Every finding on record at St Paul's Senior Community

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination for 4 of 6 residents (R10, R11, R13, and R14) reviewed for food safety in the sample of 16.On 6/15/2026 at 11:50 PM, R11 stated the food was not always hot and they have complained about it, but it is still an issue. On 6/15/2026 at 11:54 PM, R13 stated her food is cold. They really need to make sure the food stays warm. This has been going on for a while now. I am not a big fan of pork, and we sure do have a lot of pork on the menu. On 6/15/2026 at 11:55 PM, R14 stated the food is not always hot and they have complained, and it is still not getting better. On 6/15/2026 at 11:58 PM, R10 stated the food is hit and miss, and it is cold more often than it is hot. On 6/15/2026 at 12:01 PM, V42, Dietary Aid was in the kitchenette dining area on the second floor, and she was taking temperatures from the stove. After taking the temperature of each item she did not record any temperatures in the book. V12 did not sanitize between uses while taking each food temperature of the barbeque beef, sweet potatoes, pureed sweet potatoes, mixed vegetables or pureed meat while taking her temperatures. She used the same thermometer for each food item. On 6/15/2026 at 12:04 PM, V42 took the temperature of the barbeque pork, and it was at 104.0 Fahrenheit (F). All items were in the oven. On 6/15/2026 at 12:05 PM, V42 starting service and plating the food including the barbeque pork. All food went out, and the barbeque pork was not heated up before serving. On 6/15/2026 at 12:22 PM, V43, Interim Dietary Manager stated, I expect all food to be at least 135 degrees or higher and if it below that temperature than I expect staff to reheat it before serving. I did not realize there were no papers or books for staff to record temperatures. On 6/15/2026 at 12:32 PM, after the last person had been served food temperatures were taken with a calibrated metal thermometer, and the barbeque pork was at 100.0F. On 6/15/2026 at 12:49 PM, R10, R11, R13 and R14 all stated their barbeque sandwich was cold today during the lunch service. On 6/17/2026 at 2:13 PM, V28, Regional Ombudsman stated the Facility has had multiple complaints regarding the food being cold and even a few days ago we still got complaints that it is not getting better. The Facility undated Food Policy documents, Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. The temperature for each food item will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating); will have the new temperature recorded with a circle around it next to the original temperature. Proper procedures are followed to ensure that food temperatures are accurately and safely obtained according to safe food handling practices. These procedures include the following steps: A properly functioning and calibrated thermometer will be used when taking temperatures (manufacturer's directions and/or manual guidelines are followed for calibrating thermometers at least monthly). Thermometers are washed, rinsed, sanitized before, and after each meal use. An alcohol swab may be used to sanitize between uses while taking temperatures during the same meal or if contamination of the thermometer occurs. If applicable, the manufacturer's recommendations for cleaning and sanitizing the thermometer may be followed. When taking temperatures, the thermometer is inserted in the thickest part of the food, not touching any part of the container, and held until the maximum or minimum temperature is reached. If the serving/holding temperature of a hot food item is not at 135 F or higher (check your state specific regulations: some states require 140 F minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165 F for a minimum of 15 seconds.

Based on observation, interview, and record review, the facility failed to provided timely turning/repositioning and incontinent care to prevent pressure ulcers/injuries from worsening or developing new pressure ulcers/injuries for 1 of 4 residents (R50) reviewed for pressure ulcers in a sample of 47. Findings Include: R50's Face Sheet, documents that she has diagnoses of but not limited to primary osteoarthritis of right and left hand, pressure ulcer of sacral region, stage 4, and peripheral vascular disease. R50's Minimum Data Set (MDS), documents that R50 is cognitively intact with a Brief Interview of Mental Status (BIMS) of 13 out of 15 and she is dependent on staff for all her activities of daily living (ADLs). R50 is always incontinent of bowel and bladder. R50s, Care Plan, documents that R50 has impairment to skin integrity related to (r/t) pressure injury to coccyx r/t pain, bladder incontinence, decreased mobility and poor circulation. R50 refuses repositing at times. Interventions include but are not limited to administer treatments as ordered and monitor for effectiveness, apply moisture barrier with each incontinent episode, evaluate wound for: size, depth, margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, float heels while in bed as tolerated, heel protectors on while in bed, and the resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. R50's Current Braden Scale- for Predicting Pressure Ulcer Risk Evaluation, dated 02/05/26, documents that R50 is a very high risk for developing pressure ulcers. R50's Physician's Orders, dated 12/05/25 at 2:18 PM, documents COCCYX: Cleanse wound with soap and water. Pat dry. Protect peri-wound area with skin protectant (Skin Prep). Do not put it in open area. Apply collagen particles to wound bed. Apply a thin layer of SSD to wound bed. Apply calcium alginate to wound base. Cut to fit INSIDE wound edges. Do not place on skin. Cover with bordered gauze. Change dressing daily and PRN (as needed) for soiling, saturation, or unscheduled removal. R50's Skin and Wound Note, dated 03/12/28, documents that R50's wound assessment location: coccyx, is pressure ulcer/injury, stage 4, currently stable, measures 5 centimeters (cm) x 4 cm x2 cm, and has subcutaneous and adipose tissue exposed. It also documents that the peri wound (the skin surrounding the wound) is macerated and the wound has a moderate amount of serosanguineous amount of drainage. She rates wound pain a four at rest. Assessment/Plan: Pressure Injury to coccyx assessed and debrided on today's skin assessment; please keep the patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure on any bony prominence by adhering to turning protocols and floating heels as applicable. Given patients history, comorbidities, and current condition; the risk of complications and/or morbidity/mortality of the patient's management is high. During observations on 03/24/26 from 9:15 AM through 2:10 PM, with 15-minute intervals R50 was seen up in her wheelchair with no repositioning or checking for incontinence being done. On 03/23/2026 at 10:15 AM, R50 is sitting up in her wheelchair in her room. R50 asked this surveyor if I knew what a pressure ulcer was. She said she has got one since she has been here at the facility. She was asked if she had any pressure ulcers before she came to the facility and she said, Absolutely Not! R50 said they do not come and check, change or turn her every two hours. On 03/25/2026 at 10:27 AM, V27, Certified Nursing Assistant (CNA) said residents should be turned/repositioned/changed every two hours. V27 said she feels like they don't have enough staff working and sometimes it's hard to get her rounds done every two hours. On 03/26/26 at 11:50 AM, V3, Assistant Director of Nursing (ADON) and V33, Infection Preventionist (IP) both stated they would expect the resident to be checked, changed, and repositioned at least every two hours. On 03/26/26 at 1:00 PM, V3, ADON said they don't have a turning and repositioning policy they just follow protocol for wounds and turn the residents every two hours. She said for someone who has wounds they want to relieve that pressure.

Based on interview, observation and record review, the facility failed to serve food at palatable temperatures for 5 of 7 residents (R1, R6, R7, R8, R9) reviewed for Food and Nutrition Services in a sample of 13. Findings include:1.R1's Facesheet documented he was admitted to the facility on [DATE]. 2.R6's Facesheet documented he was admitted to the facility on [DATE].3.R7's Facesheet documented he was admitted to the facility on [DATE].4. R8's Facesheet documented he was admitted to the facility on [DATE].5.R9's Facesheet documented he was admitted to the facility on [DATE].On 3/9/26 at 11:22 AM, V3 (dietary director) stated they are serving turkey wraps with sweet potato fries and mixed vegetables with pudding for dessert. V3 stated they temped all the wraps prior to putting them in the coolers and they will be re-temped once they get to the floors. V3 calibrated this surveyor's thermometer to be 32.5 degrees and will subtract 0.5 from all findings. At 11:47 AM, the turkey wraps temped at 49.8 degrees and V3 stated they are putting them in the freezer; will send out the hot food first so they can get that in the ovens until the cold food is ready. At 12:07 PM, V1 temped the turkey wraps after being in the freezer, at 45 degrees and put them back in the freezer.On 3/9/26 at 12:14 PM, food arrived at 2 South Unit. V4 (dietary aide) was preparing to serve the food. V4 checked the temperature of the mixed vegetables at 132 degrees and stated it's not warm enough and put them back in the oven. V4 checked the temperature of the sweet potato fries at 134.5 degrees and stated they had to go in the oven too. V4 checked the temperature of the turkey wraps at 43.4 degrees at 12:20 PM and left them out and over ice. At 12:25 PM, V4 started serving the food without rechecking the temperatures. R6, R1, R7, R8 and R9 all received the food that was served. On 3/9/26 at 1:00 PM, the sample tray was served once all residents were served. The following food temperatures were recorded in degrees Fahrenheit: turkey wrap: 43.2, mixed vegetables: 102, sweet potato fries: 97.6, pureed wrap: 65.7, pureed vegetables: 103.8, pureed sweet potato fries: 114.5. On 3/10/26 at 1:58 PM, V2 stated his expectations for food temperatures are to be following the facility's policy.On 3/10/26 at 3:34 PM, V21 stated her expectations for food temperatures are for the policy to be followed. V21 stated they did just have some of the equipment updated and is aware and working on those dietary concerns. V21 stated they are working on a long-term solution but that will take time.The facility's Food Holding Temperature Log for 2 South dated 3/9/26 documented the following temperatures: entree at 43.4, vegetable at 132, starch at 134 with no reheating temperature noted. The Log continues to document that all hot foods must be 140F (degrees Fahrenheit) and above, all cold foods must be 41F and below. The facility's Monitoring Food Temperatures for Meal Service Policy, undated, documented food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. The policy continued to document any food item not found at correct temperature will not be served but will undergo the appropriate corrective action listed: the temperature for each food item will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating); will have the new temperatures recorded with a circle around it next to the original temperature. The policy further documented hot food items not at 135 degrees Fahrenheit when checked prior to meal service will be reheated to at least 165 for a minimum of 15 seconds and for cold food items not at 41 degrees Fahrenheit will be chilled on ice or freezer until it reaches 41 degrees Fahrenheit or less before service. The policy also documented food temperatures of hot foods on room trays at the point of service are preferred to be at 120 degrees Fahrenheit or greater to promote palatability for the resident.

Based on interview, observation, and record review, the Facility failed to ensure food served was appetizing and at a palatable temperature for 1 of 3 residents (R4) reviewed for food and nutritional services in the sample of 6.Findings include: 1-R4's Face Sheet documents R4 was admitted to the facility on [DATE] with a diagnosis of paraplegia. R4's Minimum Data Set (MDS) dated [DATE] documented R4 was cognitively intact and was independent with eating. R4's Diet Order dated 3/19/25 documented R4 was on a carbohydrate controlled diet. On 1/6/26 at 10:30 AM, R4 stated the food is always cold and lacks flavor. On 1/6/25 at 12:41 PM, a test tray was conducted using a metal calibrated thermometer after the last resident tray was served. The beef tacos measured 110 Fahrenheit (F), the broccoli measured 107 F, and the rice measured 101 F. The broccoli was mushy and light green in color. The Facility's Resident Council Meeting Minutes dated 11/28/25 document cold food as an issue/concern. The Facility's Resident Council Meeting Minutes dated 12/26/25 document food too spicy as an issue/concern. On 1/8/26 at 1:56 PM, V2, Director of Nursing (DON), stated he expects the Facility to adhere to its policy regarding food temperature and palatability. The Facility's Undated Monitoring Food Temperatures for Meal Service documents, Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Food temperatures of hot foods on room trays at the point of service are preferred to be at 120 F or greater to promote palatability for the resident.

Based on observation and interview, the Facility failed to post nurse staffing information in a prominent place that was readily accessible to residents and visitors. This has the potential to affect all 99 residents living in the Facility.Findings include: On 1/8/26 at 8:32 AM, V18, Receptionist, was sitting at the front desk in the lobby of the Facility. She stated nursing assignments are posted back by the employee time clock. There was no visible staffing posted in the front lobby. On 1/8/26 at 8:35 AM, there was no nurse staffing visibly posted on Unit 1-South. V3, Assistant Director of Nursing (ADON), stated daily nurse staffing assignments are not posted in a place where residents and visitors can see. On 1/8/26 at 8:42 AM, there was no nurse staffing visibly posted on Unit 1-North. V7, Nurse Manager, stated nurse staffing is not posted for visitors. If a visitor wants to know which staff are caring for a certain resident the nurse can check their paperwork and let them know. On 1/8/26 at 10:04 AM, there was no nurse staffing visibly posted on Unit 2-North. On 1/8/26 at 10:07 AM, there was no nurse staffing visibly posted on Unit 2-South. V19, Licensed Practical Nurse (LPN), stated she has the nursing assignments written on a paper, but they are not posted for residents or visitors to see. On 1/8/26 at 10:09 AM, there was no nurse staffing visibly posted on Unit 3-South. On 1/8/26 at 10:10 AM, there was no nurse staffing visibly posted on Unit 3-North. On 1/8/26 at 10:00 AM, V2, Director of Nursing (DON), stated the Facility has not been posting staffing information. The Facility does not have a policy regarding nurse posting and they would just follow the regulations. The Facility's Centers for Medicare & Medicaid Services Form 802 printed 1/6/26 documents there are 99 residents living in the Facility.

Based on observation, interview and record review, the facility failed to ensure 2 of 4 residents (R3, R5) reviewed for resident rights were treated with dignity and respect by allowing staff to use personal cell phones excessively during work hours in the sample of 5. Findings include:On 11/21/25 at 2:19 PM, V6, Certified Nursing Assistant (CNA), was sitting at a table in the 1 South Dining Room looking at a cell phone.On 11/22/25 at 5:20 AM, V15, Licensed Practical Nurse (LPN), was sitting at the 1 South Nurse's Station looking at a cell phone.On 11/22/25 at 5:25 AM, V16, CNA, was sitting at a table in the 1 South Dining Room looking at a cell phone.1-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including age related physical debility and muscle wasting and atrophy.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired.On 11/21/25 at 11:00 AM, R3 stated staff are frequently on their cell phones at work.2-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including hemiplegia and need for assistance with personal care. R5's MDS dated [DATE] documented R5 was moderately cognitively impaired.R5's Grievance dated 9/26/25 documents, Cell phone use during meals and in general, as a complaint.On 11/21/25 at 3:10 PM, V2, Director of Nursing (DON), stated it is in the Employee Handbook that staff are not to be on cell phones during work hours.On 11/25/25 at 8:20, AM, V3, Assistant Director of Nursing (ADON), stated there is a no nonsense policy regarding cell phone use for which staff are not allowed to use their cell phones unless they are on break or off the unit.The Facility's Undated Employee Handbook documents, Unless approved for Community business, the possession or use of cellular phones, pagers, and other portable communication devices is strictly prohibited while on duty except during your scheduled rest and meal periods. Use of these devices will be restricted to the break room or outside of the Community. While you are on duty, these devices will be stowed in your locker, purse/backpack, or vehicle. If the purse/backpack is stowed in a work area, these devices must be in an off position.The Facility's Resident Rights Policy: dated 12/2024 documents, Each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal.

Based on interview, observation and record review, the Facility failed to follow its approved menu for 2 of 4 residents (R2, R3) reviewed for dietary services in the sample of 5. Findings include:1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease.R2's Diet Order dated 10/16/25 documents R2 is on a mechanical soft diet.The Facility's Mechanical Soft Menu for 11/21/25 documents ground sausage links will be served at Breakfast.R2's 11/21/25 Meal Ticket for Breakfast documents ground sausage will be served. On 11/21/25 at 8:51 AM, V5, Dietary Aid, began plating food for breakfast service.On 11/21/25 at 9:05 AM, V3, Assistant Director of Nursing (ADON), served R2 breakfast in the 1-South Dining Room. There were cubes of a white colored meat on the plate that were approximately one-half inch in size.On 11/21/25 at 9:07 AM, V5 stated she would not know what kind of meat was on R2's plate.On 11/21/25 at 9:10 AM, V6, Certified Nursing Assistant (CNA), was feeding R2. She stated the meat looked like ham or diced up turkey. V7, Housekeeping Director, was standing nearby and stated, That's baked ham.On 11/21/25 at 10:23 AM, V10, Assistant Dietary Manager, stated R2 got turkey on his breakfast tray. The sausage that was supposed to be served was on the food truck that had not come in yet, so she just chopped up some turkey for him.2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including age related physical debility and muscle wasting and atrophy.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired.R3's Diet Order dated 2/21/25 documents R3 is on a controlled carbohydrate, no added salt diet.On 11/21/25 at 11:00 AM, R3 stated the facility does not always serve what is listed on the menu.On 11/25/24 at 8:27 AM, V2, Director of Nursing (DON), stated menus should be followed as prescribed. The Facility's Guidelines for Menu Planning from the 2012 Long Term Care Diet Manual does not address adhering to prescribed menus.

Based on interview and record review, the Facility failed to provide meals at palatable temperatures for 1 of 4 residents (R3) reviewed for food and nutritional services in the sample of 5.Findings include:1-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including age related physical debility and muscle wasting and atrophy.R3's Minimum Data Set (MDS) dated [DATE] documented R3 was moderately cognitively impaired.R3's Diet Order dated 2/21/25 documents R3 is on a carbohydrate controlled, no added salt diet.On 11/21/25 at 11:00 AM, R3 stated sometimes the food is served cold.The Facility's Resident Council Meeting Minutes dated 10/24/25 document cold food as an issue/concern.On 11/25/25 at 8:27 AM, V2, Director of Nursing (DON), stated the food should consistently be served hot.The Facility's Undated Monitoring Food Temperatures for Meal Service Policy documents food temperatures will be monitored daily to prevent foodborne illness and ensure foods are served at palatable temperatures.

Based on interview and record review, the Facility failed to ensure nurse aids had the skills and competencies to care for 1 of 3 residents with urinary catheters (R2) in the sample of 3.Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including paraplegia and neuromuscular dysfunction of bladder.R2's Minimum Data Set (MDS) dated [DATE] documented R2 was independent with cognitive skills for daily decision making, required partial assistance with rolling from side to side, was dependent for transfer, and had indwelling catheter.R2's Physician Order dated 8/27/25 documents R2 has indwelling urinary catheter with diagnosis of neurogenic bladder.R2's Care Plan initiated 6/3/24 documents R2 has a catheter related to neuromuscular dysfunction of the bladder and will remain free from catheter-related trauma.R2's Progress Note by V7, Registered Nurse, on 9/10/25 at 5:31 PM documents R2 stated V4 Certified Nursing Assistant (CNA) pulled on his catheter. The catheter is leaking urine, and R2 requested to go to the emergency room (ER).R2's Hospital After Visit Summary dated 9/10/25 documents R2 was seen for displacement of indwelling urinary catheter.R2's Progress Note by V8, Medical Doctor (MD), on 9/12/25 documents R2 was seen for catheter pain and reported forceful tugging on the catheter on behalf of his nurse aid. There was no evidence of significant trauma at that time. R2's Grievance Form dated 9/10/25 documents, CNA was being rough and pull(ed) on catheter. (R2) stated that he does not want that CNA in his room.On 9/17/25 at 8:48 AM, R2 was lying in bed in his room with catheter tubing running into a dignity bag hanging off the side of his bed. R2 stated V4 (always takes the catheter bag off the bed to empty his urine, whereas the other nurses just open the clamp and let it drain out into the urinal. One morning V4 was emptying his catheter, and the tubing just went snap. He had to catch the line higher up (toward his body) to keep it from pulling more. He stated if he had not grabbed the tubing the catheter would have come completely out. R2 added, I don't wish this on nobody, but I know what it felt like, and it wasn't good. It's another trip to the hospital my insurance shouldn't have to pay for.On 9/17/25 at 8:45 AM, V6, Licensed Practical Nurse (LPN), stated R2 complained that V4 pulled on his catheter and is generally not very careful with it.On 9/17/25 at 11:51 PM, V4 stated she was providing care to R2 last week when he told her his catheter hurt. The catheter bag had been placed on the bed frame, so she tried to lift the mattress off the bed frame to remove the bag. When R2 said it hurt, she pulled up his bed sheet. The leg strap that connects to the tube to keep it from pulling was in the middle of his thigh. V4 stated that probably should have been further up on his leg or not be worn at all, as he usually does not.On 9/17/25 at 1:35 PM, V2, Director of Nursing (DON), stated it is not procedure to lift the mattress on residents' beds while emptying catheter bags. Staff should open the clamp on the bag and allow the urine to drain into a urinal. The leg bands that secure catheter placement should always be worn. It was a competency issue when V4 pulled on R2's catheter, and staff were in serviced regarding the Facility's catheter care policy and procedure after this happened.V4's Employee Suspension Form dated 9/10/25 documents, The allegation occurred on 9/10/25. Resident states staff pulled his catheter by not following correct procedures which caused issues with his catheter, leaking and pain. The incident was described as poor work quality and was classified as a category II offense where employee is not entitled to back pay while on suspension.The Facility's Catheter Care, Urinary Policy reviewed 4/20 documents, Ensure resident is not lying on the catheter and keep the catheter and tubing free of kinks. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.

Based on interview, observation, and record review, the Facility failed to provide appetizing food at palatable temperatures for 3 of 5 residents (R1, R2, R5) reviewed for food and nutrition services in the sample of 5.Findings Include:1- R1's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses including gastric ulcer, end stage renal disease, and muscle wasting and atrophy.R1's 8/15/25 Diet Order documents liberal renal precautions; no orange juice or bananas; limit potatoes and tomatoes; provide double protein portions three times daily; restrict fluid to 1500 mL (milliliter) in 24 hours.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact.On 9/4/25 at 9:20 AM, R1 stated the food is not good and is always cold.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.R2's 8/12/25 Diet Order documents renal diet with no orange juice, oranges, bananas, or milk; limit tomatoes and potatoes to one meal per day.R2's MDS dated [DATE] documented R2 was cognitively intact.On 9/4/25 at 9:45 AM, R2 stated the food is awful about half the time. It usually arrives late and is cold.3-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.R5's 11/14/24 Diet Order documents pureed diet with double portions and mechanical soft preferences, per Speech Language Pathologist (SLP).R5's MDS dated [DATE] documented R5 was moderately cognitively impaired.The Facility's 6/11/25 Grievance by R5 documents R5 concerned that food quality is not good.On 9/4/25 at 3:10 PM, R5 stated the food is still lousy most of the time.On 9/4/25 at 12:40 PM, obtained temperatures from a sample meal from the Two South Kitchenette using a metal calibrated thermometer after the last resident tray was served. The gravy was in a pan on the counter and had no method for maintaining the temperature during meal service. The gravy temperature was 105 F (Fahrenheit). V13, Assistant Dietary Manager, stated that needs to be kept in the warmer. The Facility's Resident Council Meeting Minutes dated 6/27/25 documents food is cold as an issue/concern The Facility's Resident Council Meeting Minutes dated 8/29/25 documents food cold as an issue/concern.On 9/4/25 at 3:57 PM, V1, Regional Director of Operations/Interim Administrator, stated she expects staff to serve food at acceptable temperatures as described in the Facility policy.The Facility's Undated Monitoring Food Temperatures for Meal Service Policy documents, Food temperatures of hot foods on room trays at the point of service are preferred to be 120 F or greater to promote palatability for the resident.

Based on interview and record review, the Facility failed to ensure always available alternative options were available for 2 of 5 residents (R2, R5) reviewed for food and nutrition services in the sample of 5.1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including stage 3 sacral pressure ulcer, burns involving 50-59% of body surface, dependence on renal dialysis, and muscle wasting and atrophy.R2's 8/12/25 Diet Order documents renal diet; no orange juice, oranges, bananas, or milk; limit tomatoes and potatoes to one meal per day.R2's MDS dated [DATE] documented R2 was cognitively intact. On 9/4/25 at 9:45 AM, R2 stated the Facility has an alternative menu, but is always told they do not have the items he requests.2-R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including unspecified pressure ulcer of sacral region, muscle wasting and atrophy, and need for assistance with personal care.R5's 11/14/24 Physician Order documents pureed diet with double portions and mechanical soft preferences, per Speech Language Pathologist (SLP).R5's MDS dated [DATE] documented R5 was moderately cognitively impaired.R5's 6/11/25 Grievance documents the Facility is always out of food items.On 9/4/25 at 3:10 PM, R5 stated he does not like the food, but does not ask for alternates because he knows is not going to get it. They always tell him they don't have it.On 9/4/25 at 10:17 AM, V8, Dietary Manager, stated they run out of some alternative items like chicken strips and French fries.On 9/4/25 at 3:57 PM, V1, Regional Director of Operations/Interim Administrator, stated the alternative menu is available from 7:00 AM to 7:00 PM. There will be isolated instances where certain foods are not available from time to time, but in general, the alternative options should be available to residents.On 9/4/25 at 2:28 PM, requested Facility policy regarding alternative menus from V1.On 9/5/25 at 10:00 AM, no policy was received from the Facility.The Facility's Alternative Menu documents two pages of food choices, including chicken tenders, French fries, and various soups and sandwiches.

Based on interview, and record review the facility failed to provide diets as ordered and failed to follow pre-planned meals for 2 of 4 residents (R3, R4) in a sample of 7. Findings Include: 1. On 3/28/2025 at 9:10 AM, R3 stated he does not always get what he orders from the facility's menu, due to the facility running out of food or not having what is listed on the menu for that meal. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact. R3's Physician Order dated 3/19/2025 documents R3 is on a Consistent Carbohydrate diet with regular texture and liquid consistency. 2. On 3/28/2025 at 11:52 AM, R4 stated she is on a mechanical soft diet and will receive 2 items on her tray but will not always receive 3 or 4 items. R4 stated the facility does not always have available what is listed on the menu. R4's MDS dated [DATE] documents R4 is mildly cogitatively impaired and needs supervision or touching assistance with eating. R4's Physician Order dated 3/4/2025 at 7:38 PM, documents R4 has a regular diet with mechanical soft texture, regular liquid consistency. R4's Care Plan dated 7/01/2024 documents diet to be followed as prescribed. Grievance dated 1/31/2025 documents description of incident: Not offering different choices in drinks only giving half sandwiches for a meal. Residents ordering food and never getting it. Grievance dated 1/31/2025 documents description of incident: Early dialysis patients not getting breakfast before dialysis. Grievance dated 1/31/2025 documents description of incident: Food quality-no protein in meals, burnt food, being out of milk, juice, lemonade etc. Serving the same soup 2-3 days in a row. Two people had this concern. Grievance dated 2/28/2025 documents description of incident: Food is cold, not getting what is on the menu, no protein offered on some meals. Grievance dated 3/2/2025 documents description of incident: Lunch menu said shrimp but served grilled cheese and chips on paper plates. Grilled cheeses were burnt-dietary aide told nurse she didn't know how to work the stove top. Dietary aid didn't serve any soup. Nurse made all new sandwiches. Never any fruit with meals or on hall. On 3/28/2025 at 8:15 AM V4, Interim Certified Dietary Manager stated he has been in his current position for about a month and when he started this position the facility was not making everything on the menu for the residents who have special diets such as pureed and mechanical soft. V4, Interim Certified Dietary Manager, stated residents were not receiving the proper number of items off the menu if they have a special diet. On 3/28/2025 at 8:34 AM V5 Licensed Practical Nurse (LPN) stated residents that are on a mechanical soft or pureed diet will receive 2 things off the facility menu made for their diet, but not always 3 or 4 items. On 3/28/2025 at 9:30 AM, V3, Assistant Director of Nursing (ADON), stated residents who have orders for special diets such as a mechanical soft or pureed diet are expected to receive the facility's full menu made to how the resident's diet is ordered, which should consist of at least 3 items. On 3/28/2025 at 11:47 AM V11, Activities Assistant, stated residents who are on special diets will not always receive 3 items from the menu made for them, but they will receive 2 items. On 3/28/2025 at 11:50 AM V12, Certified Nursing Assistant (CNA), stated residents with special diets will receive 2 items from the facility's menu made per their diet, however they will not always receive 3 items. On 3/28/2025 at 12:00 PM V14, LPN stated not everything on the facility's menu will be made for the residents with special diets such as mechanical soft or pureed. V14, LPN, stated she knows on the weekends, residents will only receive maybe 2 items from the menu, but not 3 or 4 items. The Facility's Menus and Special Diets Policy, Subject Menu Planning dated 9/7/2017 states The nutritional needs of residents will be met in accordance with the recommended dining allowances of the Food and Nutrition Board of the National Research Council, National Academy of Science (which are adjusted for age, gender, activity level, and disability). through nourishing well balanced diets, unless contraindicated by medical needs. Menus will also be prepared and presented in a hospitality charged environment.

Based on observation, interview, and record review the facility failed to ensure respiratory care needs met current standards of practice for 5 of 6 (R1, R2, R4, R5, R6) reviewed for respiratory care. This failure resulted in R1 experiencing chest pain and tightness, shortness of breath and decreased oxygen saturations after R1 did not receive ordered nebulizer treatments. Findings include: 1.R1 was admitted to the facility on [DATE] with diagnoses of, in part, acute on chronic congestive heart failure (CHF), lymphedema and chronic obstructive pulmonary disease (COPD). R1's Minimum Data Set (MDS) dated [DATE], documented R1 is cognitively intact, and is on oxygen therapy. R1's Care Plan dated 2/18/25 documented R1 has oxygen therapy related to shortness of breath (SOB); R1 has pneumonia, give medications as ordered, monitor/document for side effects and effectiveness; R1 has asthma related to COPD, give nebulizer treatments and oxygen therapy as ordered, monitor for signs and symptoms of impending asthma attack: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue; and R1 has COPD, give aerosol or bronchodilators as ordered, monitor/document any side effects and effectiveness, give oxygen therapy as ordered by the physician. R1's orders dated 2/17/2025 at 12:00, documented Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours for cough, shortness of breath for 5 Days. R1's Medication Administration Record (MAR), documented on 2/17/25 through 2/20/225, V14 LPN, V19, LPN, and V20 LPN gave R1 breathing treatments. R1's breathing treatments on 2/17/25 at 12:00 PM and 6:00 PM were documented as administered by V14. R1's breathing treatments on 2/18/25 at 12:00 AM and 6:00 AM were documented as administered by V19 LPN. R1's breathing treatment on 2/19/25 at 6:00 AM was documented as administered by V19. R1's breathing treatments on 2/20/25 at 12:00 AM and 6:00 AM were documented as administered by V20 LPN. On 2/18/25 at 12:40 PM, V4, Licensed Practical Nurse (LPN), went into R1's room to administer her breathing treatment. V4 stated she would need some time getting the supplies together because it is a new order and would be the first treatment she's received at the facility. R1 was receiving oxygen via nasal cannula and her tank was set to 3(liters)L. At this time, R1 stated she had not received a breathing treatment at the facility yet, she had gotten some while in the hospital though and feels like it would help her. On 2/18/25 at 1:16 PM, V4 went back to R1's room after getting all the supplies she needed for R1's breathing treatment. R1 stated she had feeling constricted in her chest for a few days now. R1 had her right hand over her chest stating her chest felt heavy. V4 stated the orders were for 3milliters(mL) of breathing treatment solution to be given over 10-15minutues for five days. V4 administered the breathing treatment to R1. V4 stated she was not aware the breathing treatments were to be started yesterday and was not told they hadn't been given. V4 stated she noticed the orders today and assumed she was the first to get them. At 1:35 PM, R1 stated she was not feeling worse after the breathing treatment was completed but not much better. On 2/19/25 at 10:30 AM, R1 stated last night she got her breathing treatment but did not get it this morning. R1 stated, The nurse might have charted giving me my breathing treatment, but I know it wasn't done. R1 stated she doesn't like to complain because the CNAs (certified nursing assistant) don't care. R1 stated she doesn't remember anyone checking her vital signs today yet either. R1 stated the less I say the better off I am but she was feeling lightheaded and tired now. On 2/19/25 at 10:40 AM, V6, LPN checked R1's oxygen level and reported it to be 93% while R1 was receiving 2L of oxygen via nasal cannula. R1 reported to V6 her chest felt tight and did not get her breathing treatment this morning. V6 told R1 she would look at her orders and get her something to help. On 2/19/25 at 10:47 AM, V4, LPN, stated she was not aware R1 missed her breathing treatment this morning, the nurse did not report that to her in hand off. On 2/20/25 at 10:03 AM, R1 stated she did not get her breathing treatment again at midnight or at 6:00 AM. R1 stated she was having chest pain and reported it to the CNA about 44 minutes ago and still hasn't been seen. R1's oxygen was set to 1.5L via nasal cannula at this time. R1 does not have orders for oxygen to be given or orders on the settings it should be at. On 2/20/25 at 10:06 AM, this surveyor reported R1's complaints of chest pain to nurses V6 LPN and V14 LPN. V14 stated V13 CNA had not reported anything to her about R1 having chest pain. V14 stood up and went to R1's room with vitals sign monitor. R1's vitals were 98.2 temperature, 131/66 blood pressure, 88% oxygen saturation, 125 heart rate with reports of shortness of breath, feeling uncomfortable and having audible wheezes while breathing. V14 told R1 to take some deep breaths and offered her a dose of her albuterol inhaler. R1 stated would rather get her breathing treatment instead since she missed her other doses earlier today. V14 left and came back with a different pulsometer and got readings of 100% oxygen saturation with heart rate of 72. V14 stated R1's lungs were crackled but did not listen to them with a stethoscope. V14 stated the nurse that gave hand off report to her did not mention R1 missed any breathing treatments. V14 told V6 to contact R1's provider about her findings. On 2/20/25 at 12:45 PM, R1 stated she feels like the staff should be giving her breathing treatments as ordered, if they had been I might be feeling better now but my chest still feels heavy. V14 came in and checked R1's oxygen levels and reported them to be 76%. R1's oxygen was set at 1.5L. V14 changed R1's oxygen to 3L after her readings. R1 had a saturation of 82% after being placed on 3L. V14 stated she was going to notify the doctor. On 2/19/25 at 2:39 PM, V2, DON, stated V19 charted giving R1 her breathing treatments but did not actually administer them. V2 stated she could not deny this because R1 is cognitively with it. V2 stated the nurse told her she had pulled R1's nebulizer treatment and had it ready to go, charted that it was given but forgot to give it. V2 stated she told V19 if she charts it given, then she needs to actually give it. V2 stated she expects staff to document accurately. V2 stated she was going to be completely honest, on 2/17/25 the breathing treatments hadn't been started if V4 had to go and find new supplies to administer it. On 2/24/25 at 8:48 AM, V18, R1's Nurse Practitioner, stated she would expect the facility to administer medications to R1 as ordered and if she was missing over half the amount of breathing treatments to be notified of that also. V18 stated the breathing treatments were ordered for R1 due to an acute breathing issue with shortness of breath. V18 stated R1 should be on 2L of oxygen but just noticed now R1 didn't have oxygen orders in her chart. V18 stated missing breathing treatments and having the wrong amount of oxygen administered could cause R1 to have worsening/exacerbation of her COPD and increased workload on her heart with all the excess fluid she has. 2.R2 was admitted to the facility on [DATE] with diagnoses of, in part, congestive heart failure, iron deficiency anemia, and chronic obstructive pulmonary disease. R2's MDS dated [DATE] documented R2 is moderately cognitively impaired. R2's Care Plan dated 2/17/25 documented R2 has oxygen therapy related to CHF and to monitor for signs and symptoms of respiratory distress and report to medical doctor (MD) as needed (PRN): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color; R2 has oxygen (O2) via nasal prongs/mask; R2 has asthma relate to CHF; R2 has COPD, give aerosol or bronchodilators as ordered, monitor/document any side effects and effectiveness; R2 has altered respiratory status/difficulty breathing related to chronic respiratory therapy. R2's orders dated 2/19/2025 at 2:30 PM documented R2 to be on 3L of oxygen nasal cannula continuously. On 2/20/25 at 9:42 AM, R2 was in his room directly across the hall from the nurse's station with his door wide open, no nasal cannula was attached to his face. This surveyor observed R5 looking out his window in his wheelchair and could hear an oxygen concentrator turned on from the hallway. Upon entering R2's room, this surveyor observed R2's nasal cannula hooked up to the concentrator set to 3L laying on the floor. On 2/20/25 At 10:20 AM, R2 was in the same position with his nasal cannula lying on the floor. At 10:22 AM, V10, Physical Therapy, came to take R2 for a session. V10 removed R2's nasal cannula from his concentrator and hooked it up to the empty tank on the back of R2's wheelchair. At 10:25 AM, R2 was noted to be pale and took fast shallow breaths. This surveyor requested V11, CNA, check R2's oxygen saturation level before leaving to physical therapy. V11 assessed his oxygen levels and were running at 48-50%. V11 asked R2 via a communications board if he was having trouble breathing and he responded yes. V11 hooked R2 back up to his concentrator and removed R2 from the oxygen saturation monitor before leaving him in his room. V11 left R2 in his room alone after having oxygen saturation levels at 50% and reports of trouble breathing without notifying his nurse. At 10:30 AM, V11 returned with one oxygen tank and told the other CNA that she is going on break then left the unit. V12, Registered Nurse, stated V11 did not report any vital signs to her on R2. On 2/20/25 at 10:37 AM, V10, came back to R2's room and hooked R2 up to the new oxygen tank. V10 stated he was not told of what R2's oxygen saturations levels were and did not check to see what they were or verify if it was safe with nursing staff to take him. V10 left the unit with R2 at 10:44 AM. On 2/20/25 at 8:50 AM, V5 CNA stated she did not know how to check how many liters a resident was on while receiving oxygen, she would rely on the nurses to set it and check to make sure it was right. V5 stated yesterday, 2/19/25, R2 had come back from physical therapy with an empty oxygen tank and his saturation levels were in the 50s, she reported it immediately to the nurse who told her to stay with R2 while she went to get more oxygen for him and set it up. On 2/20/25 at 10:45 AM, V15, CNA, stated that she would tell the nurse immediately if a resident had oxygen levels in the 50s. On 2/20/25 at 10:55 AM, V16, CNA, stated she would get the nurse and wait to do anything while staying with the resident if they had oxygen levels in the 50s or reported chest pain. On 2/20/25 at 10:58 AM, V17, CNA stated she would get the nurse for oxygen levels in the 50s or chest pain reports. V17 stated she checks on oxygen tanks before hooking them up and every two hours while using them to make sure they are not empty. 3.R4 was admitted to the facility on [DATE] with diagnosis of, in part, type two diabetes mellitus and chronic kidney disease. R4's MDS dated [DATE] documented R4 is moderately cognitively impaired. R4's Care Plan dated 1/9/25, documented R4 has oxygen therapy with no documentation of what it was related to and R4 has shortness of breath. R4's current orders dated 4/10/2024 at 2:30 PM are for oxygen at 2L continuously. On 2/19/25 at 10:51 AM, R4 was lying in bed with oxygen on via nasal cannula at 3L (Liters). 4. R5 was admitted to the facility on [DATE] with diagnoses of, in part, acute and chronic respiratory failure, acute on chronic congestive heart failure, emphysema, and chronic obstructive pulmonary disease. R5's MDS dated [DATE] documented R5 is cognitively intact. R5's Care Plan dated 2/17/25 documented R5 has respiratory infection; R5 has oxygen therapy related to chronic respiratory failure; and R5 has COPD Give oxygen therapy as ordered by the physician. On 2/20/25 at 9:33 AM, R5 was sitting in the dining room with an empty oxygen tank hooked to the back of his wheelchair set to 3L. R5 stated he could not feel any oxygen running through his nasal cannula. R5 stated his lungs felt a little tight usually and thinks he should get breathing treatments but doesn't. R5 pulled out an albuterol inhaler from his pocket and stated he will take puffs from that whenever he needs it. R5 reported to V8 that he needed more oxygen. V8 stated looks like you're out of oxygen too, then left to get R5's concentrator from his room. R5's oxygen saturation was 97%. On 2/17/2025 at 6:30 AM documented R5 is supposed to get 2L of oxygen nasal cannula. 5.R6 was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and malignant neoplasm of bronchus. R6's MDS dated [DATE] documented R6 is cognitively intact. R6's Care Plan dated 2/10/25 documented R6 has altered respiratory status/difficulty breathing related to acute respiratory failure and R6 has COPD, give oxygen therapy as ordered by the physician. On 2/20/25 at 9:30 AM, R6 was sitting in the dining room with an empty oxygen tank hooked to the back of her wheelchair set to 2L. R6 stated she did not feel any oxygen coming through the nasal cannula. At 9:35 AM, V8 stated the floor was completely out of oxygen tanks. On 2/20/25 at 1:45 PM, V2 stated her expectation from staff when running low on oxygen tanks is to be notified right away so I can make an urgent delivery on them. V2 stated if someone has oxygen saturations in the 50s after not having oxygen on or if oxygen is not being administered, I expect to be notified. The facility's Oxygen Administration Policy dated 12/24, documented under preparation to verify that there is a physician's order for this procedure for oxygen administration. The facility's Medication Administration Policy undated, documented all staff members are expected to follow these guidelines strictly and to report any issues or deviations from the policy; residents who self-administer must have a profile only MAR which lists their medications and indicates that they self-administer; medication administration should be accurately documented on the MAR immediately after each administration, any errors, omissions, or incidents related to medication administration must be documented in the clinical record and reported as per facility policy. The facility's Nebulized Medication Policy undated, documented under tasks to access lung sounds before and after treatments are given.

Based on interview, observation, and record review, the facility failed to maintain residents' pride and dignity for 3 of 5 residents (R1, R3, R5) reviewed for resident dignity in the sample of 5. This failure resulted in expressed feelings of embarrassment and frustration. The Findings Include: 1. R1's Admission Record, dated 2/5/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Malignant Neoplasm of bronchus or lung, Hypertension (HTN), Morbid Obesity, Diverticulosis, Sleep Apnea, Nicotine Dependence, Lymphedema, Pulmonary HTN, Congestive Heart Disease (CHF), and Peripheral Vascular Disease (PVD). R1's Care Plan, dated 1/24/25, documents R1 has COPD: Interventions: Give aerosol or bronchodilators as ordered, give oxygen therapy as ordered by the physician, monitor for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, monitor for signs/symptoms of acute respiratory insufficiency. It continues R1 has Oxygen (O2) Therapy related to shortness of breath (SOB). Interventions: The resident has O2 via nasal prongs/mask continuously, humidified, monitor for signs/symptoms of respiratory distress and report to Medical Doctor as needed (PRN). It continues R1 has altered respiratory status/Difficulty Breathing related to acute respiratory failure. Interventions: Administer medication/puffers as ordered, elevate head of bed (HOB). It continues R1 has bladder incontinence. Interventions: the resident uses disposable briefs, change (freq/frequent) and PRN, check the resident (freq) and as required for incontinence, wash, rinse, and dry perineum, change clothing PRN after incontinence episodes. R1 has bowel incontinence. Interventions: Provide bedpan/bedside commode, provide peri-care after each incontinent episode. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent on staff for Activities of Daily Living (ADLs). R1 is frequently incontinent of both bowel and bladder. On 2/6/25 at 8:40 AM, R1 was seen lying on her side with a strong odor of feces in the room. R1 stated I am very upset because I let the Certified Nursing Assistant (CNA) know that I had a Bowel Movement (BM) and was saturated about 30-minutes ago and was told that she would be right back. I have been lying in my BM since then, and no one has come in to take care of me yet this morning. I am usually out of bed by now. On 2/6/25 at 8:44 AM, V13, CNA, brought in R1's breakfast tray and set it on her bedside table. R1 stated You're bringing me my breakfast without even cleaning me up first? V13 stated We already had this discussion. and walked out of the room. R1 stated Her discussion was 'You missed breakfast and now have to eat in your room.' Now my breakfast will be cold by the time I get to eat it. I am very messy and stinky. This has me very frustrated and embarrassed and it takes away my dignity and pride, and I have no control over it. On 2/6/25 at 8:52 AM, R1 was provided incontinence care by V13, CNA, and V16, CNA. On 2/6/25 at 9:20 AM, When asked if R1 notified her of being soiled this morning, V13 stated Yes, she did. She put her call light on, and I answered it and told her I would be right back. Then I was helping another resident and was going to go to her after that. When asked why she would bring her breakfast tray to her before cleaning her up, V13 stated I was given the cart of trays and told to deliver them to all the residents in the rooms and I didn't want all the food to get cold. What was I supposed to do? 2. R3's Admission Record, dated 1/5/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Hypoglycemia, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Cerebral Infarction, Aphasia, HTN, Spinal Stenosis Cervical, and Anemia. R3's Care Plan, dated 12/9/24, documents R3 has bladder incontinence. Interventions: The resident uses medium disposable briefs, change (freq) and PRN, check the resident every two Hours and as required for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes. It continues R3 has bowel incontinence. Interventions: Check resident every two hours and assist with toileting as needed, observe pattern of incontinence, and initiate toileting schedule if indicated, provide bedpan/bedside commode, provide peri-care after each incontinent episode, take resident to toilet at same time each day resident usually has bowel movement. It continues R3 has an ADL Self-Care Performance Deficit. Interventions: The resident is totally dependent on staff for toilet use, requires two staff participation to use toilet. R3's MDS, dated [DATE], documents R3 has a moderate cognitive impairment and is dependent on staff for toileting and transfers, requires substantial/maximum assistance from staff for other ADLs. R3 is frequently incontinent of both bowel and bladder. On 2/5/26 at 1:56 PM, V11, R3's daughter, stated My mom (R3) called me on Saturday morning (2/1/25) around 7:30 AM. She told me she had to use the restroom and put her call light on, and no one is answering it. Mom said her call light has been on for an hour and half already. While I was on the phone with her, a CNA (V9) came in and told mom that she was the only one working the floor and that mom was a two-person assist and she could not get her to the restroom herself. The CNA told her to just go in her bed and to put her call light on and she will clean her up when she is done. When the CNA left, my mom said (V11), I don't sh** in my pants, what am I supposed to do. We waited about two minutes later, and I had mom turn on the call light to see if the CNA would come back and we waited 20 more minutes, and she never came back. At that point, I decided to come on in myself. It takes me a while to get there but I would say within an hour I was there, and mom's call light was still on, and no one had helped her. Mom did wet her pants but did not have a bowel movement. (V3, Assistant Director of Nursing/ADON) was here by then and told me that everyone called in and she was the one on-call, so she had to come in to assist. (V3) told me she was very sorry and that it was just her and one CNA working. She said she called (staffing agency) and they didn't have anyone. (V3) told me she called (V2, Director of Nursing/DON) five times and that (V2) did not answer her phone. (V2) never showed up to help the staff out. There was mom's physical therapist (V10, Physical Therapist Assistant/PTA) who happened to be visiting her family member and both of us were helping other residents get up and to the dining room to eat. I'm a Licensed Practical Nurse (LPN) so knew what needed to be done, however, I did not work as a nurse, more as a CNA, and (V3) allowed us to help everyone out. I have been working with (V1, Administrator) and the Social Service person to get mom out of there and I believe we are moving her this coming Friday (2/7/25). On 2/5/25 at 2:25 PM, V3, ADON, stated I was called Saturday (2/1/25) because we had a bunch of call-offs. I couldn't get anyone to come in, so I came in. There was only one Nurse and one CNA working the 100-South unit. When I got here (R3's) daughter was very upset and I had to talk to her. The CNA working (V9) did tell (R3) that she was by herself and could not get her up to use the toilet and to go ahead and go in the bed and she will clean her up afterwards. I had a talk with (V9) and told her that was not the way she should have handled it. (V9) could have gotten the nurse on duty to help her or ask me when I got here. I told (V9) that it was not acceptable, and she should never tell a resident something like that. I called the DON, and she didn't answer, and I don't blame her, it was her day off. I tried again later, and she answered, and I explained what was going on and the DON called (R3's) daughter to talk to her. I ended up working the entire shift because no one would come in. I know that (R3's) daughter did not help with other residents because I was here helping out. On 2/5/25 at 2:35 PM, V10, PTA, stated I was here visiting my grandmother who is staying on this floor (100-South). There was only one CNA working and she had no help to get people up. I did not help anyone but my grandmother that day. I did not see (R3's) daughter assisting other residents either. On 2/5/25 at 2:55 PM, V2, DON, stated Yes, that did happen Saturday, we only had one CNA, but (V3) did come in to assist. (V9) should not have told any resident to go in the bed and she'll clean her up afterwards. I only received one phone call, and I was in the shower and as soon as I got out, I called (V3) back to see what was going on. On 2/5/25 at 3:55 PM, R3 stated (V9) did tell me to just go in my pants in bed and she would clean me up later. She said she didn't have any help to get me up. It's embarrassing enough to go in my pants by accident, but for someone to tell you to do it, it hurt my pride and my dignity. I could not believe someone who works here told me to do that, that is her job. 3. R5's Admission Record, dated 2/6/25, documents R5 was originally admitted to the facility on [DATE] with diagnosis of Cholecystitis, Deep Vein Thrombosis (DVT), Hemiplegia/Hemiparesis, Cerebral Infarction, PVD, Morbid Obesity, Cervicalgia, Type 2 Diabetes Mellitus (DM), Myocardial Infarction (MI), Hyperlipidemia, HTN, CHF, Osteoarthritis, Cardiomegaly, Benign Prostatic Hyperplasia (BPH), and Atherosclerosis. R5's Care Plan, dated 12/26/24, documents R5 has an ADL Self Care Performance Deficit. Interventions: can transfer from bed to chair with stand by assist-1 assist, uses quarter rails to help with repositioning in bed, Active Range of Motion, Transfer using one assist, Toilet Use: The resident is able to wash hands, hold grab bars, wipe self, adjust clothing. R5's MDS, dated [DATE], documents R5 is cognitively intact and requires substantial/maximal assistance from staff for toileting, and supervision/touching assistance with transfers. R5 is always continent of both bowel and bladder. On 2/6/25 at 11:00 AM, R5 stated I am the President of the Resident Council, and we have meetings every month. In just about every meeting, there are complaints of the facility not having enough staff to take care of the resident needs. I feel that one of the biggest problems I see at the facility is that we are being treated like children and don't know what is going on, or that the staff think we are ignorant. They should treat everyone the same, as adults. It makes me feel like a lesser person because of how I am treated. There are some staff who seem to bully me, for example, they will bring me something like juice and will just sit it down and say Here. I don't know why some staff are even working because they don't want to do their job. The Facility's Resident Rights Policy, dated 12/2024, documents Each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal. No staff member or contracted provider of care will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights. It is the responsibility of all who work in this community, including employees of the community and any others who provide services to the residents of the community, to advocate and protect the rights of each resident. All staff members are trained on this Resident Right Policy at the time of employment, prior to providing care to residents, and at least annually to ensure full understanding related to ensuring each resident's Resident Rights.

Based on interview, observation, and record review, the facility failed to provide sufficient staff to care and tend to resident needs for 4 of 5 residents (R1, R2, R3, R5) reviewed for sufficient staffing in the sample of 5. The Findings Include: 1. R1's Admission Record, dated 2/5/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Malignant Neoplasm of bronchus or lung, Hypertension (HTN), Morbid Obesity, Diverticulosis, Sleep Apnea, Nicotine Dependence, Lymphedema, Pulmonary HTN, Congestive Heart Disease (CHF), and Peripheral Vascular Disease (PVD). R1's Care Plan, dated 1/24/25, documents R1 has an Activities of Daily Living (ADL) Self Care Performance Deficit. Interventions: Toilet Use: The resident requires (two) staff participation to use toilet, the resident requires assistance (specify: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet) to use toilet, Transfer: The resident requires (two) staff participation with transfers. Mobility: The resident requires staff (Specify: supervision, encouragement, assistance) with mobility (Specify: by placing equipment nearby, providing weight bearing support, providing non-weight bearing support, praising efforts), the resident uses wheelchair for locomotion, provide supportive care, assistance with mobility as needed. It continues R1 has bladder incontinence. Interventions: the resident uses disposable briefs, change (freq) and as needed (PRN), check the resident (freq) and as required for incontinence, wash, rinse and dry perineum, change clothing as needed (PRN) after incontinence episodes. R1 has bowel incontinence. Interventions: Provide bedpan/bedside commode, provide peri-care after each incontinent episode. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent on staff for ADLs. R1 is frequently incontinent of both bowel and bladder. On 2/5/25 at 10:15 AM, R1 stated The staff have to use a (full body mechanical lift device) to get me out of bed to my wheelchair. I use my call light for help, and it can get answered in around 15-30 minutes, depending on if they have staff working. I know when I have to use restroom, however I am incontinent at times, and will get cleaned up eventually, it all depends on if the staff show up or not. On 2/5/25 at 3:50 PM, R1 stated On Saturday (2/1/25), (V9, CNA) said she was the only one working the floor. She got me out of bed with the (full body mechanical lift device) by herself. She cleaned me up first, then got me up using the (full body mechanical device) to my wheelchair, then I went to the dining room for breakfast. On 2/6/25 at 8:40 AM, R1 was seen lying on her side with a strong odor of feces coming from the room. R1 appeared tearful and stated I am very upset because I let the CNA know that I had a BM (bowel movement) and was wet 30-minutes ago and was told that she would be right back. I have been lying in BM since then, and no one has come in to take care of me yet this morning. I am usually out of bed by now. I am very messy and stinky. This has me very frustrated and embarrassed and takes away my dignity and pride and I have no control over it. 2. 1. R2's Admission Record, dated 2/5/25, documents R2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory failure, Malnutrition, Thrombocytopenia, Hypertension (HTN), Anxiety disorder, Depression, Hyperlipidemia, and Dysphagia. R2's Care Plan, dated 1/24/25, documents R2 has an ADL Self Care Performance Deficit. Interventions: Transfer: The resident requires (two) staff participation with transfers, provide supportive care, assistance with mobility as needed. Document assistance as needed. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires partial to moderate assistance from staff for Activities of Daily Living (ADLs). On 2/5/25 at 10:00 AM, a loud beeping was heard coming from R2's room which was audible from nurse's desk. Upon entrance to her room, R2 had a nasal cannula on and connected to oxygen concentrator which was beeping and appeared to be off with no O2 running and no one going to check the loud beeping. V5, CNA, was working the hall and a room away from R1's room. V5 eventually entered R1's room and turned the oxygen concentrator switch on and O2 began infusing at 2 L/NC. V5 stated she would notify the nurse of the machine beeping, no nurse arrived to check out the concentrator. The nurse was seen sitting at the desk. On 2/5/25 at 10:05 AM, R2 stated I use my call light, but it takes a while for it to get answered. I usually let them know when I have to use the restroom, and eventually they will come and help me. The staffing is ok but could use more since it takes a while to get some assistance. On 2/5/25 at 3:35 PM, V4, R2's Daughter, stated I visit my mother every day and when we use the call light when my mother needs help, sometimes it takes a while to get someone to answer it, and one time, no one ever showed up at all. They definitely need more help here. 3. R3's Admission Record, dated 1/5/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Hypoglycemia, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Cerebral Infarction, Aphasia, HTN, Spinal stenosis cervical, and Anemia. R3's Care Plan, dated 12/9/24, documents R3 has an ADL Self-Care Performance Deficit. Interventions: The resident is totally dependent on staff for toilet use, requires two staff participation to use toilet. It continues R3 has bladder incontinence. Interventions: The resident uses medium disposable briefs, change (freq) and PRN, check the resident Every Two Hours and as required for incontinence, wash, rinse, and dry perineum, change clothing PRN after incontinence episodes. It continues R3 has bowel incontinence. Interventions: Check resident every two hours and assist with toileting as needed, observe pattern of incontinence, and initiate toileting schedule if indicated, provide bedpan/bedside commode, provide peri-care after each incontinent episode, take resident to toilet at same time each day resident usually has bowel movement. R3's MDS, dated [DATE], documents R3 has a moderate cognitive impairment and is dependent on staff for toileting and transfers, requires substantial/maximum assistance from staff for other ADLs. R3 is frequently incontinent of both bowel and bladder. On 2/5/26 at 1:56 PM, V11, R3's Daughter, stated My mom (R3) called me on Saturday morning (2/1/25) around 7:30 AM. She told me she had to use the restroom and put her call light on, and no one is answering it. Mom said her call light has been on for an hour and half already. While I was on the phone with her, a CNA (V9) came in and told mom that she was the only one working the floor and that mom was a two-person assist and she could not get her to the restroom herself. The CNA told her to just go in her bed and to put her call light on and she will clean her up when she is done. When the CNA left, my mom said (V11), I don't sh** in my pants, what am I supposed to do. We waited about two minutes later, and I had mom turn on the call light to see if the CNA would come back and we waited 20 more minutes, and she never came back. At that point, I decided to come on in myself. It takes me a while to get there but I would say within an hour I was there, and mom's call light was still on, and no one had helped her. Mom did wet her pants but did not have a bowel movement. (V3, Assistant Director of Nursing/ADON) was here by then and told me that everyone called in and she was the one on-call, so she had to come in to assist. (V3) told me she was very sorry and that it was just her and one CNA working. She said she called (staffing agency) and they didn't have anyone. (V3) told me she called (V2, Director of Nursing/DON) five times and that (V2) did not answer her phone. (V2) never showed up to help the staff out. There was mom's physical therapist (V10, Physical Therapist Assistant/PTA) who happened to be visiting her family member and both of us were helping other residents get up and to the dining room to eat. I'm a Licensed Practical Nurse (LPN) so knew what needed to be done, however, I did not work as a nurse, more as a CNA, and (V3) allowed us to help everyone out. I have been working with (V1, Administrator) and the Social Service person to get mom out of there and I believe we are moving her this coming Friday (2/7/25). On 2/5/25 at 3:55 PM, R3 stated (V9) did tell me to just go in my pants in bed because she was working by herself and she didn't have anyone to help her, so she would clean me up after I went. It's embarrassing enough to go in my pants by accident, but for someone to tell you to do it, it hurt my pride and my dignity. I could not believe someone who works here told me to do that, that is her job. 4. R5's Admission Record, dated 2/6/25, documents R5 was originally admitted to the facility on [DATE] with diagnoses of Cholecystitis, Deep Vein Thrombosis (DVT), Hemiplegia/Hemiparesis, Cerebral Infarction, PVD, Morbid Obesity, Cervicalgia, Type 2 Diabetes Mellitus (DM), Myocardial Infarction (MI), Hyperlipidemia, HTN, CHF, Osteoarthritis, Cardiomegaly, Benign Prostatic Hyperplasia (BPH), and Atherosclerosis. R5's Care Plan, dated 12/26/24, documents R5 has an ADL Self Care Performance Deficit. Interventions: can transfer from bed to chair with stand by assist-one assist, uses quarter rails to help with repositioning in bed, active range of motion, transfer using one assist, Toilet Use: The resident is able to wash hands, hold grab bars, wipe self, adjust clothing. R5's MDS, dated [DATE], documents R5 is cognitively intact and requires substantial/maximal assistance from staff for toileting, and supervision/touching assistance with transfers. On 2/6/25 at 11:00 AM, R5 stated I am the President of the Resident Council, and we have meetings every month. In just about every meeting, there are complaints of the facility not having enough staff to take care of the resident needs. I have had conversations with (V1) and (V2), and both told me that they are trying to eliminate using agency staff and are trying to hire more of their own staff. There are not enough CNAs working to take care of all the residents, especially at night. At night there is only one CNA working the hall and that one CNA can't help everyone. On 2/5/25 at 2:25 PM, V3, ADON, stated I was called Saturday (2/1/25) because we had a bunch of call-offs. I couldn't get anyone to come in, so I came in. There was only one Nurse and one CNA working the 100-South unit. When I got here (R3's) daughter was very upset and I had to talk to her. The CNA working (V9) did tell (R3) that she was by herself and could not get her up to use the toilet and to go ahead and go in the bed and she will clean her up afterwards. (V9) could have gotten the nurse on duty to help her or ask me when I got here. I called the DON, and she didn't answer, and I don't blame her, it was her day off. I tried again later, and she answered, and I explained what was going on and the DON called (R3's) daughter to talk to her. I ended up working the entire shift because no one would come in. On 2/5/25 at 2:35 PM, V10, Physical Therapy Assistant (PTA), stated I was here visiting my grandmother who is staying on this floor (100-South). There was only one CNA working and she had no help to get people up. On 2/5/25 at 2:55 PM, V2, DON, stated Yes, that did happen Saturday, we only had one CNA, but (V3) did come in to assist. I only received one phone call, and I was in the shower and as soon as I got out, I called (V3) back to see what was going on. On 2/6/25 at 8:45 AM, V15, CNA, stated I am on this floor (100-South) and covering the first set of rooms on the first hall, and (V13) is covering the other hall rooms, there are just the two of us. On 2/5/25 at 11:35 AM, V3, Assistant Director of Nursing (ADON), stated We staff with one nurse per unit, then usually two Certified Nursing Assistants (CNAs) per unit. The 100-South floor usually has three CNAs. We have an internal agency that we use for staffing, and we also use (outside staffing agency). If there is a call-off, and once it is put into the system, both agencies get automatically notified that there is an open shift and it almost always gets filled by one of them, and if by chance it does not get filled, then the manager-on-call will come in and work. I have never heard of only having one CNA and one Nurse on the 100-South Unit, there would never be just one CNA working by herself. On 2/5/25 at 11:40 AM, V6, CNA, stated I heard (V3) mention that we staff with three CNAs on the 100-South Hall. They may schedule three of us, but they pull one of us to be a float, so we always only have the two working on the floor. The Facility's Daily Staffing Sheets, dated 2/1/25, documents only one CNA was working on the 1-South Unit. On 2/6/25 at 3:00 PM, V1 stated We don't have a Staffing Policy, we follow state guidelines.

Based on observation, record review and interview the facility failed to provide a safe transfer for 1 of 1 resident (R1) reviewed for resident safety in the sample of 4. The Findings Include: R1's Admission Record, dated 2/5/25, documents R1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Malignant Neoplasm of bronchus or lung, Hypertension (HTN), Morbid Obesity, Diverticulosis, Sleep Apnea, Nicotine Dependence, Lymphedema, Pulmonary HTN, Congestive Heart Disease (CHF), and Peripheral Vascular Disease (PVD). R1's Care Plan, dated 1/24/25, documents R1 has COPD: Interventions: Give aerosol or bronchodilators as ordered, give oxygen therapy as ordered by the physician, monitor for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, monitor for signs/symptoms of acute respiratory insufficiency. It continues R1 has oxygen (O2) Therapy related to shortness of breath (SOB). Interventions: The resident has O2 via nasal prongs/mask continuously, humidified, monitor for signs/symptoms of respiratory distress and report to Medical Doctor as needed (PRN). It continues R1 has altered respiratory status/Difficulty Breathing related to acute respiratory failure. Interventions: Administer medication/puffers as ordered, elevate head of bed (HOB). It continues R1 has bladder incontinence. Interventions: the resident uses disposable briefs, change (freq) and PRN, check the resident (freq) and as required for incontinence, wash, rinse and dry perineum, change clothing PRN after incontinence episodes. R1 has bowel incontinence. Interventions: Provide bedpan/bedside commode, provide peri-care after each incontinent episode. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent on staff for Activities of Daily Living (ADLs). R1 is frequently incontinent of both bowel and bladder. On 2/5/25 at 10:15 AM, R1 stated The staff have to use a (full body mechanical lift device) to get me out of bed and to my wheelchair. On 2/5/25 at 2:25 PM, V3, Assistant Director of Nursing (ADON), stated I was called Saturday (2/1/25) because we had a bunch of call-offs. I couldn't get anyone to come in, so I came in. There was only one Nurse and one CNA working the 100-South unit. On 2/5/25 at 2:35 PM, V10, Physical Therapy Assistant (PTA), stated I was here visiting my grandmother who is staying on this floor (100-South). There was only one CNA working, and she had no help to get people up. On 2/5/25 at 3:50 PM, R1 stated This past Saturday (2/1/25), (V9, CNA) told me that she was the only one working the floor, and in the morning, she got me cleaned up and out of bed and to my wheelchair with the (full body mechanical lift device) by herself, so I was able to go to the dining room for breakfast. On 2/6/25 at 8:52 AM, V13, CNA, and V16, CNA/Staffing Coordinator, was seen assisting R1 from her bed to her wheelchair using the full body mechanical lift device. The lift device sling was placed under R1, then V16 brought the full body mechanical lift device in and attached the sling to the lift. R1 was lifted off her bed by V16 and pulled to the middle of the room, while free swinging in the air. V13 brought the unlocked wheelchair over to R1, and R1 was lowered to the unlocked wheelchair and disconnected from the sling. There was no one holding onto R1 while she was freely swinging in the air and moving toward the wheelchair. The wheelchair was not locked while R1 was being lowered into the wheelchair. The Facility's Safe Lifting and Movement of Residents Policy, dated 12/2024, documents Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. The (Full Body Mechanical Lift Device User Manual, dated 5/2011, documents Page 36, 8.3: Transferring to a Wheelchair. When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hoks of the swivel bar. Although (company) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. 1. Ensure the legs of the lift (with patient) are in the open position. 2. Move the wheelchair into position. 3. Engage the rear wheel locks of the wheelchair to prevent movement of the chair. Page 37: Use the straps or handles on the side and the back of the sling to guide the patient's hips as far back as possible into the seat for proper positioning.

Based on Interview, observation, and record review, the facility failed to provide timely and complete incontinent care for 2 of 4 residents (R1, R3) reviewed for incontinence care in the sample of 5. The Findings Include: 1. R1's Admission Record, dated 2/5/25, documents R1 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Malignant Neoplasm of bronchus or lung, Hypertension (HTN), Morbid Obesity, Diverticulosis, Sleep Apnea, Nicotine Dependence, Lymphedema, Pulmonary HTN, Congestive Heart Disease (CHF), and Peripheral Vascular Disease (PVD). R1's Care Plan, dated 1/24/25, documents R1 has bladder incontinence. Interventions: the resident uses disposable briefs, change (freq) and as needed (PRN), check the resident (freq) and as required for incontinence, wash, rinse, and dry perineum, change clothing PRN after incontinence episodes. R1 has bowel incontinence. Interventions: Provide bedpan/bedside commode, provide peri-care after each incontinent episode. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and is dependent on staff for Activities of Daily Living (ADLs). R1 is frequently incontinent of both bowel and bladder. On 2/6/25 at 8:40 AM, R1 was seen lying on her side with a strong odor of feces in the room. R1 stated I am very upset because I let the Certified Nursing Assistant (CNA) know that I had a Bowel Movement (BM) and was saturated about 30-minutes ago and was told that she would be right back. I have been lying in my BM since then, and no one has come in to take care of me yet this morning. I am usually out of bed by now. On 2/6/25 at 8:43 AM, V13, CNA, brought in R1's breakfast tray and set it on her bedside table. R1 stated You're bringing me my breakfast without even cleaning me up first? V13 stated We already had this discussion. and walked out of the room. R1 stated her discussion was You missed breakfast and now have to eat in your room. R1 stated Now my breakfast will be cold by the time I get to eat it. I am very messy and stinky. This has me very frustrated and embarrassed and takes away my dignity and pride and I have no control over it. On 2/6/25 at 8:52 AM, V13, CNA, entered R1's room with a few washcloths, placed them in the sink with running water. There was no hand hygiene performed prior to V13 donning gloves to do peri-care on R1. V16, CNA/Staffing Coordinator, entered to assist. V13 used a wet washcloth, with no peri-cleaner, and wiped once to R1's right groin, once to R1's left groin, then folded the washcloth and wiped once down the middle of R1's vagina. V13 then told R1 to roll over to her right side. Very large bowel movement noticed going up and all over both buttocks. V13 then used wet washcloths, with no peri-cleaner, and wiped R1's anal area and buttocks. V13 kept the same gloves on, which had visible feces on them, and while adjusting the linen and holding R1 over to her side, smeared more feces onto R1's buttock and sheets. V16 then brought more wet washcloths in and V13 wiped the feces she had smeared on R1's buttocks, off R1's buttock again, then had R1 roll to her back while a clean incontinence brief was pulled through her legs. R1 then rolled to her left side and soiled linen/brief was pulled out and clean brief fastened to R1. There was no wiping of R1's right side once rolled to her left side. With the same soiled gloves on, V13 then got R1's clean clothes from her recliner and began putting R1's clothes on her. There was no cleaning solution used to clean R1, no rinsing, and no drying of R1 after incontinent care was provided. V13 used the same pair of gloves throughout the care even when visibly soiled with feces. On 2/6/25 at 9:20 AM, When asked if R1 notified her of being soiled this morning, V13, CNA, stated Yes, she did. She put her call light on, and I answered it and told her I would be right back. Then I was helping another resident and was going to go to her after that. When asked why she would bring her breakfast tray to her before cleaning her up, V13 stated I was given the cart of trays and told to deliver them to all the residents in the rooms and I didn't want all the food to get cold. What was I supposed to do? On 2/6/25 at 3:25 PM, V2, Director of Nursing (DON), stated I was told the same thing about the peri-care, the CNA was smearing feces all over and did not change her gloves, and giving her a breakfast tray before cleaning her up. That CNA was sent home and will not be back here again. 2. R3's Admission Record, dated 1/5/25, documents R3 was admitted to the facility on [DATE] with diagnosis of Hypoglycemia, End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Cerebral Infarction, Aphasia, HTN, Spinal stenosis cervical, and Anemia. R3's Care Plan, dated 12/9/24, documents R3 has bladder incontinence. Interventions: the resident uses disposable briefs, change (freq) and prn, check the resident every two hours and as required for incontinence, wash, rinse, and dry perineum, change clothing PRN after incontinence episodes. It continues R3 has bowel incontinence. Interventions: Check resident every two hours and assist with toileting as needed, observe pattern of incontinence, and initiate toileting schedule if indicated, provide bedpan/bedside commode, provide peri-care after each incontinent episode, take resident to toilet at same time each day resident usually has bowel movement. It continues R3 has an ADL Self Care Performance Deficit. Interventions: The resident is totally dependent on staff for toilet use, requires two staff participation to use toilet. R3's MDS, dated [DATE], documents R3 has a moderate cognitive impairment and is dependent on staff for toileting and transfers, requires substantial/maximum assistance from staff for other ADLs. R3 is frequently incontinent of both bowel and bladder. On 2/5/25 at 9:45 AM, R3 stated there are times when she is incontinent and will let the staff know when she is incontinent, and sometimes will still have to wait a long time to get cleaned up. On 2/5/25 at 1:56 PM, V11, R3's Daughter, stated My mom (R3) called me on Saturday morning (2/1/25) around 7:30 AM. She told me she had to use the restroom and had put her call light on, and no one was answering it. Mom said her call light had been on for an hour and a half already. While I was on the phone with her, a CNA (V9) came in and told her that she was the only one working the floor and that mom was a two-person assist and she could not get her to the restroom herself. The CNA told her to just go in her bed and to put her call light on, and she will clean her up when she is done. When the CNA left, my mom said [NAME], I don't sh** in my pants, what am I supposed to do. We waited about two-minutes later, and I had mom turn on the call light to see if the CNA would come back. We waited another 20-minutes, and she never came back. At that point, I decided to come on in myself. It took me a while to get there, but I would say within an hour, I was there, and mom's call light was still on, and no one had helped her. Mom did wet her pants but did not have a bowel movement. On 2/5/25 at 2:25 PM, V3, Assistant Director of Nursing (ADON), stated I was called Saturday (2/1/25) because we had a bunch of call-offs. I couldn't get anyone to come in, so I came in. There was only one Nurse and one CNA working the 100-South unit. When I got here (R3's) daughter (V11) was very upset and I had to talk to her. The CNA (V9) working did tell (R3) that she was working by herself and could not get her up to use the toilet and to go ahead and just go in the bed and she will clean her up afterwards. I had a talk with (V9) and told her that was not the way she should have handled it. (V9) could have gotten the nurse on duty to help her or ask me when I got here. I told (V9) that it was not acceptable, and she should never tell a resident something like that. On 2/5/26 at 2:55 PM, V2, DON, stated Yes, that did happen Saturday (2/1/25), we only had one CNA, but (V3) did come in to assist. (V9) should not have told any resident to just go in the bed and she'll clean her up afterwards. On 2/5/25 at 3:55 PM, R3 stated (V9) did tell me to just go in my pants in bed and she would clean me up later. She said she didn't have any help to get me up. It's embarrassing enough to go in my pants by accident, but for someone to tell you to do it, it hurt my dignity and my pride. I could not believe someone who works here told me to do that, that is her job. On 3/6/25 at 3:30 PM, V2, DON, stated I would expect the staff to perform timely and completed incontinent care, including changing their gloves when they are soiled and providing hand hygiene. I would expect the staff to ensure the residents dignity and pride are maintained and never to tell the resident to just void in their pants and they will clean them up afterwards. We don't have an Incontinence Care policy; we just follow standard of practice for peri-care. All I have is our Skills Checklist. The Facility's Peri-Care Skills Checklist, undated, documents Identify patient, explain procedure; Wash hands; Ensure privacy; Place basin of warm water and cleansing solution on over-bed table; Put on gloves; Position bed at comfortable working height; Offer resident bed pan or urinal; Help resident into Dorsal Recumbent position, not restrictions in mobility; Ask patient to bed knees and open legs; Drape with bath blanket; Position towel or disposable protector under buttocks; Wash and dry upper thighs covering thighs with bath blanket when finished; Raise bath blanket to expose perineal area; Apply soap to wet washcloth; Separate Labia and wash Urethral area first; Wash between and outside Labia in downward strokes alternating from side to side moving outward to thighs; Use different part of washcloth for each stroke; With fresh water and a clean washcloth, rinse area thoroughly with same strokes; Gently pat dry in same direction; Position patient on side exposing buttocks toward caregiver; Apply soap to wet washcloth; Clean rectal area wiping from base of Labia over Buttocks using a different part of washcloth for each stroke; Rinse and dry anal area thoroughly; Remove pad or towel from underneath patient; Assist patient to comfortable position; Lower bed, call light in reach; Remove gloves and wash hands; Document Procedure in clinical record. The Facility's Infection Prevention and Control Policy, dated 2019, documents Gloves: a. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. e. Remove gloves after contact with a patient, bodily fluids/excretions, and the surrounding environment (including medical devices) using proper technique to prevent hand contamination. f. Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face, clothing, etc.).

Based on Interview, observation, and record review, the facility failed to provide oxygen (O2) to 1 of 3 residents (R2) that is Oxygen dependent, reviewed for residents on oxygen in the sample of 5. The Findings Include: 1. R2's Admission Record, dated 2/5/25, documents R2 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory failure, Malnutrition, Thrombocytopenia, Hypertension (HTN), Anxiety disorder, Depression, Hyperlipidemia, and Dysphagia. R2's Care Plan, dated 1/24/25, documents R2 has Oxygen Therapy related to acute Respiratory Failure. Interventions: Oxygen Settings: The resident has O2 via nasal prongs/mask at three Liters (L) continuously. Humidified, monitor for signs/symptoms of respiratory distress and report to Medical Doctor (MD) as needed (PRN): Respirations, pulse oximetry, increased heart rate (Tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, skin color. It continues R2 as Shortness of Breath (SOB) while lying flat. Interventions: Assist with positioning over bedside table with pillows, elevate head of bed (HOB), encourage patient to use pursed lip breathing, prop with extra pillows, administer PRN medications as ordered. It continues R2 has COPD: Interventions: Give aerosol or bronchodilators as ordered, monitor/document any side effects and effectiveness, give oxygen therapy as ordered by the Physician, HOB to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea), monitor for difficulty breathing (Dyspnea) on exertion, remind resident not to push beyond endurance, monitor for signs/symptoms of acute respiratory insufficiency: Anxiety, confusion, restlessness, SOB at rest, cyanosis, somnolence. It continues R2 has altered respiratory status/Difficulty Breathing related to anxiety and acute respiratory failure. Interventions: Administer medication/puffers as ordered, elevate HOB, encourage sustained deep breaths, maintain a clear airway by encouraging resident to clear own secretions with effective coughing, monitor/document changes in orientation, increased restlessness, anxiety, and air hunger, monitor for signs/symptoms of respiratory distress and report to MD PRN. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and requires partial to moderate assistance from staff for Activities of Daily Living (ADLs). On 2/5/25 at 10:00 AM, R2 was seen lying in bed. There was a loud beeping coming from her room which was audible from the nurse's desk down the hall. Upon entrance to R2's room, R2 had a nasal cannula (NC) on, and it was connected to a oxygen concentrator which was beeping and appeared to be off with no O2 running. V5, Certified Nursing Assistant (CNA), entered the room and turned the oxygen concentrator switch on and the O2 began infusing at 2 L/NC. V5 stated I'll tell the nurse about the machine beeping. After notification of R2's O2 not running, the nurse did not go check on the resident. The nurse was seen sitting at the desk. On 2/5/25 at 10:23 AM, V6, CNA, stated (R2) was on a facemask with a breathing treatment being given earlier, but there was nothing in the container, so I took it off and put her NC back in her nose. I assumed the O2 was on at that time. On 2/5/25 at 10:25 AM, V7, Registered Nurse (RN), stated (R2) has continuous Oxygen and should always be on 3 L/NC. I did not know about R2's O2 being off. It was on earlier because I did her vital signs, and her oxygen was working at that time. I did not give (R2) a breathing treatment today, so if she had one on earlier, it must have been from the night nurse. There were no vital signs documented as completed in R2's Electronic Medical Record except for 1:46 AM. On 2/5/25 at 12:13 PM, V3, Assistant Director of Nursing (ADON), stated I went in and checked (R2's) O2 concentrator in her room and it was still randomly beeping, and then it shut itself off. I immediately got her a new one and took that one to maintenance because there must be something wrong with it when it beeps like that. The new one is working fine and is not beeping. On 2/5/25 at 3:35 PM, V4, R2's Daughter, stated I visit my mother every day and twice last week, when I got to the facility, mom was sitting in the dining room without her oxygen on. I had to get staff to get her oxygen and put it on. During this interview, R2's Oxygen concentrator was noted to only be on 1 L/NC, V4 stated It's only on 1 L/NC and she is supposed to be on 3 L/NC. This was confirmed as only on 1 L/NC and V4 turned it up to 3 L/NC herself. On 2/6/25 at 12:55 PM, V18, Nurse Practitioner (NP), stated I follow (R2's) care and (R2) was just sent to the hospital last week for exacerbation of her COPD. She is to always be on continuous Oxygen and should not be off it. If her Oxygen is off, it could be detrimental to her health and life. R2's Physician Order, dated 2/1/25, documents Cont. (continuous) O2 at 3L. R2's Physician Order, dated 1/24/25, documents Continuous O2 at 3 liters via nasal cannula, every shift. On 2/6/25 at 3:30 PM, V2, Director of Nursing (DON), stated I would expect the staff to make sure any resident who requires oxygen will be provided oxygen as ordered by their Physician. The Facility's Oxygen Administration Policy, dated 12/2024, documents Verify that there is a Physician's order for this procedure for Oxygen administration. 6. Turn on the Oxygen. Start the flow of oxygen at the rate ordered. 8. Adjust the Oxygen delivery device so that it is comfortable for the resident and the proper flow of Oxygen is being administered. 10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 11. Observe the resident upon setup and periodically thereafter to be sure Oxygen is being tolerated.

Based on observation, interview, and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 103 residents living in the facility. On 01/14/25 at 10:02 AM on the 100 South Hall there are two refrigerators in the kitchen unit, in the first refrigerator there was a non- resident refrigerator and inside was a block of yellow cheese slices approximate 30 slices that was not covered as the plastic wrap had come off and was exposing it to the air the top slice was leathery in texture, and all dried out. There was also a large styrofoam container containing some type of rice with vegetables inside of it that was not labeled or dated. On 1/14/2025 at 10:08 AM on the 100 South Hall in the resident refrigerator there was four cooked eggs in a metal container with no date or label. There was a large three-quart clear pitcher that was full and was brown in color with no date and or label. There was also a plastic container full of a brown meat like product that was not labeled and or dated. On 1/14/2025 at 10:11 AM, in the Resident Refrigerator on the 100 South Hall was a laminated sign that was hanging on the door of the refrigerator that documented the following: Any items placed in the refrigerator and freezer should be clearly labeled with name and date. Any items that are not properly labeled with a name and date will be discarded immediately. Thanks Household Dietary Manager. On 1/14/2025 at 10:18 AM, on the 100 North Hall kitchen unit in the Resident's Refrigerator there are five bags of food tied of with a grocery bag with no date or labels. There is also a package of Swiss cheese that was halfway opened and was not covered entirely in plastic wrap that was not covered, dated, or labeled. There were two two-quart pitchers of thickened clear substance that was not dated and or labeled. There was a large three-quart brown pitcher of a substance with no date and or label on it. On 1/14/2025 at 10:22 AM, on the 100 North Hall kitchen unit the other refrigerator were five bags of food wrapped in a grocery store none of the bags were dated and or labeled. There was also a block of yellow cheese not dated and or labeled. There was a large box of pizza not dated or labeled. And a metal container of what appeared to be chocolate pudding was sitting on the shelf that was not dated and or labeled. On 1/14/2025 at 10:24 AM, on the 200 South Hall in the main refrigerator there was a styrofoam container of rice with no date and or label on it. There was a large industrial pitcher of a brown liquid with no date and or label. There was a block of butter wrapped in aluminum foil with no date and or label. On 1/14/2025 at 10:26 AM, on the 200 Hall Resident Refrigerator there were two fast food bags with food inside with no date and or label. There was a sausage patty with no date and or label. There were two slices of pizza with no name, date and or label. On 1/14/2025 at 10:29 AM, on the 300 North Hall there were five small round pancakes wrapped in plastic wrap with no date or label. There was also a block of yellow cheese with no date or label. On 1/14/2025 at 10:30 AM, in the Resident Refrigerators there was a plastic container with a substance that appeared red with beans that was not dated and or labeled. There was a large 30-ounce container of yogurt with a use by date of 12/24/2024. (23 days old), and three styrofoam containers of food covered with grocery bags with no name, date and or labels. On the top shelf was a dinner plate with a thermal lid on top with no date and or label. There was also a sausage patty wrapped in plastic with no date and or label. On 1/14/2025 at 1:14 PM, V9, Dietary Manager stated, Any items placed in the refrigerator and freezer even on the kitchenette should always be clearly labeled with name and date. The Labeling and Dating Foods (Date Marking) Policy undated documents, All Foods stored will be properly labeled according to the following guidelines. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or be the manufactures expiration date. Prepared food or opened food items should be discarded. The CMS 671 Form dated 1/14/2025 documents there were 103 residents living in the facility.

Based on Interview and Record Review the facility failed to submit the required Payroll-Based Journal (PBJ) data for the 4th quarter of 2024. This has the potential to affect all 103 residents in the facility. Findings include: PBJ report for the 4th quarter of 2024 dated 10/1/2024-12/31/2024, documents Low weekend staffing, RN (Registered Nurse) coverage for 8 consecutive hours/day, licensed nurse for 24 hours/day, one star staffing rating, failed to submit PBJ data. On 1/14/2025 V1, Administrator, provided a notice the facility received from the State Agency documenting the facility had failed to provide the required staffing information. On 1/17/2025 at 12:50PM V1, Administrator, stated the corporate office had a new employee. The PBJ data was submitted to the corporate office from our facility in a timely manner, but not submitted to CMS (Centers for Medicare & Medicaid Services). On 1/17/2025 at 1:10PM V1, Administrator, stated facility has no policy regarding PBJ submission data.

Based on interview, observation, and record review, the facility failed to provide complete and timely incontinent care using proper technique; and failed to perform hand hygiene and glove changes for 3 of 4 residents (R6, R7, R8) reviewed for incontinence care in the sample of 10. This failure resulted in R7 obtaining a Urinary Tract Infection, (UTI), and being placed on an Antibiotic. The findings include: 1. R7's Face Sheet, undated, documents R7 was admitted to the facility on [DATE], with diagnoses of Hypertension, (HTN), Respiratory Failure, Atrial-Fibrillation, (A-Fib), Chronic Kidney Disease, (CKD)-stage 3, Type 2 Diabetic Mellitus, (DM), Congestive Heart Failure, (CHF), Cardiac pacemaker, Atherosclerotic Heart Disease, (ASHD), and Hyperlipidemia. R7's Care Plan, dated 3/7/24, documents R7 has bladder incontinence. Interventions: the resident uses disposable briefs. Change, establish voiding patterns, R7 is Incontinent: Check the resident and as required for incontinence, wash, rinse and dry perineum, change clothing PRN, (as needed), after incontinence episodes, monitor/document for s/sx, (signs/symptoms), 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, observe pattern of incontinence, and initiate toileting schedule if indicated, provide bedpan/bedside commode, provide peri-care after each incontinent episode. R7's on Antibiotic Therapy r/t, (related to), UTI. R7 has Urinary Tract Infection. Interventions: Check at least every two hours for incontinence, wash, rinse and dry soiled areas, give antibiotic therapy as ordered, monitor/document/report to MD, (Medical Doctor), PRN for s/sx of UTI: Frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. R7 has an ADL, (Activities of Daily Living), Self Care Performance Deficit r/t mobility disturbance and weakness. Interventions: Toilet Use: The resident requires X 2 staff participation to use toilet. Transfer: The resident requires X 2 staff participation with, (full body mechanical lift device). R7's Minimum Data Set, (MDS), dated [DATE], documents R7 is cognitively intact and is dependent on staff for toileting, bathing, dressing, and transfers. R7 is frequently incontinent of both bowel and bladder. R7 Lab Result, dated 6/8/24, documents R7 has a UTI. R7's Nursing Note, dated 6/8/24 at 12:25 PM, documents, Resident complained of, (c/o), some burning while urinating. resident is afebrile. MD notified and ordered UA, (urinalysis). Urine collected and in fridge awaiting pick-up. R7's Physician Order, dated 6/10/24, documents, Ciprofloxacin HCl, (Hydrochloride), Tablet 250 MG, (milligram). Give 1 tablet by mouth every 12-hours for UTI for 5 Days. R7's Nursing Note, dated 6/11/24 at 11:35 PM, documents, ABT, (antibiotic), for UTI with no complaints of pain or discomfort. No s/s of adverse reaction. Fluids encouraged. R7's Nursing Note, dated 6/12/24 at 1:33 AM, documents, Resident continues on ABT therapy r/o UTI no c/o pain or burning when voiding, fluids encouraged. Resident is INC, (Incontinent), of urine and using bedpan at night peri care given when in INC, resting quietly in bed at this time, will continue to monitor condition, call light within reach. On 6/11/24 at 9:48 AM, V14, Certified Nursing Assistant, (CNA), brought in supplies to do peri-care on R7. V14 did hand hygiene, donned gloves, turned R7 to her right side, and the bedpan was removed. R7 had small amount of soft stool on anal area and buttocks. V14 used a wet washcloth and wiped most of the stool from the anal area and put the bedpan in the restroom. V14 changed gloves, with no hand hygiene done. R7's soiled brief was tucked underneath her. V14 sprayed peri-wash onto R7's buttocks and wiped R7's right buttock and anal area. Using the same gloves, V14 got a wet washcloth out of the clean water and wiped between R7's legs and anal area again. V14 used the same gloves and rolled R7 to her left side. V14 tucked R7's linen underneath her, and using the same soiled gloves, pulled R7's bedside table with supplies over to the other side of the bed, took R7's pillow out from under her, then got another washcloth from the clean water, sprayed R7's right buttock with peri-wash and wiped it off. V14 sprayed peri-wash onto washcloth and wiped between R7's legs and anal area, using same gloves, got clean towels and dried R7. V14 doffed her gloves, went outside the room door to get more washcloths, then donned gloves then rolled R7 to her right side and pulled out the soiled brief and linen. R7 was then rolled to her back and V14, used the same soiled gloves, lifted R7's left leg and sprayed peri-wash on washcloth and wiped from back to front between R7's legs, including up and through her vagina. V14 fastened R7's brief and gave pillow and blanket to R7, and then doffed her gloves. 2. R6's Face Sheet, undated, documents, R6 was originally admitted to the facility on [DATE], with diagnoses of CHF, CKD-stage 3, Gastroenteritis/colitis, Cardiac Pacemaker, Intestinal malabsorption, COVID-19, Chronic Obstructive Pulmonary Disease, (COPD), Non-ST Elevation MI, (myocardial infarction), (NSTEMI), Major depressive disorder, Idiopathic Neuropathy, Hyperlipidemia, HTN, Osteoporosis, Sick Sinus Syndrome, (SSS), A-Fib, and Anxiety disorder. R6's Care Plan, dated 5/23/24, documents, R6 has bladder incontinence. Interventions: Incontinent: Check the resident every two hours and as required for incontinence, wash, rinse, and dry perineum, change clothing PRN after incontinence episodes, monitor/document for s/sx 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. R6 has bowel incontinence r/t impaired mobility. Interventions: Observe pattern of incontinence, and initiate toileting schedule if indicated, provide bedpan/bedside commode, provide peri-care after each incontinent episode, take resident to toilet at same time each day resident usually has bowel movement. R6 has Urinary Tract Infection. Interventions: Give antibiotic therapy as ordered, monitor/document for side effects and effectiveness, monitor/document/report to MD PRN for s/sx of UTI: Frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. R6 has an ADL Self Care Performance Deficit r/t Musculoskeletal impairment. Interventions: Toilet Use: The resident is totally dependent on staff for toilet use, the resident requires 2 staff participation to use toilet. Transfer: The resident requires 2 staff participation with transfers, the resident requires Mechanical Aid Sit-To-Stand device for transfers. R6 MDS, dated [DATE], documents, R6 is cognitively intact and is totally dependent on staff for toileting, bathing, and dressing. R6 is always incontinent of both bowel and bladder. On 6/11/24 at 10:37 AM, R6 stated she has diarrhea all the time, and there are times when she has to sit in it for about 15-30 minutes before staff cleans her up. R6's Nursing Note, dated, 5/23/24, at 11:05 PM, documents, Resident is on po ABT r/t UTI. No ASE (adverse side effects) noted. Afebrile. A&Ox4, (alert and oriented X 4). Able to make needs known. PO, (oral), fluids encouraged and tolerated. Appetite is fair. No c/o pain or discomfort. Resident is resting in bed with call light in reach. Will continue to monitor. R6's Physician Order, dated 5/23/24, documents, Cephalexin Oral Capsule 500 MG, (Cephalexin). Give 1 capsule by mouth two times a day for UTI for 7 Days. This order was completed and discontinued on 5/31/24. R6's Nursing Note, dated 5/31/24, at 6:13 AM, documents, Remains on PO abt, (antibiotic), for UTI no ASE noted. Denies any pain or discomfort with urination. PO fluids encouraged tolerated well. Call light in reach. On 6/11/24 at 10:29 AM, R6, seen lying in bed, and had put her call light on after having BM (bowel movement), while on the bedpan, and she needed cleaned up. V12, CNA, entered with supplies to provide peri-care to R6. V12 obtained wash basin of water, wet a washcloth, and wiped both of R6's groins, and then using same washcloth, wiped down the middle of R6 vagina, which appeared very reddened with R6 complaining of pain upon touch. V12 tucked R6's soiled brief between her legs and underneath R6, then rolled R6 over to her left side. V12 did not change her gloves. V12 obtained another wet washcloth and wiped R6's anal area, which was also very reddened, then using the same soiled gloves, put clean bed linen and a bath blanket on the bed, rolled R6 over to her right side and pulled the soiled linen out from under R6 and adjusted the clean linen under R6. There was no wiping of R6's left buttock while turned to her right side. V12 rolled R6 to her back and still using her same soiled gloves, got moisture barrier cream, and put cream on R6's reddened vaginal area, and nothing to her anal area/buttocks. V12 secured R6's incontinence brief, adjusted R6 in bed, including her pillow, put socks on R6, then covered R6 with sheet and blanket, all while using same soiled gloves. V12 pulled the bedside table with personal belongings over to bed, then doffed gloves. 3. R8's Care Plan, dated 4/10/21, shows R8 is at risk for complications with her skin integrity r/t her preference to sit up in her recliner for longer periods of time rather than changing position, h/o, (history of), pressure area, incontinence. Interventions: Pressure reducing cushion to wheelchair when up in wheelchair, the resident needs one assist/encouragement to turn/reposition at least every 2-hours, more often as needed or requested. R8 has an ADL Self Care Performance Deficit due to confusion and hearing deficit. Alert with confusion. Needs 1 assist for most tasks. Incontinent of bowel and bladder. Interventions: Toilet Use: The resident is not toileted. R8 is incontinent of bowel and bladder, The resident requires X 1 staff participation with transfers. R8's MDS dated , 4/16/24, scored her with being severely cognitively impaired, and is dependent on staff for toileting, bathing, and transfers. R8 is always incontinent of both bowel and bladder. On 6/11/24 at 10:43 AM, V13, CNA, performed incontinent care on R8. V13 donned gloves and removed R8's soiled brief by rolling it between R8's legs. V13 then instructed R8 to roll over and took a wet towel and wiped R8's buttock from back to front, folded the same towel, and had R8 roll onto her back again and used the same towel to wipe R8's vaginal region from back to front and rolled V8 to her other side. While using the same towel and same soiled gloves, V13 wiped the other side of R8's buttock region from front to back. R8's peri region is visibly red and irritated. V13 stated she used one towel but folded it up to a new section for each region. V13 then removed the dirty linen and brief and placed them on the floor. V13 then donned new gloves and placed a new incontinence brief on R8. On 6/12/24 at 8:25 AM, V4, Licensed Practical Nurse, (LPN), stated she does not get to witness the CNAs often, and was unsure if they change their gloves properly in-between care procedures. On 6/12/24 at 8:43 AM, V17, CNA, stated she does hand hygiene before touching residents and when leaving the resident's room. V17 stated she puts on gloves every time she enters a room to provide care on a resident. V17 stated residents should be checked for incontinence care and have position changes every 2 hours, but that doesn't always happen due to having busy workloads. V17 feels like more training on hand hygiene and glove use would be useful. On 6/12/24 at 8:45 AM, V18, CNA, stated gloves must be changed in between dirty to clean care, on top of when entering the room. V18 stated more training would be useful for the CNAs on proper hand hygiene and glove use. On 6/12/24 at 11:00 AM, R10, Resident Council President, stated he frequently monitors the residents on his floor for the care they receive, and he does not observe staff checking on residents every two hours like they should. R10's MDS, dated [DATE], documents, R10 is cognitively intact. On 6/12/24 at 1:20 PM, V1, Administrator, stated, I would expect the staff to perform timely and complete incontinence care to the residents. I would expect the staff to perform hand hygiene before resident care, during glove changes, and after resident care, and glove changes when going from a dirty area to a clean area. On 6/12/24 at 1:25 PM, V1, stated, We don't have a policy on incontinent care, we always just use the checklist. The Facility's Peri-Care (Female) Policy/Checklist, undated, documents, Wash Hands, Put on Gloves, Wash and dry upper thighs covering thighs with bath blanket when finished, Apply soap to wet washcloth, Separate Labia and wash Urethral area first, Wash between and outside Labia in downward strokes alternating from side to side moving outward to thighs, Use different part of washcloth for each stroke, With fresh water and a clean washcloth, rinse area thoroughly with same strokes, Gently pat dry in same direction, Clean rectal area wiping from base of Labia over Buttocks using a different part of washcloth for each stroke, Rinse and dry Anal area thoroughly, Remove gloves and wash hands. The Facility's Infection Control/PPE Policy, dated 2019, documents, Gloves are worn as per standard precautions. The Facility's Infection Control Policy, dated 2019, documents The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. c. Standard and transmission-based precautions to be followed to prevent the spread of infections. a. Selection and Use of PPE. f. The hand hygiene procedures to be followed by staff involved in direct resident contact. Elements of the program: Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure-related infections. The Facility's Hand Hygiene Policy, dated 2019, documents, Appropriate hand hygiene is essential in preventing transmission of infectious agents.

Based on interview and record review the facility failed to ensure proper transfer techniques to prevent falls and injuries for one of 7 residents (R2) reviewed for supervision to prevent falls in the sample of 7. This failure resulted in an Immediate Jeopardy when V8, Certified Nurse's Aide (CNA) transferred R2 incorrectly causing R2 to sustain bilateral femur (thigh) fractures and expiring on 04/14/24. This past non-compliance occurred from 04/11/24 to 04/12/24. The Immediate Jeopardy began on 4/11/24, when V8 attempted to transfer R2 by herself, and R2 falling and sustaining bilateral femur fractures. On 4/17/24, at 2:17 PM, V1, Administrator, V25, Regional Corporation Nurse and V26, Director of Clinical Operations were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 4/12/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R2's Electronic Medical Record, EMR, undated documents R2 was admitted to the facility on [DATE]. R2's EMR, dated 05/29/19, documents R2 has a diagnosis of Alzheimer's Disease, unspecified. R2's EMR, dated 02/17/21, documents a diagnosis of chronic pain syndrome. R2's EMR, dated 10/01/22, documents a diagnosis of Vascular Dementia, unspecified severity, with agitation. R2's Care Plan dated 04/13/21 documents ADL (Activities of Daily Living): (R2) has an ADL Self Care Performance Deficit r/t (related to) limited mobility from her past left hip fracture, weakness and confusion. Alert, oriented to self. Incontinent of B&B (bowel and bladder). Able to feed self. Utilizes wheelchair for mobility. Hesitant in new environments and does not do well with too many options. Requires extensive assist and encouragement to complete most tasks. Has a stuffed, interactive cat that she often has nearby as a companion. R2's Care Plan Intervention, dated 03/10/22 documents TRANSFER: sit to stand using 2 assist. R2's Minimum Data Set, MDS, dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 99, which means the resident had severe cognitive impairment. The MDS documents that the resident required substantial/maximal assistance for roll left and right, sit to lying, and lying to sitting on side of bed. The MDS documents that the resident was dependent for sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R2's Health Status Note dated 04/11/24 at 11:39 PM documents The resident was being transferred into the room by aide and the resident's weight shifted toward the aide making the aide fall backward the resident came down forward and once this nurse immediately arrived at the room it was observed that the resident down on one knee and the aide holding her up best, she could. Resident was immediately assessed for injuries. there was no open area to the knees, this nurse attempted ROM (Range of Motion) and upon review the left femur seems to have a deformity. The right thigh had some swelling and at this time the aide and nurse was not clear if this was normal muscular tight swelling or from the fall. So, EMS (Emergency Medical Services), MD (Medical Director) and family notified once EMS arrived and was given report was informed of all concerns of bilateral knees and femurs. Pt (patient) vitals were stable. pt did not hit her head and was sent to (local hospital). R2's Health Status Note dated 04/12/24 at 12:24 PM documents Resident admitted to (local hospital) due to BLE (bilateral lower extremities) fractures. R2's Radiology Report dated 04/12/24 documents Acute significantly displaced and comminuted fracture of the mid left femur. Acute significantly fracture of the mid right femur. R2's Health Status Note dated 04/12/24 at 1:43 PM documents Clarification note per Nurses note incident occurred at 21:00. Facility's Lift Transfer Past Non-Compliance form, dated 04/12/24 documents under problem On 4-11-24 patient (R2) was transferred with 1 person assist but care plan was for sit to stand using 2 assist. On 04/16/24 at 2:09 PM, V8, CNA (Certified Nursing Aide) stated that she was putting R2 in her bed and R2 fell on her. She stated that she yelled for help because R2 was on top of her, and she could not move. She stated that she noticed R2's leg was deformed. She stated that she told the nurse that something was not right with R2's leg. She stated that R2 is normally a 2 assist, but she has been working with her for months. She (V8) stated she has been transferring R2 by herself for a while. She stated that R2's legs are contracted, and she always has her legs crossed. She (V8) stated that lifted her (R2) with a gait belt and put her (V8's) leg between R2's legs. She (V8) stated that she stumbled and R2 fell on top of her. She (V8) stated that the unit was not short staffed. She (V8) stated that R2 fell between 9:00 PM and 9:30 PM. She (V8) stated that it took a long time for the ambulance to get there. She (V8) stated that the ambulance arrived around 10:30 PM. She (V8) stated that the nurse ordered x-rays instead of calling an ambulance. On 04/16/24 at 2:27 PM, V9, Licensed Practical Nurse, LPN, stated that she was sitting at the nurses' station. V9 stated that she heard yelling down the hall. She (V9) stated she ran to see R2 with one knee on the floor kneeling and V8 holding R2 up with R2's back against the dresser. She (V9) stated that she was able to assist R2 into her wheelchair. She (V9) stated that she assessed R2 and noticed a bulging area on her right thigh. She (V9) stated that she ordered a STAT x-ray. She stated that she had another aide come look at R2's legs and that aide stated that her legs did not look that way before. She (V9) stated that instead of waiting on (mobile x-ray company), she called the ambulance. She (V9) stated that the hospital could get an x-ray quicker and that R2 had already been given her norco (pain medication) at 8:00 PM, so the ER (emergency room ) could give her more pain meds. She (V9) stated that she did not see a gait belt or a sit to stand. She stated that V8 never asked her or the other CNA on the unit for help to transfer R2. On 04/17//24 at 12:47 PM, V21, ER Physician, stated that the resident (R2) had very severe osteopenia and never would have survived surgery. He (V21) stated that he is unsure if the fractures contributed to her death, but it did not help. On 04/17/24 at 2:08 PM, V19, Medical Director stated that in his professional opinion the bilateral femur fractures contributed to R2's death. Facility's Fall Prevention Policy (S.A.F.E.) dated 02/2021 documents The S.A.F.E. program promotes Safety, Assessment, Fall prevention and Education of both staff and residents. The Immediate Jeopardy and deficiency practice that began on 4/11/24 was corrected/removed on 4/12/24 after the facility took the following actions to correct the noncompliance prior to the start of current survey: 1. DON (V2) or Designee (V14) to provide 100% of nursing staff were educated on 2 person transfers with all lifts following the patient Kardex prior to their next assigned shift. Done 04/12/24. 2. DON or Designee will provide education to direct care staff on correct procedures for following the Kardex prior to allowing staff to work their next assigned shift. Done 04/12/24. 3. Staff will not be allowed to work and will be taken off the schedule until all education is completed. 4. Education will continue until all nursing staff have been educated, staff will not be allowed to return to work until the education has been provided. 5. All new nursing staff and agency will have the same information reviewed with them at the time of orientation. 6. AD HOC QAPI meeting was immediately held with the medical director on 04/12/24. 7. The DON or Designee will complete 5 lift educations a week for 8 weeks. 8. Any deficient practices will be corrected immediately. Patterns or trends will be reported to QA committee for further recommendations and follow-up. 9. All resident's transfer status' reassessed and reviewed by V3, Assistant Director of Nursing, ADON on 04/12/24.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (R2) reviewed for medication errors in the sample of 13. This failure resulted in R2 having a drop in blood pressure requiring hospitalization , intravenous fluids, and blood pressure support medication. This past non-compliance occurred on 2/26/24. Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Supraventricular Tachycardia, Myocardial Infarction, Cognitive Communication Deficit, need for assistance with personal care, Hypertension, and Hypotension. R2's Care Plan dated 11/28/23 documents, (R2) has Hypertension. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (tachycardia) and effectiveness. The Care Plan also documents, (R2) is on diuretic therapy r/t (related to) hypertension. Many other medications may interact with antihypertensives to potentiate their effect (Levodopa, Nitrates). Monitor for Interactions/Adverse Consequences. R2's Progress Note by V17, Licensed Practical Nurse (LPN), on 2/26/24 at 10:43 AM documents, Resident is A&O (Alert and Oriented) x/times 4 able to make needs known. Nurse approached resident with medication, asked resident if his name was (R5), resident stated yes. Nurse than {sic} gave resident medication. Nurse than {sic} noticed it was a mediation {sic} error. Resident received his roommate's medication. (V2) and (V18) contacted immediately. (V18) gave new orders for every 30 minutes blood pressure check and to monitor closely. VS (Vital Signs): BP (Blood Pressure): 109/86 P (Pulse): 82 O2 (Oxygen): 95 (Percent) RA (Room Air) T (Temperature): 97.2 (Degrees Fahrenheit). (V18) returned call at 1050 am with new orders to send resident to (Local Hospital). (Emergency Medical Services) contacted and transported resident to hospital. Family notified and hospital called for report. The Facility's 2/26/24 Hand-Written Statement by V17, LPN, documents, Resident (R2) is A x O x 4 able to make needs known. Nurse approached resident with medication, asked resident if his name was (R5) resident stated yes. Resident was given the medications. Nurse noticed resident was given his roommates {sic} medications. (V2), (V18) was contacted immediately. (V18) gave new orders every 30 min (minutes) blood pressure checks and to monitor closely. VS: BP: 109/86, P: 82, O2: 95 RA T: 97.2. (V18) contacted nurse back giving new orders to send resident to hospital. EMS contacted and resident was sent out to hospital family made aware. This nurse contacted hospital at 2PM. Hospital nurse stated that resident will be admitted to hospital r/t low blood pressure 83/47. Resident is alert and oriented, talking but lightheaded. (V2) and (V18) made aware. On 3/7/24 at 8:17 AM, V17, LPN, stated I went in and pulled the med, asked what I thought was (R5), and he said, Yes, my name is (R5). I went back to the med cart and heard another staff member call him (R2). I realized I had the wrong person and immediately notified (V1), (V2), (V18). We had a meeting and planned to monitor his vitals more closely, but he ended up being sent out (to the hospital). R2's Progress Note by V2, Director of Nursing (DON), on 2/26/24 at 11:38 AM documents, (R2) was given another resident's medications in error. (V18) was notified and gave orders for BP (Blood Pressure) Q30 (every 30) minutes x2 hours and monitor closely. Returned call after talking to (V19) and requested resident be sent to (Local Hospital) for eval (evaluation) and treat. R2's Progress Note dated 2/26/24 at 2:00 PM documents, (Local Hospital) contacted r/t (related to) resident condition. Hospital nurse states that resident is admitted to hospital with BP (Blood Pressure): 83/47. Alert and oriented, talking but lightheaded. (V18) and (V2) made aware. R2's Med Error Report dated 2/26/24 at 10:11 AM documents, (V17) notified (V2) of (R2) being given another resident's medications by mistake. (V18) notified with orders to monitor closely, BP Q30 (every 30) minutes and report each one back for 2 hours. At 10:50 AM, (V18) returned call with orders to send to (Local Hospital) for eval and treat. R2's Progress Note by V19, Physician, on 3/1/24 documents, Received furosemide, carvedilol, isosorbide mononitrate, hydralazine, and tamsulosin that were intended for his SNF (Skilled Nursing Facility) roommate. The Progress Note also documents, Had episode of SVT (Supraventricular Tachycardia) rate in the 190's (beats per minute) after having BM (bowel movement) on commode and Lightheaded. On 3/5/24 at 3:30 PM, V11, Pharmacist, stated, (R2) had an additional 4 items that lowered blood pressure. Furosemide is a duplication of his diuretic. Carvedilol duplicates (his) Metoprolol. Isosorbide Mononitrate and Hydralazine are pure extra blood pressure lowering medications. Tamsulosin can lower blood pressure, as well. I know it was an accident, but this is pretty major, and I can see how his blood pressure dropped. This is definitely significant since it caused (R2) to have to go to the hospital. On 3/7/24 at 7:53 AM, V1, Administrator stated V17 was a new agency nurse and was not allowed to return to the facility due to this incident. On 3/7/24 at 9:32 AM, V19, Physician, stated he was not here when this medication error occurred, but was told the resident's names were similar and V17 gave R2 the wrong medications. V19 stated he would expect the facility to give medications as ordered. On 3/7/24 at 9:27 AM, V2, Director of Nursing (DON), stated this incident may not have happened if V17 had asked R2 to tell her his name. V2 stated she expects medication orders to be followed. On 3/7/24 at 10:55 AM, V1, Administrator, stated he expects staff to follow all policies, including medication administration, and expects medications to be given as prescribed by the physician. The Facility's Administration of Medications Policy dated 4/21 documents, The nurse's station shall have necessary items and equipment available for proper administration of medications, and current standards of practice should be followed. Nursing staff will report immediately to the attending physician any medication errors, or adverse drug reactions. The pharmacy shall be informed, and a copy of all incident reports forwarded. The facility shall check the Physician's Order Sheet and MAR against the current Physician's Orders, to assure proper administration of medications to each resident. Prior to the survey date, the Facility took the following actions to correct the noncompliance. Immediate Actions: 1-Director of Nursing, Assistant Director of Nursing, and/or Designee immediately in-serviced all nurses regarding the Five Rights of Medication Administration to include accurate identification of patient/resident prior to medication administration. 2-Director of Nursing, Assistant Director of Nursing, and/or Designee immediately initiated ongoing audits of medication administration per clinical managers to ensure that nurses are compliant with the Five Rights of Medication Administration to be immediately addressed upon identification and/or re-education provided three times per week for four weeks. 3-Facility pharmacy consultant and/or pharmacy nurses initiated ongoing audits of medication administration per clinical managers to ensure that nurses are compliant with the Five Rights of Medication Administration. Any variances will be immediately addressed upon identification and/or re-education provided. 4-Ad Hoc QAPI meeting was completed to review occurrence, immediate intervention, and plans for ongoing audits to ensure continued compliance. Ongoing Actions: 1-Education will be provided to new employees prior to being allowed to work in the Facility. 2-Concerns will be addressed immediately and discussed during the monthly QAPI Committee for resolution.

Based on interview, observation and record review, the facility failed to implement fall interventions to prevent falls for 3 of 3 residents (R1, R2, R3) reviewed for falls in the sample of 3. This failure resulted in R1 sustaining a laceration to her left eye and R2 sustaining a left hip fracture. Findings include: 1. R1's Face Sheet, undated, documents R1 has a diagnosis of Dementia, Osteoporosis, Stage 3 Chronic Kidney Disease and Type 2 Diabetes. R1's MDS (Minimum Data Set), dated 10/23/23, documents R1 has severe cognitive impairment, is dependent with toileting, bed mobility and transfers and has a history of falls. R1's Care Plan, dated 7/1/22, documents R1 is at risk for falls with an intervention, dated 12/4/23, not to leave R1 in her room unattended. R1's Fall Risk Assessment, dated 9/24/23, documents R1 is at high risk for falls. R1's Progress Note, dated 12/3/23 at 8:16 PM, documents resident fell out of her reclining wheelchair around 6:55 PM. The aide stated that she stepped out of the room to go across the hall and when she went back to the resident's room, she was on the floor. The nurse assessed R1, and she was lying face down on the floor. The aides turned her over and there was a laceration to the left eyebrow, redness to the tip of her nose and chin, a skin tear to the left elbow and an abrasion to the left knee. Hospice called and notified, verbal orders received to monitor and treat. POA (Power of Attorney) and DON (Director of Nurses notified. Provider and management notified via texting application. Vital signs WNL (within normal limits). Resident is stable at this time. Bed is in the lowest position and call light is within reach. R1's Progress Note, dated 12/17/23 at 2:14 PM, documents at 1:28 PM, resident was found in room by aide after falling out of her chair onto the floor. Resident able to respond to name. Breathing is even and non-labored. Injury noted to the left eye and left upper leg. Hospice, POA and DON notified. Resident sent to hospital for evaluation. R1's Progress Note, dated 12/17/23 at 9:57 PM, documents resident returned to the facility at 9:45 PM by ambulance. Resident went out for an unwitnessed fall and was seen for a left eyebrow laceration. CT/computed tomography scan of the head was clear, and no fractures were found. Steri-strips were applied to the laceration with instructions to change the dressing as needed, use antibiotic ointment on area 2-3 times per day and to wash with mild soap and water. Resident is alert and oriented to self. Resident is lying in bed with the bed in the lowest position and the call light within reach. R1's AVS (After Visit Summary), dated 12/17/23, documents R1's CT scan showed chronic bilateral nasal bone fractures, no new fractures, new left frontal scalp hematoma and periorbital hematoma and a contusion/hematoma tracking down the left cheek bones. R1 was diagnosed with a Fall and had laceration repair to the left eyebrow. On 12/20/23 at 9:20 AM, R1 was observed at the dining room table in her reclining wheelchair. R1 had a laceration to the left eyebrow with steri-strips in place and reddish bruising to the left upper eye, eye lid and lower eye area. There was a bandage in place below the left eye. On 12/20/23 at 2:00 PM, V11, LPN, stated that R1 fell on [DATE] after lunch between 12:00 PM and 1:00 PM. V11 stated the CNA who was caring for R1, unsure of name, was not familiar with R1 and was taking R1 out of the dining room. V11 stated she asked the CNA where she was taking R1, and the CNA told her she was taking her to her room to lay her down. V11 stated she told the CNA they normally keep her at the nurse's station or in the dining room for a little while until they get her in bed and the CNA stated she was going to lay her down. V11 stated approximately 3-4 minutes later, the CNA told her R1 was on the floor. When V11 entered the room, R1 was on the floor face down in front of her reclining wheelchair. V11 stated the CNA told her she stepped away to get towels to clean R1 up and R1 fell while she was out of the room. 2. R2's Face Sheet, undated, documents R2 has a diagnosis of Sepsis, Dehydration, Stage 3 Chronic Kidney Disease, Vascular Dementia, Muscle Weakness, Left Femur Fracture (7/18/23), Heart Failure, Hypertension (HTN), History of Falling, Atrial Fibrillation, Muscle Wasting and Atrophy. R2's MDS, dated [DATE], documents R2 has severe cognitive impairment, is dependent with toileting and transfers and requires maximum assistance with bed mobility. R2's Care Plan, dated 7/10/23, documents R2 is at risk for falls. R2's Fall Risk Assessment, dated 12/1/23, documents R2 is at high risk for falls. R2's Progress Note, dated 11/29/23 at 10:17 PM, documents the CNA (Certified Nurse Assistant) went into the resident's room to do the last round and the CNA informed the nurse that the resident's legs were hanging off of the side of the bed. CNA stated that one of R2's legs was against the bedside table and that she (CNA) put the resident's legs back on the bed. The nurse went to assess the resident. No bruising, bleeding, lacerations, swelling or complaints of pain were noted. Resident lying in bed resting with eyes closed. Bed is in lowest position and call light is within reach. There was no documentation in R2's care plan or progress note that an intervention was implemented to prevent R2 from falling after she was observed by staff with her legs hanging off of the bed. R2's Progress Note, dated 12/18/23 at 1:30 AM, documents while the CNA was doing her rounds, she found the patient down on the mat on her left side by the bed. The bed is in the lowest position with the call light on her side. Assessed with no physical injuries. Vital signs were taken and are stable. Patient is awake and not really good at verbal communication. Nurse called for help from the regular staff in charge to help assess the patient. They put her back to bed with a full mechanical lift. R2's Progress Note, dated 12/18/23 at 2:37 AM, documents the patient was re-evaluated at bedside and it was noted that R2 was guarding her left thigh and made a moan when changing her incontinence brief. When asked if she was in pain, she answered yes, and her hand was on that side of the leg. There was a bump and swelling noted to the left thigh. Hospice was called and was advocated for an x-ray. Informed POA/power of attorney (V15, R2's Daughter) and Physician (V16, R2's Physician/Medical Director) and V16 stated to send to the ER/emergency room for further evaluation and treatment. Family was informed that the patient was being sent out to the ER for an x-ray. After some time, hospice called and said they just wanted a portable x-ray for the patient. V16 was called to inform of hospice's wish and V16 insisted that the patient be sent to the ER. R2's Progress Note, dated 12/20/23 at 12:40 PM, documents R2 returned to the facility with an indwelling urinary catheter, family requests not to remove. Continues with hospice services. Resident is not verbally responsive. Will open eyes for brief periods. R2's Progress Note, dated 12/20/23 at 12:43 PM, documents R2's left lower extremity (LLE) displays internal rotation. R2's Hospital Records, dated 12/20/23, documents R2 was admitted to the hospital from 12/18/23 - 12/20/23 with a diagnosis of a Closed Femur Fracture. On 12/20/23 at 1:00 PM, R2 was observed in her room with her bed with family at bedside. R2 appeared ill with open mouth breathing and was not responsive. On 12/20/23 at 1:00 PM, V14, R2's Granddaughter, stated R2 was sent to the hospital after a fall on 12/18/23 and was diagnosed with a left hip fracture and bladder infection. V14 stated they did not do any surgical repair of the left hip fracture due to R2 already being on hospice and the doctors said she most likely wouldn't make it through the surgery. V14 stated R2 moans in pain when turned or when being provided care, so they left the indwelling urinary catheter in place to help with the pain. V14 stated the facility staff had told her that R2 had been putting her legs out of the bed and she isn't sure why they didn't put alarms on her or do more than just have the mats beside her bed, you'd think they would put other precautions in place. V14 stated R2 had a fall in July 2023 at home, sustained a left hip fracture and they had to put pins in it and it healed, then she fell and broke it again. V14 stated R2 was somewhat awake before the fall on 12/18/23. On 12/20/23 at 1:00 PM, V15, R2's Daughter, stated on the day R2 fell (12/17/23), she was here until around 9:30 PM. V15 stated she received a call from the facility nurse, unsure of name, around 2:00 AM, stating R2 had fallen out of bed. V15 stated then a little later on, unsure of time, she received another phone call from the same nurse, stating that the nurse looked at R2's hip and it was swollen and R2 was in pain, so they were sending her to the hospital for an x-ray. V15 stated they did an x-ray at the hospital and her left hip was broken, she had a bladder and kidney infection. On 12/20/23 at 1:20 PM, V10, LPN, stated that R2 had been fidgety and would put her legs out of the bed. V10 stated that is how they knew she was ready to get out of bed, so they would get her up. V10 stated she doesn't work nights so she isn't sure how she is on nights, but she does that during the day at times. On 12/20/23 at 2:40 PM, V16, R2's Physician and Medical Director stated he was on call the night that R2 fell . V16 stated the nurse called him and stated that R2 had fallen and had a deformity of the upper leg, and she was thinking it was fractured, so he revoked hospice's order to complete the x-ray at the facility and told them to send her to the hospital for further evaluation and treatment. V16 stated he would expect the facility to implement interventions to prevent falls. On 12/21/23 at 10:00 AM, V12, Agency RN, stated R2 was last checked on by her around 10:00 PM and she was awake. V12 stated R2 was stiff, doesn't really move but at times tries to get out of bed. 3. R3's Face Sheet, undated, documents R3 has a diagnosis of Acute Cystitis, Neurocognitive Disorder with Lewy Bodies, Need for Assistance with Personal Care, Dementia, Parkinson's Disease, Syncope, Unsteadiness of Feet, HTN and Stage 4 Kidney Disease. R3's MDS, dated [DATE], documents R3 has severe cognitive impairment, requires maximum assist with toileting, is independent with bed mobility, requires supervision/touching assist with transfers and has a history of falls. R3's Care Plan, dated 8/5/23, documents R3 is at risk for falls related to weakness with an intervention to be sure the call light is within reach. R3's Fall Risk Assessment, dated 11/6/23, documents R3 is at high risk for falls. On 12/20/23 at 9:05 AM, R3 was observed in his room in bed. R3's call light was on the floor to the left of the resident out of his reach. R3 stated he's had a couple of falls but didn't get hurt. R3 stated he uses his call light sometimes. On 12/21/23 at 8:30, V2, DON, stated she would expect fall interventions be implemented and in place to prevent falls. The Fall Policy, dated 9/17/19, documents the facility shall ensure that a fall management program be maintained to reduce the incidence of falls and risk of injury to the resident to promote independence and safety. Residents found to be at high risk for falls are placed on the fall program and interventions are implemented to meet their individual needs.

Based on interview and record review, the facility failed to maintain residents' highest practicable physical well-being by assessing and providing timely care and treatment of fractures for 1 of 3 residents (R22) reviewed for quality of care in the sample of 43. This failure resulted in R22 not receiving timely care and treatment for three days after a fall. When R22 was sent to the hospital for treatment, it was identified that he had bilateral femur fractures and a dislocated knee. The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. Again on 11/24/23, R22 had another syncope episode while being transferred with a sit to stand lift. On 11/26/23, after having pain throughout the day, R22 was sent to the hospital. R22's sustained severely displaced fracture of the right proximal femur shaft, a severely comminuted distal left femoral fracture with displacement with likely disruption of the knee joint. On 12/1/23, at 12:50 PM, V3, Director of Nursing (DON) and V28, Licensed Practical Nurse/Travel Nurse Manager was notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 12/2/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R22's Face Sheet, undated, documents R22 has the following diagnoses: Rheumatoid Arthritis, Weakness, Bilateral Osteoarthritis of the Knees and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact and is dependent with transfers. R22's Care Plan, dated 8/17/23, documents R22 is at risk for falls. R22's Care Plan does not address that R22 has episodes of syncope. R22's Progress Note, dated 9/13/2023 at 2:00 PM, the CNA (Certified Nurse's Assistant) was assisting resident in bed, staff states resident's legs gave out, so she slowly lowered him to the floor. Upon assessment no injuries noted and Power of Attorney at bedside. Resident helped up and laid down in bed. Vital signs 130/66 (blood pressure), 88 (pulse), 18 (respirations), 98.3 (temperature) and 97% (oxygen saturation) on 2 liters. Will continue to monitor. R22's Progress Note, dated 11/23/23 at 8:30 PM, documents Returned to facility per (Outside Company) transport. Taken to room (Room #). CNAs times/x2 to assist to bed per sit to stand. Was unable to raise bed. Resident passed out. Lowered to floor. There was no documentation in R22's medical record that after R22 had a syncope episode on 11/23/23, the facility reassessed R22 for the safest mode of transfer due to syncope. There was no documentation that staff conducted a full assessment to ensure that R22 had not sustained any injuries after this incident. R22's Progress Note, dated 11/24/23 at 9:31 PM, documents Resident had a syncope episode tonight while being transferred in sit to stand. When aide lifted the resident, the resident became unconscious and started to snore. Episode last for 20 secs (seconds). Resident now in bed and is still drowsy. R22's Progress Note, dated 11/26/23 at 5:08 AM, documents R22 was given pain medication during the night for pain. R22's legs were edematous, and the left knee area was bruised from the fall. R22 had difficulty moving his left leg. There is no documentation that the Physician was notified of R22's change in condition. R22's Progress Note, dated 11/26/23 at 10:15 PM, documents R22 was complaining of pain to his buttocks and back throughout the day with several needs for pain medication. V15, Nurse Practitioner, called the facility and an update on R22's condition, increased edema and bruising to the knee. R22's Progress Note, dated 11/26/23 at 10:37 PM, documents upon assessment of R22's left leg, it has had a significant change with increased swelling, abnormal coloring, and increased pain. Physician exchange notified, awaiting response. R22's Progress Note, dated 11/26/23 at 10:51 PM, documents the nurse spoke with the on-call Physician and a new order was obtained to send to the local ER (emergency room ) for evaluation and treatment. R22's Progress Note, dated 11/27/23 at 4:37 AM, documents R22 was admitted to the hospital with a diagnosis of Low Hemoglobin, A Dislocated Left Knee and Bilateral Femur Fractures. R22's ER notes, dated 11/27/23, document R22 was brought into the ER for bilateral knee pain, swelling and deformity after a fall at his nursing facility 2-3 days ago. Patient states he fell at the nursing home and the pain became worse today. R22's right femur x-ray showed a severely displaced fracture of the right proximal femur shaft. R22's left femur x-ray showed a severely comminuted distal femoral fracture with displacement. R22's left knee x-ray showed a severely comminuted and displaced distal femoral fracture with likely disruption of the knee joint. Discussed patient history, exam, and other pertinent info with orthopedic surgeon. He advises sending patient to an orthopedic trauma specialist at an outside hospital. Patient has been accepted and will be transferred to the outside hospital for further treatment. On 11/30/23 at 9:10 AM V12, CNA, stated she had worked 6 AM - 2:30 PM on 11/23/23 and R22 was okay. V12 came back in and worked the night shift on 11/23/23 from 11:00 PM - 6:00 AM, R22 had his call light on, so she went into his room, and he told her that he did not faint, he was dropped by staff. V12 stated R22 was complaining of a lot of pain and didn't want to be touched. V12 stated she is not sure if he had any injuries because he was hurting and wouldn't let her touch him. V12 stated R22 needed some pain medication, so she let the nurse know. On 11/30/23 at 9:50 AM, V14, CNA, stated R22 had been passing out in the sit to stand mechanical lift off and on since admission. V14 stated on 11/23/23, unsure of exact time, she and V16, RN, were getting R22 ready for bed and was going to lay him down. V14 stated R22 was in the sit to stand mechanical lift and passed out so she had to spring to get the other CNA to ease R22 to the floor. V14 stated V16, RN, asked R22 if he was hurt, R22 stated yes, and he needed some pain medication. V14 stated she did not see V16, RN, do any other assessments on R22 and he was placed in the bed using a full mechanical lift. V14 stated she did not see any visible injuries to R22. V14 stated if R22 had injuries, he should have been sent out. On 11/30/23 at 10:22 AM V15, Nurse Practitioner, stated she was sent a message through (communication application) on 11/23/23 that R22 had a syncopal episode in the sit to stand. V15 stated she had discontinued R22's Midodrine a couple of weeks earlier, so she gave orders to restart that. V15 stated she called the facility on Sunday, 11/26/23, during the day, to check in with all the units. V15 stated she talked to the nurse on duty for R22 and reminded her that R22 had been restarted on his Midodrine and the nurse did not report anything to her about R22's fall, any injuries or pain. V15 stated she got a text message that night from the on-call Physician stating R22 was sent to the hospital with his bone protruding. V15 sated they should have notified her or the Physician with any changes. On 11/30/23 at 11:20 AM V21, R22's Daughter, stated V17, R22's Wife notified her (V21) that R22 had fainted and was lowered to the ground and R22 immediately got on the phone and told her (V21) that they dropped him. On 11/30/23 11:20 AM V22, R22's Son, stated that the facility called V17, R22's Wife, on her cell phone and she was told that R22 fainted and was lowered to the floor but R22 said he was dropped. V22 stated R22 laid in his bed from Thursday night (11/23/23) until Monday morning (11/27/23). V22 stated the nurse on duty, unsure of name, communicated with V17 several times on 11/26/23 and R22 needed to be sent to the hospital. V22 stated R22 had bilateral fractured femurs with significant displacement and the bone was protruding from the skin. V22 stated R22 was kept at the local hospital for a couple of hours and was then sent to an outside hospital due to the extent of his injuries and they were worried that the femoral artery was damaged. V22 stated he was admitted to the outside hospital, has had significant blood loss, and required two surgeries with the orthopedic and vascular doctor and remains in ICU at the hospital. On 12/05/23 at 9:28 AM, V3, Director of Nursing, stated she would expect staff to identify changes in condition and provide the necessary care and treatment needed. The Significant Condition Change & Notification policy, dated 11/2019, documents the purpose of the policy is to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as: an accident or incident, with or without injury, that has the potential for needed medical practitioner intervention, a significant change in the resident's physical, mental or psychosocial status, a need to significantly alter treatment and transfer of the resident from the facility. Charting will include an assessment of the resident's current status as it relates to the change in condition. The Immediate Jeopardy that began on 11/23/23 was removed on 12/2/23 when the facility took the following actions: Section 1 1. On 12-1-23, The V1, Administrator and V3, DON were educated to ensure all residents must be assessed and provide timely care and treatment by V4, Regional Nurse Consultant, to ensure the safety of the facility's residents. 2. On 12-1-23, The facility has assessed all residents for change in condition. These initial assessments were done by the Nurse Management Team. The Nursing management team consist of V3, DON, V26, MDS Coordinator, V40, Care Plan Coordinator, V8 and V9, Infection Control Nurses and V18, Wound Care Nurse on 12-1-23. From the facility's assessment done by the Nursing Management Team, those resident change in condition have been addressed. The Nurse must assess the resident after a change in condition and notify the MD and RR immediately and inform the V3, DON/Designee of the occurrence. In Clinical meeting the occurrence will be discuss in depth. The following residents' changes in conditions that occurred on 12-2 and 12-3 are reviewed by the IDT Team on 12-4-23. R20, R52, R33 and R75 to ensure that Proper documentation, SBAR (Situation, Background, Assessment, and Recommendation), Nurses notes, Medical Doctor/MD, and RR (resident representative) notification were done, and treatment was carried out by the nurse immediately. 3. On 12-1-23, The facility will ensure that all residents are assessed for change in condition timely and the residents' care plan will be updated accordingly. Any change in condition, the nurse must assess the resident immediately, notify the MD and RR and inform the V3, DON/Designee of the occurrence. Change in condition that occurred on 12-2 and 12-3 are reviewed by the IDT Team (V3, DON, V26, MDS Coordinator, V40, Care Plan Coordinator, V8 and V9, Infection Control Nurses, and V18, Wound Care Nurse) on 12-4-23. R20, R52, R33 and R75 to ensure that Proper documentation, SBAR, Nurses notes, MD and RR notification were done, and treatment was carried out by the nurse immediately. The nursing management team (V3, DON, V26, MDS Coordinator, V40, Care Plan, V8 and V9, Infection Control Nurses and V18, wound Care nurse) will monitor the resident in the facility for possible residents' changes in condition to ensure that the nursing staff identify and provide timely treatment for the resident. Weekly to ensure compliance. 4.On 12-1-23, The facility will ensure that all residents are assessed for change in condition timely. 5. On 12-1-23, An ADHOC meeting with V42, Medical Director was held, and the identified issues were discussed. During this time the following policies for Falls, Transfers and Mechanical Lifts and identifying change in condition and notifying the MD of those changes were reviewed. At this time, it was determined that the facility would allege compliance as of 12-1-23 with the safety of all residents. Section 2 Other residents have the potential to be affected by the alleged deficient practice. Section 3 Systemic Changes to Ensure Compliance All nursing staff will be in-serviced on the following: The IDT Team and the ADHOC committee reviewed the policies and procedures to ensure current practices are being followed. This review occurred on 12-1-23. The policy for change in condition was reviewed. At this time, it was determined the facility would allege compliance with as of 12-2-23. License nursing staff was in-serviced on assessing and providing care and treatment and to provide timely documentation. The nurse must assess and document their assessment after each fall/lowering of the residents or change in conditions. This assessment must be communicated to the physician. This in-service was performed on 12-1-23 and 12-2-23 by V3, DON/Designee. Certified Nursing staff was in-serviced to communicate any changes in the resident status (i.e., falls or changes in condition) to all nursing immediately and through on and off shift report. This assessment must be communicated to the physician. This in-service was performed on 12-1-23 and 12-2-23 by V3, DON/Designee. Section 4 V3, DON/Designee will review residents' progress notes 4 x week to ensure that residents' assessments, care, and treatments are performed in a timely manner and documented in a timely manner. Any noted issues will be immediately addressed and reviewed in the QAPI process. The abatement plan was validated on 12/5/23. R20, R341, R33 and R75 were reviewed for changes in condition. The following staff were interviewed for validation that the in-servicing had been completed: V28, LPN/Travel Nurse Manager; V2, Assistant Administrator; V4, Regional Nurse; V3, DON; V30, CNA; V11, LPN; V12, CNA; V31, LPN; V27, LPN; V32, CNA; V19, CNA; V33, CNA; V34, LPN; V13, CNA; V34, LPN; V35, CNA; V36, LPN; V37, CNA, and V38, CNA.

A. Based on interview and record review, the facility failed to assess for and provide safe transfer techniques to prevent falls/injury for 1 of 14 residents (R22) reviewed for safe transfer techniques to prevent injury/falls in the sample of 43. This failure resulted in an Immediate Jeopardy when the facility failed to reassess R22 for the safest mode of transfer after having syncope episodes while being transferred with a sit-to stand lift. R22 sustained severely displaced fracture of the right proximal femur shaft, severely comminuted distal left femoral fracture with displacement of the knee joint. R22 has had two surgeries, a blood transfusion and remains in the Intensive Care Unit (ICU). The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. Again on 11/24/23, R22 had another syncope episode while being transferred with a sit to stand lift. On 11/26/23, after having pain throughout the day, R22 was sent to the hospital. R22's sustained severely displaced fracture of the right proximal femur shaft, a severely comminuted distal left femoral fracture with displacement with likely disruption of the knee joint. On 12/1/23, at 12:50 PM, V3, Director of Nursing (DON) and V28, Licensed Practical Nurse/Travel Nurse Manager was notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 12/2/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. R22's Face Sheet, undated, documents R22 has the following diagnoses: Rheumatoid Arthritis, Weakness, Bilateral Osteoarthritis of the Knees and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact and is dependent with transfers. The MDS does not indicate that R22 utilizes a mechanical lift. R22's Care Plan, dated 8/17/23, documents R22 is at risk for falls and requires an assistance of one staff with transfers. R22's Care Plan does not indicate that R22 utilizes a mechanical lift. R22's Care Plan did not document R22 had any syncope episodes. R22's Progress Note, dated 9/13/2023 at 2:00 PM, the CNA (Certified Nurse's Assistant) was assisting resident in bed, staff states resident's legs gave out, so she slowly lowered him to the floor. Upon assessment no injuries noted and Power of Attorney at bedside. Resident helped up and laid down in bed. Vital signs 130/66 (blood pressure), 88 (pulse), 18 (respirations), 98.3 (temperature) and 97% (oxygen saturation) on 2 liters. Will continue to monitor. There was no documentation in R22's medical record that the facility reassessed R22's for safe transfer techniques after he was lowered to the floor on 9/13/23. R22's Progress Note, dated 11/23/23 at 8:30 PM, documents Returned to facility per (Outside Company) transport. Taken to room (Room #). CNAs x2 to assist to bed per sit to stand. Was unable to raise bed. Resident passed out. Lowered to floor. There was no documentation in R22's medical record that after R22 had a syncope episode on 11/23/23, the facility reassessed R22 for the safest mode of transfer due to syncope. R22's Progress Note, dated 11/24/23 at 9:31 PM, documents Resident had a syncope episode tonight while being transferred in sit to stand. When aide lifted the resident, the resident became unconscious and started to snore. Episode last for 20 secs (seconds). Resident now in bed and is still drowsy. R22's Progress Note, dated 11/26/23 at 5:08 AM, documents R22 was given pain medication during the night for pain. The Note documented R22's legs were edematous, and the left knee area was bruised from the fall and R22 had difficulty moving his left leg. There is no documentation that the Physician was notified of R22's change in condition. R22's Progress Note, dated 11/26/23 at 10:15 PM, documents R22 was complaining of pain to his buttocks and back throughout the day with several needs for pain medication. V15, Nurse Practitioner, called the facility and an update on R22's condition, increased edema and bruising to the knee. R22's Progress Note, dated 11/26/23 at 10:37 PM, documents upon assessment of R22's left leg, it has had a significant change with increased swelling, abnormal coloring, and increased pain. Physician exchange notified, awaiting response. R22's Progress Note, dated 11/26/23 at 10:51 PM, documents the nurse spoke with the on-call Physician and a new order was obtained to send to the local ER (emergency room ) for evaluation and treatment. R22's Progress Note, dated 11/27/23 at 4:37 AM, documents R22 was admitted to the hospital with a diagnosis of Low Hemoglobin, a Dislocated Left Knee and Bilateral Femur Fractures. R22's ER notes, dated 11/27/23, document R22 was brought into the ER for bilateral knee pain, swelling and deformity after a fall at his nursing facility 2-3 days ago. Patient states he fell at the nursing home and the pain became worse today. R22's right femur x-ray showed a severely displaced fracture of the right proximal femur shaft. R22's left femur x-ray showed a severely comminuted distal femoral fracture with displacement. R22's left knee x-ray showed a severely comminuted and displaced distal femoral fracture with likely disruption of the knee joint. Discussed patient history, exam, and other pertinent info with orthopedic surgeon. He advises sending patient to an orthopedic trauma specialist at an outside hospital. Patient has been accepted and will be transferred to the outside hospital for further treatment. The Facility Investigation regarding R22's fractures, undated, documents the following: Interview with V14 conducted on 11/27/23 documents the resident was back from his family visit and took resident to his room to place him bed. She called out from the room for assistance because the resident went limp and passed out in the Sit to Stand Lift. The Interview documented V14, V16, RN (Registered Nurse) and V27, LPN (Licensed Practical Nurse) assisted and lowered R22 to the floor. The Interview documented a full mechanical lift was obtained and R22 was placed in the bed. Interview with V27, Agency LPN, conducted on 11/27/23, documents V27 came to the floor to talk with V16, and heard V14 call for help from R22's room. The Interview documented V27 immediately ran into the room and saw R22 hanging in the sit to stand lift in a fetal position. The Interview documented they immediately lowered R22 to the floor. Interview with V16, RN, conducted on 11/27/23, documents V14was putting R22 to bed and he went limp in the sit to stand lift, he R22 was very heavy so they lowered him to the floor. Interview with V25, LPN, conducted on 11/27/23, documents V25 stated that in report from the midnight nurse on 11/26/23, that the resident legs were swollen, and he was in pain. At 1:00 PM, V25 observed the left leg with bruising and swelling notified. V15, Nurse Practitioner (NP) called for an update on R22. At 10:22 PM, R22 wanted more over the counter (OTC) pain medication and V25 went into the room to assess R22. V15 was called because R22 had pain in his back and buttocks. V25 received order to transfer to the ER (emergency room ) for evaluation and treatment, Summary: Interview with staff and the CNA (V14). This CNA was suspended pending investigation related to the transfer. We cannot substantiate that the incident that occurred on 11/23/23 was the primary causative factor. (R22) has a history of chronic steroid use and has received injections prior to his nursing home admission. Being on prednisone for long period of time may predispose the resident to osteopenia which makes him prone to fractures. With the weight of (R22) and the transfer from the bed to the sit to stand, (R22) became limp. V14's Employee Suspension Form, dated 11/27/23, documents the following: Offense being investigated - Improper operation of community equipment that resulted in harm of team member, resident, or visitor; Date of alleged offense and a brief narrative of the events that led to the suspension: 11/23/23 - Improper transfer of resident using (sit to stand) lift by herself. On 11/30/23 at 9:10 AM V12, CNA, stated she had worked 6 AM - 2:30 PM on 11/23/23 and R22 was okay. V12 came back in and worked the night shift on 11/23/23 from 11:00 PM - 6:00 AM, R22 had his call light on, so she went into his room, and he told her that he did not faint, he was dropped by staff. V12 stated R22 was complaining of a lot of pain and didn't want to be touched. V12 stated she is not sure if he had any injuries because he was hurting and wouldn't let her touch him. V12 stated R22 needed some pain medication, so she let the nurse know. On 11/30/23 at 9:50 AM, V14, CNA, stated R22 had been passing out in the sit to stand mechanical lift off and on since admission. V14 stated on 11/23/23, unsure of exact time, she and V16, RN, were getting R22 ready for bed and was going to lay him down. V14 stated R22 was in the sit to stand mechanical lift and passed out so she had to spring to get the other CNA to ease R22 to the floor. V14 stated V16, RN, asked R22 if he was hurt, R22 stated yes, and he needed some pain medication. Stated she did not see V16, RN, do any other assessments on R22 and he was placed in the bed using a full mechanical lift. V14 stated she did not see any visible injuries to R22. V14 stated if R22 had injuries, he should have been sent out. V14 stated because R22 was passing out in the sit to stand, she wasn't sure why he wasn't made to use the full mechanical lift. V14 stated when they were transferring R22 on 11/24/23, he felt lightheaded, and they had to slide the full mechanical lift pad under him and use that lift. On 11/30/23 at 10:22 AM V15, Nurse Practitioner, stated she was sent a message through (communication application) on 11/23/23 that R22 had a syncopal episode in the sit to stand. V15 stated she had discontinued R22's Midodrine a couple of weeks earlier, so she gave orders to restart that. V15 stated she called the facility on Sunday, 11/26/23, during the day, to check in with all the units. V15 stated she talked to the nurse on duty for R22 and reminded her that R22 had been restarted on his Midodrine and the nurse did not report anything to her about R22's fall, any injuries or pain. V15 stated she got a text message that night from the on-call Physician stating R22 was sent to the hospital with his bone protruding. V15 sated they should have notified her or the Physician with any changes. On 11/30/23 at 11:20 AM V21, R22's Daughter, stated V17, R22's Wife notified her (V21) that R22 had fainted and was lowered to the ground and R22 immediately got on the phone and told her (V21) that they dropped him. On 11/30/23 at 11:20 AM V22, R22's Son, stated that the facility called V17, R22's Wife, on her cell phone and she was told that R22 fainted and was lowered to the floor but R22 said he was dropped. V22 stated R22 laid in his bed from Thursday night (11/23/23) until Monday morning (11/27/23). V22 stated the nurse on duty, unsure of name, communicated with V17 several times on 11/26/23 and R22 needed to be sent to the hospital. V22 stated R22 had bilateral fractured femurs with significant displacement and the bone was protruding from the skin. V22 stated R22 was kept at the local hospital for a couple of hours and was then sent to an outside hospital due to the extent of his injuries and they were worried that the femoral artery was damaged. V22 stated he was admitted to the outside hospital, has had significant blood loss, and required two surgeries with the orthopedic and vascular doctor and remains in ICU at the hospital. V22 stated on 11/23/23, R22 was with the family celebrating Thanksgiving and around 8:20 PM, R22 was taken back to the facility by an outside transportation company. V22 stated R22 had been back at the facility for a very short time before he had fallen. V22 stated R22 is adamant that he was dropped. V22 stated R22 had no ambulatory capacity and was unable to walk. V22 stated he is not sure why the facility was using the sit to stand lift if he couldn't stand. V22 stated R22 told him V14, CNA, was frustrated because the bed was not working. On 11/30/23 at 11:42 PM, V23, Certified Occupational Therapy Assistant (COTA) stated, We saw (R22) in October and at that time we evaluated him and for transfers we recommended a sit to stand. (R22) was able to stand at the parallel bars and was weight bearing. If a resident was hooked up properly to the sit to stand, they should not have been able to fall out of it. On 12/1/23 at 9:20 AM V23, LPN, stated she worked on 11/26/23 and sent R22 to the hospital. V23 stated when she came in for her shift, she was told by the night shift nurse that R22 needed his compression socks put on, but she couldn't get them on because his legs were so swollen. V23 stated the night nurse told her that R22 was lowered to the floor 3 days prior but was not on fall precautions because it wasn't a fall. V23 stated she assumed that he was being assessed for the bruising and edema and now they were just monitoring it. V23 stated early in her shift she went in to assess R22's legs and there was some edema and bruising noted. V23 stated R22 was complaining of pain in his back and butt and was given pain medication throughout the day. V23 stated she had just given R22 pain medication around 9:00 PM and R22 was asking for it again, this concerned V23, so she went and assessed R22 again and he was complaining of left leg pain. R22's left leg was so much worse about three times the size it was that morning and the left knee had a big knot that looked like it was protruding. V23 stated it was not there at the beginning of her shift. V23 stated it had been a few hours since she had seen it. V23 stated she called the physician on call and received new orders to send R22 to the hospital. V23 stated she did not notify the physician earlier in the shift because his condition hadn't changed until that night. The Immediate Jeopardy that began on 11/23/23 was removed on 12/2/23 when the facility took the following actions to remove the Immediacy: 1. On 12-1-23, The V1, Administrator, and V3, DON, were educated on the Fall Risk and Transfer Status and Safety when utilizing mechanical lifts and updating the care plan by the Regional Nurse, V4, to ensure the safety of the facility's residents. 2. The facility performed a whole house audit to ensure transfers status of all residents. This audit was performed by the Nursing Management Team consist of V3, V26, MDS Coordinator, V40, Care Plan Coordinator, V8 and V9, Infection Control Coordinators, and V18, Wound Care Nurse on 12-1-23. When there is a concern with the mode of transfer, the nurse along with the IDT team will reassess transfer status. This reassessment will occur with changes in conditions, quarterly and as needed. When a transfer poorly goes the nursing staff will notify the MD, POA and V3, V3/Designee of the occurrence. The nursing staff will consult the MD on the new mode of transfer. V3/Designee will notify the Therapy Dept to perform a screen. The IDT Team will update the new mode of transfer on the care plan and any changes will be communicated to the nursing staff from the V3/Designee immediately. The IDT Team consist of V3, DON, V1, Administrator, V2, Asst Administrator, V40, Care Plan Coordinator, V26, MDS Coordinator, V18, Wound Care Nurse, V8/V9, Infection Control Nurse, V41, Social Service Therapy. 3. On 12-1-23, The facility has assessed all residents fall risk. This audit was performed by the Nursing Management Team on 12-1-23. When there is a concern with the mode of transfer, the nurses along with the IDT Team will perform a reassessment if a change in condition occurs, quarterly or as needed. When a transfer poorly goes the nursing staff will notify the MD, POA and V3/Designee of the occurrence. The nursing staff will consult the MD on the new mode of transfer. V3/Designee will notify the Therapy Dept to perform a screen. The IDT Team will update the new mode of transfer on the care plan and any changes will be communicated to the nursing staff from the V3/Designee immediately. 4. On 12-1-23, The facility will ensure safety is utilized with the use of mechanical lifts through observational returned demonstrations and the residents' care plan have been updated accordingly. Nursing staff performed return demonstrations on 1-person, 2-person, sit to stand and Hoyer lift transfers on 12-1-23 and 12-2-23. These demonstrations were observed by the Nursing Management Team. These return demonstrations will be conducted Quarterly and as needed by the Nursing Management Team. I am concerned that in Section 4 they noted that they will be done 3 x weekly for 8 weeks. 5. On 12-1-23, The IDT Team and the ADHOC meeting with the V42, Medical Director was held, and the identified issues were discussed. During this time the following policies for Falls, Transfers and Mechanical Lifts were reviewed. At this time, it was determined that the facility would allege compliance as of 12-2-23 with the safety of all residents. Section 2 Other residents have the potential to be affected by the alleged deficient practice. Section 3 Systemic Changes to Ensure Compliance The IDT Team and the ADHOC committee reviewed the policies and procedures related to the use of the mechanical lift to ensure current practices are followed. This review occurred on 12-1-23. All nursing staff will be in-serviced on the following: Nursing staff (Licensed Nurses and Certified Nursing staff) was in-service by the V3/Designee on transferring the resident appropriately based on the resident mode of transfer. When there is a concern with the mode of transfer, the nurses along with the IDT Team will be performing a reassessment if a change in condition occurs immediately, quarterly, and as needed. This service in-service was performed by the V3/Designee on 12-1-23. Nursing staff was in-serviced by the V3/Designee on using the appropriate equipment to maintain safety of all residents. This will be communicated to all nursing staff through on and off shift report. This in-service was performed by the V3/Designee on 12-1-23. Section 4 V3, DON/Designee, will do observational audits 3x a week for 8 weeks to ensure that the resident mode of transfer is correct and appropriate transfer methods are being done to prevent falls. Any noted issues will be immediately addressed and reviewed in the QAPI process. The abatement plan was validated on 12/5/23. R20, R341, R33 and R75 were reviewed for falls, transfer status, fall risk and care plans with no concerns. The following staff were interviewed for validation that the in-servicing had been completed: V28, LPN/Travel Nurse Manager; V2, Assistant Administrator; V4, Regional Nurse; V3, DON; V30, CNA; V11, LPN; V12, CNA; V31, LPN; V27, LPN; V32, CNA; V19, CNA; V33, CNA; V34, LPN; V13, CNA; V34, LPN; V35, CNA; V36, LPN; V37, CNA, and V38, CNA. B. Based on interview and record review, the facility failed to ensure residents at risk for elopement were being adequately supervised in 1 of 2 residents (R74) reviewed for supervision to prevent elopement in the sample of 43. Findings include: R74's Face Sheet, undated, documents R74 has the following diagnoses: Alzheimer's disease, Cognitive Communication Deficit and Senile Degeneration of the Brain. R74's Minimum Data Set (MDS), dated [DATE], documents R74 has moderate cognitive impairment, is independent with ambulation and wanders daily. R74's Care Plan, dated 3/9/23, documents R22 is at risk for elopement/wandering due to a history of attempts to leave the facility unattended, impaired safety awareness and wanders aimlessly. R74's Elopement Assessment, dated 5/12/23, documents R74 is at risk for elopement. R74's Progress Note dated, 8/25/23 at 4:13 PM, documents the following: Resident is wandering from 3 South to 3 north trying to get on the elevator. Resident went through the emergency door on 3 north and went down the stairs. This writer was unable to redirect resident. He then went through the emergency door on 1 north. This writer was able to redirect him back inside. Resident is sitting in the dining area watching TV at this time. Will continue to monitor 9/2/2023 18:01 Resident has removed his wander guard. Resident continues to leave all and try to get on the elevator. Also going to 3 North try to go out the exit door. Resident becomes combative when you try too re-direct him. Will continue to monitor. R74's Progress Note, dated 9/5/23 at 10:33 AM, documents the following: Resident continues wandering and exit seeking behaviors. Requires redirection from entering peers' rooms. Easily redirected at this time. Wander guard not in place. Nurse Manager informed this writer that resident had removed his wander guard. R74's Progress Note, dated 9/10/23 at 12:20 PM, documents the following: CNA reported to this nurse resident had gone with activity assistant at approximately 10:30 AM to church. This nurse was then notified at approximately 12:00 PM that resident had not returned back from church. Building was searched thoroughly for resident's whereabouts. On call nurse was notified of not being able to locate resident at that time immediately. On call nurse stated administrator had been notified with proper procedures being conducted. R74's Progress Note, dated 9/10/23 at 4:00 PM, documents the following: Resident returned to facility at 3:45 PM, all assessments including Skin, Elopement, Neuros, fall, Pain, and SBAR being conducted per protocol. Resident denies any pain or discomfort. No injuries noted, skin intact per usual with dark purple bruising to upper extremities and reddened knees. 15-minute checks initiated. Resident pleasant and cooperative with care. The Facility Investigation documents the following: Final report 9/10/23 - On 9/10/23 at approximately 12:00 PM a family member reported to staff that they had seen R74 walking down the street. Staff members went out searching. Police department was notified. Next of kin and physician were notified. R74 was found at approximately 3:30 PM. R74 was found still on the property on the west edge. R74 stated he was trying to go to the bank and that he knew they were searching for him, but he was trying to hide R74 was assessed and found to have no injuries. R74 had been in the chapel for church services. Staff were assisting residents back to their respective neighborhoods when R74 left by crossing over the building to the independent living side and exiting the building. R74 walked down the sidewalk west on F Street then turned right, toward Catawba Avenue. R74 was found sitting off the right side of the road. R74 had his wander guard on when he returned, and it was functioning. Chronological events per V10, Activity Aide: 9/10/23 at 10:45 AM, church started and V10 went to get residents for church. R74 walked with her to the chapel; 11:15 AM, church was over and V10 took another resident to their room, R74 was sitting in the chapel talking to other residents; 11:23 AM, V10 returned to the chapel, noticed R74 was gone, V10 checked the bathroom next to the chapel and didn't see him, so she checked 2 north and 2 south and did not see him; 11:50 AM, V10 went to kitchen and asked if they saw R74; 11:55 AM, V10 went to 3 south and 3 north and asked if they saw him or not or if he was in his room; 12:00 PM, V10 checked 1 south and 1 north and did not see him; 12:05 PM, V10 went to front desk and walked around the building and didn't see him so then she walked to the police station and looked inside and did not see R74. On 11/30/23 at 9:10 AM, V12, CNA, stated R74 wanders and tries to escape all the time. V12 stated he is not allowed off of the unit by himself. On 11/30/23 at 10:22 AM, V15, Nurse Practitioner, NP, stated R74 is at risk for elopement and has no safety awareness. On 12/05/23 at 9:28 AM, V3, Director of Nursing, DON, stated she would expect staff to assess residents after a fall and provide the necessary care and treatment, and provide adequate supervision/monitoring for residents at risk for elopement. The Elopement Policy, dated 5/2023, documents it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. C. Based on interview and record review the facility failed to assess for causative factors related to residents' falls and implement progressive interventions based upon this assessment for 5 of 11 residents (R39, R45, R52, and R69) reviewed for falls in the sample of 43. Findings include: 1. R39's Face Sheet, undated, documents R39 has the following diagnoses: Repeated Falls, Trans-Ischemic Attack (TIA), Alzheimer's Disease and Vascular Dementia. R39's Minimum Data Set, MDS, dated [DATE], documents R39 is severely cognitively impaired and has a history of falls. R39's Fall Risk Assessment, dated 10/17/23, documents R39 is at high risk for falls. R39 did not have a Care Plan addressing his fall risk or interventions to prevent falls. R39's Progress Note, dated 9/14/23 at 5:09 PM, documents R39 was observed on the floor by the bed. Vital signs were within normal limits (WNL). When asked what happened, R39 stated he was trying to get into bed. Denies hitting his heads. Neuro checks started due to fall being unwitnessed. Family and MD made aware. There was no documentation in R39's progress note that a new intervention was implemented to prevent further falls. R39's Progress Note, dated 10/12/23 at 12:55 AM, documents the evening CNA reported to the nurse that during her last round R39's arm was bleeding from a fall he had earlier on the evening shift around 6:00 PM or 6:30 PM. When nurse went to check on the resident, two skin tears with bruising were noted to the right arm side by side just above the elbow. Both areas were cleansed with wound cleanser. Resident stated he was not having any pain at this time. POA and MD notified of findings. Will continue to monitor. There was no documentation in R39's record of the fall that allegedly occurred on the evening shift, the root cause of the fall was identified or that a new intervention was implemented to prevent further falls. 35156 2. R52's Physician Order Sheets (POS) dated November 2023 documents diagnoses of Multiple Sclerosis, Myocardial Infarction, Hypertension, Pressure Ulcer of Sacral Region, Pressure Ulcer of Right Heel, Pressure Ulcer of Sacral Area, Pressure Ulcer of Right Buttock, Right Heel, Need for Assistance with Personal Care, Pressure Ulcer of Left Heel. R52's Fall Risk assessment dated [DATE] at 1:58 PM, document R52 was High Risk for falls. R52's Nurse's Notes dated 9/12/2023 at 1:42 PM, Resident was yelling and was found lying on his back was on the floor and lower half on bed. This nurse assessed resident with no injuries noted. Resident complained lower abdominal pain, will not let this nurse palpate. Resident is more confused today than normal. R52's Care Plan dated 9/12/2023 intervention for R52's fall was documented as Resident sent to ED (Emergency Department) for evaluation of fall. No other intervention for R52's fall for 9/12/2023 was documented. R52's Follow up Report documents, Resident sustained fall on 9/12/2023. No injuries noted. Observed on floor in room. Root cause of fall may be attributed to the following diagnostic weakness, muscle wasting and atrophy, multiple sclerosis. Immediate intervention-send to ED, Emergency Department for evaluation. Care Plan updated and followed. 3. R69's Face sheet dated 5/13/2023 document diagnoses of wedge Compression Fracture of Second Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Alzheimer Disease with Early Onset, Unspecified Dementia, Unspecified Severity, with Psychotic Disturbances, Alzheimer Disease And Anxiety. R69's Care Plan documents, R69's daughter is her POA (Power of Attorney) for healthcare and is assisting with decision making related to (R69's) memory deficits. The resident has impaired cognitive function/dementia or impaired thought process. R69's Minimum Data Set (MDS) dated [DATE] document R69 was severely impaired for cognition for activities of daily living. R69's Behavior Note dated 5/1/2023 at 12:07 AM, Note Text: resident still up after midnight, wandering the hall, reaching over the nurses' desk, very confused, staff attempted several times to get resident to go to bed, resident refusing and continuing to wander. R69's Nurse's Notes dated 5/1/2023 at 152 AM, Note Text: resident still up wandering the hall, attempting to go into other residents' rooms, resident is not able to be redirected at this time. R69's Nurse's Notes dated 5/1/2023 at 10:25 PM, Note Text: Resident was in another resident room trying to get into the floor on right side. Hematoma to mid/right side forehead. (Right forehead). Unwitnessed. R69's Fall Report dated 5/1/2023 documents, Resident was in roommates room trying to get into recliner and fell on to floor on right side, moves all extremities WNL (within normal limits) upon assessment hematoma noted to middle/right side of forehead. This nurse and CNA helped resident back to her bed. Intervention: Care Plan documented Staff to ensure resident is ready for bed and in bed before shift change. This intervention did not address that R69 has a history of wandering throughout the night and does not wish to go to bed. On 12/1/2023 at 10:28 AM, V26, Care Plan Licensed Practical Nurse (LPN)/MDS Coordinator stated, Our former Care Plan person is no longer here. We reviewed all falls as a team, and I would expect appropriate interventions to be added to all Care Plans. I am not sure what happened but hopefully now that we have new staff members, we can address those things properly and make sure all interventions moving forward are carried over. 33110 4. R45's Electronic Health Record dated 11/10/21 documents R45 had diagnoses of Alzheimer's Disease. R45's Electronic Health Record dated 3/14/23 also documents R45 has a diagnosis of Vascular Dementia. R45's Fall Risk Data Collection dated 9/29/23 documents R45 is low risk for falls. R45's Fall Risk Data collection dated 11/11/23 documents R45 is high risk for falls. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired. R45's Care Plan, dated 10/6/23, documents R45 will be free of injury through the next review date. R45's interventions are ensuring proper visual aides are available to support (R45) participation in activities. Ensure R45's glasses are clean and in good working condition. R45's Fall Investigation dated 1/24/23 documents resident was on the floor laying on her back by the bathroom door a small bump and bruise on the back of her head. R45's Care Plan was not revised with a progressive intervention to prevent her from potential future falls after she fell on [DATE]. R45's Fall investigation dated 3/2/23 documents (R45) found by CNA (Certified Nursing Assistant) sitting on floor next to the toilet in her room Resident said that she was trying to get back into her wheelchair. R45's Care Plan was revised on 3/3/23 with initiation of intervention on 3/2/23 and documented Increase frequency of checks on reside while she is in her room. R45's Care Plan was updated on 3/6/23 with another intervention anti-roll backs on wheelchair. R45's Fall Investigation dated 3/17/23 documents resident fell trying to transfer herself to the recliner. R45's Care Plan was revised on 3/17/23 with intervention Be sure (R45's) call light is within reach and encourage the resident to use it. R45's Fall Investigation dated 5/27/23 documents resid [TRUNCATED]

Based on interview and record review, the facility failed/neglected to prevent abuse/neglect for 4 of 5 residents (R22, R29, R53, R69) reviewed for abuse/neglect in the sample of 43. This failure resulted in R22 not being assessed timely and provided care and treatment after sustaining a fall that resulted in two fractured femurs and a dislocated knee. This failure also resulted in R53 being abused by an employee, with bruising, bleeding, and pain to her lower leg. Findings Include: 1. R22's Face Sheet, undated, documents R22 has the following diagnoses: Rheumatoid Arthritis, Weakness, Bilateral Osteoarthritis of the Knees and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact and is dependent with transfers. R22's Care Plan, dated 8/17/23, documents R22 is at risk for falls. R22's Progress Note, dated 11/23/23 at 8:30 PM, documents R22 was being assisted to bed with two Certified Nursing Assistants, CNAs, per sit to stand mechanical lift, staff was unable to raise R22's bed, and R22 passed out and was lowered to the floor. R22's Progress Note, dated 11/26/23 at 5:08 AM, documents R22 was given pain medication during the night for pain. The Progress Note documents R22's legs were edematous, and the left knee area was bruised from the fall. R22 had difficulty moving his left leg. There is no documentation that the Physician was notified of R22's change in condition. R22's Progress Note, dated 11/26/23 at 10:15 PM, documents R22 was complaining of pain to his buttocks and back throughout the day with several needs for pain medication. V15, Nurse Practitioner, called the facility and an update on R22's condition, increased edema and bruising to the knee. R22's Progress Note, dated 11/26/23 at 10:37 PM, documents upon assessment of R22's left leg, it has had a significant change with increased swelling, abnormal coloring, and increased pain. Physician exchange notified, awaiting response. R22's Progress Note, dated 11/26/23 at 10:51 PM, documents the nurse spoke with the on-call Physician and a new order was obtained to send to the local ER (emergency room ) for evaluation and treatment. R22's Progress Note, dated 11/27/23 at 4:37 AM, documents R22 was admitted to the hospital with a diagnosis of low hemoglobin, a dislocated left knee and bilateral femur fractures. R22's ER Note, dated 11/27/23, document R22 was brought into the ER for bilateral knee pain, swelling and deformity after a fall at his nursing facility 2-3 days ago. Patient states he fell at the nursing home and the pain became worse today. R22's right femur x-ray showed a severely displaced fracture of the right proximal femur shaft. R22's left femur x-ray showed a severely comminuted distal femoral fracture with displacement. R22's left knee x-ray showed a severely comminuted and displaced distal femoral fracture with likely disruption of the knee joint. Discussed patient history, exam, and other pertinent info with orthopedic surgeon. He advises sending patient to an orthopedic trauma specialist at an outside hospital. Patient has been accepted and will be transferred to the outside hospital for further treatment. On 11/30/23 at 9:10 AM V12, CNA, stated she had worked 6 AM - 2:30 PM on 11/23/23 and R22 was okay. V12 came back in and worked the night shift on 11/23/23 from 11:00 PM - 6:00 AM, R22 had his call light on, so she went into his room, and he told her that he did not faint, he was dropped by staff. V12 stated R22 was complaining of a lot of pain and didn't want to be touched. V12 stated she is not sure if he had any injuries because he was hurting and wouldn't let her touch him. V12 stated R22 needed some pain medication, so she let the nurse know. On 11/30/23 at 9:50 AM, V14, CNA, stated R22 had been passing out in the sit to stand mechanical lift off and on since admission. V14 stated on 11/23/23, unsure of exact time, she and V16, Registered Nurse, were getting R22 ready for bed and was going to lay him down. V14 stated R22 was in the sit to stand mechanical lift and passed out so she had to spring to get the other CNA to ease R22 to the floor. V14 stated V16, RN, asked R22 if he was hurt, R22 stated yes, and he needed some pain medication. V14 stated she did not see V16 do any other assessments on R22, and he was placed in the bed using a full mechanical lift. V14 stated she did not see any visible injuries to R22. V14 stated if R22 had injuries, he should have been sent out. On 11/30/23 at 10:22 AM V15, Nurse Practitioner, stated she was sent a message through (communication phone application) on 11/23/23 that R22 had a syncopal episode in the sit to stand. V15 stated she had discontinued R22's Midodrine a couple of weeks earlier, so she gave orders to restart that. V15 stated she called the facility on Sunday, 11/26/23, during the day, to check in with all the units. V15 stated she talked to the nurse on duty for R22 and reminded her that R22 had been restarted on his Midodrine and the nurse did not report anything to her about R22's fall, any injuries or pain. V15 stated she got a text message that night from the on-call Physician stating R22 was sent to the hospital with his bone protruding. V15 sated they should have notified her or the Physician with any changes. On 11/30/23 at 11:20 AM V21, R22's Daughter, stated V17, R22's Wife notified her (V21) that R22 had fainted and was lowered to the ground and R22 immediately got on the phone and told her (V21) that they dropped him. On 11/30/23 11:20 AM V22, R22's Son, stated that the facility called V17, R22's Wife, on her cell phone and she was told that R22 fainted and was lowered to the floor but R22 said he was dropped. V22 stated R22 laid in his bed from Thursday night (11/23/23) until Monday morning (11/27/23). V22 stated the nurse on duty, unsure of name, communicated with V17 several times on 11/26/23 and R22 needed to be sent to the hospital. V22 stated R22 had bilateral fractured femurs with significant displacement and the bone was protruding from the skin. V22 stated R22 was kept at the local hospital for a couple of hours and was then sent to an outside hospital due to the extent of his injuries and they were worried that the femoral artery was damaged. V22 stated he was admitted to the outside hospital, has had significant blood loss, and required two surgeries with the orthopedic and vascular doctor and remains in ICU (intensive care unit) at the hospital. 2. On 11/30/23 at 9:15 AM R53 stated she got into a fight with V5, Former CNA. R53 stated she (V5) was standing up and I (R53) was in my wheelchair. R53 stated she is not sure who kicked who first, but she thinks V5 kicked her first. R53 stated V5 kicked her in the right shin, and she had bruising and a bump from it. V5 stated it hurt for a few days. R53 stated the nurse fired V5 and she hasn't been back. R53's Minimum Data Set (MDS), dated [DATE], documents R39 has moderate cognitive impairment. R53's Progress Note, dated 7/17/23 at 8:00 PM, documents the following: This nurse arrived back to the floor on 3 south to find (R53) sitting in room with (R37). R53 had her leg elevated on a chair with a wet towel on the top of her shin. When (R53) was asked what happened, she stated a CNA (V5, Former CNA) kicked her in the leg because she was mad and (R53) went into the kitchen area after being told she could not enter the kitchen due to the floor being wet. V5 was not on the floor when the nurse arrived. Call placed to the DON (Director of Nurses). Message sent to the MD and Nurse Practitioner. Call placed to POA. Range of motion (ROM) not performed due to resident complaints of pain, bleeding and swelling to the shin. The Facility Abuse Investigation documents the following: Incident date of 7/17/23 at 8:00 PM, it was reported that V5, Former CNA, had allegedly kicked R53 in the shin after R53 kicked V5. V5 was immediately suspended pending investigation. R53 was assessed and found to have bleeding and swelling from the shin. MD notified and a treatment was applied. All required notifications have been made, including local law enforcement. A thorough investigation has been completed. V5 denies kicking R53. R53 reports that she kicked V5 first and then V5 kicked her back. This incident was witnessed by R37, who corroborates R53's version of the story. The incident was not witnessed by any other residents or team member. The local police department was asked to come out to investigate. The officer indicated that he did not believe any charges would be brought against V5 since R53 admitted to having kicked her first. The officer indicated that this would then move the situation into an area of self-defense rather than elder abuse. While the local police department found the incident to be self-defense, the facility chose to terminate the employment of V5. Statement given by R37, dated 7/17/23, R37 stated that she and R53 was sitting in their wheelchairs and R53 attempted to go into the kitchen from the dining room for a drink and was forcefully pushed out of dining room by V5 and V5 told R53 she could not go into the kitchen because it was wet. R53 attempted to go into the kitchen a second time and was again pushed forcefully out by V5. After the 2nd push, R53 kicked V5 because that was all she could do and V5 kicked R53 back. V5 had shoes on and R53 only had socks on. That is what started it and they were going back and forth and kicking and yelling. After a while R37 told R53 that was enough, and they stopped. R53 came to R37's room and R53's leg was bleeding, and she (R37) gave R53 a wet towel and dry towel for her leg. Written statement by V5, dated 7/17/23, documented I was sitting in the dining room and (R53) was going into the kitchen while the kitchen lady was cleaning. I told both of them to come out of there. (R53) kept rolling up on me kicking me as I asked her to stop several times and she continued to keep doing it, calling me out of my name. I then walked and got my water bottle and went to my car. Written statement by V7, RN (Registered Nurse), dated 7/17/23, at approximately 8:00 PM, V7 found R53 sitting with her leg elevated on a chair and R37 applying a wet washcloth to R53's right lower extremity, shin area. When asked what happened, R53 stated she was kicked in the leg by V5. V5 was not on the unit when V7 arrived. When the washcloth was lifted, V7 found a large gray/white hematoma the size of an adult fist and the area was bleeding. R53 states pain at site. Leg kept elevated and intermittent ice applied to area. V5 was outside on parking lot and was asked to leave the facility related to abuse allegation. R53 statement, dated 7/17/23, I (R53) was taking a spoon and coffee into the kitchen so it could be washed for the next morning and V5 yelled at her and told her to get out of the kitchen and I (R53) told her I am only taking this cup into the kitchen it's no big deal. She (V5) kept yelling saying the floor was wet. V5 forcibly tried to get her (R53) wheelchair out of the kitchen. V5 tried to push her chair and I (R53) had her hands on the wheels and told her she did not need to push me out. V5 came out of the kitchen, and I (R53) started kicking her (V5), with my foot on her upper leg with my right foot and I (R53) could not kick her hard because I (R53) don't have the strength. They kicked back and forth about 2-3 times then R53 left. R53 waited until V7 got back and told her what happened. On 11/30/23 at 11:23 AM, R37 stated R53 was kicked by a female employee, unsure of her name, a few months back. R37 stated she doesn't recall the exact details of what happened, but she told them to stop. R37 stated she brought R53 back to her (R37) room and placed a towel on R53's leg because it was bleeding. On 12/05/23 at 9:28 AM V3, Director of Nursing (DON), stated she would expect staff to follow the abuse policy and refrain from abusing any resident. V3 stated she would expect staff to provide the care and services necessary for the resident. Abuse, Prevention and Prohibition Policy, dated 11/2018, documents Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Policy documents The facility prohibits mistreatment, abuse, or neglect. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The Policy documents Neglect means failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. 35156 3. R69's Face Sheet dated 5/13/2023 documents R69 has diagnoses of Wedge Compression Fracture of Second Lumbar Vertebra, Subsequent Encounter for Fracture With Routine Healing, Alzheimer Disease With Early Onset, Unspecified Dementia, Unspecified Severity with Psychotic Disturbances, Alzheimer Disease and Anxiety. R69's Care Plan, initiation date of 10/12/22, documents, R69's daughter is her POA (Power of Attorney) for healthcare and is assisting with decision making related to (R69's) memory deficits. The resident has impaired cognitive function/dementia or impaired thought process. R69's Minimum Data Set (MDS) dated [DATE] document R69 was severely impaired for cognition for activities of daily living. R69's Nurse's Notes dated 5/13/2023 (Saturday) at 12:17 AM, documents was slapped/punched in the face by another resident, POA (Power of Attorney), notified skin assessment performed, pain assessment performed. On 11/29/2023 at 2:29 PM, V7, Registered Nurse stated, I did not witness the incident. I was called over to the floor that day because of the incident. It was reported to me by (V6, CNA) that (R69) was just sitting in her chair across from the nurse's station and the other resident (R29) just walked up to her and punched her in the face. Both residents were on the dementia unit. There was an agency nurse working that day and the agency nurse was not familiar with the residents, so they called me over. I did an assessment on (R69). Poor thing. I can only imagine how she must have reacted to the situation. R69's Incident Report, dated 5/13/2023 at 12:08 AM, Resident to Resident Altercation, documents On 5/13/2023 at 12:07 AM, on the Memory Care Unit, resident (R29) entered (R69's) room. (R29) made a statement about (R69) sleeping with her husband and struck her. (V6) was in the room providing care to another resident, they were able to immediately intervene and redirect (R29) out of the room successfully. Assessment completed indication no injury or pain. All required notifications completed. Full medical work up completed by NP (Nurse Practitioner) along with the medical review and lab work. Lab results indicted abnormal urine. Antibiotic treatment was started. No further issues noted. Both residents remain at baseline with no signs of distress noted. SSD (Social Service Director) following up routinely. Statement by V6, Certified Nursing Assistant (CNA) dated 5/13/2023 documents, I was doing care on patient and another resident hit the patient during care. I then verbally told the combative resident to exit which she did. Statement by V7, Registered Nurse (RN), undated documents CNA made me aware, CNA told me of witnessed incident between two residents. R29's Face sheet documents diagnoses of Alzheimer disease with late onset, unspecified dementia, unspecified severity, without behavior disturbances, mood disturbances, and anxiety. Vascular dementia, and anxiety. R29's MDS dated [DATE] documents R29 was severely impaired for cognition. R29's Care Plan documents, The resident has impaired cognitive function/dementia or impaired thought process related to Alzheimer, and dementia. R29's Nurse's Notes dated 5/13/2023 at 12:12 AM, documents, Late Entry, called to unit by CNA who witnessed resident follow her into a room which she was providing care and punch/slap another resident of whom she states was sleeping with her husband. Executive Director, DON (Director of Nursing), on call nurse notified of occurrence.

Based on observation, interview, and record review, the facility failed to assess and monitor pressure ulcers, ensure pressure ulcer treatments/services are administered per standards of practice and orders are administered per physician's orders (PO) for 1 of 7 residents (R8) reviewed for pressure ulcers in the sample of 40. This failure resulted in R8's unstageable pressure ulcer to right buttocks/thigh worsening and becoming infected. Findings include: R8's Face Sheet documents R8 was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region: Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining and tunneling) pressure ulcer, moderate protein-calorie malnutrition, Alzheimer's disease, muscle weakness, unspecified abnormalities of gait (ambulation) and mobility, and need for assistance with personal care. R8's Care Plan dated [DATE] documents, R8 has actual impairment to skin integrity r/t (related to) (nothing else listed). R8's Care Plan Interventions document to administer treatments as ordered and monitor for effectiveness. R8's Revised Care Plan, dated [DATE] documents, R8 has actual impairment to skin integrity r/t (related to) being admitted with need of assist with ADLs (activities of daily living), transfers and meals. admitted stage 4 pressure ulcer to coccyx. R8 is currently on IV (intravenous) ABT (antibiotic) for osteomyelitis (infection in the bone) to wound. V11 (R8's daughter) involved with care and assist with teaching on wound care. R8's Care Plan documents Interventions: avoid shearing while repositioning when in bed use assist, educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage good nutrition and hydration in order to promote healthier skin, float heels while in bed as tolerated, inform the resident/family/caregivers of any new area of skin breakdown, low air mattress: check for placement and function every shift, monitor dressing to coccyx when providing care to ensure it is intact and adhering, report lose dressing to nurse, supplements to promote wound healing, teach the resident/family/caregiver to avoid risks for skin injury and decreased circulation, the resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. R8's medical record documents R8 was being seen by a Consultant Wound Physician for the Stage IV sacral pressure ulcer beginning in [DATE]. R8's Physician Order, dated [DATE], documented she was admitted to Hospice Care. R8's Minimum Data Sheet (MDS) dated [DATE] documents R8 is severely cognitively impaired and requires extensive 2+ person assistance with bed mobility and transfers. The MDS documents R8 is incontinent of bowel and bladder and is at risk for developing pressure ulcers. The MDS documents R8 had a Stage IV pressure ulcer present upon admission. R8's Revised Care Plan, dated [DATE], documents that R8 has actual impairment to skin integrity r/t being admitted with need of assist with ADLs, transfers, meals. admitted stage 4 pressure ulcer to coccyx. R8 is currently on IV ABT for osteomyelitis to wound. V11 (R8's daughter) involved with care and assist with teaching on wound care. Continue for preventive/Unstageable right buttock wound. Intervention documented: use pillows/wedges for repositioning. R8's Physician's Order Sheet (POS) dated [DATE] through [DATE] documents weekly skin assessment every Thursday evening. R8's medical record had no documented weekly skin assessments from facility staff from [DATE] through [DATE], although R8 had a Stage IV sacral ulcer. R8's Consultant Wound Physician's Note, dated [DATE], documents R8 had a right buttock pressure wound. The Note had no documentation/description in the section Wound type. The Note documented the wound measured 4.5 centimeters (cm) by (x) 6.5 cm x 0.1 cm depth. The Note document the wound had moderate drainage present. The Note documented that the Treatment was Calcium Alginate and honey. R8's Physician's Order (PO), start date of [DATE], documents Cleanse areas rt. (right) lower buttock with wound cleanser. Apply thin layer of medihoney to wound bed, cover with calcium alginate and dry dressing. Change daily and PRN (as needed) every day shift. R8's [DATE] Treatment Administration Record (TAR) had no documentation that R8 received the treatment to right buttock on ,d+[DATE] and [DATE]. R8's [DATE] TAR had no documentation that R8 received the treatment to R8's Right Buttock on ,d+[DATE] and [DATE]. R8's Consultant Wound Physician's Note, dated [DATE], documents R8's right buttock wound measuring 2.0 cm x 7.8 cm x 0.1 cm. The note documented the wound type as MASD (incontinence-associated dermatitis, perspiration, drainage). R8's Consultant Wound Physician's, dated [DATE], documents R8's right buttock wound description was now Trauma. The Note documented the measurements as 4 cm x 3.8 cm x .5 cm. The Note documented 40% slough (non-viable yellow, tan gay, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture). The Note documented treatment of 0.125% NaClO (Dakin's solution) moist gauze light pack or Vasche (wound cleanser solution). R8's PO, dated [DATE], document to cleanse areas rt (right) lower buttock with Dakins or Vashe, lightly pack wound bed with Vashe or Dakin's moistened gauze, cover with dry dressing. Change daily and prn every day shift. R8's [DATE] TAR had no documentation that R8 received this treatment on [DATE]. R8's Consultant Wound Physician's Note, dated [DATE] documents right buttock wound measuring 3 cm x 3 cm x 0.3 cm. On this Note, the wound type was documented as MASD. The Note documented 30% slough. R8's Consultant Wound Physician's Note dated [DATE] documents right buttock wound measuring 2 cm x 4 cm x 1 cm. The Note documented the wound type as pressure and unstageable. The Note documents the pressure ulcer was 70% neurotic (dead tissue). The Note documented, Needs wound culture order for Monday morning (right buttocks). R8's Significant Change MDS dated [DATE] documents, R8 is incontinent of bowel and bladder, is at risk for developing pressure ulcers, and has one unstageable pressure ulcer that was not present upon admission. R8's Wound Physician's Note dated [DATE] documents right buttock wound measuring 3 cm x 8 cm x 2 cm. and the wound type documented as pressure. R8's Progress Note, dated [DATE] at 8:35 PM, documents, Wound culture result received this PM with moderate growth of Enterococcus faecalis, and light growth of Streptococcus agalactiae-Grp B. MD (physician) and wound physician made aware. New order obtained to start resident on Augmentin ,d+[DATE] milligrams (mg) BID (twice a day) x 7 days for wound infection. CBC/CMP/Pre-Albumin to be drawn on [DATE]. POA informed of wound culture results and new orders. POA is in agreement with plan of care. There were no further Consultant Wound Physician's Notes in R8's medical Record after [DATE]. The facility's Skin Check Weekly & PRN (as needed) Note, dated [DATE], documents R8 had an unstageable pressure ulcer on the right buttock measuring 3 cm x 8 cm x2 cm with 50% slough and 50% granulation. The Note documented the treatment as to pack with Dakins and cover with dd (dry dressing) daily and prn. R8's PO, start date [DATE], documents Cleanse Right buttock wound cleanser, pat dry. Apply collagen and Calcium Alginate. Cover with foam dressing every day shift for wound care. R8's [DATE] TAR has no documentation that R8 received the treatment on [DATE]. R8's Skin Check Weekly & PRN Notes dated [DATE] documented no new changes this week. R8's Skin Check Weekly & PRN Note, dated [DATE] documented Right posterior thigh: 4 (cm) x 7.4 (cm) x 3 cm, heavy yellow-brown and wet slough covering 95% of wound bed, moderate serosanguineous drainage noted. The Note documented no new changes this week. R8's TAR dated [DATE] through [DATE], documents physician's treatment order to treat the pressure ulcer on R8's right gluteal fold/right posterior thigh. R8's Physician Order, start date [DATE], documented Cleanse with NS (normal saline) and hibiclens [sic], rinse with NS, pat-dry and apply thin layer of Santyl to wound bed, then cover with cut-to fit calcium alginate to wound bed. Cover with Dry dressing daily and PRN for soiling/loosening. One time a day for Wound Care. R8's [DATE] TAR treatment, with start date of ,d+[DATE] and discontinued date of [DATE], documented Right posterior thigh: cleanse with NS (normal saline) and hibiclens [sic], rinse with NS, pat-dry and apply thin lay of Santyl to wound bed, then cover with cut-to-fit calcium alginate to wound bed. Cover with dry dressing daily and PRN for soiling/loosening. One time a day for Wound Care. R8's TAR has no documentation that R8 received this treatment on ,d+[DATE] or [DATE], ,d+[DATE], and ,d+[DATE] although R8's PO (Physician Order) was not written until [DATE]. On [DATE] at 11:45 AM V8 (Certified Nurse Aide/CNA) and V4 (Wound Nurse) entered R8's room and explained to her that they were going to change her dressings. V4 removed the dressing from R8's sacral pressure ulcer. V4 then removed the dressing from R8's right thigh. Immediately after removing the dressing, there was a very foul odor coming from R8's thigh pressure ulcer. The pressure ulcer bed was pink but had some yellow slough present. V4 then hand sanitized after removing the dressings and donned new gloves. V4 cleansed both areas with normal saline. She removed her gloves and used hand sanitizer. V4 donned new gloves and applied Santyl and Ca Alginate to R8's thigh pressure ulcer wound bed and covered with a dry dressing. V4 hand sanitized again and donned new gloves. V4 did not cleanse R8's thigh pressure ulcer with Hibiclens during the observation of pressure ulcer treatment per order. On [DATE] at 11:52 AM, V4 (Wound Nurse) stated R8 was on Augmentin (antibiotic) from [DATE] to [DATE]. R8's family wants to give another round of antibiotics. We are planning to culture wound today. V4 stated R8's daughter (V11) requested to do the dressing changes when she is here and was doing them prior to when I started here. On [DATE] at 1:45 PM, V4 (Wound Nurse) stated, We are walking a fine line between curative and palliative care. If we order the wound culture, they (Hospice) will consider it curative rather than palliative and it will not be covered by insurance. R8's family are not able to pay out of pocket for it, so they don't want it. Hibiclens was ordered but not used for dressing change. V4 stated she ran out of it on [DATE]. V4 stated it's supposed to be delivered to the facility on [DATE]. When questioned regarding V11 completing the treatments for R8, V4 responded R8's daughter (V11) is a wound nurse, an LPN (Licensed Practical Nurse), I believe. She is not currently working in the medical field. I have not asked to see her license. On [DATE] at 3:34 PM, V2 (Director of Nursing /DON), stated, All I know is the nurse's do the dressing changes. I was not aware the daughter was changing any dressings here, and I do not think she is a nurse. If I had known a family member wanted to change dressings, I would have gotten an order and gone about the proper documentation. On [DATE] at 10:07 AM, V2 (DON) stated, The previous wound nurse said she and the wound doctor showed (R8)'s daughter how to do dressing changes with return demonstration. If the doctor does change the order, the nurse should be there with them, and the nurse would sign off that the dressing was done. R8's Progress Note dated [DATE] at 8:13 AM documents, Late entry [DATE]: This nurse spent time with daughter (V11, R8's Daughter), educating her on wound treatment to coccyx. Daughter was able to return demo and verbalized understanding of wound care to coccyx. On [DATE] at 10:07 AM, V2 stated, There are no wound reports (from Wound consultant physician) after [DATE] because the family does not want R8 to be seen by him anymore. The family just wants her followed by the wound nurse. The previous wound nurse said she and the wound doctor showed R8's daughter how to do dressing changes with return demonstration. If the doctor does change the order, the nurse should be there with them, and the nurse would sign off that the dressing was done. On [DATE] at 12:17 PM, V2 stated I would expect staff to follow physician orders for treatments. If we have done some teaching with the family member, we should be able to do the wound treatment. Family members who have preference we have to obey their wishes, but it is not best practice. I would expect family members to be retrained if the orders change. I would expect them to be documenting each time orders change, because how else would the family member know. The expectation would be we educate, someone is there each time, and ensure proper documentation. As of [DATE] at 11:17 AM, the Illinois Department of Financial and Professional Regulation License Lookup documents V11's, Licensed Practical Nurse/LPN, license expired on [DATE]. On [DATE] at 11:40 AM, V2 stated, Skin checks should be done weekly and documented on the weekly skin assessment. If there is an issue, it should be documented, and the physician and wound nurse will be notified. The right gluteal wound popped up in [DATE]. R8 had a specialty wound physician assessing her coccyx pressure ulcer in [DATE] but the specialist didn't assess the right gluteal fold wound until [DATE] and that's when he started documenting the wound assessments. On [DATE] at 2:06 PM, V11 (R8's daughter) stated, I started changing my mom's dressings because they were not being done in a timely manner. There were several days there were no dressings on, and I could tell some days they were not being changed. The Facility did not provide any documentation that V11 was trained after right buttock wound developed or after subsequent orders were changed. On [DATE] at 3:00 PM, V2 stated, There are no weekly skin checks documented for ,d+[DATE]. When staff document the weekly skin assessment was completed, she expects to be able to find the skin assessment in the resident's electronic medical record, but they are not there. The physician's order dated [DATE] through [DATE] was for R8's left leg/buttocks not her right buttocks she didn't know what staff were treating because she was not working at the facility at that time, but she expected staff to document what the wound/skin breakdown was in the nurse's notes and to notify the physician when a new skin wound was initially identified and include in the assessment the size of the wound, wound bed description, drainage and if there was odor and get a wound treatment order from the physician as soon as possible. V2 also didn't know what was on R8's right gluteal fold/right upper posterior thigh on [DATE] through [DATE]. V2 was certain that R8's right gluteal fold wound was not assessed by staff until [DATE] and that was by the specialty wound physician. On [DATE] at 11:58 AM, V9 (Medical Director) stated, I expect wound treatments to be administered as ordered, and they should be documented in the resident's treatment administration record. I have not seen V11 (R8's family) changing her dressing, but she should not be doing that. Hygienically, we don't know if good practices are being followed or even where the wound supplies are coming from. It should be the wound doctor or wound nurse or an experienced nurse doing the dressing changes. If there is an odor coming from a wound, they should be informing us, the provider, so we can order labs and cultures. The NP (Nurse Practitioner) is currently on maternity leave, but she was previously here 5 days a week, so this should have been communicated. The wound needs to be clean because it is a constant source of infection. Perhaps she needs a rectal tube to keep the wound clean and dry. I would expect weekly skin assessments to be completed. I cannot say whether weekly skin checks would have found the wound sooner. The right gluteal wound is classified as an unstageable pressure ulcer. One time I was here and V11 had R8 sitting up in her wheelchair without a pressure cushion, so I had to tell her why it was important to use it. Not having that cushion could make the wound worse. R8 is on hospice, but that should not stop them from treating her wounds and doing the necessary tests. On [DATE] at 3:58 PM, V1 (Administrator) stated, I do not have a policy regarding who is able to perform dressing changes. The facility's Wound Assessment Policy revised ,d+[DATE] documents, It is the policy of the facility to assess each wound initially, either at the time of admission or at the time the wound is identified. Each wound will be assessed weekly thereafter or with any significant noted change in the wound. Identify the etiology of the wound if possible. Is it a pressure ulcer/pressure injury, venous stasis ulcer, arterial ulcer, or diabetic ulcer? Accurate etiology is important to ensure correct MDS (Minimum Data Set) coding.

Based on interview and record review, the facility failed to assess, monitor, and treat pressure ulcer changes for 1 of 4 residents (R8) reviewed for pressure ulcers in the sample of 12. This failure resulted in R1 being transferred to the hospital for fever and surgical debridement of his right gluteal pressure ulcer. Findings Include: R8's Braden Scale for Predicting Pressure Sore Risk dated 6/22/22 documents is at high risk for pressure ulcers. R8's Admission Minimum Data Set (MDS) dated [DATE] documents for bed mobility the resident is an extensive assist of 2 staff persons. R8's TAR (Treatment Administration Record) dated 6/22/22 documents cleanse open areas to right and left buttock and coccyx with normal saline every shift and apply [MEDICATION(S)] (absorbent foam dressing). There were no measurements for these areas. This order was discontinued on 6/22/22. R8's TAR dated 6/23/22 documents cleanse open areas to right and left buttock and coccyx, and apply Triad cream (barrier cream). R8's Wound Line List dated 6/29/22 documents the deep tissue injury to the Coccyx measures 9 centimeters (cm) x 5 cm. (no change in treatment on this date.) There was no documentation of any assessment or measurements prior to this. R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Wound Consultant Form dated 7/1/22 documents the Wound measures 9 x 8.5x 0.1. R8's TAR dated 7/1/22 documents cleanse buttocks wound apply soaked Dakins and cover with a dry dressing twice daily. The Triad Cream was continued for 2 days after the open area was found before there was a change in treatment. The wound measurement increased from 9 x 5 cm to 9 x 8.5 x 0.1 in 2 days R8's Health Status Note dated 7/1/22 documents wound doctor came in today and debrided the area on resident buttocks. resident has a new order for area to be cleansed with wound cleanser apply soaked Dakins gauze and cover with dry foam dressing. MD also recommended an air mattress for the resident. resident tolerated treatment well. resident POA (Power of Attorney) was called and voice mail to call the facility to get more information. resident will continue to be monitored. R8's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's Health Status Note dated 7/5/22 at 5:54 PM documents wound to left buttock appears dark in color with odor. Findings reported to V11 (Nurse Practitioner /NP) along with picture via mediprocity. Daughter present and aware. Findings reported to nursing administration along with V11 (NP). Awaiting further orders. R8's Health Status Note dated 7/5/22 at 6:06 PM documents daughter present and took pictures of wound, consulted with surgeon at a (local Hospital) hospital and resident to be sent out for debridement. V11 (NP) made aware. R8's Health Status Note dated 7/5/22 at 6:26 PM, Ambulance in building to transport resident to (local hospital.) Daughter and son present at the time of transfer. Resident transferred from bed to stretcher by (emergency medical technicians) EMS x2 and staff x2 without incident. R8's Pressure Ulcer Care Plan was not documented in the Electronic Health Record. R8's Regional Teaching Hospital records dated 7/5/22 documents he (R8) presents from nursing home on account of worsening decubitus wound, associated with fever. He was admitted to the rehab facility about 1.5 weeks ago. The patient's son is a nurse at this facility, and he reached out to the patient's (R8) surgeon. R8's decubitus involves both gluteal regions. the upper portion is a stage 2. The right gluteal is large and unstageable due to brown dying skin. The patient (R8) was admitted , surgery treating for wound debridement of right buttock. On 7/21/22 at 10:45 AM, V11 (NP) stated, I saw the Wound several times it was just pink. I saw the pictures the night he (R8) went out to the hospital and it never looked like that. V13 (MD) also saw the patient (R8). I honestly have no idea what happened I did remind the resident to turn, and he stated I sleep on my left side. The resident could turn himself. R8's MDS documents R8 requires extensive assist of 2 staff persons for bed mobility. On 7/21/22 at 10:15 AM, V12 (POA) stated, They did a bedside Debridement on my dad's wounds and he will go back to the operating room on Friday for more surgery and a wound vac.

Based on observation, interview, record review, the facility failed to provide appropriate interventions with adequate assistance to prevent falls for one of six residents (R2) reviewed for falls in the sample of 8. This failure resulted in R2's fall sustaining a laceration requiring 2 sutures and requiring hospitalization . Findings Include: R2's Face sheet printed 6/15/22 documents diagnoses to include Acute Respiratory Failure, Abnormal Gait, Shortness of Breath, Trans Ischemic Attack, Unsteadiness, Muscle Weakness. R2's care plan-initiated date 4/4/2019 documents R2 is at risk for falls related to deconditioning, incontinence, psychoactive drug use, vision/hearing problems. Transfers-extensive staff x2, R2 requires two staff participation with transfers. R2's Care Plan also documents R2 is at risk for complications related to anticoagulant therapy initiated 12/31/20. R2's Minimum Data Set, (MDS) dated [DATE] documents R2 has moderate cognitive impairment, requires extensive assist with ADLs (activities of daily living), and Substantial/maximum assist with sitting to standing. R2's MDS dated [DATE] documents Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed. R2 requires substantial maximum assistance. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed. R2 requires substantial maximum assistance. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. R2 requires substantial maximum assistance. R2's fall risk assessment dated [DATE] at 11:28AM, documents R2's score of 30.0, high risk for falls. R2's progress note dated 5/6/2022 5:20 AM, documents R2 sent out related to witnessed fall. Aide stated that she went in the resident's room to check to see if she was wet and needed to be changed. Aide stated that the R2 was in her recliner and that she put her shoes on so she could stand her up and pull her briefs and pad from underneath her and after putting clean pad under R2, R2 sat back down and was at the edge of the recliner and slid down out of the recliner chair. R2 has 2 large skin tears to right lower leg and right elbow. R2 had a lot of bleeding. Pressure applied to areas. This writer called another nurse to come up and help with R2. Ambulance arrived around 5:20 AM. POA (Power of Attorney) already notified. R2's progress notes dated 5/6/2022 at 1:15 PM, document Skin/Wound Note Text: R2 returned from hospital with 2 sutures to left calf area, skin tear with steri strips to other part of skin tear measures 15x 9x 0.1 cm this nurse cleanse and rewrapped site. Also skin tear to right elbow steri strips intact measures 6.5 x 4.6x0.1 cm. tx orders until healed. R2's progress notes dated 6/8/2022 at 7:49AM, documents R2 sustained a witnessed fall. According to facility fall log, V10 (Certified Nurse Aide/CNA), stated that R2 rolled over in bed too far during peri care and fell out of the bed. V10 said it happened so fast she couldn't keep R2 from falling over side of bed. R2's progress notes dated 6/8/2022 at 7:49AM, document CNA reported that R2 rolled out of bed when she was changing her adult brief and providing peri care. R2 had laceration and swelling to head, LLE (left arm and left lower extremity). CNA reported this around 6:50AM, EMS (Emergency Medical Services) called and R2 sent to hospital. R2's progress notes dated 6/13/2022 10:36PM, document R2 returned from hospital. According to R2's progress notes R2 has bruising to most of body. Laceration to right forehead, skin tear to left upper arm. Laceration to right forearm, laceration to right shin, laceration to left shin, hematoma to bilateral knees, skin tear to toe on left foot. On 6/10/2022 at 11:00 AM, V8 (Certified Nursing Assistant/CNA) stated, I was here the morning when R2 rolled out of bed. When I came in her room, R2 was on her right side on the right side of the floor. V10 was with R2 when she rolled out of bed. According to fall reports dated 5/6/2022 and 6/8/2022, one person was assisting in care for R2. On 6/14/2022 at 8:30 AM, R2 stated, I am ok. I fell twice. I don't know who was here. I don't want to get anyone in trouble, but I do know it was only one girl both times I fell . When I fell out of bed, I think I was pushed. I can't roll in these beds, so I had to have been pushed to have gotten out of the bed. On 6/14/2022 at 9:30AM, V9 (Certified Nursing Assistant/CNA) stated, V10 was working with R2 when R2 rolled out of bed. V10 is one of the best staff we have. She's been here a long time. When I came into the room, R2 was on floor on her right side on right side of the bed. We usually can use 1 CNA for peri care on R2. R2 can help a little bit. On 6/14/2022 at 9:35AM, V8 stated, We just started using 2 people to turn R2 since this last fall. R2 always needs changed in the bed not the chair. On 6/14/2022 at 9:40AM, V8 and V9 (CNAs) provided peri care to R2. R2 has bruised right knee, bandage on right shin and gauze wrap on left leg. R2 groaned upon rolling side to side. R2 able to use grab bar on bilateral sides. V8 and V9 assisted R2 to roll far onto side for peri care, with R2 holding grab bar. On 6/14/2022 at 12:45PM, V9 stated, We don't always have enough help to get 2 people to change someone. On days we need another person. What happened to R2 was an accident. On 6/14/2022 at 8:33AM, V2 (Director of Nursing/DON) stated, R2 is able to assist with peri care and transfers. She can pivot a little from wheelchair to bed or vice versa. She can help to hold herself when she needs to roll. Even though the care plan says she needs 2 assist, one person can do it. On 6/14/2022 at 12:15PM, when asked how many assist is R2, and V2 stated She needs 2 people. The CNAs use 2 people to assist R2. Facility Fall Policy dated 2/2021, documents, 1. At the time of admission/readmission the Fall Risk Data Collection and Fall Risk Questionnaire will be completed. 2. Thereafter the Fall Risk Data Collection should be completed, with MDS schedule including quarterlies, annuals and significant change/correction assessments. 3. Residents found to be at high risk or falls are placed on S.A.F.E. (Safety Assessment, Fall prevention and Education) program and specific interventions are implemented o meet individual needs. 4. Resident representative will be notified of placement of the resident on the S.A.F.E. program and interventions the facility is implementing related to the resident's high risk or falls. As updates occur the resident representative will continue to be notified.

Based on observation, interview and record review, the facility failed to assess, implement progressive interventions including offloading of pressure to treat pressure ulcers for 2 of 5 residents (R31, R35) reviewed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R31 developing a facility acquired Stage III pressure ulcer to his right heel that deteriorated to an unstageable pressure ulcer requiring antibiotic treatment. Findings include: 1. R31's Face Sheet showed R31 was admitted to the facility on [DATE]. R31's Admission Nurse Assessment, dated 7/30/21 at 12:51 PM, documented R31 was at moderate risk for skin breakdown and had no wounds or open areas at the time of admission. R31's Admission Minimum Data Set (MDS), dated [DATE] documented R31 had no cognitive impairment. The MDS documented R31 required extensive assistance from two staff persons for bed mobility and transfers. The MDS documented R31 does not walk in room or in the corridor. The MDS documented R31 required one-person physical assist with dressing, toileting, personal hygiene and bathing. Mobility devices used include a walker and a wheelchair. The MDS documented R31 was at risk for developing pressure ulcers but currently had no pressure ulcers. On 10/5/21 at 11:10 AM, R31 was self-propelling around his room sitting up in his wheelchair. R31 had yellow nonslip socks on and a hospital gown. R31 said R31 has a surgical wound on R31's back and another wound on R31's right heel and it hurts like the dickens. There was a heel protector in R31's recliner chair in the room. R31 said R31 wears the boot on the right foot while in bed. During medication administration on 10/6/21 at 9:10 AM V9, Licensed Practical Nurse (LPN) asked R31 if R31 was in pain and resident said R31's right heel hurt 9 out of 10 (10 being the worse pain) on a pain scale. On 10/6/21 at 2:00 PM, V4, Wound Care Nurse and V9, Licensed Practical Nurse (LPN) entered R31's room to provide pressure ulcer care to R31's right heel. V4 and V9 washed their hands and put on clean gloves. V4 removed the nonslip sock off the resident's right foot. The rolled gauze wad dated 10/5/21. The drainage on the dressing was [MEDICATION(S)], there was no other drainage on the dressing. The entire wound bed was covered with eschar and measured 2.3 cm x 3.5 cm. V4 applied a 4x4 [MEDICATION(S)]-soaked gauze directly on the pressure ulcer then an ABD and rolled gauze then dated and initialed the dressing. On 10/8/21 12:15 PM, R31 was sitting up in a wheelchair in R31's room. R31 had on nonslip socks with both feet directly on the pedals of the wheelchair. R31 had no pressure relief to either heels. R31's foam boots were on the bed. R31 showed the surveyor the new air overlay on R31's bed and said R31 had the boots on prior to therapy today but that they did not put them back on after therapy. R31 said R31 is able to self-propel wheelchair using R31's arms for short distances, but cannot self-propel long distances using R31's feet because they hurt so bad. R31 showed the surveyor R31 cannot bend foot up and down, and puts heel directly on the floor and moves forward to propel himself forward. On 10/8/21 at 12:30 PM, V19, Physical Therapist, stated she worked with R31 today. V19 stated R31 had wheelchair pedals on and boots on both feet prior to therapy. V19 stated she did not put the boots back on R31's feet after the therapy session because she thought R31 only needed them on in bed. V19 was aware the resident has a wound on his right heel, but no one told her R31 needs to have the boots on while up in the wheelchair. R31's Nurse's Note, dated 7/30/21 at 2:54 AM, staff documented R31's feet have red dry peeling skin with redness and tenderness noted to the right heel and going to inner right ankle with no open area noted. The Note documented Red dry skin to left heel with no tenderness. R31's Braden scale, dated 7/30/21, documented R31 was at risk for skin breakdown. R31's Care Plan, dated 7/30/21, documented the following interventions related to skin integrity: avoid shearing while repositioning when in bed, encourage good nutrition and hydration in order to promote healthier skin, float heels while in bed, for dry and flaky skin use high quality moisturizers to rehydrate skin, assist resident to turn/reposition at least every two hours, more often as needed or requested. R31's Progress Note, dated 7/30/21 and 8/2/21, written by V13, Nurse Practitioner, documented no assessment of R31's right heel. R31's Skin Check Weekly & (and) PRN (as needed) form, dated 8/6/21, documented R31 had no new skin breakdown and no new areas of skin impairment. R31's Progress Note, dated 8/10/21, written by V13, documented no type of assessment of R31's right heel. There was no documentation of any skin impairment on R31's right heel. R31's Skin Check Weekly & PRN form, dated 8/13/21, documented R31 had no new skin breakdown. R31's Progress Note, dated 8/18/21 at 11:01 AM, documented LATE ENTRY. This resident is experiencing a change in condition. See SBAR (Situation, Background, Assessment, Recommendation form) assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is new area to right heel. R31's SBAR dated 8/18/21, documented R31 had a new area on the right heel. The SBAR documented things that make the condition worse was unknown. The SBAR documented things that make the condition better were float heels, supplements and change of positions. The SBAR documented under the Section Assessment to have area new area to right heel pressure ulcer maybe started as blister area has dry darken brown skin layer with pink granulated present. There was no other skin assessment information documented including measurement of the pressure ulcer, description of wound bed, description of wound edges, drainage and/or presence of odor. On 10/6/21 at 2:30 PM, V4, the facility wound nurse said she initially assessed the pressure ulcer on the R31's right heel on 8/18/21 and she documented an SBAR. When she initially assesses a new pressure ulcer, she documents the assessment on an SBAR because it is a change in condition. V4 stated, as the facility wound nurse, she assesses the pressure ulcers weekly and documents the weekly skin assessment in resident's medical record. She used to document the weekly skin assessments on a tablet, but she could not see all the options to document all the information on all the weekly skin assessments as far as draining and the appearance of the wound bed. R31's Progress Note, dated 8/18/21 at 2:18 PM documented therapy communicated that resident has open area on right heel. resident was assessed and area is a Stage 2, area cleaned and covered with a cushioned dressing. NP (Nurse Practitioner) is aware. R31's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in R31's medical record regarding the measurement or description of R31's right heel pressure ulcer from 8/18 through 8/24/21. R31's Skin & Wound Evaluation, dated 8/24/21, documented R31 had a new facility acquired Stage III pressure ulcer on right heel that measured 1.8 centimeters (cm) x (by) 2.0 cm x 0.2 cm. The wound bed was covered with 10% epithelial and 90% granulation tissue. There was no assessment documented regarding exudate (drainage), the periwound area, pain, orders or treatment. The Evaluation documented the nurse practitioner was notified of the new pressure ulcer on the resident's right heel. The National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages documented a Stage III pressure ulcer as Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. R31's Care Plan, updated 8/25/21, documented R31 had a right heel stage III pressure ulcer with new treatment orders in place until healed. The Care Plan Goal documented right heel will continue to heal without complication until healed. The Care Plan Interventions documented a nutritional supplement to be given and heel protectors while in bed. The Care Plan did not address how R31 should offload pressure from his heels while up in his wheelchair. R31's Skin and Wound Evaluation, dated 9/1/21, documented R31 had a facility acquired Stage III pressure ulcer on his right heel that measured 1.8 cm x 1.8 cm x 0.1 cm. The Evaluation documented the wound bed was covered with 80% epithelial and 20% granulation tissue. The Evaluation documented Treatment: cleanse with generic wound cleanser and foam dressing. The Evaluation documented R31's pressure ulcer progress was improving. There was no assessment documented regarding exudate (drainage), the periwound area, pain or orders. R31's Skin Check Weekly & PRN form, dated 9/2/21, staff documented there was a pressure ulcer on the resident's right heel. No other skin assessment was documented. R31's Skin & Wound Evaluation, dated 9/8/21, staff documented R31 had a facility acquired Stage III pressure ulcer on his right heel that measured 4.3 cm x 5.1 cm. The Evaluation documented the wound bed was covered with 70% epithelial and 30% granulation tissue. The Evaluation documented there was light amount of serosanguineous drainage (yellowish with small amounts of blood) and no odor present. The Evaluation documented the periwound area was dry/flaky and fragile (skin that is at risk for breakdown.) The Evaluation documented the progress of R31's pressure ulcer was improving. R31's History and Physical, dated 9/8/21, written by V21, Physician, documented no assessment or documentation of R31's right heel pressure ulcer. R31's Skin Check Weekly & PRN form, dated 9/10/21, documented no new skin changes this week. No other skin assessment was documented. R31's Skin & Wound Evaluation, dated 9/14/21, documented R31 had a facility acquired Stage III pressure ulcer on his right heel that measured 2.1 cm x 2.0 cm. The Evaluation documented the wound bed was covered with 50% granulation tissue and 50% eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of wound. The Evaluation documented there was no drainage and no odor present, periwound area was dry/flaky. The Evaluation documented R31's pressure ulcer was improving although the pressure ulcer was now covered with 50% of eschar. There were no documented changes in R31's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's Physician's Progress note, dated 9/14/21, documented right heel dressing clean, dry and intact. There was no further assessment of the pressure ulcer on his right heel documented. R31's Skin Check Weekly & PRN form, dated 9/17/21, documented R31 had no new skin changes this week. No other skin assessment was documented. R31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . See wound/skin assessments for full details. There was no further assessment of the pressure ulcer on R31's right heel documented. R31's Skin & Wound Evaluation, dated 9/21/21, staff documented the resident had a facility acquired Stage III pressure ulcer on right heel that measured 2.0 cm x 2.9 cm. The Evaluation documented the wound bed was covered with 100% eschar. The surrounding tissue was dry/flaky and calloused. Staff documented the progress of the pressure ulcer was stable although the R31's pressure ulcer was now covered with 100 % eschar. R31's Physician's Progress note, dated 9/21/21 no open areas and right heel with black, dry scab, see wound/skin assessments for full details. Today the dressing was clean, dry and intact. There was no further assessment of the pressure ulcer on R31's right heel documented. R31's Skin & Wound Evaluation, dated 9/28/21, documented R31 had a facility acquired Stage III pressure ulcer on his right heel that measured 1.9 cm x 2.5 cm. The Evaluation documented the wound bed was covered with 100% eschar. No drainage noted, periwound edges attached. The Evaluation documented the progress of the pressure ulcer was improving. Staff documented resident seen by physician; orders for dopplers. Education: keep heel protectors on while in bed and continue nutritional supplement. There was no documentation as to how R31 should offload heels while up in R31's wheelchair. Review of the facility's wound report, dated 9/28/21 at 7:02 PM, documented a Stage III on R31's right heel measuring 1.9 cm X 2.5 cm. The wound report documented R31's pressure ulcer status was improved. R31's POS, dated 9/28/21, documented a bilateral arterial doppler study was ordered due to chronic right heel wound, pain of the toes of both feet which are cool to palpation. R31's x-ray lower extremity arteries/arterial bypass graft, dated 9/29/21, documented impression as no evidence of hemodynamically significant stenosis. Staff documented reported to physician and dated the document 9/29/21. Reason for arterial doppler: swelling in bilateral lower extremities, pain in bilateral toes, bilateral weak pulses, chronic right heel stage II pressure ulcer, skin cool to touch. R31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Right heel with black/dry scab. See wound/skin assessments for full details. Today dressing last changed 9/29/21 but no SOI (signs of infection). Assessment and plan: new Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Nutritional supplement, wound care, discussed with nursing imperativeness of dressing change, reminded resident to wear heel protectors and elevate heel on pillow, especially if hurting. R31's POS, dated 10/4/21, documented to consult (Wound consultant company) for R31's right heel. R31's POS, dated 10/5/21, new treatment order for right heel: cleanse right heel, pat dry, apply a [MEDICATION(S)] soaked 4x4 and cover with an ABD dressing and rolled gauze. R31's skin and wound evaluation, dated 10/6/21, showed staff documented the resident had a facility acquired Stage III pressure ulcer on the right heel that measured 2.3 cm x 3.0 cm. The wound bed was covered with 100% eschar. No drainage noted. Staff documented the surrounding tissue was normal in color. The progress of the pressure ulcer was stable. Staff documented notes: refer to (Wound Care Company) wound care physician. On 10/6/21 at 10:40 AM, V9, LPN, said she did not assess skin breakdown on R31's right heel before it was assessed by the wound nurse. She recalled when R31 was initially admitted to the facility the resident's heels were red and R31 complained they hurt. When the wound nurse assessed R31's right heel the physician's treatment was 8/18/21 float heels and apply foam dressing and 8/25/21 change foam dressing until healed. R31's Progress Note, dated 10/7/21 at 8:21 AM, documented the physician assessed resident today regarding right heel. The Progress Notes documented a new order to discontinue [MEDICATION(S)] soaked 4x4 order and start new treatment order to: Cleanse right heel, pat dry, apply Santyl to 4x4 gauze apply to right heel cover with ABD pad and rolled gauze. The Note documented concerns of new redness to periwound right heel new orders to start antibiotic. Th Note documented Add a mattress overlay to mattress. Some redness to buttocks and scrotum, the physician is aware and pending new treatment orders. The resident understands the new orders. The Progress Note did not address/document how R31 should offload heels while up in wheelchair. R31's Progress Note, dated 10/7/21 at 12:12 PM, staff documented new order for a venous doppler to right lower extremity due to pain and non-healing wound on right heel. PRN pain medication administered as needed, will continue to monitor resident and update as results become available. R31's Nurse's Progress Note, dated 10/7/21 at 1:05 PM documented, spoke with resident's physician clarification as unstageable as of 9/14/21. On 10/7/21 at 1:18 PM, V21, R31's Physician, stated she started following R31 in September 2021. V21 stated she initially assessed R31 on 9/14/21 but did not take the dressing off the right heel. She stated she does not always take the dressing off to assess a wound. V21 stated the wound on R31's right heel was an unstageable pressure ulcer. She could not recall when she initially assessed the pressure ulcer on R31's right heel, she referred the surveyor to read the documented notes in R31's electronic medical record labeled physician's progress note. Review of R31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . V21 said R31 self-propelling in wheelchair would not cause the pressure ulcer on the right heel to be worse. R31's Physician's Progress Note, dated 10/7/21 at 6:14 PM, documented R31's right heel wound with black dry scab, appears about the same size but surrounding tissue is red and tender to touch. R31's POS, dated 10/7/21, documented new antibiotic ordered [MEDICATION(S)]-Pot Clavulanate Tablet 875-125 mg (milligram) twice a day for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's POS, dated 10/7/21, consult with (Wound Company) skin specialists re (regarding) R (right) heel wound. On 10/7/21 at 11:05 AM V13, Nurse Practitioner, said when R31 was initially admitted she was R31's nurse practitioner, but a new physician group started mid-September 2021, so she is no longer assigned to the resident. V13 stated when R31 was initially admitted she recalled R31 wore lace up work boots and R31 wanted to continue to wear them. She recommended to the resident and V4, the wound nurse that R31 should no longer wear them due to the pressure they cause. V13 assessed R31's heels at one point and said there was a spot on R31's right heel. V13 stated she never saw the wound as a Stage III pressure ulcer. V13 documents assessments in the resident's electronic record under progress notes. V13 stated if there were no documented assessments of the pressure ulcer on the R31's right heel then the assessment was not done. R31's electronic medical record dated 8/18/21 through 9/15/21, showed no assessment of the pressure ulcer on R31's right heel documented by V13, the nurse practitioner. R31's Progress Note, dated 10/8/21 at 12:54 AM, documented R31 had a doppler done on right lower extremity with result of no evidence of acute deep venous [CONDITION(S)]. Start antibiotic, no complaint of pain or discomfort. Dressing dry and intact. On 10/8/21 at 2:00 PM, V20 wound surgeon from (Wound consultant company), said the wound classification on R31's right heel is an unstageable pressure ulcer. He stated skin prep would not be an appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V20 stated the most important part of the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R35's October 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/5/2021 at 8:39 AM, R35 was sitting in a geriatric wheelchair with right heel covered in a bandage and the heel was sitting directly on the bottom of the footrest. R35's heel was touching the footrest directly with both feet resting on the footrest. R35's POS, dated 9/6/21, documents To RT. (right) heel q (every) shift apply heel protectors to both feet Q HS (time of sleep/night) every shift to prevent skin breakdown. R35's Wound Evaluation document on 9/15/2021, R35 developed a new pressure deep tissue injury with the surface area of 8 centimeters (cm) and 2 cm in length. This was acquired in house. (Facility Acquired Deep Tissue Injury). The Skin & Wound Evaluation dated 9/15/2021 document the area was 8.0 cm x length 2.0 cm x width 4.0 cm. The Wound bed was 20% of wound covered epithelial and 80% of wound filled. Heel Suspension/Protection device, positioning wedge and Turning and Repositioning Program. Progress was documented as new. R35's Skin Check dated 9/23/2021 document, new right lower extremity skin discoloration. The Check documented New areas of skin impairment. R35's Wound Evaluation dated 9/29/2021, documents R35's deep tissue injury increased in size to 10.08 cm x 2.4 cm. R35's POS, dated 9/30/21 documents [MEDICATION(S)] solution (Providone-Iodine), Apply to right heel topically as needed for wound apply [MEDICATION(S)] to a 4 x 4 soak place to right heel cover with ABD pad with rolled gauze. R35's Care Plan with a Focus Area of Skin, undated, document, DTPI Deep Tissue Pressure Injury (DTPI) right heel treatment order in place. The Goal documented Right heel shows signs of improvement by next review. R35's Care Plan also documents R35 receives assistance with activities of daily living and utilizes a wheelchair. On 10/5/2021 at 8:50 AM, V17, Licensed Practical Nurse (LPN) stated, (R35) has boots that R35 wears at night. R35 does not have any boots in the day. I suppose R35's foot should not be touching the footrest. On 10/8/2021 at 2:11 PM, V20, Wound Surgeon stated, I would expect all wounds to be off loaded to decrease pressure and promote healing. The Pressure Ulcer/Pressure Injury Prevention (PUP) with a revision date of 04/2018 documents Prevention of Pressure Ulcers/Injuries A pressure ulcer/injury (PU/PI) can occur wherever pressure has impaired circulation to the tissue. A facility must: Identify whether the resident is at risk for developing or has a PU/PI upon admission and thereafter: Evaluate resident specific risk factors and changes in the resident's condition that may impact the develop and/or healing of a PU/PI; Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors; and If a PU/PI is present, provide treatment to heal it and prevent the development of additional PU/PIs.The first step in the prevention of PU/PIs, is the identification of the resident at risk of developing PU/PIs. This followed by implementation of appropriate individualized interventions and monitoring for the effectives of the interventions. 2. Planning: An individual plan of prevention will be developed to meet the needs of the resident. It will include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility, continence, skin condition and overall clinical condition of the resident as well as the risk factors as they apply to each individual. The goal is for the resident to be free of preventable pressure ulcer/pressure injury. 3. Implementation Interventions for the prevention of pressure ulcer/pressure injury will be individualized to meet the specific needs of the resident. Interventions will consider the assessment of risk and skin condition of the resident. Minimize Pressure: Turning and Repositioning-every two to three hours when in bed, or more frequent depending on the need of the resident. Every hour when a chair. Teach the resident techniques for self-repositioning every 15 minutes. Utilize 30-degree lateral positioning, as opposed to direct side lying, using pillows or wedges for positioning. Avoid use of donuts and ring type devices. Avoid sheepskin for pressure reduction, useful for comfort only. Use support surfaces on beds and chair to redistribute or relieve pressure. Relieve pressure to heels by using pillows or other devices. Do not depend on heel protectors, they do not provide pressure reduction/relief. Pressure reduction/relief devices should serve as adjuncts and are not replacements for repositioning protocols. 4. Evaluation and Reassessment - The facility's Care Management System committee will review program components to evaluate the effectiveness of the prevention program and facility systems. Findings and recommendations will be reviewed with the QA Clinical Committee. Based on evaluation, the need for reassessment and further changes to the individual resident's plan of care will be determined and acted upon.

Based on interview and record review, the facility failed to consult with vascular surgeon per professional standards of practice to treat vascular surgical wounds for 1 of 3 residents (R2) reviewed for wound care in the sample of 3. This failure resulted in staff removing staples and sutures of surgical wounds without consulting vascular surgeon. R2's groin wound became infected and required antibiotic treatment. Findings include: R2's Face Sheet documented R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Health Status Note dated 06/16/21 at 1:02 AM documents left upper chest resident have 13 staples with site dry intact with no s/s (signs or symptoms) of infection. healing scar below staple site on left chest no drainage. bruising on left side going downside. bruising on both arms. rt (right) groin area has 10 sutures site free of s/s of infection dressing in place. on left groin area have 11 sutures with dry blood. scrotum red bruising tender to touch with some swelling. R2's Health Status Note dated 06/24/21 at 8:40 AM by V4, Wound Nurse, documents Talked with (daughter) via phone made her aware of new orders to remove staples and place wound closure strips. Resident had 13 staples removed and wound closure strips placed area is well approximated and no c/o (complaint of) pain or discomfort noted. There was no documentation in R2's medical record that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation in R2's medical record that the facility contacted V5, Vascular Surgeon, prior to removing the staples in R2's chest. R2's Health Status Note dated 06/28/21 at 1:29 PM by V4 documents Dehiscence of left surgical incision suture intact but wound dehiscence removed suture per NP (V8, Nurse Practitioner). cleansed area, apply Santyl and calcium alginate. There was no documentation in R2's medical record the facility contacted V5 to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was written by V5, Vascular Surgeon. R2's Health Status Note dated 07/01/21 at 9:13 AM by V2, Assistant Director of Nursing documents spoke with (V5's, Vascular Surgeon) office regarding surgical incision to left groin. had dehiscence, order from in-house NP to remove sutures from left groin. R2's Health Status Note 07/01/21 2:06 PM by V4 documents (R2) continues antibiotic related to wound infection. Dressing changed to left groin. Green colored purulent drainage noted. On 07/08/21 at 1:06 PM, V5, Vascular Surgeon stated, They called my office and was told by my nurses to not remove the sutures or staples and they did it anyway. The resident had a very complicated procedure and now he might have to have another complicated surgery if it doesn't heal. The poor guy is already in poor health. On 07/08/21 at 1:15 PM, V4, stated, (R2) had surgical incision to left chest that had staples in it and two incisions in the bilateral groin with sutures. They had called me to (R2's) room to look at his staples. The staples were loose, so I called the NP (V8). She gave me an order to go ahead and remove the staples. I know that (V5) didn't want anyone to touch the incisions. Then they called one day because the incision to the left groin had dehiscence. I called (V5's) office 4 times but could not get a hold of him. The sutures were loose, and the wound was open, so I called the NP (V8). She said she got ahold of (V5) and he wasn't real happy about it but told her to go ahead and remove the stitches. (V11) his primary physician put him on the antibiotic. When I saw the incision, it didn't look infected. I got an order from the NP for Santyl and Calcium Alginate because the wound had slough. On 07/08/21 at 1:53 PM V8, Nurse Practitioner, stated, The incisions were open to air when he was admitted . Staples in the chest and sutures in the groin that surgeon wanted to remove. The family was asking to remove the staples. The wound nurse said that the staples were ready to come out. I didn't give an order to the remove the staples. I did not give an order to remove the sutures in his groin. I didn't personally see the groin. If it looked like it was dehiscence than it seems reasonable to me to take them out. I don't know who started him on the [MEDICATION(S)]. I don't know if (V11, Physician) or (V5) ordered the antibiotic.

Based on interview and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 22 residents (R2) reviewed for Advanced Directives/Full Code for CPR in the sample of 26. Facility staff failed to follow R2's Advanced Directive by not initiating CPR for R2, who subsequently expired. This failure resulted in an Immediate Jeopardy, which began on [DATE] when the facility failed to perform CPR on R2 and R2 expired. This failure had the potential to affect 17 of 74 residents (R1, R2, R3, R6, R7, R9, R11 through R26) whose Advanced Directives indicate Full Code Status. This past noncompliance occurred from [DATE] to [DATE]. Findings include: R2's Medical [DIAGNOSES REDACTED]. R2's Care Plan, dated [DATE], documented Code Status as Full Code, residents wishes for Advanced Directive and End of Life Care will be honored. R2's Advanced Directive, dated [DATE], signed by R2's Health care surrogate decision maker, documented, Attempt Cardiopulmonary Resuscitation, full treatment of [REDACTED]. R2's State of Illinois Certification of Death Worksheet, documented, Cause of Death, [MEDICAL CONDITION], pronounced death dated [DATE] at 1:05 PM. R2's Progress Note dated [DATE] at 1:23 PM, documented, in part, Resident expired at 1:05 PM, no further documentation if R2 was assessed, vitals obtained, CPR initiated and 911 was notified. The Facility's Final Investigation Report, dated [DATE], documented V4's (Licensed Practical Nurse/LPN) interview statement that (R2) stayed in bed at breakfast. At approximately 10:30 AM, V5 (Certified Nurse Aide/CNA) bathed R2. At approximately 11:00 AM-11:30 AM, Physical Therapy stated that they were discharging (R2) from therapy due to lack of progress. At approximately 12:00 PM-12:30 PM, V5 brought R2 to the dining room. At 12:45 PM, (R2) would not take her medication and V4 stated she would re-attempt when (R2) is eating. At approximately 1:00 PM, V5 sat with (R2) to provide feeding assistance and V5 identified that (R2's) hands were cold and blue. V4 stated that V5 reported to her (V4), she thinks (R2) is dead. V4 stated she noted color, cold and no pulse. V4 stated that she and V5 transferred (R2) to her bed. V4 stated she then notified the coroner and family. V4 stated she then noticed (R2's) code status was CPR and thought it had been changed to DNR (Do Not Resuscitate) and placed on Hospice. The Facility's Employee Corrective Action Form, dated [DATE], documented, V4 (LPN) failed to follow policies and procedures that resulted in harm or potential harm to R2. Also included, V4's failure to follow policy on Advance Directive that resulted in CPR not being delivered to R2 who was a full code, resulting in R2's death. Corrective Action: V4's termination of employment. The Facility's Education Sign in Sheet, dated [DATE] at 8:30 AM, entitled, education on the following subjects: Advance Directives/CPR, documented V4's printed name, signature name and job title as LPN. On [DATE] at 2:50 PM, V18 (Physical Therapist) stated that R2 was seen early in the morning of [DATE], and made the assessment that (R2) was not progressing with physical and occupational therapy and discharged therapy for (R2) on that same date. On [DATE] at 2:05PM, V11 (LPN) stated you need to access residents' electronic medical record, as the face sheet will identify a resident's code status, assess the resident, perform vitals, call 911, the physician and then family. This is for a resident full code or DNR. V11 stated she was recently in-serviced on the procedure to access a resident's code status. On [DATE] at 2:15 PM, V12 (LPN) stated the same as V11, but included that there is a Crash Cart in the Crash Cart closet that has a clip board for quick access of residents who are DNR and Full Code, the night shift nurses are responsible to assure this is currently updated and changed out every day, related to the recent in-service received from the facility. On [DATE] at 2:25 PM, V13 (CNA) stated A resident found unresponsive, I would stay with the resident, hit the call light or yell to notify the nurse assigned, obtain vitals, call 911, if the nurse requested. On [DATE] at 2:35 PM, V14 (CNA/agency staff) stated, If I find a resident unresponsive, she would 'Scream for help,' and stay with resident until the nurse arrives. On [DATE] at 3:30 PM, V1 (Administrator) stated, (V4) should have followed the facility's policy and procedure regarding (R2's) Advanced Directive as a Full Code to initiate CPR and should have notified the emergency medical service, (911). On [DATE] at 4:20 PM, V6 (R2's Nurse Practioner) stated the facility should have followed R2's Advanced Directive of Full Code Status and performed CPR. The Facility's policy and procedure, entitled, Emergency Procedure-Cardiopulmonary Resuscitation, dated ,[DATE], documented, If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record. If the resident is full code, per the medical record, a staff member that is certified in CPR will initiate. Facility staff certified for CPR is available for each shift in the case of an actual [MEDICAL CONDITION]. Staff will call 911 when CPR is initiated. The Immediate Jeopardy that began on [DATE] when the facility failed to initiate CPR for R2 who was a full code status and expired, was removed on [DATE]. Prior to the survey date, the facility took the following actions to remove the immediacy and correct the noncompliance: 1. On [DATE], the facility conducted an investigation into this incident which occured on [DATE]. V4 was suspended pending investigation, re-educated on CPR policy and terminated on [DATE]. Final investigation was completed on [DATE] by Executive Director. 2. A 100% audit that each resident has a code status in place. A 100% audit that each resident has a POLST (Physicians Orders for Life-Sustaining Treatment) in place that matches the code status order and ensuring that all signatures are in place, and that both pages of the POLST are scanned into the Emergency Health Record.A 100% audit of code status care plans to ensure these match the orders and the POLSTs. Completed on [DATE] by Corporate Regional Nurse. 3. On [DATE] began re-education with certified and licensed staff on the facility's CPR policy. To include that when a resident is found unresponsive without pulse or blood pressure and not breathing normally a nurse will assess them and EHR will be viewed to verify code status. If the resident is a full code CPR will be initiated and 911 will be called. The nursing staff will continue CPR until paramedics arrive. This correction was completed [DATE]. Nursing staff will be educated at the time of hire on the above information a part of the orientation process, including location of information on Advanced Directives. Completed by Administrative Nurse Manger on [DATE]. 4. On [DATE] the facility nurse management team will audit certified and licensed nursing staff on appropriate action if resident is found unresponsive with no pulse or blood pressure and not breathing normally five times a week for sixty days. Any noted issues will be addressed and will be discussed during the QAPI process. Ongoing by QA team

Based on interview and record review the facility failed to provide adequate supervision to prevent a fall for 1 of 3 residents (R3) reviewed for falls with injuries in the sample of 13. This failure resulted in R3 falling and sustaining a left hip fracture, resulting in an Open Reduction Internal Fixation (ORIF) of the left femur. Findings include: R3's Minimum Data Set, dated dated [DATE], documents R3 requires extensive assist of one staff for transfers, ambulation, dressing, hygiene and bathing and has moderately impaired daily decision making skills. It also documents R3 is frequently incontinent of both bowel and bladder. R3's Admission Fall Risk Evaluation, dated 5/14/16, documents R3 has intermittent confusion, had a history of [REDACTED]. R3's Preliminary Care of Plan, dated 5/14/16, documents, At Risk for Falls based on fall risk screening related to age, recent admission, and history of falls, balance, and mental status. Goal: Manage risk factors in order to eliminate or minimize risk of falling and injury. Approaches (checked): Provide orientation/re-orientation to new home as needed. Keep room free from clutter and well lighted. Remind to use call light. Evaluate fall risk weekly x 4 weeks. Monitor response to medications, observing balance/gait disturbance. Medication management for depression/anxiety/agitation with specific behaviors monitored and evaluated. Assist in meeting toileting needs. R3's Final Incident Report Form - IDPH Notification, dated 5/27/16, documents, Resident found on the floor complaining of hip pain. Resident sent to ER for evaluation. Final: admitted to hospital with hip fracture. (E12, Certified Nursing Aide/CNA) has been terminated from (facility) because she failed to provide appropriate care to (R3) according to standards of practice and facility policies and procedures. On 6/20/16 at 9:23 AM, E5(Licensed Practical Nurse/LPN), stated she responded to a call from staff that R3 was on the floor. E5 stated she found R3 on the floor in front of the bathroom door with her wheelchair next to her, yelling and hollering. E5 stated R3 did not have any alarm on her. E5 stated she cannot remember any individualized fall interventions for R3 except that R3 was confused and needed more frequent monitoring and checking. E5 stated she assumed the staff would toilet R3 when she needed to be toileted and not leave her in her room and without toileting her. On 6/20/16 at 10:19 AM, E6(CNA), stated she was assigned to take care of R3 on 5/27/16 and normally she would check R3 every 2 hours, and (E6) would toilet R3 before and after activities. E6 stated R3 is pretty good with telling staff she needed to go to the bathroom. E6 stated when R3 returned from activities that morning, E5 told her or E12 that R3 stated she needed to go to the bathroom. E6 stated she was taking care of another resident at that time so E12 took care of R3. On 6/20/16 at 10:25 AM, E4(Assistant Director of Nursing/ADON), stated E12 was not a regular staff of R3's hall, but she was still expected to do her duties, work as a team, and to toilet R3 when R3 said she needed to go to the bathroom. E4 stated if E12 had toileted R3 then, the fall and injury could have been avoided. E4 stated when they found R3 on the floor, R3 was incontinent of bladder. E4 stated R3 was sent to the hospital immediately. R3's Hospital Radiology Result, dated 5/27/16, documents, Left pelvis with hip: acute angulated and displaced and comminuted fracture, intertrochanteric location, proximal femur. R3's Hospital Consult Report dated 5/28/16 documents, Open Reduction Internal Fixation (ORIF) of the left femur. The Facility Policy on Fall Risk Reduction, dated 7/2007, documents, Purpose: To identify residents at risk for falls and implement interventions to reduce risks. Protocol: If a resident is assessed to be at moderate or high risk for falls, risk reduction interventions will be documented on the initial admission/re-admission plan of care and each subsequent care plan. Strategies for Fall Risk Reduction (in part): Toilet schedule.

Based on observation, interview and record review the facility failed to use safe transfer techniques for 1 of 16 residents (R10) reviewed for falls in the sample of 16. This resulted in R10 being lowered to the floor and sustaining a displaced malleolar fracture. Finding includes: The facility's Resident Incident Report, dated 10/30/2015, documents, I assisted her to stand with her walker as we were about to turn and sit, I saw her knees buckle so I lowered her to the floor. The Report documented only one staff was present during the fall, E19, Certified Nurse's Asssistant (CNA). R10's X-ray Report, dated 10/30/2015, documents Impression: Acute mildly displaced lateral malleolar fracture. On 12/15/2015 at 12:15 PM, R10 stated I was going to the bathroom with my walker and (E19) was helping me when my knees gave out on me back in October and I fell and broke my left ankle. I told her I wasn't feeling very stable. R10's Minimum Data Set (MDS), dated [DATE], documents R10 is cognitively intact. R10's MDS documents she requires extensive assist, staff provide weight-bearing support with two person physical assist for transfers. R10's MDS documents R10's is not steady and only able to stabilize with staff assistance for moving from seated to standing position. R10's Care Plan, dated 10/04/2015 documents under Activities of Daily Living Functional/Rehab Potential: 2. I transfer with the assist of two staff using a mechanical lift Under Falls: dated 10/04/2015 documents 2. Transfer me with assist of 2 using a mechanical lift. On 12/22/2015 at 12:15 PM, E2, Director of Nursing, (DON) stated therapy transferred R10 with gait belt and two assist. E2 stated staff should have being using the mechanical lift for transfers. On 12/18/2015 at 1:05 PM, E19 stated she was transferring R10 with a gait belt on her and when R10 stood up she went to turn around and her knees gave out on her. E19 stated she then lowered R10 to the floor. When asked what type of transfer R10 was she stated R10 was a one assist/2 assist transfer. The Mechanical Lift Policy dated 10/2011 with no year documents in part, Mechanical Lift purpose: to provide a safe transfer for residents that are unable to be transferred by staff due to a physical condition. The Policy also stated two (2) CNA's must be used for all mechanical transfers according to policy and procedure for safety.

Based on interview, observation, and record review, the facility failed to provide appropriate treatment including timely dressing changes as needed (PRN) and cleansing of the wound for 3 of 3 residents (R1, R2, R3) reviewed for treatments of pressure ulcers in the sample of 7. This failure resulted in R1 developing maggots in her heel pressure ulcer on 6/27/15 when the dressings were not kept clean, dry and intact. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, no cognitive impairment. The Admission Record documents R1 was admitted to the facility on [DATE] with a stage IV pressure ulcer on her right heel with an exposed Achilles tendon. R1's June 2016 physician's orders [REDACTED]. R1's Care Plan interventions for pressure ulcer, dated 5/6/15, documents staff are to provide the treatment as ordered. Labs, dated 6/28/15, document R1 has normal limits of total Protein 8.0 (normal 6.4 - 8.3) and [MEDICATION NAME] 3.5 (normal 3.5 - 5.2). R1's Nurses Notes, dated 6/27/15 at 10:00 PM written by E9, Licensed Practical Nurse (LPN), document This nurse entered room to change dressing. Found live larva inside wound crawling in and out of wound. Nurse supervisor informed and witnessed. Instructed to call the doctor. At 10:25 PM, E9 documented Cleansed wound c (with) NS (normal saline). [MEDICATION NAME] gauze applied and wrapped with (elastic gauze.) At 10:35 PM, E9 documented the Physician was called and gave ordered to send R1 to the hospital. The Nurses Notes, dated 6/28/15 at 1:00 AM document the hospital called reporting R1 was admitted with a wound infection and maggot infestation. R1's Hospital History and Physical, dated 6/28/15, documents 79 y/o (year old) female admitted for right heel ulcer, found to have maggots in wound in ED (Emergency Department). On 7/2/15 at 8:40 AM, E9, LPN, stated R1's wound dressing was loose with the wound bed exposed weeping through the dressing when she went to change it at approximately 10:00 PM on 6/27/15. E9 stated the dressing was odorous and wet with drainage when she removed the gauze. E9 stated she was not told in report that R1's wound was draining. E9 stated she did not see any flies in the building, but knew R1 liked to sit outside with her nephew every evening and did so that night until 10:00 PM the evening of 6/27/15. E9 stated the dressing she removed was not dated and/or labeled. E9 stated R1 was interviewable and could make her needs known. On 7/2/15 at 9:40 AM, E11, Certified Nurses Aide (CNA), stated R1's wound kept running and had lots of drainage. E11 stated she would see the dressing when she got R1 dressed in the morning as she slid her pants on and that the drainage had already soaked through the gauze at that time. E11 stated R1 liked to go outside with her family every night and was alert and oriented. R1's June 2015 Treatment Administration Record (TAR) only documented the treatment being done daily with no PRN treatments documented. The TAR documents E13, LPN did the pressure ulcer treatment the evening of 6/25/15 and 6/26/15. There is no documentation the wound dressing was changed any more often than daily. On 7/2/14 at 11:35 AM, E13 stated the wound had no odor on 6/26/15 when she did the dressing change around 10:00 PM, but did have noticeable drainage. E13 stated the ulcer dressing was loose and had slipped down exposing the wound bed on 6/26/15. E13 stated she cleansed the wound then dressed it. E13 stated R1 had been outside with family earlier that evening. E13 also identified R1 as alert and oriented. R1's Nurses Notes from 6/20/15 at 6:00 AM through 6/27/15 have no documentation of any drainage from R1's heel ulcer as reported by E13 and E9, LPN on 7/2/15 and seldom referred to the ulcer. There is no documentation that shows the nurses were monitoring the dressing and/or the direct care staff were informing the nurses that R1's dressing was not intact/clean and/or dry. R1's Wound Specialist Report, dated 6/24/15 documented the ulcer to be chronic, measuring 6 cm (centimeters) x 5.8 cm x .4 depth, yellow base (80%), tendon exposed, moderate yellow drainage with no odor documented. The Report also documents R1 wears a boot at all times on the affected leg. On 7/2/15 at 8:30 AM, Z2, Wound Specialist stated typically the wound dressing was dry and intact when she saw R1. Z2 stated the wound had been declining and when she saw her on 6/24/15, she recommended a surgical consult. Z2 stated she had never seen larva in a wound and that she would have expected the nurses to keep R1's wound covered with the dressing clean and dry. Z2 stated it is feasible that R2 was exposed to the larva on 6/26/15 and they hatched 24 hours later. Z2 stated she has never observed nurses at the facility do the dressing change. On 7/2/15 at 11:25 AM, R1 stated her leg ulcer dressing was seldom changed daily, adding that some times it would go 2-3 days without being changed. R1 stated when the nurse found the bugs that evening, the dressing hadn't been changed in a few days. R1 stated she noted the wound also smelled several days prior to that. R1 stated she saw the doctor on 6/26/15 but he didn't look at her sore. R1 stated she went outside to visit with her nephew and would not go to bed until 10:00 PM or after and that's when the nurses would do her dressings. On 7/6/15 at 2:30 PM, Z3, Physician, stated he saw R1 on 6/26/15, but did not unwrap the wound. Z3 stated R1 is definitely interviewable and information provided by her would be reliable. Z3 stated he assumed the treatments on R1's heel were being done routinely and whenever they needed to be done to ensure that R1's heel dressing was intact, clean and dry at all times. Z3 stated the eggs hatch in 24 hours. Z3 stated he also would think that if the nurse cleansed the wound appropriately the evening of 6/26/15, the eggs of the larva would have been removed and would not have had the live larva on 6/27/15. Z2 stated that R1's labs for Protein and [MEDICATION NAME] were within normal limits and R1 should be showing some signs of healing. Z2 stated With good nursing care, this all could have been avoided. The facility's policy entitled Pressure Ulcer Prevention and Management documents Any resident with a pressure ulcer will receive treatment and services consistent with the resident's goals of treatment. Typically the goal will be one of promoting healing and preventing infection unless resident's preferences and medical condition necessitate palliative care as the primary focus. The policy continues to document the facility is committed to providing staff education to establish and maintain competency related to pressure ulcer prevention, assessment and management. 2. R2's Admission Record documents he was admitted to the facility on [DATE] with 2 wounds to his right buttock and coccyx. R2's Wound Specialist Weekly Report, dated 7/1/15, documents R2's coccyx wound measured 5 cm x 3 cm x 2.2 cm and right buttock measured 6 cm x 2.5 cm with the upper right buttock measuring 1.2 cm x 0.8 cm. R2's July 2015 POS documents the treatment order, dated 6/11/15, as Apply Santyl + [MEDICATION NAME] PWD (powder) to Right buttock after cleansing with normal saline then cover with dressing till resolved daily and PRN. On 6/29/15, an order documents Right buttock to coccyx ulcer cleanse upper right buttock #2 area with normal saline, then apply allevyn change every two hours and PRN until resolved. The Care Plan, dated 6/26/15, also reflects the treatment order to be done daily and PRN. On 7/1/15 at 2:00 PM, R2's coccyx/right buttock wound was soaked throughout with drainage. The upper right quarter from 12:00 o'clock to 3:00 o'clock was loose and bunched up. The wound had a strong odor. E4, LPN, had been on the floor for the day shift which ended at 3:00 PM. There is no documentation in the Nurses Notes that E4 monitored and/or was informed the by nurses that R2's dressing was not intact and dry prior to the observation being done at 2:00 PM. At 3:40 PM, R2's dressing was noted to be clean, intact and dry. On 7/2/15 at 9:15 AM, R2's dressing was clean and dry but was not the same dressing as the one observed at 3:40 PM the day before. R2's TAR for July 2015 documented R2's wound dressing change was done only one time on 7/1/15 and 7/2/15 even though three different dressings were observed in place within a 24 hour period of time. 3. R3's July 2015 TAR documents a treatment for [REDACTED]. The Care Plan, dated 2/23/15, includes interventions for treatments to be done daily and PRN. On 7/1/15 at 1:08 PM, R3's coccyx wound dressing was soaked and pulled away from the pressure ulcer on her coccyx. E4 stated night shift nurses do her treatment, but she would go ahead and change it at that time. E2, Director of Nurses, noted R3's dressing was soaked with urine. On 7/2/15, R3's TAR for 7/1/15 did not reflect the PRN dressing change although E4 did change it shortly after 1:08 PM on 7/1/15. There is no documentation in R3's Nurses Notes of 7/1/15 that R3's dressing needed changed and/or was not intact/dry and clean at 1:08 PM or that the CNA's reported that the dressing needed changing until the observation was made.

Based on interview and record review the facility failed to thoroughly investigate injuries of unknown origin and / or potential abuse. This has the potential to affect all 93 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/18/14, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff, evaluate the effectiveness of the facility policies and procedures, and assess and revise their system of communication regarding incidents of unknown origin for potential abuse. Finding include: 1) R1's Minimum Data Set ((MDS) dated [DATE], documents that R1 has a Brief Interview of Mental Status (BIMS) score of 5 (with 15 being the highest cognitive level). This same MDS documents that R1 requires the extensive assistance of 2 staff members for transfers. The "Profile Face Sheet", dated 11/13/2014, documents [DIAGNOSES REDACTED]. R1 was discharged from Physical Therapy on 09/25/2014. R1's Therapy Discharge Note, dated 9/25/14, documents that R1 required the maximum assistance of 2 staff members, or the assistance of 2 staff members with use of a mechanical lift, for transfers. The form documents that R1 was unable to ambulate due to poor standing balance. R1's Nurse's Notes dated 11/02/2014, at 6:30 AM, documents "Certified Nurses Aide (CNA) informed this nurse of resident's (leg) having been fractured. This nurse went down and saw the resident's left leg which seemed to be dislocated. When asked what happened she stated she (R1) fell . There wasn't a fall reported. Call placed to Doctor waiting on call back VS (vital signs) 125/96, 97, 74, 68." R1's "physician's orders [REDACTED]." R1's Nurses Notes, dated 11/02/2014, at 10:30 AM documents, "Portable x-ray company here to x-ray LLE (left lower leg) at this time." R1's "physician's orders [REDACTED]. R1's "Electronic Health Record Medical Necessity Recommendation" from the hospital, dated 11/02/2014, documents "Pertinent Findings, Imaging X-ray of: Left tibia/fibula: Abnormal findings: Complete oblique fracture mid tibia with mild comminution and a proximal fibula shaft fracture. Computerized Tomography (CT) of Head: Abnormal findings: Small area of hyperdensity in the right parietal lobe may be artifact (error in the perception or representation by the involved equipment used) versus minimal subarachnoid hemorrhage. X-ray of the left ankle: complete [MEDICATION NAME] fracture mid tibia with some bayonetting, complete [MEDICATION NAME] fibula shaft with comminution, and a spiral, nondisplaced [MEDICAL CONDITION] tibia. X-ray of the left knee: Probable complete [MEDICAL CONDITION] fibula with overriding. X-ray of the left foot: Diffuse soft tissue swelling". R1's "Discharge Summary/Instructions" from the hospital, dated 11/08/2014, documents "1. Left tibial fracture Comment: status [REDACTED]. 2. Subarachnoid hemorrhage Comment: CT scan shows possible subarachnoid hemorrhage versus artifact. No evidence of focal neurological deficit. 3. Elder physical abuse Comment: Patient has multiple fractures and some of them spiral. Patient has previous history of falls. Social work consult for possible elder abuse family wants to take her back to the same nursing home. Procedures: Intramedullary rod in the left tibia" The "INCIDENT REPORT FORM - IDPH NOTIFICATION", dated 11/2/2014, documents, "Describe what happened, cause of injury: Unknown origin. Resident unable to explain what happened. Left leg was swollen 2 weeks ago. Doppler was done (and) negative. Was on antibiotic therapy (ABT) for possible [MEDICAL CONDITION]. Sent toER on [DATE]. Sent back to facility with an increase in ABT dose. This morning complaining of pain in left (L) leg. X-ray ordered. Final : X-ray L leg shows acute mildly displaced fracture (Fx) of the mid shaft & tibia & distal fibula. Send to ER". The x-ray results documerent that this x-ray was a mobile x-ray performed in the facility. The (E2)Director of Nurses (DON) review of the incident investigation was signed off as completed on 11/3/2014. The review documents: "Exact cause not identified but potential causes identified. Resident unable to ambulate. Staff used mechanical lift to transfer resident. Resident's daughter would insist on R1 to be assisted up (with) a walker ambulate to bathroom with weight bearing on leg, possible injury during these times (with) daughter (with) staff present". The facility collected 6 statments from the staff, dated 11/6/14, which was 3 days after E2, DON concluded her investigation for R1's multiple leg fracture. The statements collected were only from CNA's and pertained only to the potential of R1 falling. E2's investigation did not include other causative factors, or question the potential for abuse. On 11/19/2014, at 12:44 PM, E25, Director of Environmental Service, stated that she was the manager on duty on 11/2/2014 at 6:30 AM. E25 stated that a CNA came to the nurses station and informed the nurse that R1's left leg looked "funny, maybe like broke". E25 stated the nurse went to R1's room and assessed R1, then began calling the doctors. On 11/13/2014, at 2:50 PM, E21 Assistant Director of Nurses (ADON), stated "when she did the investigation into R1's leg fracture she did not investigate the potential for abuse because she wasn't thinking of abuse". E21 also stated that she does not know how the [MEDICAL CONDITION] leg happened. On 11/12/2014, at 2:50 PM, E26, CNA, stated she was unsure how R1's fracture happened. On 11/12/2014 at 2:55 PM, E28 CNA, stated she was unsure how R1's fracture happened. On 11/12/2014 at 3:02 PM, E27 CNA, stated she was unsure how R1's fracture happened. On 11/13/2014 at 2:50 PM, E2 DON, E3, Careplan Coordinator and E21, ADON, all stated they do not know how R1's left leg fracture happened. 2) R6's MDS, dated [DATE], documents that R6 has a BIMS score of 4 (with 15 being the highest level of cognitive functioning), uses a wheelchair for ambulation and requires the extensive assistance of 1 staff member for transfers. R6's Nurses's Notes, dated 03/31/2014, at 11:00 AM document "Resident alert with confusion, up sitting in reclining chair, complaint of right arm pain right wrist swollen". R6's Nurses' Notes, dated 4/1/2014 at 6:00 AM, documents "Order received for x-ray of right hand and wrist". Portable x-ray report of R6's right hand, dated 04/01/2014, documents: "Impressions: 1: Defect involving capitate bone that may represent a nondisplaced fracture. 3. Severe degree of [MEDICAL CONDITION]. 4. Moderate [MEDICAL CONDITION]". The Facility "Investigation of Unknown Swelling", undated, documents: "On 3/30/14, residents daughter approached me regarding her observation of swelling and discomfort of resident's right wrist and lower portion of arm, adjacent to wrist. Noted area felt slightly warm to touch. Dr. notified. Orders received to give Tylenol for pain. During observation, DON noted resident was previously on [MEDICATION NAME], which is a medication for inflammation for [MEDICAL CONDITIONS], and arthritis. This medication was discontinued two weeks prior to noting [MEDICAL CONDITION] of R6's wrist. On 4/4/14, new orders were received for an x-ray of right wrist and hand which revealed defect involving capitate bone that may represent a non- displaced Fx with a severe degree of [MEDICAL CONDITION] and moderate [MEDICAL CONDITION]. A wrist splint was applied by physical therapy after evaluation". This document was signed by E2. There was no documentation that an investigation into R6's injury of unknown origin/potential abuse occurred. On 11/19/2014 at 2:47 PM, when asked about R6's injury to her right hand, E26, CNA stated, "I heard it was swollen, I didn't think it was broke." On 11/19/2014 at 2:54 PM, when asked about R6's injury to her right hand, E27, CNA stated "I came in and it was swollen, it was x-rayed and she got a brace. I do not know what happened." On 11/19/2014 at 3:00 PM, when asked about R6's injury to her right hand, E29, Licensed Practical Nurse (LPN) stated, "I remember something wrong with her hand, I did not think it was fractured but it was swollen." On 11/19/2014 at 2:52 PM, when asked about R6's injury to her right hand, E28, CNA stated "I thought it was sprained or something. I do not know anything about how it happened." 3. R4's most recent admission sheet documents that R4 was admitted to the facility on [DATE] with a diagnoses, in part, of Anxiety, [MEDICAL CONDITION] and Dementia with Behavior Disturbances. R4's MDS, dated [DATE], documents R4's ambulation as independent without physical help from staff. R4's highest cognitive level of function was not assessed. R4's Nurses' Notes document that on 10/20/14 "Staff informed nurse that bruise to right eye (was found) when doing rounds. Assessment reveals right eye purple - starting at eyebrow down to inner eyelid. R4 unable to tell what happened. Displays no sign of pain, no bleeding. Noted slight swelling. R4 has a habit of wandering, is very confused and walks independently. Has a history of falls, bruises easily.." "Resident Incident Report", dated 10/20/14, documents: "Type of incident: bruise, Details of incident: Resident able to communicate what occurred? NO ; What was the resident doing prior to incident? sleeping; Explain in detail what occurred: staff informed of discoloration on residents right eye. Assessment reveals discoloration, purple in color starting at right eyebrow down to inner eyelid; Is cause of the injury known? Yes; Summary of Probable Cause of Accident and intervention o reduce risk of Recurrence: Probably bumped into door or another object. Wanders in hallway and in/out of rooms. Staff will continue to observe residents when about and attempt to sit with resident for short rest periods. On 11/12/14, at 1:00PM, E21, ADON, stated "I don't know anything about R4's eye bruising and did not get any incident report on it." On 11/12/13, at 1:10PM, E23, LPN, stated that he (E23) came on shift the morning after R4's black eye was noted. E23 stated "R4 scratched it or something." On 11/12/14, at 2:45 PM, E21, ADON, stated "there is no investigation into the causative factors of R4's black eye or how R4's black eye occurred. " On 11/13/14 at 1:30 PM, E2, DON, stated she did not recall R4's black eye. On 11/18/14 at 10 AM, E1, Administrator, stated that she was not working in this position when R4's black eye occured. On 11/17/14, at 2:45 PM, E3 stated that there is no further investigation for causative factors of R4's black eye. 4. R18's current facesheet documents that R18 was admitted on [DATE], with diagnoses, in part, of Generalized Pain and Anxiety. R18's MDS, dated [DATE], documents that R18 requires the extensive assistance of one staff member for dressing, eating, hygiene and bathing; and the extensive assistance of two staff members for transfers. The MDS further documents that the BIMS was not assessed. R18's Nurses' Notes, dated 9/25/14, document "Upon awakening right ankle noted to be swollen and purplish in color. Wanderguard in place on left ankle. Physician Assistant to see R18 today related to right ankle." R18's Nurses' Notes dated 9/26/14 document "X-ray report received and Z2, Physican Assistant, notified of acute mildly displaced fracture of distal tibial metaphysis". R18's X-ray Report, dated 9/26/14, documents "Impressions:1. Acute mildly displaced fracture, distal tibial metaphysis. 2. Mild medial soft tissue swelling. 3. Moderate [MEDICAL CONDITION] demonstrated. 4. Mild [MEDICAL CONDITION] arthritis". R18's Progress Notes dated 9/25/14 documents "Asked to see patient for right lower extremity swelling and discoloration. No reported injury to leg. Sudden onset." "Incident Report Form-IDPH Notification" documents " Describe what happened, cause, injury: Prelimary Report. Resident X-ray on 9/26/14 revealed displaced fracture of right tibia. 9/30/14 Unable to determine origin. Investigation complete. 10/1/14 Additional documentation regarding this occurrence" The initial notification dated 9/30/14 written by E30, Acting Administrator at the time of occurrence, documents "A complete investigation was completed regarding resident R18. Based on the documentation and interview, there is no conclusion as to how this fracture may have occurred. There is no evidence of abuse or neglect." The final report written by E30 documents "Based on the documentation and interviews, there is no conclusion as to how this fracture may have occurred. There is no evidence of abuse or neglect." On 11/13/14 at 11:30 PM, E21 stated "I don't know what facility policy is on abuse and I don't know what F-tags are. There is no further information or documentation on investigation for R4's black eye or R18's broken leg-not sure how they happened." On 11/13/14 at 1:30 PM, E2 stated that she did not recall R18's broken leg. On 11/19/14 at 2:40PM, E21 stated that she does not know or remember anything about R18's broken leg. E21 stated there is no other documentation. 5. On 11/18/14 at 10:00AM, E1, Administrator was interviewed and stated she was not the Administrator of the Facility at the time of R6, R4 and R18's incidents. E1, agreed the investigations into these resident's injuries of unknown origin were not thoroughly investigated. On 11/19/14 at 1:00PM, E1 stated she thought the facility was investigating the incidents and that it was a documentation issue as to why they did not have more documentation on incident investigations. 6. The Resident Census and Conditions of Residents, CMS 672, dated 11/10/14, documents that there are 93 resident's in the Facility. 7. The Immediate Jeopardy situation was identified and determined to have begun on 11/2/14 when R1 was found to have multiple fractures of unknown origin to the left lower leg. E1, E2, E3 and E34, Corporate Consultant, were notified of the Immediate Jeopardy on 11/18/14 at 3:42 PM. On 11/18/14 at 5:00 PM, The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 11/18/14, E2 immediately inserviced facility staff regarding identification and investigation of injuries of unknown origin and incidents of abuse. All evening shift staff were inserviced by 4:24 PM on 11/18/14. 2. On 11/18/14, other staff were inserviced near the start of their shift until all staff were inserviced. Facility staff were not allowed to work until they received this inservice. 3. On 11/18/14, Administrative staff along with evening shift and night shift, performed body audits/examinations on all current residents to determine any injuries of unknown origin or changes in skin condition.

Based on interview and record review the Facility failed to operationalize and follow its Abuse Prevention Policy to thoroughly investigate incidents of unknown origin/potential abuse. This has the potential to affect all 93 residents living in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/18/14, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures and their system of communication regarding incidents of unknown origin/potential abuse. Finding include: 1. R1's Nurse's Notes dated 11/02/2014 at 6:30 AM documents "Certified Nurses Aide (CNA) informed this nurse of residents (leg) having been fractured (fx). This nurse went down and saw residents left leg which seemed to be dislocated. When asked what happened she stated she fell . There wasn't a fall report. Call placed to Doctor waiting on call back". R1's hospital "Electronic Health Record Medical Necessity Recommendation", dated 11/02/2014, documents "Pertinent Findings, Imaging X-ray of: Left tibia/fibula: Abnormal findings: Complete oblique fracture mid tibia with mild comminution and a proximal fibula shaft fracture. X-ray of the left ankle: complete [MEDICATION NAME] fracture mid tibia with some bayonetting, complete [MEDICATION NAME] fibula shaft with comminution, and a spiral, nondisplaced [MEDICAL CONDITION] tibia. X-ray of the left knee: Probable complete [MEDICAL CONDITION] fibula with overriding. X-ray of the left foot: Diffuse soft tissue swelling". The "INCIDENT REPORT FORM - IDPH NOTIFICATION" dated 11/2/2014 documents, " Describe what happened, cause of injury: Unknown origin. Resident unable to explain what happened. Left leg was swollen 2 weeks ago. Doppler was done (and) negative. Was on antibiotic therapy (ABT) for possible [MEDICAL CONDITION] sent to emergency room (ER) on 10/23/2014. Sent back to Facility with an increase ABT dose. This AM complained of (c/o) pain left (L) leg. X-ray ordered. Final : X-ray L leg shows acute mildly displaced Fx of the mid shaft & tibia & distal fibula. Send to ER". The x-ray referred to was a mobile x-ray performed in the facility. E2, the Director of Nurses (DON) review the incident report and signed off that the investigation was completed on 11/3/2014. The investigation documents: "Exact cause not identified but potential causes identified. Resident unable to ambulate. Staff used mechanical lift lift to transfer. Resident's daughter would insist on her mother to be assisted up (with) a walker ambulate to B/R (bathroom) with wt (weight bearing) on leg possible injury during these times (with) daughter (with) staff present". The Facility collected statements from 6 staff members, dated 11/6/14, which was 3 days after E2 concluded her investigation for R1's multiple leg fractures. The 6 statements collected were only from CNA's and pertained only to the potential of R1 falling, and did not thoroughly investigate other causative factors, including the potential for abuse. On 11/13/2014 at 2:50 PM, E21 Assistant Director of Nurses (ADON), stated that when she did the investigation into R1's leg fracture, she did not investigate abuse because she was not thinking of abuse. E21 also stated that she does not know how the fracture of R1's left leg occurred. The Facility Policy "Reporting Incidents of Resident Abuse" dated 1/28/14, documents: POLICY: The staff of Facility shall promptly report any incident or suspected incident of residents abuse, including injuries of unknown origin. PROCEDURES: 2. Any incident or suspected incident, occurring at the Facility, involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of resident property, must be reported immediately to the Administrator. 3. All staff, residents, visitors, are encouraged to report incidents of residents abuse or suspected incidents of abuse". 2. R6's Nurses's Notes dated 03/31/2014, at 11:00 AM document "Resident alert with confusion, up sitting in reclining chair complaint of right arm pain right wrist swollen". R6's Nurses' Notes, dated 4/1/2014, at 6:00 AM documents "Order received for x-ray of right hand and wrist'. The portable x-ray report of R6's right hand, dated 04/01/2014, documents: "Impressions: 1: Defect involving capitate bone that may represent a nondisplaced fracture. 3. Severe degree of [MEDICAL CONDITION]. 4. Moderate [MEDICAL CONDITION]". The Facility "Investigation of Unknown Swelling", undated, documents: "On 3/30/14, residents daughter approached me regarding her observation of swelling and discomfort of resident's right wrist and lower portion of arm portion adjacent to wrist. Noted area felt slightly warm to touch. Dr. notified. Orders received to give Tylenol for pain. During observation, DON noted resident was previously taking [MEDICATION NAME], which is a medication for inflammation for [MEDICAL CONDITIONS], and arthritis. This medication was discontinued two weeks prior to R4's [MEDICAL CONDITION] of the wrist. On 4/4/14, new orders were received for x-ray of right wrist and hand which revealed defect involving capitate bone that may represent a non displaced fracture Fx with a severe degree of [MEDICAL CONDITION] and moderate [MEDICAL CONDITION]. Wrist splint applied by physical therapy after evaluation". This document was signed by E2, DON. This investigation lacked documentation that a thorough investigation was done to determine how this injury of unknown origin and/or potential abuse happened. On 11/19/2014 at 2:47 PM, when asked about R6's injury to her right hand, E26 CNA stated, "I heard it was swollen, I didn't think it was broke." At 2:54 PM, when asked about R6's injury to her right hand, E27 CNA stated "I came in and it was swollen, it was x-rayed and she got a brace. I do not know what happened." At 3:00 PM, when asked about R6's injury to her right hand, E29 Licensed Practical Nurse (LPN) stated, "I remember something wrong with her hand, I did not think it was fractured but it was swollen." At 2:52 PM, when asked about R6's injury to her right hand, E28 CNA stated "I thought it was sprained or something. I do not know anything about how it happened." 3. R4's Nurses' Notes document that on 10/20/14 "staff informed nurse that (R4) had a bruise to the right eye when doing rounds. Assessment reveals right eye purple starting at eyebrow down to inner eyelid. R4 unable to tell what happened. Displays no sign of pain, no bleeding. Noted slight swelling. R4 has a habit of wandering, is very confused and walks independently. Has a history of falls, bruises easily." The "Resident Incident Report", dated 10/20/14, documents the following: "Type of incident: bruise, Details of incident: Resident able to communicate what occurred? NO; What was the resident doing prior to incident? sleeping; Explain in detail what occurred: staff informed of discoloration on residents right eye. Assessment reveals discoloration, purple- in-color starting at right eyebrow down to inner eyelid; Is cause of the injury known? Yes; Summary of Probable Cause of Accident and intervention to reduce risk of Recurrence: Probably bumped into door or another object. Wanders in hallway and in/out of rooms. Staff will continue to observe residents when about and attempt to sit with resident for short rest periods". On 11/12/14 at 1:00 PM, E21, Assistant Director of Nursing, (ADON) stated "I don't know anything about R4's eye bruising and did not get any incident report on it." On 11/12/14 at 1:10 PM, E23, Licensed Practical Nurse, LPN stated he (E23) came on shift the morning after R4's black eye was noted. E23 stated "R4 scratched it or something." On 11/12/14 at 2:45 PM, E21, ADON stated "there is no investigation into the causative factors of R4's black eye or how R4's black eye occurred. " On 11/13/14 at 1:30 PM, E2, DON, stated she did not recall R4's black eye. On 11/18/14 at 10:00 AM, E1, Administrator, stated she was not the Administrator at the time of R4's black eye. On 11/17/14 at 2:45 PM, E3 stated that there is no further investigation in the reports for R4's black eye. 5. R18's Nurses' Notes dated 9/25/14 document "Upon awakening right ankle noted to be swollen and purplish in color. Electronic ankle bracelet in place on left ankle. Z2, Physician Assistant to see R18 today related to right ankle." R18's Nurses' Notes, dated 9/26/14, document "X-ray report received and Z2 notified of acute mildly displaced fracture of distal tibial metaphysis". R18's X-ray Report dated 9/26/14 documents "Impressions: 1. Acute mildly displaced fracture, distal tibial metaphysis. 2. Mild medial soft tissue swelling. 3. Moderate [MEDICAL CONDITION] demonstrated. 4. Mild [MEDICAL CONDITION] arthritis". R18's Progress Notes dated 9/25/14 documents "asked to see patient for right lower extremity swelling and discoloration. No reported injury to leg. Sudden onset." The "Incident Report Form-IDPH Notification" documents "Describe what happened, cause, injury: Preliminary Report. Resident X-ray on 9/26/14 revealed displaced fracture of right tibia. 9/30/14 Unable to determine origin. Investigation complete. 10/1/14 Additional documentation regarding this occurrence" The initial notification, dated 9/30/14, written by E30, acting administrator at the time of occurrence, documents "A complete investigation was completed regarding resident R18. Based on the documentation and interview, there is no conclusion as to how this fracture may have occurred. There is no evidence of abuse or neglect." The final report, written by E30, documents "Based on the documentation and interviews, there is no conclusion as to how this fracture may have occurred. There is no evidence of abuse or neglect." On 11/13/14 at 1:30 PM, E2, DON stated she did not recall R18's leg being broken. On 11/19/14 at 2:40 PM, E21, ADON, stated she does not know or remember anything about R18's broken leg. E21 stated there is no other documentation regarding R18's broken leg. On 11/13/14 at 11:30 PM, E21, ADON stated "I don't know what the facility policy is on abuse and I don't know what tags are". There is no further information or documentation on investigation for R4's black eye or R18's broken leg-not sure how they happened." On 11/18/14 at 10:00 AM, E1, Administrator was interviewed and stated she was not the Administrator of the Facility at the time of R4, R6 and R18's incidents. E1 confirmed that the Facility had not thoroughly investigated R1, R4, R6 and R18's injuries of unknown origin according to the Facility's policy and procedures. 4. The Resident Census and Conditions of Residents, CMS 672, dated 11/10/14, documents that there are 93 resident's in the Facility. 5. The Immediate Jeopardy situation was identified and determined to have begun on 11/2/14 when R1 was determined to have multiple fractures of unknown origin to the left lower leg. E1, E2, E3 and E34, Corporate Consultant, were notified of the Immediate Jeopardy on 11/18/14 at 3:42 PM. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 11/18/14, E2 immediately inserviced facility staff regarding identification and investigation of injuries of unknown origin and incidents of abuse. All evening shift staff were inserviced by 4:24 PM on 11/18/14. 2. On 11/18/14, other staff were inserviced near the start of their shift until all staff were inserviced. Facility staff were not allowed to work until they received this inservice. 3. On 11/18/14, Administrative staff along with evening shift and night shift, performed body audits/examinations on all current residents to determine any injuries of unknown origin or changes in skin condition.

Based on record review and interview, the Facility failed to identify risk factors for the development of a pressure sore and implement interventions based on the identified factors for 1 (R19) of 4 residents with a history of pressure sores in the sample of 19. This failure resulted in R19 developing a Stage III pressure sore from a leg brace. Findings include: The Facility "Investigation Summary", dated [DATE], documents, "On [DATE] at 8:30 PM, R19 attempted to transfer self from bed because she said another resident (male) had entered her room. R19 fell on the floor causing an injury to her left knee. Assessed by nurse, assisted to bed by staff when nurse noted some swelling and warmth to knee. Physician notified, orders received to send to hospital for evaluation. R19 admitted to hospital with [DIAGNOSES REDACTED]. No surgery performed. On [DATE], R19 returned to the Facility with left knee brace. Prior to incident, resident's power of attorney had stated that resident has been bed bound for three years. " R19's Hospital Transfer Summary, dated [DATE], documents, "Patient complains of discomfort with the brace. Velcro knee immobilizer in place. Patient complained that the brace was rubbing. Stockinette was placed on the limb and brace readjusted with good relief of discomfort." R19's Discharge Instructions, dated [DATE], document, "Leg Fracture: Cast or splint care: Check the skin around the cast or splint every day. " The "Skin/Wound Log" documents the following for R19: the week of [DATE] - "cast/brace left leg, skin clear, the week of [DATE] - cast intact; the week of [DATE] - brace intact. " R19's Nurses Note's documents, "[DATE], 4:50 PM, (R19) refused to remove brace to left leg for skin assessment. " There is no other documentation regarding skin assessments for R19 in the clinical record until her development of a pressure sore on [DATE]. R19's Nurses Notes dated [DATE], 7:00 PM, document, "Summoned to R19's room by resident's power of attorney, stated that she noticed some drainage on resident's pillow slip. Leg brace removed and extremity inspected. Upon assessment, Stage 2 or 3 decubitus noted to posterior left lower extremity. Area measures approximately 3 centimeters (cm) round, redness around boarder noted". E3, Care Plan Coordinator, confirmed in an interview on [DATE] at 2:45 PM, that there is no other documentation regarding the condition of R19's skin around or underneath the splint prior to the development of a Stage III pressure sore from the splint and there is no documentation that R19's skin around the splint was being checked on a daily basis. The "Weekly Pressure Ulcer Log" documents the following for R19's Facility Acquired Pressure Sore of the left lower leg: The week of [DATE] - "Stage III measuring 2.3 cm in length by 1.5 cm in width and 1.0 cm in depth". The week of [DATE] - "Stage III measuring 2.0 cm in length by 2.3 cm in width (the area on the form for recording depth is blank)". The week of [DATE] - "Stage III measuring 1.9 cm in length by 2.3 cm in width and 0.2 cm in depth". The week of [DATE] - "Stage III measuring 1.7 cm in length by 2.0 cm in width (the area on the form for recording depth is blank)". The week of [DATE] - "hospital". The week of [DATE] - "Stage III measuring 1.0 cm in length by 1.7 cm in width and 0.3 cm in depth". The week of [DATE] - "deceased ". There is no further documentation regarding R19's pressure sore on the "Weekly Pressure Ulcer Log". The Facility "Nursing Service Policy and Procedure Manual, Pressure Sore Care", documents "Observe daily for the following signs of potential pressure signs and report accordingly: 1) redness or a darker, deeper bruise-like color. 2) Heat. 3) Tenderness. 4) Pain or discomfort. 5) Cracks in the skin. 6) Excessive dryness. 7) Sores, cuts or abrasions".

Based on record review and interview, the Facility failed to identify potential safety hazards and implement progressive interventions to reduce those hazards for 1 of 6 ( R7) residents with injuries in the sample of 19. This failure resulted in R7 falling and sustaining an Acute Cerebellar Hemorrhage. Findings include: 1. R7's Minimum Data Set (MDS), dated [DATE], documents the following: Brief Interview for Mental Status (BIMS), "05", with 15 being the highest level of cognitive functioning; does not ambulate; not steady and only able to stabilize with staff assistance for walking and surface-to-surface transfers; and requires the extensive assistance of one person for transfers. The Facility "Resident Fall Report/Fall Investigation" documents that on 7/21/14, at 10:30 AM, R7 fell in the dining room. The report further documents "Type of fall - Unwitnessed Fall, Skin abrasion/bruise, Head Injury or Probable Head injury, fell out of wheelchair, found on the floor. Resident Diagnosis/Medical Conditions - muscle weakness, hypertension, depression. Potential cause of fall - incorrect wheelchair. Fall preventative devices in use at the time of fall: None. Probable cause and Interventions to Recurrence - at 10:30 AM, this nurse was called to dining area. Upon entering resident was observed lying on the floor in front of wheelchair. Resident had been observed leaning forward in chair prior to fall. Probable cause: resident had fallen forward out of wheelchair. Incorrect wheelchair for resident. New wheelchair in place. Resident found on floor in dining room. Apparently fell asleep in wheelchair and fell forward to floor. Apparently resident was not in correct wheelchair. Appropriate wheelchair provided. Offer resident to lay down if falling asleep in wheelchair. Injuries: redness to left arm, swelling and bruising to right knee, redness to middle of forehead and abrasion to bridge of nose". The Facility nurses notes document: "7/21/14, 10:30 AM, this nurse was called to dining area. Upon entering resident was observed lying on floor in front of wheelchair. Resident had been previously observed leaning forward in chair. Resident had fallen out of wheelchair related to incorrect chair. Appropriate chair now in place. 11:30 AM, send resident to emergency room ." The "Nursing Assistant Resident Fall Report", dated 7/21/14, documents "R7 was with the activity aide in the activity room and was leaning forward in the wheelchair". E13, Certified Nurses Aide (CNA), stated in an interview on 11/19/14 at 9:55 AM, that she was the CNA who completed the "Fall Report". E13 said that E14, Activity Aide, was pushing R7 out of the dining room in her wheelchair and she fell forward out of the wheelchair. E13 said that she did not witness the incident but, was told that was what had occurred. E14, Activity Aide, was interviewed on 11/13/14 at 1:30 PM, and stated that she does not really remember what happened to R7. E14 said that she thinks it happened during church but she's not sure. E14 said "R7 leans a lot in her wheelchair". The "Nursing Home to Hospital Transfer Form", dated 7/21/14, documents "Reason for transfer: Fall and elevated blood pressure". The form documents R7's blood pressure was 218/100 and pulse was 50. R7's "emergency room Visit Report", dated 7/21/14, documents "Clinical Impression: Falls, Acute Cerebellar Hemorrhage. Progress Note: Discussed Head Computerized Tomography (CT) finding with primary care physician and patient's family. Family does not want aggressive measures, refuses transfer. Blood pressure controlled here. Physician and family okay with discharging R7 back to the care Facility". R7's plan of care, with an original date of 8/6/09, documents "Problems: Falls. I am at risk for falls. I have balance deficits, and decline in functional status. I have a history of falls". Approaches for this Problem include: "Apply chair alarm". The care plan documents the Approach "Offer to lay resident down if falling asleep in wheelchair" was added on 7/21/14. E21, Assistant Director of Nursing (ADON), confirmed in an interview on 11/13/14 at 1:10 PM, that the Facility failed to thoroughly investigate the cause of R7's fall on 7/21/14, and assess R7 for leaning forward in her wheelchair prior to the fall which resulted in an Acute Cerebral Hemorrhage. E21 stated that she did not know what the "wrong" or "right" type of wheelchair was for R7 and did not know how it contributed to her fall.