the Antimicrobial Management of Urinary Tract Infections in Older Adults document (undated), documents Patient presents with new signs and symptoms of UTI (Urinary Tract Infection): new or marked incontinence, fever and/or leukocytosis, gross hematuria, pain on urination, new or worsening urinary frequency, lower abdominal pain/discomfort (if yes, then); criteria met for treatment with antibiotics (symptomatic bacteriuria): assess for medication allergies, assess for renal impairment, asymptomatic patients with bacteria in the urine do not have a UTI and are not candidates for treatment with antibiotics. This same sheet documents UTI in older persons and males are considered complicated with or without pyelonephritis (kidney infection).The facility's Guidelines for Incontinence Care policy, dated 9/21/23, documents It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal every two-hour checks as well as care planning.R1's Care Plan, dated 9/8/25, documents R1 has diagnoses of Chronic Kidney Disease, stage three and Hypertensive Chronic Kidney Disease. The care plan documents (R1) has bladder incontinence related to impaired mobility. Monitor/document for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. This care plan also documents (R1) has an ADL (Activities of Daily Living) self-care performance deficit related to impaired mobility, weakness. Bed Mobility: The resident is independent with bed mobility. Toilet Use: The resident requires supervision with toileting.On 2/27/26 at 12:05 PM, V10 (R1's family member) stated R1 got a UTI in December and again in January. V10 confirmed R1 was undergoing cancer treatments and her immune system was compromised. V10 stated I know (R1) was not getting cleaned adequately. She sat in soaked incontinence briefs for too long without being cleaned. She required more help towards the end of her stay, and it seemed like staff didn't understand.R1's nursing progress note, dated 12/11/25 at 2:37 PM, documents NP (Nurse Practitioner, V9) assessed (R1) today. (R1) complained of fatigue, cough and suprapubic pain.R1's nursing progress note, dated 12/12/25 at 6:32 AM, documents UA (urine analysis) was collected. Hematuria, complaints of suprapubic pain, no complaints of SOB (Shortness of Breath) and no complaints of cough.R1's nursing progress note, dated 12/13/25 at 3:26 AM, documents 12:30 AM, UA was set up for a c/s (culture and sensitivity), temperature 98.4, incontinent of dark brown odorous urine, complaints of suprapubic pain and dysuria, fluids encouraged, denied the need for anything for pain, resting quietly since.R1's nursing progress note, dated 12/17/25 at 3:17 PM, documents reported ESBL (Extended- Spectrum Beta-Lactamase infection) positive urine collection.R1's urinalysis lab results report, dated 12/17/25, documents initial urine results showed R1's urine color to be dark brown, extra turbid clarity, two plus protein, three plus blood and three plus leukocytes (inflammatory white blood cells) on 12/12/25. This same report documents the final culture was complete on 12/17/25 at 3:17 PM and grew positive for Klebsiella Pneumoniae and Proteus Mirabilis ESBL. This report documents Confirmed ESBL producing organism. ESBLs are enzymes that mediate resistance to (antibiotics). Recommend caution and monitoring of patients during and after therapy.R1's nursing progress note, dated 12/18/25 at 2:44 AM, documents Final UA culture and sensitivity results shows ESBL in the urine, placed on Contact Isolation and will notify NP (V9) in AM.R1's nursing progress note, dated 12/18/25 at 2:44 PM, documents V9 (Nurse Practitioner) reviewed urine culture results and ordered Levaquin 500 milligrams (antibiotic medication) every other day for seven days.R1's Medication Administration Record (MAR), dated 12/1/25- 12/31/25, documents R1's first dose of Levaquin was administered at 8:00 PM on 12/18/25 (seven days after R1's urinary infections symptoms were first identified and more than 28 hours after R1's positive ESBL urine culture results were received).On 3/2/26 at 12:00 PM, V9 (Nurse Practitioner) confirmed she ordered a urinalysis for R1 after she complained of having pelvic pressure in December. V9 stated With a UTI, we usually look at the big clinical picture. If someone is just having confusion but no other signs or symptoms, we may wait for cultures to come back to start medication. I remember ordering a UA on (R1) and then waiting for cultures to come back for an antibiotic. I wasn't aware that nurses were documenting more symptoms or that her signs and symptoms seemed to worsen over several days before cultures came back. In that case I would have started an antibiotic sooner, because sometimes those cultures can take forever. If they (staff) had called me to tell me everything that was being charted in the nursing notes, then yes, I would have started her treatment sooner. I believe I saw her when ordering the UA and then not again until January. I have to be notified if there are changes. V9 confirmed R1 was diagnosed with a subsequent UTI in late January 2026, that was also positive for ESBL.R1's Minimum Data Set assessment, dated 12/29/25, documents R1 requires supervision/touching assistance for toileting and hygiene and partial to moderate assistance with toilet transfers.R1's Minimum Data Set assessment, dated 2/3/26, documents R1 is dependent for toileting and requires substantial/maximal assistance for toilet transfers.R1's Care Plan at the time of discharge (2/3/26) does not document any increased care needs for toileting, hygiene or interventions and monitoring for R1's urinary tract infections. On 3/3/26 at 1:15 PM, V2 (Director of Nursing) stated (R1) has had a steady decline that happened fairly quickly after her UTI began in December. (R1's) care level for incontinence/toileting and her toileting care plan interventions were not updated to match her level of care. V2 confirmed R2 was diagnosed with a UTI with ESBL in December and a second one in late January. V2 stated (R1's) change occurred in the last few weeks she was here. The nurses and CNAs (Certified Nursing Assistants) would not have known she was requiring peri-care and more dependent on staff from her care plan, it would just be report and word of mouth between staff. I don't have any paper documentation to show (R1's) change in condition or that incontinence care and monitoring needs had changed.

Based on Observation, Interview and Record Review the facility failed to ensure sufficient staff were available to meet the needs of the residents. This failure has the potential to affect all 73 residents currently residing at the facility.Findings include:The facility's Daily Census Report dated 2/26/26 and provided by V1 (Administrator), documents 73 residents reside in the facility.The facility's Facility Assessment Tool, dated 2/12/26, documents Based on the facility's resident population and their needs for care and support, staffing is provided at adequate levels to ensure that the needs of the residents can be met at any given time. Taken into consideration are the state and federal regulations for appropriate staffing levels, facility layout, and resident acuity as well as census. Nursing Services : The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment.On 2/27/26 at 2:05 PM, R4 was in her room lying in bed. R4 stated she has a history of falling and getting dizzy and passing out and that she waits a long time when she pushes her call light for assistance. R4 stated Call lights take an hour sometimes before they come see what I need.On 3/2/26 at 10:19 AM, V8 (Licensed Practical Nurse) confirmed she works in the facility as needed and the facility has issues with staffing. V8 stated The other day we had two CNA's (Certified Nursing Assistants) for 50 residents. Things like showers do not get done when we don't have enough staff. Nearly every weekend is that way. I believe Thursday or Friday of last week, there were like three to four CNA's that called in. (R5) complained to me that he waited over an hour to go to bed and it took that long for his call light to be answered.On 3/2/26 at 12:35 PM, V14 (Licensed Practical Nurse) stated They (the facility) do not have enough nurses and staff to get things done that need to be. There are times I spend the entire shift on my feet, and I don't get to everything or the charting that needs completed. The ratio of patients to nurses with the residents needs makes it impossible to get everyone adequate help.On 3/3/26 at 11:12 AM, R7's call light was alarming. At this time, R7 was sitting in her room in wheelchair and hanging clothes up with one hand/arm, the opposite arm appeared flaccid. R7 stated I have my call light on because I need changed and can't do it on my own. Call lights always take a long time and I have to wait. I have had accidents while waiting for them to come. Usually takes over thirty minutes to get help.On 3/3/26 at 11:20 AM, R8 was sitting in the hallway outside of the dining room working on a puzzle. R8 stated I have only lived here for about eight months and call lights take a long time to be answered. Typically, it's 30-45 minutes for someone to answer my call light.On 3/3/26 at 12:08 PM, V15 (Certified Nursing Assistant) stated she works 2nd and 3rd shift overlap. V15 stated There are CNA call-ins every day and they are not always replaced. We often start a shift fully staffed and then by the end there's been call offs, people don't come in and the shift ends with not enough help. Second shift is especially short staffed. Last night was rough and we didn't even have any call offs. The residents are busy too and some have dementia and require more help. It becomes really hard to give good patient care and answer call lights when there are not enough staff there. Residents do have to wait longer to get changed and cleaned up. It is an issue. I know (R9) gets frustrated often due to long wait times when she uses her call light.On 3/3/26 at 1:00 PM, R6 was sitting in her room in a wheelchair. R6 stated she is the resident council president and call lights, and staffing are frequently an issue. R6 stated The call lights do take a long time to be answered, and they (the facility) do not have enough staff. I sometimes am having to wait an hour. Even when I press the light, they just don't come. I have had accidents waiting for staff to help me to the bathroom. It's humiliating and I can't do anything about it. One night I waited from 11:00 PM to 12:00 AM for help to go to the bathroom. It's painful to wait that long and try and hold it. This topic is brought up all of the time in council meetings and it's not fixed. There are not enough staff here to care for us (residents). I have even thought about moving to a different facility, but I don't think there's anywhere to go that will be any better.On 3/3/26 at 2:45 PM, V2 (Director of Nursing) stated We have been aware of concerns with call lights. I would expect that staff get to residents timely when they are needing assistance and I know that for them five minutes might feel like an hour. V2 confirmed that 30 minutes is too long for someone to be expected to hold their bladder and that staff calling off work seems to increase this time of year (Spring).

Based on observation, interview, and record review the facility failed to ensure daily weights were completed as ordered for a resident with congestive heart failure and failed to identify an increase in weight for a resident with congestive heart failure for 1 of 3 residents (R1) reviewed for weights in the sample of 9. This failure resulted in R1's weight not being monitored appropriately, changes not being communicated with the physician, and R1 being transferred to the acute care hospital for treatment of congestive heart failure exacerbations on 4/3/25 and 4/10/25. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute diastolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, need for assistance with personal care, acute and chronic respiratory failure with hypoxia, primary pulmonary hypertension, other forms of dyspnea, obstructive sleep apnea, and anxiety disorder. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and requires substantial to maximum assist of staff for most cares. On 5/2/25 at 1:08 PM, R1 said, . The daily weights have not happened the way I want it to. Since I've been here it has not hardly been done at all. The fluid content in my body has to be monitored. I used to weigh myself every day at home . R1's 2/3/25 hospital discharge orders showed, . Discharge Plan . Reason for Admission: CHF (Congestive Heart Failure) exacerbation . Instructions for Patients with Heart Failure: Please weigh daily (with the same scale and at the same time each day if possible) . Report weight gain of 3 lbs in 1 day or 5 lbs in 1 week to cardiologist . R1's weight under the vitals tab in the electronic record showed on 2/3/25 she weighed 210 lbs (pounds). R1's February 2025 eMAR (electronic Medication Administration Record) showed an order start date of 2/4/25 for Daily weight due to CHF one time a day. Report a weight gain of greater than 3 pounds in 1 day . R1's weight was documented on this eMAR on 2/4/25 as 216.5 lbs (a weight gain of 6.5 lbs in one day). R1's medical record showed no evidence of notification to her physician on 2/4/25 of the 6.5 lbs weight gain. R1's 2/5/25 nursing note entered at 2:37 PM showed, Possible admission to hospital. Currently on 2 liters of oxygen and COVID positive . R1's record showed she remained in the acute care hospital until 2/18/25. R1's 2/18/25 hospital discharge orders showed, . Discharge Plan . Acute bronchitis with COPD . COVID-19 . Hypoxia . Instructions for Patients with Heart Failure: Please weigh daily (with the same scale and at the same time each day if possible) . Report weight gain of 3 lbs in 1 day or 5 lbs in 1 week to cardiologist . R1's census showed she was present in the facility from 2/18/25 through 2/25/25. R1's eMAR showed an order started 2/19/25 for Daily weights x 3, Weekly weight x 4, monthly weight . No order was entered to reflect daily weights. R1's record showed weights documented 2/19/25 as 186, 2/20/25 as 186, and 2/21/25 as 185.6. No weights were documented for 2/22/25, 2/23/25, 2/24/25 or 2/25/25 due to the incorrect order being entered. R1's record showed she remained in the acute care hospital from 2/25/25 through 3/5/25. R1's 3/5/25 hospital discharge orders showed, Discharge Plan: . Instructions for Patients with Heart Failure: Please weigh daily (with the same scale and at the same time each day if possible) . Report weight gain of 3 lbs in 1 day or 5 lbs in 1 week to cardiologist . R1's census showed she was present in the facility from 3/5/25 through 4/3/25. R1's eMAR showed an order start date of 3/6/25 for Daily weights x 3, Weekly weight x 4, monthly weight . No order was entered to reflect daily weights until 3/27/25. R1's record showed her weight documented 3/6/25 as 185.6 lbs, 3/7/25 as 201.4 lbs, and 3/8/25 as 204.1 lbs. R1's medical record showed no evidence of notification to the physician of her weight change 3/7/25. No weights were documented from 3/9/25 through 3/26/25 due to the incorrect order being entered. No daily weights were entered 4/1/25, 4/2/25, or 4/3/25. R1's 4/3/25 nursing note entered at 9:48 AM showed, Patient resting in bed with eyes closed. Had to sternal rub to wake her up. Did respond to verbal stimuli but would not stay awake. Blood pressure 88/48 pulse ox 90 % on room air, appears short of breath, using accessory muscles. Notified [R1's doctor], okay to send to emergency department for evaluation and treatment . R1's record showed she remained in the acute care hospital from 4/3/25 through 4/7/25. R1's 4/7/25 hospital discharge orders showed, . Hospital Course: . presented to the hospital with worsening shortness of breath and cough. admitted for acute CHF and was requiring 2L of O2 throughout the day, rather than only at night. She was diuresed with intravenous Lasix and transitioned back to oral Lasix, her dyspnea (difficulty breathing) resolved . Discharge Plan: . Instructions for Patients with Heart Failure: Please weigh daily (with the same scale and at the same time each day if possible) . Report weight gain of 3 lbs in 1 day or 5 lbs in 1 week to cardiologist . R1's census showed she was in the facility from 4/7/25 through 4/10/25. One weight was documented between 4/7/25 and 4/10/25. 1 of 3 weights completed as ordered. R1's 4/10/25 nursing note entered at 11:47 AM showed, Call placed to [R1's Physician], reviewed current assessment findings of increased confusion . Respirations 32 utilizing abdominal accessory muscles with spO2 98% on 2L per nasal cannula, lung sounds with expiratory wheezing . Guest will open eyes with verbal and tactile stimulation for short periods. New order received for Albuterol Nebulizer treatment one time, reassess after nebulizer treatment and call report back to [R1's Physician]. R1's 4/10/25 nursing note entered at 12:18 PM showed, Call placed to [R1's Physician], reviewed assessment. New order received to send to [acute care hospital] for respiratory distress. R1's 4/17/25 hospital discharge orders showed, . Hospital Course: . presented with dyspnea and was admitted with acute on chronic respiratory failure secondary to CHF exacerbation and metabolic encephalopathy . Discharge Plan: . Instructions for Patients with Heart Failure: Please weigh daily (with the same scale and at the same time each day if possible) . Report weight gain of 3 lbs in 1 day or 5 lbs in 1 week to cardiologist . R1's census showed she has been in the facility from 4/17/25 through current. R1's eMAR shows from 4/18/25 through 4/30/25 there were 5 daily weights not completed as ordered. R1's care plan initiated 4/24/25 showed R1 has Congestive Heart Failure but did not include information regarding daily weights or physician notification of weight changes. On 5/6/25 at 11:25 AM, V4 RN (Registered Nurse) said daily weights are important for monitoring residents with CHF to monitor how their heart is functioning and identify when they are retaining fluid. On 5/6/25 at 3:40 PM, V2 DON (Director of Nursing) said, This is considered an order for daily weights. I expect daily weights to be done daily to monitor for fluid overload. Typically, if there is an order for parameters, usually weight gain over 3 lbs in one day we would contact [R1's Physician] so she can evaluate if there should be a need for a fluid restriction, add or change a diuretic, or possibly the need to be seen. Daily weights are important for monitoring the fluid for people with CHF because if there is too much fluid they can go into cardiac arrest especially with quick fluctuations. On 5/6/25 at 12:49 PM, V7 (R1's Physician) said she has concerns with the facility completing daily weights. V7 said she is frustrated because she sees R1 every week for the most part and tries to communicate with the facility staff. V7 said part of the problem she feels is that the staff are always changing so there is not the follow through with the orders. V7 said she has expected to receive updates on R1's weights including notification of significant changes as the parameters on R1's record shows. V7 said she has received R1's weights one time since she was admitted to the facility. V7 said R1 has CHF which is the reason she is on daily weights. The daily weights monitor for fluid retention and the need to modify her medications and diuretics. V7 said she would expect them to have given me her weights so she could adjust R1's medications and possibly prevent her from having to go to the hospital. The facility's weight policy was obtained but did not include daily weights. On 5/6/25 at 3:40 PM, V2 DON said the facility does not have a policy regarding care of residents with Congestive Heart Failure or have a policy related specifically to daily weights. V2 said the order for daily weights would be expected to be completed as all other physician orders are.

Based on observation, interview, and record review the facility failed to ensure a resident with an order for a BiPAP (Bilevel Positive Airway Pressure) machine was provided one for 1 of 3 residents (R1) reviewed for respiratory devices in the sample of 9. This failure resulted in R1 being hospitalized for respiratory failure due to not using BiPAP machine. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute diastolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, need for assistance with personal care, acute and chronic respiratory failure with hypoxia, primary pulmonary hypertension, other forms of dyspnea, obstructive sleep apnea, and anxiety disorder. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and requires substantial to maximum assist of staff for most cares. On 5/6/25 at 10:45 AM, V12 (R1's Power of Attorney) said R1 had a CPAP prescribed at home and they were in the middle of getting her settings readjusted when she went into the hospital. V12 said they took R1's home CPAP machine to the facility for use with the settings she was using at home. V12 said coming out of the hospital on 4/17/25 there was an order for a BiPAP because she was doing well on a BiPAP in the hospital. V12 said he was concerned that the facility did not have the BiPAP available until 4/22/25 (5 days after R1 returned from the hospital) which caused her to have marked difficulty with disorientation, cognitive ability, and sleep patterns . R1's 2/3/25 hospital discharge orders showed, Durable Medical Equipment (DME)(CPAP) See instructions: BiPAP at 14/7, mask and supplies . R1's 2/3/25 Admission/Readmission Screener assessment showed no oxygen used and showed no information regarding R1 wearing a CPAP or BiPAP at night. R1's census showed she went back to the acute care hospital 2/5/25 and was readmitted to the long term care facility 2/18/25. R1's 2/18/25 hospital discharge orders showed, Durable Medical Equipment (DME)(CPAP) See instructions: BiPAP at 14/7, mask and supplies . R1's 2/18/25 Admission/Readmission Screener assessment showed no oxygen was used and no CPAP or BiPAP was used. R1's February 2025 eMAR (electronic Medication Administration Record) and eTAR (electronic Treatment Administration Record) showed no orders for applying either a CPAP or a BiPAP at night. R1's census showed she went back to the acute care hospital 2/25/25 and was readmitted to the long term care facility 3/5/25. R1's 3/5/25 hospital discharge orders showed, Durable Medical Equipment (DME)(CPAP) See instructions: BiPAP at 14/7, mask and supplies . R1's 3/5/25 Admission/Readmission Screener assessment showed no information related to R1's oxygen use, CPAP, or BiPAP use. R1's March 2025 eMAR showed an order started 3/5/25 for CPAP worn at night- 14/7, every night related to sleep apnea . Between 3/5/25 and 3/31/25, there was documentation of 6 nights which R1 did not wear her CPAP. R1's census showed she went back to the acute care hospital 4/3/25 and returned to the facility 4/7/25. R1's 4/7/25 hospital discharge orders showed, Durable Medical Equipment (DME)(CPAP) See instructions: BiPAP at 14/7, mask and supplies . R1's 4/7/25 Admission/Readmission Screener assessment showed R1 was wearing oxygen at 2 LPM and had neither a CPAP or a BiPAP. R1's April 2025 eMAR showed no order for CPAP or BiPAP entered upon R1's return to the facility 4/7/25. R1's census showed she went back to the acute care hospital 4/10/25 and returned to the long term care facility 4/17/25. R1's 4/17/25 hospital discharge orders showed, Durable Medical Equipment (DME)(CPAP) See instructions: BiPAP at 14/7, mask and supplies . Hospital Course: was admitted with acute on chronic respiratory failure secondary to CHF exacerbation and metabolic encephalopathy. Respiratory failure due to noncompliance with diet and not using BiPAP. Family initially wanted a different skilled nursing facility but are now agreeable to go back to where she came from. She is requiring 2L of oxygen and is supposed to be on BiPAP at night. Patient has not been compliant with this, and long discussions have been had with her daughter regarding continuing current treatment she encouraged her mom to be compliant with BiPAP . Strongly recommend complying with BiPAP at night or patient is at risk for readmission . R1's 4/17/25 Admission/Readmission Screener assessment showed R1 using oxygen but indicated no for CPAP/BiPAP. R1's care plan initiated 4/24/25 (the first indication in R1's care plan of BiPAP use) showed, The resident utilizes a BiPAP related to Obstructive Sleep Apnea . The resident intermittently refuses to wear BiPAP as prescribed, placing them at risk for respiratory complications such as hypoxia, fatigue, and poor sleep quality . Use BiPAP as scheduled. R1's April 2025 eMAR showed an order started 4/17/25 for BiPAP at night- bilevel 14/7. The facility provided a receipt showing a BiPAP machine was delivered by their Durable Medical Equipment provider on 4/22/25. R1's same eMAR showed R1 has refused wearing the BiPAP 4 times between 4/17/25 and 4/30/25 and being compliant with wearing the BiPAP 10 nights. On 5/6/25 at 12:49 PM, V7 (R1's Physician) said, [R1] had been on BiPAP in the past in the hospital. She historically had not wanted to wear her CPAP when she was at home. Since she has been at the facility, she has not been wearing it. In part, she has hesitation to wear it, but it's only been the last week that her BiPAP was even there for her to use . Based off of the orders she had coming from the hospital she should have had the BiPAP starting all the way back 2/3/25 when she first admitted . I think the reason it was done now after this admission is there was more detail in the discharge because there was a conversation about hospice. I think it was a more forceful conversation that she has to have the BiPAP or she is not going to make it. For her, the BiPAP is very important . On 5/6/25 12:06 PM, V2 DON (Director of Nursing) said, [R1] had a CPAP at home that she was noncompliant with it . We tried to encourage her to use her CPAP, but it was hit or miss. She brought it from home when she was admitted . She went back to the hospital and when she returned to us, they changed her to a BiPAP on her last hospitalization . The family is aware that she has a lot of reasons she doesn't like wearing it. Not sure the reason, just uncomfortable. The BiPAP was delivered 4/22/25. We are fine tuning DME process. Typically, the equipment is here within a couple of days. I think the ordering of this fell on a holiday weekend and it ended up being several more days. [V7] (R1's physician) was fine with her using her CPAP until the BiPAP arrived. [Reviewing the documents from the hospital] it clearly looks like the order was for BiPAP all along (from 2/3/25) so I don't know why there was confusion . It is here and set to 16/6 which is the correct setting. I would have expected them to clarify what she was supposed to have based on the orders we received. We should have known exactly what the settings were, and it should have been on the eMAR. The facility's policy and procedure with review date of 5/6/2025 showed, Policy for CPAP/BiPAP . BiPAP provides continuous positive pressure to the airways of spontaneously breathing residents . Purpose: to augment breathing . to treat sleep disorders . to correct arterial hypoxemia . to decrease work of breathing . to increase compliance .

Based on interview and record review the facility failed to ensure safe positioning in a wheelchair was provided during care of a resident. This failure resulted in R1 sliding out of her wheelchair, being lowered to the floor, and sustaining a fracture of her left leg on 6/6/24. The findings include: The MDS (Minimum Data Set) dated 6/4/24 for R1 showed severe cognitive impairment, dependent on staff for oral hygiene, toileting, bathing, upper body dressing, lower body dressing, and personal hygiene. The MDS showed diagnoses including hypertension, gastroesophageal reflux disease, thyroid disorder, dementia, anxiety disorder, depression, psychotic disorder, senile degeneration of the brain, idiopathic neuropathy, history of falling, mild cognitive impairment, difficulty walking, and sleep disorder. Osteoporosis was not marked as a diagnosis. The Nurse's Note dated 6/6/24 at 7:34 PM showed, CNA (Certified Nursing Assistant) on duty reported having to lower the resident to the floor due to starting to slide out of wheelchair. CNA states, She was sliding out and I was unable to get her back in wheelchair, so I lowered the resident to the floor. Upon entering the resident's room this nurse observed the resident on the floor by the side of the bed. Resident noted to be alert with confusion which is the norm for the resident. No rotation or deformities noted during this time. No range of motion was documented as being performed as part of the nurse's assessment. The Administration Note for R1 dated 6/7/24 at 4:29 AM showed, R1 was given 10 mg of Morphine by mouth due to crying out saying she hurts. The Nurse's Note for R1 dated 6/7/24 at 10:55 AM showed, Guest up per usual, did complain of left knee pain, no injury noted on assessment. No swelling or redness, Guest given hydrocodone 5/325 mg as scheduled. The Administration Note for R1 dated 6/8/24 at 8:56 AM showed R1 was given 10 mg of Morphine for complaints of continuous left leg pain. The Nurse's Note for R1 dated 6/8/24 at 11:04 AM showed, Resident complaining of left leg pain frequently this shift, crying often in pain. The Administration Note for R1 dated 6/8/24 at 11:05 AM showed R1 was given 10 mg of Morphine for left leg pain. The Administration Note for R1 dated 6/8/24 at 6:34 PM showed R1 was given 10 mg of Morphine but does not state where R1's pain was located. The Nurse's Notes dated 6/9/24 for R1 showed, at 8:20 AM R1 was complaining of extreme leg pain this morning, staying in bed because of pain with movement. R1 was comfortable when not moving. The nurse positioned R1's left leg on pillow and had her right foot in an offloading boot. The nurse was using hot packs for R1's pain. At 9:23 AM, the note showed a portable x-ray was ordered for R1's femur and knee due to a fall with increased pain and decreased mobility. At 1:25 PM, V11 (R1's daughter) was contacted and a message was left. V12 (R1's son) was called, and he stated to not do the x-ray because it causes R1 extreme stress especially with her dementia, and she gets physical. V12 wanted R1 to be kept comfortable at the facility. At 1:55 PM V11 called back, the nurse updated her on everything, and she agreed with V12 to keep R1 comfortable at the facility. The Administration Note for R1 dated 6/9/24 at 11:15 PM showed R1 was given 10 mg of Morphine for complaints of left leg pain with movement. The NP (Nurse Practitioner) Note for R1 dated 6/10/24 showed, R1 was seen for chronic disease management, medication review, follow up status/post fall and left leg pain. R1 transfers via full mechanical lift. Today, R1 is having difficulty moving her left lower extremity at the knee. When the knee is attempted to be flexed, she will yell out that she is having pain. She is noted to have a bruise just below her left knee and her left knee is swollen and painful to touch. On 6/7/2024, staff reported that R1 was lowered to the floor, no injuries were noted. She was up per her usual and did have some complaints of left knee pain as the day went on. On 6/8/2024, during the night, she denied having any pain however, during the day she complained of left leg pain. She continued having left leg pain with decreased mobility in her left knee and on 6/9/2024, orders were written for a left femur x-ray however, when family was contacted about obtaining the x-ray, family did not want the x-ray obtained. Family did not want the x-ray completed as R1 does not tolerate imaging well and reported that x-rays caused her increased stress as she has dementia. X-rays were not obtained, and conservative treatment was requested and to keep resident comfortable. The Administration Note for R1 dated 6/10/24 at 3:30 AM showed R1 was given 10 mg of Morphine due to cares were going to be done so the medication was given ahead of time to prevent severe pain. The Nurse's Note dated 6/10/24 at 3:43 AM showed, Resident has a deformity to the left mid-thigh area and when asked where she hurts at, she pointed to that spot. She cries out in pain with any movement of that leg with and without as needed Morphine sulfate. Note left for NP to assess. At 3:40 PM showed, spoke with daughter V11 who didn't realize that the order for X-ray was for portable. So that X-ray could come to guest room. She wants the X-ray done; she just didn't want her mother to have to transfer to hospital. At 3:49 PM, Radiology here to do x-ray, V10 gave verbal orders for mobile x-ray to radiology. The X-Ray results dated 6/10/24 for R1 showed, Findings: Buckling of the anterior/medial cortex of the proximal tibia. Associated lipohemarthrosis of the knee. Intact internal fixation hardware. Impression: Medial tibial plateau fracture. No osteoporosis was documented on the x-ray. The NP Note dated 6/11/24 for R1 showed, Follow-up x-ray on left lower leg, left lower leg pain. R1 is having difficulty moving her left lower extremity at the knee. When the knee is attempted to be flexed, she will yell out that she is having pain. She is noted to have a bruise just below her left knee and her left knee is swollen and painful to touch. On 6/7/2024, staff reported that R1 was lowered to the floor, no injuries were noted. She was up per her usual and did have some complaints of left knee pain as the day went on. On 6/8/2024, during the night, she denied having any pain however, during the day she complained of left leg pain. She continued having left leg pain with decreased mobility in her left knee and on 6/9/2024, orders were written for a left femur x-ray however, when family was contacted about obtaining the x-ray, family did not want the x-ray obtained. Family did not want the x-ray completed as R1 does not tolerate imaging well and reported that x-rays caused her increased stress as she has dementia. X-rays were not obtained, and conservative treatment was requested and to keep resident comfortable initially however, on 6/10/2024 at approximately 3 PM, staff notified this writer and stated that family is agreeable to a portable x-ray. R1 continues to have difficulty moving her left lower extremity at the knee. Plan: Closed fracture of medial portion of left tibial plateau, initial encounter: Received final radiology report this morning and noted medial tibial plateau fracture on the left. Based on the location of her fracture, I would recommend orthopedics to evaluate. At approximately 7:55 AM, called and left message on machine for POA (power of attorney), V11. Did not receive a call back. Also contacted V12 (R1's son) and message was left on his machine. At approximately 8:45 AM, received a return call from V12. He was informed that the left lower leg does have a fracture noted and because of the potential risks associated with this type of fracture, an orthopedic evaluation is recommended. V12 stated that he does not want to treat aggressive and is not interested in an orthopedic evaluation and would prefer comfort care/conservative measures and hospice services to reevaluate. Non-weightbearing to left lower extremity. Elevate for comfort. Use ice or heat per patient's preference for discomfort. Continue acetaminophen, hydrocodone/APAP (acetaminophen), and morphine for comfort. The Long-Term Care Facility & IID - Serious Injury Incident and Communicable Disease Report dated 6/11/24 for R1 showed she had a fall with physical harm. The CNA (Certified Nursing Assistant) was getting the resident ready for bed. The CNA was assisting the resident to remove her shirt and put a gown on. The resident started to slide out of her wheelchair. The CNA lowered the resident to the floor, so the resident was sitting on the floor with her legs out in front of her. The CNA states the resident's legs slid forward between her own legs. The Interviews that were conducted by V2 DON (Director of Nursing) showed, on 6/10/24 V7 CNA (Certified Nursing Assistant) stated, I was trying to get her (R1) ready for bed. V7 states she was taking her shirt off and R1 was sitting on the edge of the wheelchair and started sliding. V7 attempted to pull her hips back but couldn't and had to lower her to the floor. At that time, V7 was in front of the resident facing her. The resident's legs were tucked between her legs during the transfer. V7 does not recall if the wheelchair was locked or not or if the pedals were on or off but she does state that is her regular practice. V7 then states she put a gown on her for dignity and left her to go get the agency nurse. She states the resident complained of right leg pain at the time of the incident. V7 states she was unable to find her hall partner, but she did find V8 CNA and V9 CNA who came to the room to assist. V7 reports that the resident's room was crowded so she left to answer call lights. On 6/22/24 at 10:36 AM, R1 was laying on her right side in bed with V4 RN (Registered Nurse) at her bedside. R1 had a low bed to the floor. R1 was confused and when asked if she fell , she did not remember falling. R1 complained of pain below her left knee. V4 stated she was not at the facility the day R1 fell . V4 stated she was told a CNA was getting R1's gown on and R1 must have slid forward. R1 was helped to the floor. R1 was in a regular wheelchair at that time. R1 must have been too close to the edge (of wheelchair) and slumped in the chair to my understanding. R1 fell on a Thursday night, and I was here the Saturday and Sunday after the fall. On Saturday R1 had pain. R1 has pain medication. On Sunday her pain was bad; I got an x-ray order. On 6/22/24 at 11:38 AM, V1 (Administrator) stated, R1 was lowered to the floor by a CNA. The CNA was taking R1's shirt off and R1 was in her wheelchair. R1 was sitting towards the end of the chair and slid out of the chair with her legs straight. The CNA could not remember if the footrests were on or not. The CNA got the nurse, and the nurse came down. They got R1 up from the floor using a mechanical lift and put her to bed. They didn't realize there was an injury at that time because R1 is always crying out in pain. They noticed bruising but not that day; it was a few days later. We offered to get an x-ray, but the family refused; R1 gets agitated with x-rays. I think they assumed we would take her to the hospital. Since we are connected to the hospital, we wheel residents over there. The second time an x-ray was brought up the family agreed to a portable x-ray. The portable x-ray showed a fracture. V2 DON (Director of Nursing), the NP and her family talked about a plan of care, and it is in her notes. On 6/22/24 at 1:02 PM, V6 CNA stated, it is the safest to have a resident all the way back in their wheelchair with the resident sitting straight up and down. V6 stated residents should never sit at the edge of the chair because the resident could slide out and fall. It is not safe. On 6/22/24 at 1:31 PM, V2 DON (Director of Nursing) stated, I interviewed V7 CNA. She was getting R1 ready for bed. R1 uses a mechanical lift for transfers. V7 was waiting for her teammate. V7 was taking R1's shirt off. R1 was at the edge of her seat. R1 slid forward and V7 grabbed R1's pants to try and pull R1 back. V7 couldn't so she lowered R1 down to the floor. R1 hollers and is a little combative. Staff are aware of her behaviors. They know how to handle R1's behaviors. V7 had taken R1's shirt off. V7 put R1's gown on when she was on the floor. I think she acted appropriately; there is nothing to be done differently. I interviewed the nurse on duty, V8 CNA, and V9 CNA and all of the statements were the same on how R1 looked. I did ask if anyone hit her leg on the mechanical lift and they said they didn't. I talked to V4 RN (Registered Nurse) the nurse on duty after the incident when R1 had increased pain. V4 talked to V11 (R1's daughter/POA) and V12 (R1's son) and they wanted the comfort approach for the resident. As soon as the family wanted an x-ray, we had a portable done here. V2 stated the CNAs have competency training. On May 1st (2024) they just had a safe patient handling training. Positioning in a wheelchair would be part of the safe patient handling program. V2 stated a resident sitting at the edge of the chair could contribute to a fall. A resident that is dependent with care would be more at risk of being pulled forward in their chair when taking her shirt off. V2 stated the CNAs are trained and would know this. On 6/22/24 at 1:47 PM, V8 CNA stated, from what I know V7 CNA claims it was an accident. She was pulling R1's shirt off and R1 slipped to the floor. V8 stated her and V9 CNA got R1 up off the floor and V7 wasn't in the room. At the time R1 complained of left thigh pain. V8 stated depending on R1's mood it could take 1 or 2 people to get her undressed. R1 doesn't just slip out of a wheelchair. R1 was laying on the floor like she would if you were going to do a stand pivot transfer. R1's feet were in the direction of the head of the bed and her head was at the direction of the foot of the bed. R1 was on the left side of the bed, and you can't get a mechanical lift in that way so R1 would have been facing the door with her back to the bed. R1's butt and back is always at the back of her wheelchair. R1 has never slid out of her chair before. We don't position a resident at the edge of the chair, especially a resident that uses a mechanical lift. They would be at risk for falling out. The resident always has to be at the back of the chair. R1 used to be a stand pivot transfer but it was stopped because she wouldn't bend her knees and stand. R1 would keep her legs straight out. R1 had a bruise under her left knee a few days later. I saw the agency nurse do vitals, but I did not see her do an assessment. I told her R1 had pain and she should probably assess R1. On 6/22/24 at 2:07 PM, V7 CNA stated, R1 was screaming when I got to her room. R1 was sitting close to the edge of her seat. I stood in front of her with her legs between mine. I took R1's shirt off, turned to get her gown, R1 started sliding, and I lowered her to the floor. I put her gown on her. I moved the wheelchair from behind her and went and got the nurse. I did not see any injuries on her. The nurse tried to ask where it hurt. The nurse wasn't moving R1's limbs to see if it caused more pain. R1 screamed whenever the nurse tried to touch her. The nurse did check R1; it was just not as thorough as I am used to seeing. I don't know if the nurse went back in there to check on her or not. V7 stated residents are to be positioned to the back of the wheelchair so they don't fall out, but she was getting R1 ready for bed and R1 was already at the edge of her chair. On 6/22/24 at 2:26 PM, V3 LPN (Licensed Practical Nurse) stated, the girl came out of the room and said the resident was on the floor. The CNA said the resident was at the edge of her chair and she couldn't get her back in her chair, so she lowered the resident to the floor. The CNA was trying to take the resident's shirt off and put a nightgown on. I don't know how the resident got to the edge of the chair. R1 was moving around in her chair but was not sitting at the edge of her chair when she saw her before that. V3 stated R1 was on the floor in her room when she went into the room. V3 stated she did an assessment; she was feeling for breaks, pain, or injury. V3 stated she did range of motion. V3 denied that R1 had any complaints of pain. V3 stated she put an incident report in the doctor's box. The nurse that she was working with that day told her to do that. The nurse told her that she didn't have to contact anyone if there wasn't an injury. On 6/22/24 at 2:47 PM, V10 NP (Nurse Practitioner) was called, and a message was left for her to return the call. A return call was not received prior to the end of the investigation. On 6/22/24 at 2:52 PM, V11 (R1's daughter/POA) was called, and a message was left. A return call was not received prior to the end of the investigation. On 6/22/24 at 3:01 PM, V1 (Administrator) stated, they presumed R1's fall caused R1's leg fracture. V1 stated there is nothing else that could have caused it. R1 did not have any other mechanism of injury that could have caused it. V1 stated she knows R1 was osteopenic but R1 wasn't standing and had it just break. The facility's Safe Lifting Procedure policy (8/2022) showed, it is expected that the safe patient handling policy be followed at all times. The policy did not show proper body mechanics in a chair prior to transferring a resident. The facility's Positioning the Resident policy (6/2024) did not show how a resident was to be safely positioned in a wheelchair. On 6/22/24 the facility's Fall Policy was requested and not received.

Based on observation, interview and record review the Facility failed to ensure placement and functionality of an electronic monitoring system bracelet and failed to provide adequate supervision for one (R1) of three residents reviewed for elopement in a sample of three. These failures resulted in R1 exiting the building and falling in the parking lot grass, requiring medical attention at the local Emergency Department. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 5/25/22, the facility remains out of compliance at a severity level two while continued monitoring of team members' understanding of the electronic monitoring system bracelet Policy; names of residents with electronic monitoring system bracelets; contents and location of Elopement /electronic monitoring system bracelet binder (placed at Nursing Stations); and electronic monitoring system bracelet availability, storage and functionality testing is conducted. Findings include: Facility Elopement Risk/Elopement (Missing Resident) Process, revised 3/2022, documents: to provide a safe environment for all residents; to properly assess resident and plan their care plan to prevent accidents related to wandering behavior and elopement; defines elopement as slipping away secretly, running away and leaving without accompaniment or knowledge of the staff; an alarm bracelet may be placed on the resident to audibly alert staff of attempts by the resident to exit the community; if for any reason the door alarms are turned off, the staff will continually visually monitor the doors and must document and assign a staff member that is not providing direct care; and if an alarm is discovered de-activated, staff will perform an immediate head count to ensure all residents are accounted for. Facility Elopement Precautions Policy, revised 4/2022, documents: elopement precautions establishes guidelines for identifying residents at risk for elopement and the process for initiating elopement prevention; elopement is a resident leaving without permission; any resident, regardless of location, if consistently exit seeking should have an electronic monitoring device; resident's on electronic monitoring will be fitted with an arm or ankle band, or will have clothing fitted with tracking devices; the tracking device, worn by the resident, will be tested daily and documented on the resident's Medication Administration Record/MAR. On 5/21/22, during the hours of 9:00 am and 12:00 pm, a sign was visible to all residents, hanging above the Medicare exit door electronic code keypad, that had the pass code numbers ( 6) that allowed exit from the door. R1's Physician Order Sheet/POS, printed 5/21/22 at 11:40 am, documents an order (dated 5/20/21) to check R1's electronic monitoring system bracelet placement to right wrist every shift. The POS also documents an order (dated 5/21/22) to check electronic monitoring system bracelet function daily and as needed every night shift. R1's Minimum Data Set/MDS, dated [DATE], documents that R1 has a Brief Interview for Mental Status/BIMS score of seven (7/15), indicating moderate/severe cognitive deficits. R1's Nursing Notes, dated 5/19/22 at 10:01 am, documents that V7 (Activity Director) spoke to R1's daughter (V8) about R1 having a electronic monitoring system bracelet on. On Sunday (5/15/21) when I was coming to work, resident tried to exit the front door when I was coming in. (R1) stated (R1) could not remember where he parked his car. I was able to redirect the resident when I came in. I did let the Administrator (V1) know my concern when I saw her. Family was 'ok' with the resident having electronic monitoring system bracelet on. R1's Nursing Note, dated 5/19/22 at 11:10 pm, documents that R1 returned to the facility, back from the Emergency Department at 8:48 pm, alert and oriented accompanied by (V8) and one facility staff. (R1) stated that his left knee was hurting him a little bit and scheduled pain medication was administered ([MEDICATION(S)]). The Nursing Notes do not document R1's Elopement incident, monitoring or interventions upon return to the facility. Facility Elopement/Missing Resident Investigation dated 5/19/22 at 7:05 pm, documents that R1 was found by V4 (R4's family member) in the facility parking lot on the grass. (V4) alerted staff that R1 had fallen out of (R1's) wheelchair and was on the ground. Emergency (911) was called and R1 was noted lying in the grass, with no injuries noted, but (R1) did complain of left side pain. R1 was transported to the Emergency Department via ambulance and returned with no new orders. The Investigation documents that R1 stated, I do not know why I exited the facility, the outside temperature was 82 degrees and that R1 exited the Medicare NS door. The Investigation documents that the door alarm did not sound when R1 exited the building. R1's Medication Administration Report/MAR, dated 5/1/22 through 5/21/22, documents that electronic monitoring system bracelet placement checks to R1's right wrist were initiated on 5/20/22 at 2:00 pm and electronic monitoring system bracelet function checks were initiated on 5/20/22 at 10:00 pm. The MAR does not document monitoring, function or placement checks from the date of placement of the electronic monitoring system bracelet (5/15/22 through 5/19/22). On 5/21/22 at 9:34 am, V1 (Administrator) stated, The last time that (R1) was seen before eloping was at 7:00 pm, on the back hall (B Hall) by V5 (Certified Nursing Assistant). We think that V4 (R4's spouse) exited the building and let (R1) out the door, then a few minutes later, (V4) came back in and told V6 (Licensed Practical Nurse) that a visitor was outside laying in the grass. V6 then called Emergency (911) and proceeded out to the grass, and that is when (V6) discovered that it was (R1) and not a visitor. I am not sure why the electronic monitoring system bracelet did not sound, but it works now. The alarm should have sounded when (R1) went through the door. Last Sunday (5/15/21), I was here and (V7/Activity Director) told me that (R1) was sitting at the front door asking about a car and (V7) got concerned and told me about it. At that time, we put a electronic monitoring system bracelet on. I am not sure if the electronic monitoring system bracelet was functioning prior to putting it on (R1). On 5/21/22 at 11:18 am, V6 (Licensed Practical Nurse/LPN) stated, I am actually the MDS Nurse and was working the floor. I was right at the nurse's station by the exit door, because I was helping another family member. (V4) came in and told me that a visitor had fallen outside on the ground, so I immediately called Emergency (911). Then I went straight out to the parking lot and that is when I realized that it was not a visitor, but it was (R1). (R1) was lying on (R1's) left side and stated that (R1's) left side hurt. (R1) was sent by ambulance to the Emergency Department for assessment. I am not sure how (R1) got out; I think that (V4) let him out. The alarms were not sounding, and I did not know that (R1) was out of the building until (V4) came to tell me. On 5/21/22 at 11:25 am, V4 (R4's spouse) stated, I came to visit my husband and when I was leaving the facility, there are two exit doors with an area in between and a gentleman in a wheelchair was already through the first exit door. I proceeded to go through the next exit door to the outside parking area and helped the gentleman out the second door, because he was in a wheelchair, I thought he probably needed help. I had a family member at another facility that was an escape artist and was constantly trying to get out of the facility and had to wear an alarm bracelet, but every time he went by a door, there were bells and whistles going off to alert that he was close to an exit door. When I exited the first door and saw (R1) at the second door, I figured he was a resident with privileges or a visitor, because no alarms were sounding, plus they have the code posted at the door, so everyone can see it. I was concerned because (R1) was in a wheelchair, so I watched (R1) wheel himself towards a car that was parked in the handicap spot, so I figured that it all made sense. Once (R1) got to the car in the handicap spot, (R1's) wheelchair bumped the car tire and (R1) popped out of the wheelchair and landed onto the grass. That is when I immediately ran back into the nurse's station and told them that (R1) had fallen. On 5/23/22 at 10:40 am, V1 (Administrator) stated, (R1's) electronic monitoring system bracelet was put on (R1's) right wrist on 5/15/22 and the Medication Administration Report/MAR and Nursing Notes do not document that it was checked until 5/20/22, after the hospital incident, then it was done. On 5/23/22 at 11:04 am, V7 (Activity Director) stated, On Sunday 5/15/22, I noticed (R1) hanging out at the facility's primary entrance and exit door, also known as the Medicare door by the nurse's station, when I came into work. (R1) had been recently wandering around the facility a little more than usual, so I notified (V1/Administrator) and (V1) and nursing initiated the placement of the electronic monitoring system bracelet on that day, 5/15/22. I did see (R1) on Tuesday, 5/17/22, and (R1) had a electronic monitoring system bracelet on (R1's) right wrist at that time. I am not sure if it was working because (R1) was not around an exit door at that time. On 5/23/22 at 2:08 pm, V11 (Certified Nursing Assistant/CNA) stated, I worked on 5/17/22 and 5/18/22, I never heard an alarm sound when R1 was by a door. I actually never saw a electronic monitoring system bracelet on R1 either, but I was not specifically looking for one either, I did not know he had one put on. On 5/23/22, at 3:29 pm, V9 (Agency Nurse) stated, On Sunday, 5/15/22, I was working the back hall, on the opposite side of the building as the Medicare Exit door, and I was (R1's) nurse. On 5/15/22 around 4:00-5:00 pm, V10 (Registered Nurse/RN) told me that (V1/Administrator) told us that we needed to put a electronic monitoring system bracelet on (R1) because (R1) was wandering a lot more than usual. I could not find one, but V10 found one and gave it to me, and I put it on (R1). I was working the back hall, on the opposite side of the building from the Medicare exit door and put the electronic monitoring system bracelet on (R1) at that time. The Immediate Jeopardy was identified on 5/25/22. It began on 5/15/22, when the facility failed to check the functionality of a electronic monitoring system bracelet after it being placed on R1 and failed to provide adequate supervision resulting in R1 exiting the facility and being found in the facility parking lot. V1 (Administrator) was notified of the Immediate Jeopardy on 5/25/22 at 10:55am. On 5/26/22 throughout the day, the surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. On 5/19/22 V6 (Licensed Practical Nurse/LPN) checked door for proper functioning of alarm system. 2. V1 (Administrator) implemented immediate education beginning on 5/20/22. All team leaders were educated on 5/20/22. All nurses and CNAs working on 5/20/22 were educated when they came in for their shift, with the remaining nurses being educated on 5/21/22. The remaining team members were educated at the All Team Member Meetings on 5/25/22. On 5/25/22, V1 (Administrator) educated all team members on elopement process, as well as, checking and responding to door alarm system timely. 3. On 5/20/22, V1 placed signs on the doors to alert visitors to ask the nursing staff before assisting anyone out the doors. 4. On 5/25/22, V12 (Registered Nurse) completed elopement assessments on residents that did not already have one in the last quarter to identify any other potential risk. Any resident with an at-risk score will have a electronic monitoring system bracelet placed with every shift checks for proper functioning to be reviewed quarterly, at significant change and annually. 5. Maintenance staff will continue to check door alarm system daily and log the results. Any identified concerns will be addressed immediately through the Quality Assurance Policy Improvement (QAPI) process. 6. For quality assurance, V2 (Director of Nursing) or designee will audit team members' understanding of the Elopement /electronic monitoring system bracelet Policy; names of residents with electronic monitoring system bracelet ; contents and location of Elopement /electronic monitoring system bracelet binder (placed at Nursing Stations); and electronic monitoring system bracelet availability, storage and functionality testing. Audit results with any identified concerns will be addressed immediately through the QAPI. Audits will be conducted weekly for 3 months. 7. For ongoing quality assurance V2 or designee will develop a plan related to elopement and the elopement monitoring/communication systems which will be reviewed during the community QAPI meetings. Abatement completion date 5/25/22.

Based on observation, interview, and record review, the facility failed to obtain a new Physician ordered treatment with the deterioration of a pressure ulcer, identify the appropriate staging of a pressure ulcer, implement a Physician ordered treatment, implement new interventions following the development of a pressure ulcer, and complete weekly pressure ulcer assessments for three of four residents (R3, R5, R41) reviewed for pressure ulcers in the sample of 34. This failure resulted in R5's pressure ulcer deteriorating from a Stage 3 to unstageable. Findings include: According to NPIAP (National Pressure Injury Advisory Panel) Pressure Injury Stages, A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. The facility's Quality of Life/Quality of Care policy, dated 8/2017, documents, Skin Integrity Processes: A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. The facility's Weekly Pressure Ulcer Progress Report policy, dated 6/2020, documents, Any signs/symptoms of infection or poor response to treatment will be reported to the DON (Director of Nursing) and to the Physician for review for new orders. The policy also documents, Care plan nurse will be responsible to add skin issues to Care Plan with each incident to identify interventions to promote healing. MDS (Minimum Data Set) Assessment Coordinator will be responsible to follow up and monitor the Care Plan and add updates as needed. Updated information regarding residents skin condition and Care Plan will be reported to the CNAs (Certified Nursing Assistants for education to provide quality care to heal and attempt to prevent further issues. The policy also documents, to provide weekly assessment and documentation of all pressure/stasis ulcers. To help prevent infections and other complications of pressure/stasis ulcers. Upon assessment of pressure/stasis ulcer, document on the weekly pressure ulcer progress report. Document in the Nurses Notes. The area will then be monitored on a weekly basis on the weekly pressure ulcer progress report. On 06/22/21 at 11:00 AM, R5 had a [MEDICATION(S)] dressing in place on R5's coccyx. R5's Braden Scale for Predicting Pressure Sore Risk Assessment, dated 3/25/21, documents a score of 15 putting R5 at risk for developing pressure ulcers. R5's Skin/Wound note, dated 1/11/2021, documents, Full thickness open area noted at coccyx measures 0.8 cm (centimeters) round with depth of 0.7 cm. R5's Pressure Ulcer Care Plan, dated 3/16/21, documents that R5 has a Stage 3 Pressure Area on her coccyx. R5's Care Plan has no documentation of revision to the care plan to include new interventions to prevent R5's pressure ulcer from worsening and/or prevention of new ulcers. On 06/24/21 at 09:23 AM, V5 (Care Plan Coordinator) confirmed that no new interventions had been implemented on R5's care plan to prevent further breakdown or worsening. R5's Skin & Wound Evaluation, dated 1/25/21, documents that R5 has a new Stage three (Full thickness skin loss) facility acquired pressure ulcer on R5's coccyx that was identified on 1/11/21. R5's pressure ulcer measured 0.9 cm (centimeters) x 0.5 cm x 0.4 cm with 0.4 cm of undermining as well. R5's Skin & Wound Evaluation, dated 2/5/21, documents, Wound Measurements: 0.5 cm x 0.2 cm x 0.3 cm. Stalled healing. Wound bed has persistent adherent yellow slough present. R5's Skin & Wound Evaluation, dated 2/11/21, documents, Wound measurements: 0.5 cm x 0.3 cm x 0.3 cm. Dressing appearance: Missing. Stalled. Dressing was missing at time of assessment. Wound has significant adherent light-colored slough present today. R5's Skin & Wound Evaluation, dated 2/17/21, documents, Wound Measurements: 0.4 cm x 0.4 cm x 0.1 cm. Dressing appearance: Missing. Stable. Dressing missing at time of assessment. Wound is stable/ unchanged with adherent light-colored slough present. New order includes hydrogel gauze to wound bed. R5's Skin & Wound Evaluation, dated 3/2/21, documents, Wound measurements: 0.6 cm x 0.4 cm x 0.3 cm. Dressing appearance: Missing. Assigned nurse notified this RN dressing was noted to be missing. Task was added recently to Plan of care for CNA (Certified Nursing Assistant) staff to notify nurse of dressing status and/or if absent. R5's Skin & Wound Evaluation, dated 3/11/21, documents, Wound measurements: 0.6 cm x 0.5 cm x 0.3 cm. R5's Skin & Wound Evaluation, dated 3/19/21, documents, Wound Measurements: 0.6 cm x 0.6 cm x 0.3 cm. R5's Skin & Wound Evaluation, dated 3/23/21, documents, Wound Measurements: 0.6 cm x 0.5 cm x 0.2 cm. Dressing appearance: Missing. The wound bed has transparent pale yellow to light brown slough appearance. R5's Skin & Wound Evaluation, dated 3/29/21, documents, Wound Measurements: 0.6 cm x 0.5 cm x 0.2 cm. Wound Bed: 80% of wound filled with slough. R5's Skin & Wound Evaluation, dated 4/7/21, documents, Wound Measurements: 0.8 cm x 0.4 cm x 0.2 cm. Dressing appearance: Missing. The wound has stalled. The wound bed has loose yellow slough. R5's Skin & Wound Evaluation, dated 4/14/21, documents, Wound Measurements: 1 cm x 0.3 cm x 0.4 cm. Wound Bed: 50% of wound filled with slough. Dressing appearance: Missing. R5's Skin & Wound Evaluation, dated 4/22/21, documents, Wound Measurements: 0.7 cm x 0.6 cm x 0.4 cm. Wound Bed: 40% of wound filled with slough. Stable. Moderate amount of loose yellow slough easily removed with cleansing leaving less than 50% wound bed covered in adherent yellow slough. R5's Skin & Wound Evaluation, dated 4/30/21, documents, Wound Measurements: 1.3 cm x 0.6 cm x 0.8 cm. Wound Bed: 70% of wound filled with slough. Deteriorating. Coccyx wound has increased depth. R5's Skin & Wound Evaluation, dated 5/6/21, documents, Wound Measurements: 0.8 cm x 0.7 cm x 0.8 cm. Wound Bed: 80% of wound filled with slough. Stable: Essentially unchanged wound. There is little exposed wound bed and portions of the pink wound bed are visible through shallow adherent yellow slough. R5's Skin & Wound Evaluation, dated 5/13/21, documents, Wound Measurements: 1 cm x 0.6 cm x 1 cm. Wound Bed: 100% of wound filled with slough. Dressing Appearance: Missing. Dressing was reported to be missing by assigned nurse. The wound is essentially unchanged. R5's Skin & Wound Evaluation, dated 5/19/21, documents, Wound Measurements: 0.7 cm x 0.7 cm x 1 cm. Dressing Appearance: Missing. Stable: Assigned nurse reports dressing was missing. R5's Skin & Wound Evaluation, dated 5/28/21, documents, Wound Measurements: 0.7 cm x 0.7 cm x 1 cm. Stable. Essentially unchanged in overall involved area from previous assessment. R5's Skin & Wound Evaluation, dated 6/3/21, documents, Wound Measurements: 1.1 cm x 0.7 cm x 1 cm. Wound Bed: 80% of wound filled with slough. R5's Skin & Wound Evaluation, dated 6/8/21, documents, Wound Measurements: 1.1 cm x 0.7 cm x 1 cm. Wound Bed: 90% of wound filled with slough. Deteriorating. R5's Skin & Wound Evaluation, dated 6/15/21, documents, Wound Measurements: 1 cm x 0.8 cm x 1.1 cm. Wound Bed: 100% of wound filled with slough. Dressing Appearance: Missing. R5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin-prep around wound. Fill wound with small piece of Hydrogel gauze and cover with a 4 x 4 [MEDICATION(S)] dressing. Change every three days and as needed if loose or soiled until resolved. The order recap also documents that this order has been in place since 2/17/21. 06/24/21 at 12:03 PM, V13 (Nurse Practitioner) stated, If the wound got larger, deeper, developed a foul smell, drainage, or symptoms of infection these are signs of a wound worsening. If a wound is stalled or deteriorating the treatment should be changed because that treatment isn't working as evidenced. On 06/24/21 at 02:24 PM, V14 (Wound Nurse), stated (R5's) wound was full thickness because I could see the structure around it. I staged it at a 3. When a wound covered with slough and you can't tell the depth, it is unstageable. If there is slough in the wound bed, you don't know what's underneath of it. (R5's) wound I could tell based on the depth and the coverage of slough that (R5's) wound deteriorated. I debated changing the order, but I didn't change it at any point. I was mortified initially when I saw it uncovered because she is incontinent of bowel, but has an indwelling urinary catheter. Being uncovered the wound could become contaminated. There were times when I would go in that the dressing would not be in place. I educated the CNAs and nurses about it. 2) Skin and Wound assessment dated [DATE] at 9:04pm indicates R41 was admitted on [DATE] with a Stage 2: Partial thickness skin loss with exposed dermis coccyx pressure ulcer measuring 0.1cm (centimeter) x 0.3cm x 0.4cm, depth 0.1cm; no drainage. R41's Skin and Wound assessment dated [DATE] at 10:12pm documents that R41 continues with a Stage 2 coccyx pressure ulcer with measurements 0.3cm x 0.4cm x 0.9cm, depth 0.1cm; wound bed 40% filled with slough and light drainage. R41's Skin and Wound assessment dated [DATE] at 5:07pm documents R41 with Stage 2 coccyx pressure ulcer measuring 0.2cm x 0.5cm x 0.5cm, depth 0.1cm; wound bed 80% filled with slough, no drainage. On 6/24/21 at 12:04pm, R41was noted to have an irregular shaped pressure wound in the crease/crack of his coccyx. The wound was noted to be full thickness with slough (whitish/yellow coating) in the base of the two distinct adjoining crater areas of the wound. The actual depth of the wound could not be visualized due to the slough covering the wound base. R41's Skin wound assessment dated [DATE] documented R41's coccyx wound was a Stage 2 pressure area that was acquired on admission. No measurements were initially documented in the assessment. R41's Skin and Wound assessment dated [DATE] at 9:30 pm documents R41 with Unstageable: Obscured full thickness skin and tissue loss due to slough and/or eschar. Coccyx wound measurements 0.5cm x 0.8cm x 0.9cm, depth not applicable; remainder of assessment is incomplete/not documented. R41's Pressure Ulcer Care Plan created on 6/9/21 did not contain interventions to reduce pressure. On 6/24/21 at 3:00pm V5, Care Plan Coordinator stated that she was told not to put the same interventions in more than one area, so she created a skin impairment Care Plan that was not specific to pressure ulcers. On 6/24/21 at 3:00pm V14, Wound Nurse stated that he initially marked R41's coccyx wound on 6/23/21 as Stage 2 even though he had observed the wound had worsened because he was not aware that a wound could stage up from the initial admission stage. V14 stated he was not wound certified and agreed the wound should be unstageable due to the wound now full thickness and base being covered with slough. V14 stated that R41 Will not stay off his back. No interventions were found to address R41's position preferences. R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/13/21, R3's Nurse's Notes document the following: Noted a small 0.2 x 0.3 cm (centimeter) scab on (R3)'s pelvic area. Also had a pink colored pimple on his leg near the knee. On 5/14/21 R3's Nurse's Notes document the following: Area to the (right) inner buttocks measures 3 cm x 2 cm in size, edges are detached and red, center is scabbed over, surrounding skin is intact, (R3) denies discomfort when area touched, but (complains of) pain if the (medicated) cream is applied for wound healing and protection. On 6/23/21 at 9:30 A.M. V2 (Director of Nursing) confirmed that R3 did have open areas (to the buttocks) and that there was no further documentation in the medical record concerning R3's pressure ulcers and open areas.

Based on observation, interview and record review, the facility failed to develop a care plan for a resident with a history of falls (R1), failed to provide adequate assistance during a transfer (R1 and R3), and failed to implement fall interventions to prevent further falls (R2) for three of three residents (R1, R2 and R3), reviewed for falls, in a sample of three. This failure resulted in R1 sustaining a complex, comminuted [MEDICAL CONDITION] leg. FINDINGS INCLUDE: The facility policy, Fall Prevention, dated (revised) 7/19/17 directs staff, Residents of (the facility) will be evaluated for risk of falling at admission and throughout their stay in the facility. Residents determined to be at high risk for falling will receive appropriate interventions (care plan) to minimize risk. Interventions will be implemented to minimize the risk of resident falls, while addressing the specific needs of each resident. Following a fall by a resident, immediate interventions will be put in place. 1. R1's (Hospital) Transfer Form, dated 4/17/18 documents the following history, (R1) presented to the ED (Emergency Department) for a fall. (R1) reports losing footing on gravel just prior to admission, falling onto left side and hitting head against (a) tire. (R1) was assisted up from the ground several times, but fell each time. This same form documents R1's Pelvic X-Ray (radiograph): Severe [MEDICAL CONDITION] in the right hip, R1's Right Knee X-Ray: Severe tricompartmental [MEDICAL CONDITION], and R1's Computerized Tomography of the Lumbar Spine as: Moderate to severe multilevel [MEDICAL CONDITION] facet disease. This Transfer form includes the following [DIAGNOSES REDACTED]. Also included in this same document are physician orders [REDACTED]. R1's Care Plan, dated 4/18/18 contains no mention of R1's history of falls or no interventions to prevent further falls. R1's Minimum Data Set Assessment (MDS), dated [DATE], completed just prior to R1's discharge documents R1's Cognitive Patterns (Section C0500) as 15 (cognitively intact). This same assessment documents R1's Balance During Transitions and Walking (Section G0300) as a 2 (not steady, only able to stabilize with staff assistance) while performing a surface to surface transfer. R1's Physical Therapy Note, dated 5/7/18 documents R1's functional status as, 'Transfers-modified independence. (Requires) Assistive device during transfers: four-wheeled walker. R1's Nursing Progress Notes, dated 5/8/18 document, 0530 (5:30 A.M.) Called to resident room by CNA, when entered room resident was sitting on scale with left leg extended out and right leg bent at knee with right foot under left knee. On 6/5/18 at 11:10 A.M., V2/Director of Nurses (DON) stated, I was the nurse on duty the morning that (R1) fell . I got a call from V3/Certified Nursing Assistant (CNA) to come to R1's room. (R1) was sitting on the scale with (R1's) right leg under (R1's) left leg. V3/CNA had gotten (R1) up for (R1's) morning weight. (R1) said (R1's) knee gave out. V2/CNA and I used the (mechanical) lift and put (R1) into bed. I called immediately and got an order for [REDACTED]. I kept (R1) informed of the situation and we kept (R1) on bedrest. (R1's) doctor had came into the facility to see patients that morning and I informed him of the situation. The doctor told me to call the (local orthopedics group). (R1) told me to ask for (V6/Orthopedic Surgeon) because R1 had seen (V6) in the past. (V6) stated to send R1 to the local Emergency Department. On 6/5/18 at 1:20 P.M., V3/CNA stated, I was supposed to get a daily weight on (R1) (5/8/18). (R1) had complained of pain in (R1's) left arm earlier in the shift. I had helped (R1) put (topical [MEDICATION NAME]) on (R1's) left arm, earlier. (R1) didn't want to get on the scale. (R1) refused often. I kept talking to (R1). (R1) stood up fine. I didn't use the walker. (R1) yelled out, 'My knee.' (R1) lowered (R1's) self onto the scale. On 6/5/18 at 3:30 P.M., R1 stated, I fell (5/8/18). I lost my balance and fell . I fell on to the scale. My knee was up against the front of the scale. I couldn't get hold of the bar with my left arm. It was weak. I had injured it previously. I told (V3/CNA) my arm was weak that morning, but (V3) insisted I try. I had to remind (V3) to put a gait belt on me. (V3) wasn't going to use one. I never did get to a standing position. I fell immediately. (V3) did not give me my walker to use. (V3) tried to do it by herself. I kept telling (V3) to go get help. They sent me to (out-of-state) hospital, where they had to do special surgery on my knee. I just got to (other skilled nursing facility) recently. I'm going to be here for a long time for therapy. My knee is painful. R1's (Emergency Department) Notes, dated 5/8/18 document, (R1) presents with right leg pain. (R1) presents from (nursing facility) post fall. (R1) was getting up with assist of a belt for a weigh in when (R1)'s arm gave out and (R1) fell forwards. States that (R1) landed hard on (R1)'s rear and right knee. Has acute pain in low back and right knee. This same document includes the following Diagnosis: [REDACTED]. R1's Radiology Report, dated 5/8/18 documents, There is an acute comminuted [MEDICAL CONDITION] femur, just proximal to the femoral hardware component of the right total knee arthroplasty. There is complete medial displacement of the principal distal fracture fragment. Marked surrounding soft tissue swelling. R1's Orthopedics Progress Note, dated 5/8/18 and signed by V7/Orthopedic Surgeon documents, I was called in regards to (R1's) right distal femur complex periprosthetic fracture. I reviewed the X-rays and talked with my partners about the films. Due to (R1's) complex medical history and [MEDICAL CONDITION] associated with (R1's) fracture, recommendation is to transfer to a tertiary care center. The worrisome appearance of (R1's) lateral femoral condylar attachment and paucity of bone surrounding the prosthesis makes it uncertain if standard ORIF (open reduction and internal fixation) would provide enough fixation. This may end up needing a complex revision with distal femoral mega-prosthesis. On 6/5/18 at 2:40 P.M., V5/Care Plan Coordinator verified there was not a care plan to address R1's risk for falls. On 6/6/18 at 9:15 A.M., V8/Physical Therapy Assistant (PTA) verified that she last performed therapy on R1 on 5/7/18 and at that time R1's functional status for transfers were modified independence with an assistive device during transfers; four-wheeled walker. An attempt to interview V6 and V7/Orthopedic Surgeons was unsuccessful. 2. R2's Physician order [REDACTED]. R2's Fall Risk Assessment, dated 3/21/18 documents that R2 scored a 20 for fall risks (high risk). R2's Post Fall Assessment Form, dated 5/9/18 documents, Observed lying on floor in hallway outside of dining room. This same form documents under Interventions Added, Call placed to hospice regarding high back char that reclines. No further fall interventions were implemented to prevent further falls. R2's Post Fall Assessment Form, dated 5/13/18 documents, fell asleep in wheel chair and fell out of chair, landing on left side. This same form documents under Interventions Added, Call placed to hospice again regarding safety intervention as no response from 5/9/18 incident. On 6/5/18 at 2:42 P.M., V5/Care Plan Coordinator verified that R2's care plan had not been updated to include new interventions to prevent further falls. 3. R3's current Physician order [REDACTED]. R3's current Care Plan, dated 3/25/18 includes the following intervention: 2:1 assist with pivot transfers. On 6/5/18 at 12:50 P.M., V4/Certified Nursing Assistant (CNA) prepared to transfer R3 from the wheel chair to bed. V4/CNA applied a gait belt around R3's waist, assisted R3 to stand, pivoted R3, and R3 fell to the bed. At that time, V4/CNA stated, (R3) is supposed to be a two person transfer.

Based on interview and record review, the facility failed to ensure a resident's right to be free from exploitation on social media for one of three residents (R1) reviewed for abuse, in a sample of three. This failure resulted in R1, who is unable to express self, to suffer public humiliation and dehumanization, when a partially clothed photo of R1 was posted on a social media site. FINDINGS INCLUDE: The facility policy, Social Media for Long-Term Care Facility Staff, dated 1/20/16 directs staff, All staff working within (the facility) will maintain ethical and professional standards. Nursing staff must recognize that they have an ethical and legal obligation to maintain resident privacy and confidentiality at all times. Facility staff must not take photos or videos which can identify residents on personal devices and/or personal electronic media. Facility staff are restricted from transmitting any information that may be reasonably anticipated to violate resident rights to confidentiality or privacy, or otherwise degrade or embarrass the resident. When using social media facility staff must not identify residents by name or post or publish information that may lead to the identification of a resident. The facility Alleged Abuse/Neglect Report, dated 9/10/17 documents, (Z1/Certified Nursing Assistant) reported to E2/Director of Nurses that E3/Certified Nursing Assistant (CNA) had taken a picture of (R1) and placed it on (social media). (Z1) said she had proof of the picture as (Z1) had taken a screen shot of it. Z1 then sent the photo to E2/DON. The photo included E3/CNA's name and the time 6:12 (A.M. or P.M. not identified). (R1) was identified as lying in bed, unclothed from the waist up. E3/CNA states she is unsure how many people saw it (picture of R1) on the Internet. On 9/25/17 at 2:20 P.M., E3/CNA stated, It was a complete accident on my part. It (happened) on 9/10/17 around 6:00 A.M. I was on my cell phone in (R1)'s room, on (social media). (R1) began getting restless, so I put my phone in my pocket, not realizing it had taken (R1)'s picture and posted it on (social media). I have received training on Abuse (Prevention) and Cell Phone (Usage). I knew I wasn't supposed to have my cell phone in my pocket. On 9/26/17 at 10:15 A.M., E7 (Abuse Prevention Coordinator) stated all facility staff had received training regarding the exploitation of residents on social media, and it had been incorporated into their Abuse Prevention policy. E7 indicated staff are given written instructions on Employee Conduct at the time they are hired and it is advised that any pictures or videos taken of residents is prohibited as part of their Abuse Prevention Program. An Employee Student Management transcript for E3 documents that E3 had received additional training on Corporate Compliance and HIPPA and Long Term Care Abuse Prevention on 01/17/17. On 9/25/17 at 3:15 A.M., Z2 (R1's son) stated, (R1) would be very mad and upset if (R1) realized a half naked picture of (R1) was out on the Internet. (R1) doesn't go for that sort of thing. (R1) is older, (R1) would be very embarrassed by it. (R1) was a business owner in our community and very proud of that. (R1) would be humiliated.

Based on record review and interview, the facility failed to monitor [MEDICATION NAME]/International Normalized Ratio (PT/INR) laboratory blood work for one resident (R1) of seven residents who were taking the [MEDICATION NAME] in a sample of seven residents. This failure resulted in R1 expiring from a Gastro-intestinal bleed secondary to [MEDICATION NAME] ([MEDICATION NAME]) toxicity. Findings include: R1's online medical record documents R1 was admitted , to the long-term care facility, on [DATE], with the [DIAGNOSES REDACTED]. R1's physician's orders [REDACTED]. On [DATE], a Consultation Report, from Z1 (Registered Pharmacist), documents upcoming labs have not been scheduled. Z1 left a note, on the Consultation Report, for Z2 (Medical Doctor) stating, (Z2), No INR's scheduled? When do you want this checked? R1's Medication Administration Record documents, R1 received daily [MEDICATION NAME] medication from [DATE] up to and including [DATE]. R1's Progress Notes, dated [DATE], at 3:10 a.m., documents: Patient had at least two large bloody stools on second shift; (R1) then had three bloody stools on third shift; (R1) was pale, cool to the touch, altered level of consciousness, delayed responses; (R1) began throwing up bright red blood; and (R1) was sent to the local hospital-emergency room . Local hospital's Final Report-History and Physical, dated [DATE] and dictated by Z3/Physician, states, Gastro-intestinal bleed secondary to [MEDICATION NAME] toxicity that required close monitoring in the intensive care. R1's Physician's Progress Note, from the local hospital, dated [DATE], documents: R1's INR to critically high at 7.7 (INR was drawn in the emergency room [DATE]) and (R1) was admitted for GI (Gastro-intestinal) bleed. After discussing with the family, it was decided to make (R1) comfort care. R1's Admission Record, dated [DATE], documents, R1 was readmitted to the long-term care facility on [DATE]. R1's New Admit Report, not dated, documents R1's admitting [DIAGNOSES REDACTED]. R1's Death Record, dated [DATE], documents R1 expired [DATE], at 8:15 a.m. On [DATE], at 12:10 p.m., E1 (Director of Nursing) confirmed: R1 was admitted [DATE] with daily INR orders; R1's INR orders were not processed, thus R1 did not have daily INR blood work done; R1's pharmacy consultation report (dated [DATE]) was misplaced; R1 continued to receive [MEDICATION NAME]; on [DATE], R1 started having bloody bowel movements; and in the early morning hours of [DATE], R1 was sent to the local hospital where R1 was admitted with a GI bleed and [MEDICATION NAME] toxicity.

Based on record review and interview, the facility failed to notify the physician of a significant change in condition for one of seven residents (R1) reviewed for a change in condition in a sample of seven. This failure resulted in R1 having continued bloody bowels movements and expiring four days later from a Gastro-intestinal bleed due to [MEDICATION NAME] toxicity. Findings include: R1's Progress Notes, dated [DATE], at 3:10 a.m., documents: Patient had at least two large bloody stools on second shift; (R1) then had three bloody stools on third shift; (R1) was pale, cool to the touch, altered level of consciousness, delayed responses; (R1) began throwing up bright red blood; and (R1) was sent to the local hospital-emergency room . R1's Event Debriefing Tool, dated [DATE], documents, Delay of care. (R1) started having coffee ground stools, pale, and weakness during first shift on [DATE]. On second shift, (R1) had one large coffee ground stool. E3 (Licensed Practical Nurse) went right to the E2 (night nursing supervisor) and gave E2 this information. E2 stated, the labs from earlier were ok, Z2 (Medical Doctor) will see R1 tomorrow. E3 stated that R1 had another coffee ground stool at the end of E3's shift, and E3 relayed all of the information to the third shift nurse. The nurses did not contact the doctor about any issues. R1's Physician's Progress Note, from the local hospital, dated [DATE], documents: R1's INR to critically high at 7.7 (INR was drawn in the emergency room [DATE]) and (R1) was admitted for GI (Gastro-intestinal) bleed. After discussing with the family, it was decided to make (R1) comfort care. R1's Admission Record, dated [DATE], documents, R1 was readmitted to the long-term care facility on [DATE]. R1's New Admit Report, not dated, documents R1's admitting [DIAGNOSES REDACTED]. R1's Death Record, dated [DATE], documents R1 expired [DATE], at 8:15 a.m. On [DATE], at 12:10 p.m., E1 (Director of Nursing) confirmed: on [DATE], R1 started having bloody bowel movements on day shift and at that time Z2 was notified and ordered some lab work; Z2 was not notified of any bloody stools that occurred on evening or night shifts and in the early morning hours of [DATE], R1 was sent to the local hospital where R1 was admitted with a GI bleed and [MEDICATION NAME] toxicity. ON [DATE] at 3:35 PM, Z2/Medical Director stated that the facility did not contact him regarding R1 ' s continued bloody stools and that he would have expected the facility to do that. He also said they made a mistake and someone was fired.

Based on interview and record review, the facility failed to verify the identity of a resident prior to medication administration for one of three residents (R1) reviewed for medication administration in the sample of three. As a result, R1 was administered R2's medications, causing R1 lethargy (drowsiness), [MEDICAL CONDITION] (low blood pressure) and [MEDICAL CONDITION] (slow heart rate), subsequently requiring R1 to be hospitalized in the intensive care unit. Findings include: The facility's Patient Identification policy (Revised 11/7/14) documents the following: Each patient will be properly identified throughout the course of his/her care.staff will identify the patient using name and date of birth and follow the practice.All departments will include name and date of birth in identification process. In some departments a third identifier may be required. All inpatients and applicable outpatients will have an ID band which will always be used to verify the name and date of birth before providing care. All supportive and direct care providers will identify each patient using two patient identifiers. Room number is never to be used to identify the patient. If the patient is unable to state their name and date of birth, the patient may be identified by checking their identification band and/or a family member when possible. R1's undated electronic [DIAGNOSES REDACTED]. R1's electronic progress notes dated 6/2/15 through 6/10/15 document the following: (R1) is alert but forgetful and sometimes confused.alert but confused at times.alert with periods of forgetfulness. R1's electronic progress note dated 6/10/15 documents the following: (E4, Occupational Therapy Assistant) was pushing (R1) in the hallway and stopped to ask (E3, Registered Nurse) if (R1) needed medications before they went to the therapy room. (E3) stated, 'Who is the patient?' (E4) stated, '(R2).' (E3) administered pills for (R2). Immediately after administration, (E3) noticed (R2) moving (in R2's bed). (E3) stated to (E4), '(R2) is in bed.' (E4) then stated, 'Oh! I (E4) have (R1)!'.All morning medications held for (R1). R1's Initial Event Debriefing Tool dated 6/10/15 documents, (R1) was wheeled out to the medication cart in the hall by (E4, Occupational Therapy Assistant), where (E3, Registered Nurse), was passing medications. (E4) asked (E3) if (E3) wanted to give (R1) his medications. (E4) stated, 'I (E4) asked (E3) if (E3) wanted to give (R1) his medications before I (E4) took (R1) to therapy.' (E3) then stopped (E3's) current medication pass and flipped to (R2's) Medication Administration Record [REDACTED]. Medications included: [MEDICATION NAME] (Antihypertensive) 20 milligrams, [MEDICATION NAME] (Antihypertensive) 25 milligrams, [MEDICATION NAME] (Anti-convulsant) 600 milligrams, [MEDICATION NAME] (blood thinner) 75 milligrams, Aspirin (Antithrombitic) 325 milligrams, [MEDICATION NAME] (decreases stomach acid production) 150 milligrams, [MEDICATION NAME] (decreases stomach acid production) 40 milligrams, and [MEDICATION NAME] (laxative) 17 grams. (E3) then stated, 'I (E3) looked into (R1 and R2's) room, and noticed that R2 was sitting in the room in bed 1. I (E3) then asked (E4) Are you sure you have (R2)?' And (E4) said (E4) actually had (R1).' This was after the medications were given.When (R1's) blood pressure started dropping, we (facility staff) called 911 and had (R1) transferred to (local emergency department). Z1's (R1's Physician) History and Physical for R1 dated 6/10/15 documents the following: Incidentally (R1) was given multiple medications by mistake, instead mixed up with other patient. (R1) has received 1 dose of Aspirin 325 milligrams, 1 dose of [MEDICATION NAME] 75 milligrams, 1 dose of [MEDICATION NAME] 25 milligrams, 1 dose of [MEDICATION NAME] 25 milligrams, 1 dose of [MEDICATION NAME] 150 milligrams, 1 dose of [MEDICATION NAME] 17 grams, 1 dose of Tylenol Arthritis, and 1 dose of Neurotin 600 milligrams. (R1) became hypotensive. (R1) was given an intravenous fluid bolus and decision was made to admit (R1) to the MICU (Medical Intensive Care Unit). I (Z1) arrived shortly after (R1) arrived to MICU. (R1's) blood pressure was 80/40.Admitting [MEDICAL CONDITION] (could be secondary to blood pressure medication was given by mistake which include [MEDICATION NAME] and [MEDICATION NAME]) On 7/6/15 at 12:51 p.m., Z1, R1's Physician, stated that R1 received another resident's medications by mistake and was hospitalized for [REDACTED]. Z1 then stated that R1 receiving the blood pressure medications, [MEDICATION NAME] and [MEDICATION NAME], could have been one cause of R1's low blood pressure. Z2's (R1's Cardiologist) Consultation Report dated 6/10/15 documents the following: (R1).was transferred from (local nursing home) to the intensive care unit because of low blood pressure and [MEDICAL CONDITION]. (R1) apparently received medications that did not belong to R1.When I (Z2) came to see (R1), (R1) was very lethargic, only opening (R1's) eyes when painful stimuli were given.(R1) has [MEDICAL CONDITION] on the monitor.(R1's) blood pressure is about 85 systolic. On 7/6/15 at 1:59 p.m., Z2, R1's Cardiologist, verified that R1 was hospitalized for [REDACTED]. Z2 then stated that R1 was very sleepy initially and only responded to painful stimuli, which may have been from the [MEDICATION NAME] (Anti-convulsant) R1 mistakenly received. R1's local hospital Shift Report notes for R1 document the following: admitted from emergency department with [MEDICAL CONDITION] and [MEDICAL CONDITION] after wrong medication administered (at nursing home).Blood pressure remains low.with [MEDICAL CONDITION] According to the Mayo Clinic, A blood pressure reading of 90 mm hg (millimeters of mercury) or less systolic blood pressure (the top number in a blood pressure reading) or 60 mm hg or less diastolic blood pressure (the bottom number) is generally considered low blood pressure. (http://www.mayoclinic.org/diseases-conditions/low-blood-pressure/basics/definition/com- 298). According to the American Heart Association, [MEDICAL CONDITION] equals too slow. A heart rate of 60 bpm (beats per minute) is called [MEDICAL CONDITION]. (http://www.heart.org/HEATRORG/Conditions/Arrhythmia/AboutArrhythmia/[MEDICAL CONDITION]-Slow-Heart-Rate_UCM_Article.jsp) R1's local hospital's Vital Signs Flowsheet dated 6/10/15 - 6/13/15 document the following blood pressure readings: 71/31 mm hg, 89/60 mm hg, 81/39 mm hg, 77/38 mm hg, 85/34 mm hg, 71/33 mm hg, 77/39 mm hg, 80/40 mm hg, 80/39 mm hg, 78/38 mm hg, 84/37 mm hg, 83/45 mm hg, 77/43 mm hg, 89/44 mm hg, 90/46 mm hg, 85/41 mm hg, 83/37 mm hg, 83/40 mm hg, and 81/45 mm hg. This same form documents the following Heart Rate readings for R1: 43 bpm, 46 bpm, 49 bpm, 48 bpm, 45 bpm, 40 bpm, and 42 bpm. On 7/6/15 at 11:48 a.m., E2, Director of Nursing, verified that R1 was given R2's medications the morning of 6/10/15. E2 stated, We (facility staff) checked (R1's) blood pressure frequently. It started registering low.we layed (R1) down and called 911. On this same date at 3:00 p.m., E2 stated the facility does not use identification bands for any of the residents, and therefore staff cannot verify a resident's identity or date of birth from an identification band. E2 then stated, We are supposed to have the resident's picture in the front of their Medication Administration Record [REDACTED]. On 7/6/15 at 12:09 p.m., E3, Registered Nurse, verified that E3 administered R2's medications to R1 on 6/10/15 at approximately 7:15 a.m. E3 then stated, I (E3) was working a hall that I (E3) had not worked in over a year and I (E3) was not familiar with the patients over there. On 7/6/15 at 1:36 p.m., E4, Occupational Therapy Assistant, verified that E3 administered R2's medications to R1 on the morning of 6/10/15.

Based on observations, interviews, and record reviews the facility failed to implement interventions to prevent pressure ulcers for a resident identified to be at high risk for development of pressure ulcers for one of four residents reviewed for pressure ulcers (R2) in a sample of four . This failure resulted in R2 developing a Stage IV pressure ulcer to the coccyx. Finding include: On 07/31/14 at 9:50 AM E3 (Wound Care Nurse), performed dressing change on R2's coccyx. Stage IV pressure ulcer noted to be approximately 5 x 5 cm and 2 inches deep. No drainage or odor noted. Exposed tissue appeared grayish in color. Admission Nursing History and Physical (H&P), dated 06/11/14, documents skin color normal, skin temperature warm, and skin turgor normal. The H&P noted a surgical incision to the right trochanter, a bruise to the right hand, a blister to the right thigh and frequent incontinence of bowel and bladder. (Skin assessment tool) dated 06/11/14, documents R2's score as 12 and states, "residents scoring 17 or less will be considered high risk for pressure ulcer." (Skin assessment tool) dated 06/19/14, documents R2's score as 11 and also states "Residents scoring 17 or less will be considered high risk for pressure ulcer." Maintenance of Skin Integrity Policy, dated 04/28/2014, states, "All residents will be assessed for skin breakdown upon admission and an ongoing basis. All residents identified at high risk for skin breakdown will receive preventative program interventions at facility. Purpose: To maintain skin integrity by providing optimum nursing care, assessment and treatment to residents residing in facility. Definitions: (skin assessment tool): a tool to help assess a residents risk of developing a pressure ulcer. Practice/Procedure: 1. All residents will be assessed on day of admission and weekly for the first 4 weeks using the (skin assessment tool) assessment form for predicting pressure ulcer risk. a. Residents with a (skin assessment tool) of 17 or below will be considered high risk for skin breakdown development. 3. Residents identified at risk or admitted with skin breakdown will be placed on an appropriate preventative intervention program." R2's care plan, dated 06/26/2014, includes interventions of: "Avoid positioning me on my back, I have a non weight bearing status on my coccyx. I need assistance with use of bed rails and assist of 2 people to assist in turning and repositioning. I require pressure relieving devices in my chair and bed. I go to wound clinic weekly. Please provide me supplements as ordered. provide diet as ordered. Monitor my skin daily and report any new red or open areas. Assist me in turning and repositioning every 2 hours. Provide treatments as ordered." There are no problems or interventions related to skin integrity included on R2's care plan prior to 06/26/2014. Facility Weekly Pressure Ulcer Report for R2, dated 06/26/14, includes a pressure ulcer stage 2, measuring 1 cm x 1 cm, and 1 cm depth to coccyx. Facility Weekly Pressure Ulcer Report for R2, dated 07/24/2014, includes a pressure ulcer unstageable, 3.5 x 3 cm, and 1 cm depth to coccyx. Facility Weekly Pressure Ulcer Report dated 07/31/2014, includes pressure ulcer stage IV, measuring 5 cm x 5 cm, and 2.5 depth to coccyx. Computer generated flowsheet documents R2 was not turned and repositioned from 06/13/14 thru 06/24/14. On 07/31/14 at 11:35 AM, E2 (Director of Nursing), stated "well 6/24/14 is when the pressure sore was found so she was placed on every 2 hour turns." E2 confirmed at that time that there were no interventions to prevent pressure ulcers in place for R2 or documented in R2's care plan prior to 6-26-14. On 7/31/14 at 1:28 PM, Z1 (R2's Wound Clinic Physician), stated "could it have been avoided, well yes all pressure sores can be. I know it's individualized, but there are things to do to prevent them. It's up to the nursing home to do everything to make sure it doesn't happen." On 07/31/14 at 9:15 AM, Z2 (R2's family member) stated, "Therapy would get (R2) up in a chair and (R2) would be there for 5 or 6 hours, I'd have to turn the light on for someone to get (R2) back to bed."