Every finding on record at Staunton Health and Rehab CTR

Based on observation, interview, and record review the facility failed to protect and prevent residents from misappropriation of medications for two of two residents (R5 and R24) reviewed for misappropriation in a sample list of 24.[NAME]'s FindingsWriting Complete | Last Updated by [NAME] 08/19/2026 12:31 PMFindings include:On 8/18/2026 at 11:00AM, V2 Director of Nursing (DON) stated nurses used heparinized flushes labeled with R24's information located in the South Hall medication room in the house stock cabinet to flush and maintain R5's midline intravenous catheter.On 8/17/2026 at 12:05PM, V24 Registered Nurse (RN) stated V24 flushed R5's intravenous catheter with saline and heparinized saline at the completion of each antibiotic dose on 8/8/2026 through 8/14/2026 and on 8/17/2026. V24 RN stated the heparinized flushes were obtained from the medication room stock supply.On 8/17/2026 at 12:36PM, V26 RN stated R5's intravenous catheter was flushed with saline and heparinized saline at the completion of each antibiotic dose administered on 8/15/2026 and 8/16/2026. V26 RN stated the heparin flush was obtained from the medication room.On 8/18/2026 at 11:00AM, V2 DON confirmed the supply of heparin flushes V2 used and other nurses have used to flush R5's midline intravenous catheter was labeled with R24's pharmacy information. V2 stated R24's medication should have been sent with R24 upon discharge from the facility or sent back to the pharmacy. R5's medical record documents R5 admitted on [DATE] with diagnosis including Peripheral Vascular Disease, Atrial Fibrillation, Diabetes Type II, Coronary Artery Disease, and Chronic Obstructive Pulmonary Disease. R5's medical record Minimum Data Set, dated [DATE] documents R5 has no cognitive impairment.R5's medical record documents Discharge Packet dated 8/7/2026, Patient's midline catheter may be removed after patient completes IV antibiotic on 8/18/2026R24's medical record documents admission to the facility on 5/6/2026 with diagnosis including Acute and Subacute Infective Endocarditis, Bacteremia, and Osteomyelitis of Vertebra, lumbosacral region. R24 was discharged from the facility on 6/2/2026.R24's medical record documents a Minimum Data Set, dated [DATE] R24 has no cognitive impairment.R24's physician orders dated 5/18/2026 documents Heparin Na (Pork) Lock Flsh PF Intravenous Solution (Heparin Sodium (Porcine) Lock Flush) Use 5 ml intravenously one time a day for flush using SASH method, saline-medication-saline-heparin.The facility's policy titled Abuse Policy with a revised date 12/2025 documents it is the responsibility of all facility staff to assure that all residents remain to be free from abuse, including injuries of unknown origin, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. It is all staff responsibility to report any allegation or witnessed abuse immediately to the Administrator (abuse coordinator).

Based on interview, observation and record review the facility failed to ensure a care plan intervention for falls risk was communicated for one (R11) of three residents reviewed for accidents in the sample list 24.Findings Include: On 8/12/2026 at 9:55 a.m. R11 observed sitting in room up in wheelchair with anti-tip devices attached on back of the wheelchair. On 8/12/2026 at 11:55 a.m. V18, Certified Nursing Assistant (CNA) presented a binder that is located at nurses' station labeled South CNA Binder that has handwritten care planned interventions in place for the residents. R11 has an intervention noted for anti-roll backs on wheelchair that was last updated on 7/22/2026. On 8/12/2026 at 12:31 p.m. R11 fall investigation report shows anti-roll backs on order 7-1-2026 but observed to have Anti-tip devices on R11's wheelchair. On 8/12/2026 at 1:15 p.m. V20, Maintenance Director (MD), verbalizes and confirms R11 has anti-tip devices are on R11's wheelchair currently. V20 confirms no anti-roll back devices placed on the wheelchair at this time.On 8/17/2026 at 9:28 a.m. V1, Admin, confirms there are no targeted care planned interventions of anti-tip devices or anti-roll backs devices on care plan for fall interventions.V20, MD, presented a copy of purchase order for anti-roll backs devices. Anti-roll back devices were ordered on 8-1-2026. V20 stated V20 placed anti-tip devices on R11's wheelchair. On 8/12/26 at 11:40am R11 medical record documents reviewed R11 was admitted on [DATE] with documented diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Occlusion and Stenosis of Bilateral Carotid Arteries, Essential (primary) Hypertension, Radiculopathy, lumbar region, Peripheral Vascular Disease, Trochanteric Bursitis, left hip, Trochanteric Bursitis, right hip, Abdominal Aortic Aneurysm, without rupture, Cerebral Ischemia, Anemia in other chronic diseases, history of falling, and sequelae of cerebral infarction.On 8/12/26 at 11:40am R11 medical record documents R11 Minimum Data Set, dated [DATE] documents R11 is cognitively intact.On 8/12/2026 at 11:42am R11 does not have anti-tippers or anti roll-back noted in care plan for fall intervention. On 8/17/2026 at 11:45 a.m. facility policy reviewed for accidents and Incidents revised on 7/1/2023 stating in section F- The Care Plan Coordinator will be notified of the accident/incident so that appropriate changes may be made to the care plan as needed.

A: Based on observation, interview, and record review the facility failed to complete wound dressing changes as ordered by the physician for two of three residents (R3 and R5) reviewed for quality of care in a sample list of 23. B: Based on interview and record review the facility failed to call Infectious Disease Physician to schedule a follow up visit for one (R5) of one reviewed for following physician orders in a sample list of 23. A: Findings Include: On 8/11/2026 at 1:50PM, R3 stated the dressings do not always get changed on the weekends because the wound nurse does not work on the weekends. On 8/12/2026 at 11:45AM, V16 CNA stated dressing changes do not always get changed on weekends due to V6 Wound Nurse not being on shift. V16 stated the assigned floor nurses are responsible for completing treatments on weekends but have a difficult time completing all the tasks. On 8/12/2026 at 12:45PM V2, Director of Nursing stated all wound treatments and dressing changes should occur as ordered by the physician by the nurses. On 8/17/2026 at 6:55AM, R5 stated I do not know when the last time my dressings were changed. On 8/17/2026 at 7:13AM, V17 Certified Nurse Assistant/CNA donned gloves and observed R5's sacral wound dressing. The dressing appeared soiled and saturated with a non-odorous yellowish substance and was not intact on the bottom border. The date on the dressing was faded and difficult to clearly visualize. V17 CNA stated the date is hard to tell but looks like 8/14. On 8/17/2026 at 7:39AM, V6 Wound Nurse donned a gown and gloves and observed R5's sacral wound dressing. V6 stated R5's dressing is dated but difficult to read. V6 stated I think it's 8/14, but I don't know. On 8/17/2026 at 10:04AM V9, License Practical Nurse (LPN), confirmed observation at the bedside, R5's Midline Intravenous Catheter dressing is dated 8/6/26. V9 confirmed the dressing contained drainage underneath and needed to be changed. R3 's medical record documents R3 admitted on [DATE] with a diagnosis including Chronic Atrial Fibrillation, Chronic Heart failure, and Weakness. R3's Minimum Data Set, dated [DATE] documents R3 has mild to moderate cognitive impairment. R3's medical record documents a physician order dated 7/24/2026 documents Cleanse LLE wound with Wound Cleanser. Apply calcium alginate and medical honey, cover with dry dressing, change every day shift for wound healing. R3's Treatment Administration Record (TAR) dated August 2026 T documented the dressing change was not completed for R3 on 8/8/2026 R5 's medical record documents R5 admitted on [DATE] with diagnosis including Peripheral Vascular Disease, Atrial Fibrillation, Diabetes Type II, Coronary Artery Disease, and Chronic Obstructive Pulmonary Disease. R5 's medical record documents the Minimum Data Set, dated [DATE] documents R5 has no cognitive impairment. R5 's medical record documents A physician order dated 6/16/2026 documents cleanse sacral ulcer with wound cleanser or NS and pat dry. Apply Collagen Particles, then Xeroform. Cover with bordered foam. Every day shift for wound care AND as needed for wound management. R5 medical record contains Treatment Administration Record (TAR) documented dressing change was not completed for R5 on 8/2/2026 and 8/8/2026. A facility policy titled Physician Orders dated 7/1/2023 documents this facility will obtain, process, and implement physician orders given by a Licensed Physician and received by a licensed nurse. 6. Treatment Orders - When recording treatment orders, specify the treatment, location, frequency, and duration of the treatment. B: Findings Include: On 8/12/26 at 10:36AM R5 is noted to have an intravenous line inserted in the right upper arm with a dressing dated 8/7/26 applied. On 8/12/26 at 10:36AM R5 stated R5 has been receiving an intravenous antibiotic since R5 returned from the hospital. On 8/17/2026 at 10:35AM V9, License Practical Nurse (LPN), stated R5 has not been scheduled a consult visit with the Infectious Disease Physician listed in the hospital discharge orders. On 8/17/2026 at 9:35AM V1, Admin, confirmed the facility nurses are to follow all physician orders including hospital discharge orders when a resident returns from the hospital and make all follow up appointments according to the hospital discharge orders. On 8/17/2026 at 11:35AM V25, Transport Driver/Scheduler, provided name and schedule date of a physician whose specialty is plastic surgery not infectious disease. V25 confirmed R5 has not been to an infectious disease physician since returning to the facility. On 8/17/2026 at 09:00AM R5's EHR documents R5 admission date of 4/21/2026 with diagnosis that include Fracture of Unspecified Part Of Neck of Left Femur, Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Heart Failure, Chronic Obstructive Pulmonary Disease, Depression, Type 2 Diabetes Mellitus Hyperlipidemia, Essential (Primary) Hypertension and Left Bundle-Branch Block. On 8/17/2026 at 09:00AM R5's Minimum Data Set (MDS) documents on August 14, 2026, R5 is cognitively intact. On 8/17/2026 at 09:00AM R5's EHR documents on 7/27/2026 at 8:00pm V24, Registered Nurse (RN), transferred R5 to the local hospital for complaints of shortness of breath by R5. On 8/17/2026 at 09:00AM R5's EHR V24, RN, documents on 7/28/2026 at 02:00 V24 followed up with local ER (emergency room) for update on R5. Local ER is keeping resident overnight for observation. On 8/17/2026 at 09:00AM R5's EHR V9, License Practical Nurse (LPN) documents on 7/28/2026 at 2:11pm documents V9 called and spoke with nurse at local hospital and stated R5 is getting IV ABT ( antibiotic) for Pneumonia. On 8/17/2026 at 09:00AM R5's EHR V9, License Practical Nurse (LPN) documents on 8/7/2026 at 5:59pm R5 arrived to facility on stretcher by ambulance from Local Hospital taken to room [ROOM NUMBER]B, oriented to room and call light, served supper tray, call light in reach. On 8/17/2026 at 09:00AM R5's EHR documents in hospital discharge records dated 08/07/26 at 3:36pm Please call Infectious Diseases to schedule a follow-up visit for this patient. Please ask if they would like any additional labs to be drawn. On 8/17/2026 at 09:00AM R5's EHR documents in hospital discharge records dated 08/07/26 at 3:36pm to consult a specific Infectious Disease Physician at a specific clinic, with name, address and phone number provided. A facility policy titled Physician Orders dated 7/1/2023 documents PURPOSE: The purpose of this policy is to establish uniform guidelines in the receiving, recording and processing of physician orders.

Based on observation, interview, and record review the facility failed to obtain Midline catheter flushing and line care maintenance orders by the physician for one (R5) of seven residents reviewed for medication administration in a sample list of 24.Findings:On 8/17/2026 at 8:57AM R5's medical record documents R5 was admitted to the local hospital on [DATE] and returned to the facility from the hospital stay on 8/7/2026 with a Midline Intravenous catheter in the right upper extremity.On 8/17/2026 at 9:57AM, V9 Licensed Practical Nurse (LPN) stated the hospital discharge orders for R5's intravenous catheter were not entered into R5's physician orders upon return from the hospital.On 8/17/2026 at 12:05PM, V24 Registered Nurse (RN) stated R5 was receiving intravenous antibiotic daily and V24 flushed R5's intravenous catheter with saline and heparinized saline at the completion of each antibiotic dose on 8/8/2026 through 8/14/2026 and on 8/17/2026. On 8/17/2026 at 12:36PM, V26 RN stated R5 had an intravenous catheter with intravenous antibiotic orders daily. V26 RN stated R5's intravenous catheter was flushed with saline and heparinized saline at the completion of each antibiotic dose administered on 8/15/2026 and 8/16/2026. On 8/17/2026 at 12:25PM, V1 Administrator stated the facility does not have a policy for Peripherally inserted central catheters (PICC) lines or Midline Catheters.On 8/17/2026 at 12:32PM, V27 Medical Director stated the facility should follow the facility's policy for flushing and intravenous line care.On 8/18/2026 at 11:00AM, V2 Director of Nursing (DON) stated the nurses were verbally instructed to flush R5's PICC line (midline/intravenous catheter) with saline prior to the antibiotic and once antibiotic was complete to flush the line with saline followed by heparinized saline.On 8/18/2026 at 11:15AM, V2 DON stated nurses are expected to obtain orders from the physician for flushing and intravenous line maintenance upon arrival to the facility if no orders were received from the hospital discharge packet. V2 stated the facility does not have a policy for PICC lines (intravenous catheter) maintenance.R5's medical record documents R5 admitted on [DATE] with diagnosis including Peripheral Vascular Disease, Atrial Fibrillation, Diabetes Type II, Coronary Artery Disease, and Chronic Obstructive Pulmonary Disease. R5's medical record Minimum Data Set, dated [DATE] documents R5 has no cognitive impairment.R5's medical record documents Discharge Packet-dated 8/7/2026, Patient's midline catheter may be removed after patient completes IV antibiotic on 8/18/2026 and Ceftriaxone 2 gram intravenous at bedtime, for 12 days. End of treatment 8/18/2026.A facility policy titled Physician Orders dated 7/1/2023 documents this facility will obtain, process, and implement physician orders given by a Licensed Physician and received by a licensed nurse.

Based on observations, interviews and record review the facility failed to return/destroy medications for one (R24) of seven residents reviewed for medication administration in a sample list of 24.Findings Include:On [DATE] at 11:00AM V2, Director of Nursing, went into south hall medication room to show where the IV anticoagulant is coming from. V2 showed a box of IV anticoagulants that is labeled with R24 dated [DATE]. V2 confirmed that was the supply that V2 used and other nurses have used for other residents. V2 confirmed that the box labeled with R24 should have been sent with R24 or sent back to pharmacy. V2 confirmed the box IV anticoagulant is 5cc syringes in box. On [DATE] at 12:01PM 24's Electronic Health Record (EHR) documents R24 admission date of [DATE] and discharged to the local hospital on [DATE] with diagnosis that include Acute and Subacute Infective Endocarditis, Methicillin Susceptible Staphylococcus Aureus Infection, Streptococcal Infection, Bacteremia, Osteomyelitis Of Vertebra, Lumbosacral Region, Chronic Obstructive Pulmonary Disease, Paroxysmal Atrial Fibrillation, and Heart Failure. On [DATE] at 12:01PM 24's Electronic Health Record (EHR) documents the minimum data set (MDS) completed on [DATE] documents R24 is cognitively intact.On [DATE] at 12:01PM 24's Electronic Health Record (EHR) documents [DATE] at 12:00PM R24 was discharged to the local hospital.On [DATE] at 12:01PM 24's Electronic Health Record (EHR) documents [DATE] at 9:53PM R24 expired while admitted to the local hospital.

Based on interviews and record review the facility failed to obtain laboratory services as ordered by the physician for one (R5) of one resident reviewed for laboratory services in a sample list of 24.Findings Include:On 8/17/2026 at 9:35AM V1, Administrator, confirmed the facility nurses are to follow all physician orders including hospital discharge orders when a resident returns from the hospital.On 8/18/2026 at 11:13AM V6, Wound Nurse, confirmed R5 was to obtain laboratory services on 8/10/2026 and 8/17/2026. V6 confirmed there are no laboratory results in the medical record. V6 stated V6 does not know if the laboratory services were provided.On 8/17/2026 at 09:00AM R5's EHR documents R5 admission date of 4/21/2026 with diagnosis that include Fracture of Unspecified Part Of Neck of Left Femur, Atrial Fibrillation, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Heart Failure, Chronic Obstructive Pulmonary Disease, Depression, Type 2 Diabetes Mellitus Hyperlipidemia, Essential (Primary) Hypertension and Left Bundle-Branch Block.On 8/17/2026 at 09:00AM R5's Minimum Data Set (MDS) documents on August 14, 2026, R5 is cognitively intact.On 8/17/2026 at 09:00AM R5's EHR documents on 7/27/2026 at 8:00pm V24, Registered Nurse (RN), transferred R5 to the local hospital for complaints of shortness of breath by R5.On 8/17/2026 at 09:00AM R5's EHR V24, RN, documents on 7/28/2026 at 02:00 V24 followed up with local ER for update on R5. Local ER is keeping resident overnight for observation.On 8/17/2026 at 09:00AM R5's EHR V9, License Practical Nurse (LPN) documents on 7/28/2026 at 2:11pm documents V9 called and spoke with nurse at local hospital and stated res is getting IV ABT Dx. Pneumonia.On 8/17/2026 at 09:00AM R5's EHR V9, License Practical Nurse (LPN) documents on 8/7/2026 at 5:59pm R5 arrived to facility on stretcher by ambulance from Local Hospital taken to room [ROOM NUMBER]B, oriented to room and call light, served supper tray, call light in reach.On 8/17/2026 at 09:00AM R5's EHR documents in hospital discharge records dated 08/07/26 at 3:36pm Please call Infectious Diseases to schedule a follow-up visit for this patient. Please ask if they would like any additional labs lo be drawn. Additionally the same documents a physician order to please draw a CBC and CMP weekly, handwritten on the document for labs to be drawn every Monday.

Based on interview, observation, and record review, the facility failed to maintain resident safety by failing to implement fall interventions and performing safe transfers. for 4 of 6 residents (R4, R5, R13, R500) reviewed for resident safety in the sample of 31. This failure resulted in R4 being hospitalized for fractures resulting in surgery and R500 being hospitalized for subdural hematoma, and spinal fractures. The findings include: 1. R4's admission Record, dated 5/28/26, documents R4 was admitted to the facility on [DATE].R4's Medical Diagnosis include on 4/6/26: Periprosthetic fracture around internal prosthetic right hip joint, displaced subtrochanteric fracture of right femur, displaced fracture of lesser trochanter of right femur. On 4/14/26 new diagnosis of wedge compression fracture of third lumbar vertebra, wedge fracture of fourth lumbar vertebra, wedge compression fracture of T7-T8 vertebra, history of falls.R4's Care Plan, dated 5/23/26, documents At risk for falls and injuries r/t (related to) Medications: Psychotropic meds/Diuretic meds/Cardiovascular Meds/Pain Meds. Medical Factors: History of Falls. Interventions: 4/9/2026: Mat to bedside, 5/12/26: non-slip pad to wheelchair, 4/6/26: Bed in lowest position, encourage call light usage, ensure proper footwear when ambulating, provide/reinforce the importance of sitting on side of bed prior to standing, provide/reinforce use of assistive devices: (Specify: Reacher, Walker, Cane, Wheelchair, Transfer Pole, etc.), scoop mattress. It continues R4 Needs assistance with activities of daily living (ADLs). Interventions: Toilet Use: Two-person physical assist required, Transfer: Mechanical lift required. sit to stand with belt around Lower Extremities. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a moderate cognitive impairment and is dependent on staff for all ADLs and transfers. R4 is always incontinent of both bowel and bladder.R4's admission Fall Risk Assessment, dated 4/6/26, documents R4 was a High Fall Risk.The facility's fall log for the last six months, documents R4 had falls on 4/9/26 and 5/12/26.On 5/26/26 at 9:40 AM, R4 was seen sitting in his wheelchair, call light on self, R4 has thoracic brace on his bed, no fall mat seen anywhere in the room, no non-slip pad seen in his wheelchair, and no scoop mattress on the bed.On 5/26/26 at 9:56 AM, V9, Certified Nursing Assistant (CNA), and V6, CNA, walked into R4's room to transfer him to his bed and perform peri-care. The full body mechanical live device sling was already under R4 while in his wheelchair. R4 was attached to the lift device and with the wheelchair unlocked, lifted R4 off his wheelchair, then moved to his bed and lowered. There was no non-slip pad seen on his wheelchair after lifting R4 off, there was no scoop mattress on his bed, and there was no mat on the floor or in the room.On 5/27/26 at 8:17 AM, R4 was sitting in his wheelchair next to his bed which had a regular mattress and no scoop mattress, there was no fall mat on the floor or seen anywhere in the room.On 5/27/26 at 2:06 PM, R4 was seen lying in bed with a regular mattress and no scoop mattress, and with no fall mat seen on the floor, around his bed, or anywhere in the room.On 5/28/26 at 11:00 AM, R4 was seen lying in bed asleep with a regular mattress and no scoop mattress and with no fall mat next to his bed. Upon examination of R4's wheelchair, there was no non-slip pad seen in his wheelchair, either on top of cushion or underneath cushion.R4's Health Status Note, dated 4/9/26 at 1:44 AM, documents Resident moaning, staff member went to check on res (resident) and he was laying on floor between wall and bed, next to air conditioning unit. S/T (skin tear) noted to left arm, bleeding noted to left arm and right great toe. Resident is on Eliquis. C/O (complaint of) back pain, call placed to 911 for transfer. MD (medical doctor) notified, pressure dressing applied to left arm. POA (power of attorney) HC (healthcare) notified and would like a call back with update if he returns from hospital. Call place to (local hospital) and report given to ER (emergency room) Nurse. Neuro checks initiated.R4's F/U (follow-up) Occurrence Note, dated 4/9/26 at 2:03 AM, documents Incident Note: Resident moaning, staff member went to check on res and he was laying on floor between wall and bed, next to air conditioning unit. S/T noted to left arm, bleeding noted to left arm and right great toe. Resident is on Eliquis. C/O back pain, Call placed to 911 for transfer.R4's Health Status Note, dated 4/9/26 at 5:30 AM, documents Received call from (local hospital) ER, resident is being transferred to (regional hospital) with diagnosis of L1-L4 fractures. Niece notified of transfer by (local hospital) ER Nurse. Manager on call notified of incident with injury and transfer.R4's Health Status Note, dated 4/9/26 at 10:49 AM, documents This writer called and spoke with ED (emergency department) nurse at (regional hospital). Resident is still in ED at this time and will be admitted with right femur fx (fracture). Resident had fx upon admission to facility per paperwork no ortho interventions were in place at time of admission. Will cont (continue) to follow for updates.R4's Health Status Note, dated 4/10/26 at 11:58 AM, documents This writer spoke with NP (Nurse Practitioner) at (regional hospital). Resident and family decided to pursuit surgical tx (treatment) to previous femoral fx. per NP surgery is today. Will continue to follow up with (regional hospital) for updates.R4's Fall Investigation, dated 4/15/26, documents Brief description of incident: Resident had fall from bed and sent to local hospital with pre-existing hip fx. Resident was sent to (regional hospital) for further evaluation. Immediate Action Taken: Resident was immediately assessed and sent out for further evaluation for fall from bed. Resident room was moved to higher traffic area. Summary of Investigative findings: On 4/9/26, resident experienced a fall at the facility. The fall was unwitnessed and occurred in resident's room. Immediate assessment was completed, and the resident was transferred to the local emergency room for further evaluation. The emergency room initially reported a new fracture. Upon further diagnostic review and comparison with prior medical records, the fracture was determined to be pre-existing and consistent with a previous injury sustained prior to admission, from a fall at home. No evidence supports that the fracture resulted from the current incident. Resident assessed immediately post-fall with no acute distress noted beyond baseline. Transferred to ER for evaluation and imaging. Notifications completed: MD, responsible party, and all required entities per protocol. Care plan reviewed and updated as appropriate to address fall risk. The alleged injury (fracture) was not caused by the facility fall and is determined to be pre-existing. Therefore, the allegation is unsubstantiated. The Follow-up actions taken after the fall: Interviewed staff regarding resident incident, a fall mat was put in place at the bedside, and R4's room was moved to a higher traffic area on return.R4's fall on 4/9/26, documents R4 was found after falling out of his bed. R4 did not have the the fall intervention of a scoop mattress in place, helping to prevent R4 from falling out of bed. The fall mat in place was added to the Care Plan after R4's fall on 4/9/26. R4's Emergency Department Record, dated 4/9/26, documents in part History of present illness: Patient arrived from the nursing home after reportedly falling form bed onto floor. Emergency Course: He has known fx R (right) femur that is being tx conservatively/non-operative. CT (cat scan) L (left)-Spine: Fx L transverse process L1, L2, L3, and R transverse process L4. XR (x-ray) R femur: Hip prosthesis, fx lesser trochanter. (regional hospital) transfer - send pt (patient) to ED for trauma evaluation: fall, hypotension, tachycardic, multiple transverse process fx L1-L4. Clinical Diagnosis: Accidental fall, Closed fracture of transverse process of lumbar vertebra, Femur fracture, right. CT lumbar spine without contrast: Impression: Multiple acute fractures of the lumbar transverse process. L1 through L4. Comparison right hip and pelvis radiographs 4/5/26, Impression: Orthopedic components of a right hip hemiarthroplasty with cerclage wire about the proximal femoral stem with redemonstration of an obliquely oriented periprosthetic fracture along the medial aspect of the femoral stem with increased displacement compared to the prior examination.R4's Fall Investigation, dated 5/12/26, documents Nursing description: Staff walking past res room and seen res sliding out of w/c (wheelchair) onto floor, res sitting on buttocks, urinal inside res pants, able to [NAME] (moves all extremities) WNL (within normal limits) for res, without pain or discomfort, used mechanical lift and two assist to pick res up and put in bed, skin assessment completed, no injuries noted, will continue to monitor, call light in reach. Resident description: Stated he was trying to pee and that urinal is junk. Immediate action taken: Applied (non-slip pad) to seat of w/c. Notes: IDT (interdisciplinary team) Note: Staff witnessed (R4) attempting to use urinal when he slid from w/c. He did not hit his head and was immediately assessed. Root cause: slipping/sliding from w/c. New intervention: (non-slip pad) to w/c.On 6/1/26 at 10:25 AM, V18, CNA, stated We have to look in a resident's care plan to see what fall interventions are in place. There is no fall book or anything else to look at. We do have report sheets that we can share things like falls or change in transfer types of things.On 6/1/26 at 10:05 AM, V1, Administrator, stated I would expect all staff to ensure that resident's fall interventions are in place at all times and to monitor high fall risk residents to keep them safe from falls.2. R13's Care Plan, dated 4/21/2026, documents that R13 is at risk for falls and injuries r/t (related to) medications (Ativan and Norco). Medical Factors: History of Falls. 4/21/26 Resolved: Provide adequate lighting. 4/27/2026 Reacher at bedside. Replace LAL (low air loss) mattress with pressure relieving mattress. 05/06/2026 Mat at bedside when in bed.R13's admission Nursing Assessment, dated 4/21/2026 at 3:40 PM, documents that R13 is alert to person, place, and time, unsteady gait, poor balance, Fall Interventions: Maintain bed in lowest position.R13's Incident Report, dated 4/27/2026, documents that Resident had an unwitnessed fall from bed. Sent to ER (emergency room) for evaluation. R13's Pertinent Diagnosis: Altered Mental Status, Osteoarthritis, and Weakness. It also documents that This nurse was called into resident room by CNA (Certified Nurse Assistant). Upon entering room, it was observed resident was on her back with her calves on the bed and her head towards the floor. Over the bed table slightly behind her left shoulder. Resident air mattress inflated properly and draw sheet and bed pad were underneath resident on floor. Resident Description: Resident stated that she was trying to reach the thing that was on the floor and slipped out of bed and hit her head.The facility's Final Report and Conclusion of Incident, not dated, documents that On 4/27/26, resident experienced an unwitnessed fall from her bed. immediate assessment was completed by nursing staff. The resident was noted to have hematoma and change in condition. Resident was transferred to the emergency room for further evaluation. At the hospital, the resident was evaluated and diagnosed with a cerebrovascular accident.R13's Health Status Note, dated 4/27/2026 at 3:54 PM, documents that Note Text: This nurse was called into resident room by CNA. Upon entering room, it was observed resident was on her back with her calves on the bed and her head towards the door. Over the bed table slightly behind her left shoulder. Resident air mattress inflated properly and draw sheet and bed pad were underneath the resident on floor. The resident stated that she was trying to reach the thing that was on the floor and slipped out of bed and hit her head. Resident assessed for injury, Vitals attempted to be taken, emergency services were called, emergency contact, (V4) was called, resident taken to (local) hospital for further evaluation. DON (Director of Nursing) and MD (Doctor) aware.On 5/26/2026 at 10:00 AM R13 observed lying in bed. No floor mat in place. Frequent observations on 5/27/2026 no floor mat in place. On 5/28 at 9:00 AM R13 lying in bed. No floor mat in place. In 5/28/2026 at 9:49 AM observed R13 in bed with mat on floor.On 5/26/2026 at 1:46 PM V5, Licensed Practical Nurse, stated that she had walked past the room and R13 was in bed. V5 stated that 5 min later the CNA informed her R13 was on floor. Head and upper body out of bed on floor. Feet on bed. V5 stated that she knew due to the way R13 was laying that R13 hit her head. V5 stated that R13 is on blood thinners, and she transferred R13 immediately. V5 stated that R13 was on an air loss mattress. V5 stated that R13 has attempted to transfer self in the past. V5 stated that the bed was not in its lowest position, it was at least knee height. V5 stated that during her assessment she identified a skin tear to R13's arm.On 5/27/2026 at 9:20 AM V2, DON, stated that when R13 was admitted she made attempts to transfer self without assist. V2 stated that the staff found R13 on the floor and notified the nurse assessed and sent the resident to ER. V2 stated that the cause of the fall was a stroke. V2 stated that she had documentation from the hospital that documented this. When asked to provide this documentation, V2 provided documentation from hospital. The hospital documentation provided by V2 does not document or indicate R13's fall was a result of a stroke as stated by V2. On 5/28/2026 at 9:00 AM V1, Administrator, stated that R13's fall was due to the air mattress. V1 stated that the air mattress was put in place a few days prior to the fall. V1 stated that although R13 made attempts to transfer self R13 had not fallen prior to the mattress being put in place. R13 stated that interventions were put in place prior to the fall. R13 stated that she expects those interventions to be in place. V1 stated that interventions were put in place after the fall and she expects those interventions to be put and remain in place.On 5/28/2026 at 9:50 AM V18, CNA Coordinator, stated that they are notified of the fall interventions by the nurse. V18 stated that all staff are responsible for putting the fall interventions in place. V18 stated that she is not sure why the R13's floor mats were not in place this week. V18 stated that they did put them in place today.On 5/28/2026 at 9:55 AM V26, CNA, stated that she is assigned to R13 today. V26 stated that she is not sure why the fall mats weren't in place this week. V26 stated that they are in place now. V26 stated that they are informed of the interventions in the communications book.3. R5's Care Plan, dated 1/20/2026, documents that At risk for falls and injuries r/t Medications (tramadol. Remeron, and gabapentin). Medical Factors History of Falls prior to admission, double BKA (below the knee amputation), requires assistance with mobility. Bed in lowest position. Orient to room. Provide adequate lighting. PT to eval and treat if indicated. 02/27/2026 - dycem between mattress and sheet. Reposition resident to middle of bed as he allows.R5's Minimum Data Set, dated [DATE], documents that R5 is moderately cognitively impaired and requires substantial/maximal assist to 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). R5's Full QA Report, not dated, documents that R5 had a fall on 2/27/2026, Resident found on floor on back. Conclusion: IDT Note: Resident found on floor on back. Resident states he was trying to roll over in bed but pulled his legs toward edge of bed causing them to be stuck under rail Resident stated he tried to straighten back out but pulled wrong way causing his body to slide off mattress. Root cause: Sliding from bed New Intervention: Dycem on mattress under sheet. Problem Statement: Resident was trying to roll over in bed but pulled his legs toward edge of bed causing them to be stuck under rail. he then states he tried to straighten back out but pulled wrong way causing his body to slide off mattress.R5's F/U (follow up) Occurrence Note, dated 2/27/2026 at 8:00 PM, documents that Note Text: Incident Note: res found on floor on back. res states he was trying to roll over in bed but pulled his legs toward edge of bed causing them to be stuck under rail. He then states he tried to straighten back out but pulled wrong way causing his body to slide off mattress. Rom (range of motion) wdl (within define limits). neuro checks wdl. denies hitting head. no apparent inj (injury). assisted back to bed via staff. Md (doctor) don and poa (power of attorney) aware. call light in reach. matt on floor next to bed. bed in lowest position.On 5/26/26 at 2:30 PM R5 stated he has had falls - stated he has the air mattress, and he did not have side rails or anything on his bed and fell off bed while transferring due to it's slickness. R5 stated that since then, they (staff) put side rails on his bed and they keep an incontinence pad under him.R5's Full QA Report, not dated, documents that R5 had a fall on 4/5/2026. It also documents Conclusion: IDT Note: Resident was in bed and repositioned self. Resident got himself too close to edge of bed and slid from bed. Root cause: repositioned self incorrectly; slide from bed New Intervention: Assist with repositioning resident to middle of bed as he allows.R5's F/U Occurrence Note, dated 4/5/2026 at 12:54 PM, documents that Note Text: Incident Note: res observed on floor in room next to bed ,stated he was too close to the side of the bed and with the mattress he has he just slid out ,moves all extremities WNL (with in normal limits) for res, denies any pain at this time, body assessment completed, no injuries noted, states he did not hit head.On 5/28/26 at 9:08 AM, R5 stated when he fell out the bed, he didn't have any dycem or non-slid/slip pad beneath him and does not have any now.On 5/28/2026 at 1:25 PM V13, Licensed Practical Nurse, stated that she was here when R5 fell. V13 stated that she observed him on the floor with back against bed. V13 stated that R5 informed her that he got too close to the edge and slid out of the bed. V13 stated that the air loss mattresses are slick. V13 stated that when R5 was on the floor he had a white sheet on him. V13 stated that she did not see a non-slid/slip device.4. R500's Care Plan, dated 3/4/2026, documents that R500 is at risk for falls and injuries r/t (related to) History of Falls, weakness, HTN (hypertension). Also has a dx (diagnosis) of macular degeneration and has poor vision.R500's Fall Risk Assessment, dated 3/5/2026, documents that R500 is a high fall risk.R500's Health Status Note, dated 3/8/2026 at 1:17 AM, documents that Note Text: Resident transferring to w/c (wheelchair) assisted by staff member and fell to floor, staff member states resident went limp, Nose and forehead bleeding. Resident alert, answering questions appropriately. B/P (blood pressure) 203/110, 76, 20, 95% on RA (room air). MD (doctor) notified, will send to ER (emergency room) for evaluation.R500's Final Report and Conclusion of Incident, not dated, documents that on 3/8/2026 The CNA was in the bathroom assisting the resident's roommate when the resident hit her call light, also needing assistance to bathroom. Resident sat herself up on the side of the bed. Staff adjusted her (R500) legs and the bed was adjusted to wheelchair height and placed to the left of the resident. Staff had placed gait belt around the resident the resident then stood up to get into her wheelchair, as she was bending at the waist to sit down the resident had gone 'limp at that time. Staff attempted to get a better hold of the resident; however, it was unsuccessful, and the resident fell to floor hitting her headfirst. The resident was assessed by nursing staff and was sent to (Local Hospital) for further evaluation from change of condition, being on aspirin therapy and hitting her head from the fall. It also documents BIMS (Brief Interview of Mental Status) 8, History of falling, weakness, Macular Degeneration, and Preglaucoma as diagnosis. Injury Subdural hematoma, T1 spinous fx (fracture) and [NAME] compression fx.V29's, Certified Nurse Assistant, written statement, not dated, documents that V29 responded to call light. R500 informed V29 that she (R500) needed to use the bathroom. V29 brought wheelchair in from the hall. Remove covers from over R500. Assisted R500 onto side of bed. Buckled gait belt around R500. Grabbed R500 under shoulder. R500 slow turned her body. Reached back for wheelchair with left. R500 never had a hold of the wheelchair before going limp and face planted.V32's, CNA, Written Statement, dated 5/8/2026, documents at 1:20 AM V32 was sitting at the nurse's station. Heard a loud gasp from the hall. Entered the room and observed R500 lying face down on the floor next to the chair. She was badly bleeding from her nose and forehead.V33's, CNA, Written Statement, dated 5/8/26, documents that V33 was at the nurse's station. Heard loud noise and gasp. Entered room R500 face down on the floor with a puddle of blood under R500's face.R500's (Local Hospital) CT (Computed Tomography) OF THE HEAD WITHOUT CONTRAST, dated 3/8/2026, documents that Findings: Moderate-sized scalp hematoma overlying the anterior midline frontal bone.R500's (Local Hospital) CT CERVICAL SPINE WITHOUT CONTRAST, dated 3/8/2026, documents a possible subtle hairline fracture of the spinous process of T2.On 6/1/2026 at 4:17 PM V29 stated that she was there when R500 fell. V29 stated that R500 needed to use the bathroom. V29 stated that R500 sat on side of the bed with a little assistance for V29. V29 stated that she did put the gait belt on R500. V9 stated that R500 stood up. V29 stated that she had a slight hold of the gait belt. V29 stated that she was holding onto it (gait belt) a little. V29 stated that she did not have a tight hold onto the gait belt. V29 stated that R500 went limp and down to the floor. V29 stated that she did not have a hold of R500 as she went down. V29 stated that she (R500) had balance problems and had episodes of going limp prior to the fall. V29 stated that she thought R500 only needed partial assistance and did not need to have a hold on to the gait belt.On 6/1/2026 at 4:35 PM V2, Director of Nursing, stated that the gait belt is to be applied to the resident tightly with a 2 finger width. V2 stated that the staff is to have a tight grip hold of the belt when transferring the resident. 1 hand on the side and 1 hand on the back. V2 stated that at no time is the employee to be grabbing for other things while transferring. V2 stated that V29 and R500 are about the same size. V2 stated that with V29 only having a slight grip on the gait belt V29 could not have held onto R500, prevented the fall or transferred R500 safely.The facility's GAIT BELT POLICY ACKNOWLEDGEMENT FORM, not dated, documents Policy: It is this facility's staff responsibility to assure that gait belts are used with all transfers and transport of residents not full independent, to assure safety for the residents and staff. Responsibility: The gait belt is a mandatory part of the Certified Nursing Assistant uniform. Nursing Assistants are expected to use the gait belt whenever ambulating or transferring a resident for the safety of the resident and the employee. Gait belts must be used when helping the resident move from the bed, chair, or commode/toilet. An employee who is injured or caused an injury to a resident because of failure to properly apply and use a gait belt is subject to disciplinary action, which may include termination.The facility's: Fall Prevention Program/Protocol, dated 07/01/23, documents that the Program Interpretation and Implementation: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Fall Risk Factors: 1. Environmental factors that may contribute to the risk of falls include: c. incorrect bed height or width. It also documents Resident-Centered Approaches to Managing Falls and Fall Risk 1. The interdisciplinary will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk (based on the falls assessment results) or with a history of falls. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, the team will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The resident, and/or responsibility, the physician and therapy department may be involved in the process for a holistic evaluation. 7. The team shall identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy, and staff will respond to alarms in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure a call light was in reach and residents had a means to call for help for 1 of 3 (R11) residents reviewed for accommodation of needs in a sample of 31. This failure resulted in R11 unable to receive help. It also resulted in R11 feeling frightened, frustrated, embarrassed, helpless and disposed of.Findings include:1. R11's admission Record, not dated, documents that R11 was admitted on [DATE] with diagnosis of Multiple Sclerosis and Quadriplegia. R11's Care Plan, dated 7/1/2025, (R11) has Quadriplegia. He requires assist with all of his ADL's (Activities of daily living). It also documents 8/4/2025 (R11) have Multiple Sclerosis. He is dependent on all ADLs. He is at increased risk for his needs not being met.R11's Minimum Data Set, dated [DATE], documents that R11 is cognitively intact and dependent on staff for all adls.On 5/26/26 at 10:20 AM, R11 observed lying in bed turned to his left side with a blow call light in front of his mouth. R11 attempted to reach the blow stem with his lips but was too far - used his tongue to move it closer to him and then was able to blow into the device to turn on his call light.On 5/26/26 at 10:20 AM R11 stated he uses it (call light) but sometimes they put it too far away like it is this morning. On 5/27/26 at 2:02 PM, R11 was heard yelling for help in his room. R11's was observed lying flat in his bed. When asked how long he had been lying flat, R11 stated Probably about 15 minutes now. They were going to get me up to my wheelchair for my doctors appointment, they laid me flat but left the room. I was starting to taste my feeding, and it scared me, that's why I was yelling. R11's call light was moved away from his mouth and was unable to use it.On 5/27/2026 at 9:15 AM R11 stated that he is not sure of the date, but he did have a change in condition and required hospitalization. R11 stated that he thought it was a stroke but found out it was shingles. R11 stated that it is multiple times that his call light is not in reach. R11 stated that he is paralyzed from the neck down. R11 stated that he can only move his head. R11 stated that he has a blow call light. R11 stated that it is activated by him blowing in it. R11 stated that there are times that his call light is not in reach. R11 stated that he must yell for help and because he doesn't have a lot of air movement his voice is low toned. R11 stated that the staff do not hear him for hours at a time. R11 stated that it's frightening because he has no way to get help if he needs it. R11 stated that he feels helpless and disposed of. R11 stated that he is aware of his limitations and tries to stay as positive as he can but it's frustrating, embarrassing and he feels helpless.On 5/28/2026 at 9:00 AM V1, Administrator, stated that R11 is quadriplegic and requires the use of the blow call light to alert staff of his needs. V1 stated that the call light needs to always be in place. V1 stated that R11 has a low voice, and it would be difficult to hear him. V1 stated that she always expects R11's call light to in his reach.On 5/28/26 at 11:20 AM, R11 stated It scared me yesterday. I can hardly talk with my voice so soft, but all I could do was try to yell and get someone's attention because they left me lying flat and I was starting to taste my feeding. It really scared me. When they keep my blow call light out of reach, I get scared because I cannot get anybody if I need help.On 6/1/2026 at V13, Licensed Practical Nurse, stated that R11's call light is to be in reach.On 6/1/26 at 10:25 AM, V18, CNA, stated (R11) has his mouth call light and he will tell us when it is placed correctly. He has to be able to reach it with his mouth.The facility's Call Light Guidance policy, dated 7/1/2023, documents that PURPOSE: To provide guidance to all facility staff on the use, response and placement of call lights. PROCEDURE: 2. A call light activation device shall be kept within resident reach while in resident rooms and bathrooms.

Based on interview, observation, and record review, the facility failed to identify, treat, and prevent pressure ulcers for 3 of 5 residents (R4, R9, R13) reviewed for pressure ulcers in the sample of 31. This failure resulted in R4 and R13 having new pressure sores that were not discovered or treated. The findings include:1. R4's admission Record, dated 5/28/26, documents R4 was admitted to the facility on [DATE]. R4's Electronic Medical Record, under Medical Diagnosis, documents R4's diagnosis dated 4/6/26: Periprosthetic fracture around internal prosthetic right hip joint, displaced subtrochanteric fracture of right femur, displaced fracture of lesser trochanter of right femur. On 4/14/26 new diagnosis of wedge compression fracture of third lumbar vertebra, wedge fracture of fourth lumbar vertebra, wedge compression fracture of T7-T8 vertebra, history of falls, Asthma, Chronic Kidney Disease, Atherosclerosis, Urinary Tract Infections, Malnutrition, Osteoarthritis, Benign Prostatic Hyperplasia, Malignant neoplasm of prostate, Anemia, Hypertension, Atrial Fibrillation. R4's Care Plan, dated 5/23/26, documents R4 has a Potential for impaired skin integrity. Interventions: Assist/provide peri-care after each incontinence episode, encourage and assist to turn and reposition routinely and per resident's request, evaluate skin at least weekly, observe skin integrity during am/pm cares, pressure redistribution cushion-wheelchair, pressure redistribution mattress to bed, reposition at least every two hours in bed. R4's Minimum Data Set (MDS), dated [DATE], documents R4 has a moderate cognitive impairment and is dependent on staff for all activities of daily living (ADLs) and transfers. R4 is always incontinent of both bowel and bladder. R4's Physician Order (PO), dated 5/26/26, documents Barrier Cream to buttock r/t (related to) incontinence as needed for when incontinent. R4's PO, dated 5/11/26, documents Cleanse left heel with NS (normal saline)/WC (wound cleanser). Apply skin prep and leave OTA (open to air) every day and night shift for wound healing and as needed for wound healing. R4's PO, dated 4/20/26, documents Daily Skin Check Using the following C-clear R-Red O-open p-Pressure S-skin tear every day shift. R4's PO, dated 4/14/26, documents Refer to Wound Care for consult as needed. R4's PO, dated 4/14/26, documents Moisture barrier cream as a preventative every shift for preventative. R4's PO, dated 4/14/26, documents Skin Inspection / Nursing Weekly Assessment on Saturdays one time a day every Sat. On 5/26/26 at 9:40 AM, R4 seen sitting in his wheelchair with a soft boot on his left foot with an obvious pressure wound seen on his heel and no dressing on, and another pressure sore noted to the lateral right foot, also without a dressing on. On 5/26/26 at 10:40 AM, V9, Certified Nursing Assistant (CNA), and V11, CNA, entered with supplies to provide incontinent care to R4. During incontinent care, there was a small open area noticed on R4's left buttock that does not appear to have been treated and neither CNA was aware of it being there before. R4's Health Status Note, dated 5/26/26 at 12:02 PM, documents Resident noted to have small, macerated area to inner left buttock. MD (medical doctor) aware with new orders to apply barrier. POA (Power of Attorney) and wound nurse aware. On 5/27/26 at 11:20 AM, V7, Wound Nurse, stated (R4) does have a new wound to his left buttock that he did not have before. On 5/27/26 at 2:06 PM, V7, Wound Care Nurse, and V18, CNA, entered to do wound care on R4. R4 was seen lying on his left side with a soft boot on his right foot. V7 stated (R4) always has one on his left foot and I'm not sure why he would have one on his right foot. Upon removing the soft boot, there was a quarter sized wound on his lateral foot. V7 stated I know nothing about that wound. No one has mentioned it to me. I would call this wound a pressure sore that is unstageable at this point. Upon looking at R4's right heel, there appears to be another sore on his medial heel that was a dark/blackened area also about a quarter size. V7 stated No one mentioned that one to me either. We had issues with this before and we did skin sweeps with our last one done in April and (R4) did not have these wounds, he only had the one on his left heel. When asked about R4's new wound to his right buttock, V7 stated That is also a new wound that was not reported to me until yesterday when you found it. We are just putting Triad paste on it for now. On 5/27/26 at 2:22 PM, V7 stated Whoever finds a new wound should be reporting it to the nurse and that nurse will report it to me. I was not told (R4) had any wounds except for his left heel. On 6/1/26 at 10:25 AM, V18, CNA, stated Any new wounds or skin issue should be written on the shower sheets when we give them a bath or shower. It should also be reported to the nurse. I report things even if they are old wounds, just to make sure. R4's Shower Sheets for the month of May 2026, documents R4's wounds as left heel open sore, and right hip surgical wound only with no mention of R4's right lateral foot, right heel, or wound to his buttock. On 6/1/26 at 8:45 AM, V30, Nurse Practitioner (NP), stated I expect any staff who find redness or a new wound to report that area to the wound nurse, who will then report it to me. We do skin sweeps every three months and look at every resident's skin and assess for redness and/or new wounds. (R4) went from one wound to five wounds because no one notified the wound nurse or me. There is a big communication problem here with reporting of skin issues. (V7, wound nurse) is a great wound care nurse but if no one tells her about a new wound, she is not able to let me know and to take care of that wound. It's sad that (R4) had to get to this, but I will get his wounds healed. On 6/1/26 at 10:05 AM, V1, Administrator, stated I would expect all staff who are caring for the residents to identify any new skin issues or wounds, notify the nurses and/or physician, to get proper physician orders, then to treat those wounds appropriately as ordered. 2. R13's Care Plan, dated 5/27/2026, documents that documents that R13 has Pressure Ulcer to sacrum. Requires assist with turning and repositioning. 4/28/26 Potential for impaired skin integrity related to: decreased mobility, incontinence, and poor nutritional intake. R13's Braden Scale, dated 5/19/26, documents that R13 is at high risk for pressure ulcers. R13's Health Status Note, 5/26/2026 at 2:52 PM, documents Note Text: While changing dressing, resident noted to have small, reddened area to sacrum. Apply barrier cream BID (twice daily) and PRN (as needed). MD (doctor) faxed. On 5/26/2026 at 9:46 AM observed V7 performing wound care for R13. During treatment observed a small red and open area to R13's coccyx. No treatment was performed. On 5/26/2026 at 9:46 AM V7 stated that the wound was open and new. 3.R9's Facesheet with a print date of 5/28/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, pressure ulcer of left buttock stage four, type two diabetes mellitus, and surgical aftercare following surgery on the skin and subcutaneous tissue. R9's MDS dated [DATE] documented she was cognitively intact and dependent on staff for all mobility tasks. R9's Care Plan dated 4/17/26 documented R9 has the potential for impaired skin integrity related to decreased mobility, and a current pressure ulcer to left buttock. R9's Care Plan dated 5/12/26 documented R9 had actual pressure ulcer; left buttock, stage four with an intervention for staff to check dressing placement every shift. R9's May 2026 Treatment Administration Record documented orders as follow: cleanse left buttock with wound cleanser or NS (normal saline), apply wet-to-dry dressing to wound bed ensuring to pack undermining, cover with dry dressing. change daily and (as needed) PRN every day shift every 3 day(s) for wound care -Start Date- 05/21/2026 0600 (6:00 AM) and cleanse right hip with NS or wound cleanser and pat dry, cover wound with bordered foam dressing. Change 3x (times) weekly 1x per hospice nurse and 2x per facility nurse. staff nurse may change prn. every day shift every 3 day(s) for wound care. -Start Date- 05/21/2026 0600. R9's Hospice Order Sheet dated 5/20/26 documented orders for stage two pressure ulcer to be changed three times weekly, 1 time per hospice nurse, two times weekly for facility staff nurse; may change if dressing becomes soiled or displaced. The hospice order sheet continued to document orders for R9's stage four pressure ulcer to be changed three times weekly, 1 time per hospice nurse, two times weekly for facility staff nurse; may change if dressing becomes soiled or displaced. On 5/27/26 at 12:21 PM, V19 (Hospice RN) and V20 (Hospice RN) went in to provide wound care for R9. V20 stated R9's left buttock pressure wound did not have a dressing in place and said she was told they recently provided peri care for her. V20 and V19 rolled R9 onto her left side. R9's right hip had an old dressing in place dated 5/23/26 with a moderate amount of drainage covered on a bordered gauze dressing. V20 stated the old dressing was dated 5/23/26 and the facility is supposed to be completing the wound care orders on days we are not here. V20 and V19 stated the orders are for the facility to be completing it two times a week and hospice will do one day while they can also change as needed. On 5/28/26 at 8:08 AM, V7 (Wound Nurse/IP) stated hospice told her last week they wanted R9's wound care to be Monday, Wednesday, Fridays; the nurse that entered her orders placed it to be done every three days and that would not amount to three times a week. V7 stated she expects staff to be following the orders as written and will have to correct R9's orders right away. The facility's Pressure Ulcer Prevention, Identification and Treatment policy dated 10/16/23 documented. It is the responsibility of the. Charge Nurse/Designee to care for pressure areas, and provide treatments as ordered. It is the responsibility of the Charge Nurse/Designee to measure and document on the pressure areas weekly. It is the responsibility of the Charge Nurse/Designee to monitor for healing progress, and ensure appropriate treatment are in use. It is recommended that D.O.N./Designee make frequent pressure ulcer rounds with the charge nurse. It is the responsibility of the CNA to report any skin conditions to the charge nurse immediately upon identification.

Based on interview, observation, and record review the facility failed to provide residents with a working call light system for 22 (R2, R4, R6 - R25) out of 23 residents investigated for physical environment in a sample of 25.Findings include:On 1/20/26 at 10:06 AM, R4 stated that her call light does not work, and the bathroom call light does not work. She stated that the bell that the facility gave her no body hears it. She stated that other resident's call lights do not work either. She stated that this has been going on for 4 months. She stated that they tried to fix it, but it's still broken.On 1/21/26 at 9:01 AM, R6 stated that her call light does not work. She stated that she cannot find her bell.On 1/21/26 at 12:24 PM, V5, Maintenance Supervisor stated that the whole call light system is getting replaced. He stated that the contractor is scheduled about 2 weeks away.On 1/21/26 at 12:27 PM, V1, Administrator stated that it's about 2 weeks until the new call light system is installed. He stated that they cannot get parts for the old system, so the facility has to replace the whole system.Facility's Grievance Form dated 11/4/25 documents Resident's daughter-in-law was upset about the call light system being down.Facility's Call Light Testing Log dated 11/26/25 documents that 22 residents call lights failed during testing.On 1/20/26 at 10:06 AM, observation of R4 had a tabletop bell sitting on her dresser.On 1/21/26 at 9:01 AM, No bell noted on R6's bedside table or dresser.On 1/21/26 at 3:07 PM, observation of tabletop bell sitting on R2's bedside table next to bed.Facility's Call Light Guidance Policy dated 7/1/23 documents 1. When initiated, the system will light up in the room, outside the room and on a central panel.

Based on interview and record review the facility failed to revise a resident's care plan with progressive interventions for 2 of 3 (R2, R5) residents investigated for falls in a sample of 25.Findings include:#1.R2's EMR Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 6/23/25 documents a diagnosis of Systemic Lupus Erythematosus, Unspecified; Epilepsy, unspecified, not intractable, without status epilepticus; and Altered Mental Status, unspecified.R2's MDS (Minimum Data Set) dated 11/28/25 documents a BIMS (Brief Interview for Mental Status) score of 9 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R2's Care Plan Care Plan dated 7/1/25 documents (R2) is at risk for falls and injuries r/t daily use of anti-hypertensive medications, Narcotic use, and Cardiovascular medications. She is also noted to have tremors, which can impair her mobility and possibly contribute to falls. She has a history of falls with head injuries and displaced dens fracture.Interventions:5/2/25 - Bed in lowest position.5/2/25 - Ensure proper footwear when ambulating.5/2/25 - Instruct resident to avoid sudden position changes.5/2/25 - oriented to room.5/2/25 - provide adequate lighting.5/2/25 - provide/reinforce the importance of sitting on side of bed prior to standing.5/2/25 - Provide/Reinforce use of assistive devices: (specify: reacher, walker, cane, wheelchair, transfer pole, etc.)5/11/25 - (R2) is to have non-skid footwear on while in bed.7/11/25 - non-skid socks on while in bed.8/10/25 - Dycem placed in wheelchair.R2's F/U Occurrence Note dated 8/17/25 at 7:15 AM documents Incident Note: unwitnessed fall. CNA (Certified Nursing Aid) found (R2) on the floor @715. (R2) states she was not standing she was washing her face and tried to put her face towel on the dresser, but the wheelchair slid from under. I did a full head to toe assessment on (R2) with ROM (Range of Motion). She hit the right side of head and blood was on her hand, floor and towel. Denies any pain. V/S (Vital sign) (blood pressure) 115/75 P. (pulse)85 R. (respirations) 18 temp.(temperature) 97.6 O2. (oxygen saturations) 96%. Pt. (patient) A&O (alert and oriented) X 2. transferred to bed with two nurses and two CNA. pt stable. called 911. contacted POA. @740. Ambulance arrived @750. Contacted MD @751. Contacted DON (Director of Nursing) @ 752 left VM (voicemail).No care plan intervention noted for this fall.Facility Fall Investigation dated 8/17/25 at 7:15 AM documents fall, resident room, sitting. Fall caused by patient intent or behavior. Laying on ground. Resident just got up out of bed and was sitting the wheelchair. Assessment/Documentation, Fall Assessment Completed, Neuro checks initiated, routine safety checks, notified immediate supervisor, first aid initiated, Do not move, call bell in reach with instruction. Resident was sent to ED (Emergency Department) for further evaluation. Problem Statement: Resident attempting to get out of wheelchair. Root Cause: Resident attempting to get out of wheelchair. Investigative Statements: Nurse: unwitnessed fall. CNA found (R2) on the floor @ 7:15. (R2) states, she was not standing she was washing her face and tried to put her face towel on the dresser but the wheelchair slid from under. I did a full head to toe assessment on [NAME] with ROM. She hit the right side of head and blood was on her hand, floor, and towel. Denies any pain. V/S 115/75 R 18 temp. 97.6 O2. 96% Pt. A&O X 2. Transferred to bed with two nurse and two CNA. Pt stable. Called 911. Resident: Resident stated she wasn't trying to get out of bed and walk, she was reaching over to put something away.R2's Health Status note dated 1/14/26 at 2:13 PM documents res (resident) leaning forward in w/c and fell forward out of chair, hit head on leg of STS (Sit to Stand), MD here and states to send to ER for Eval (Evaluation).No care plan intervention noted for this fall. Facility's Fall Investigation dated 1/14/26 at 3:00 PM documents Fall, resident room, sitting. Fall caused by patient intent or behavior. Resident went from chair to floor. No injuries noted. Assessment/Documentation, Fall Assessment completed, neuro checks initiated, notified immediate supervisor. Resident witnessed hit head and sent to ED per MD for further evaluation, education to staff to lay resident down immediately after meals. Problem Statement: Resident is A&O x 2, poor safety awareness, BIMS 9, intention of getting out of the w/c. Root Cause: Resident is A&O x 2, poor safety awareness, BIMS 9, intention of getting out of the w/c so she could get to bed. Investigative Statements: Nurse: res leaning forward in w/c and fell forward out of chair, hit head on leg of STS, MD here and states to send to ER for eval. Resident: resident stated she fell and that she wanted out of her chair. Witness: This nurse was walking past room and witnessed resident scooting to edge of wheelchair and pushed self out of chair and fell to floor hitting head on based of sit to stand. Resident was assessed and stated her head hurt. Floor nurse notified POA and MD. Resident to be sent to ED for further evaluation.#2.R5's EMR undated documents that the resident was admitted to the facility on [DATE].R5's EMR dated 8/22/25 documents a diagnosis of Parkinson's Disease without Dyskinesia, without mention of fluctuations, encounter for palliative care, and Malignant Neoplasm of Unspecified Renal Pelvis.R5's MDS dated [DATE] documents a BIMS score of 12 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, chair/bed to chair transfer, and tub/shower transfer. The MDS documents that the resident has an indwelling catheter.R5's Care Plan dated 8/26/25 documents [NAME] is at risk for falls and injuries r/t side effects of his psychotropic and opioid medication use. He is also at risk due to his diagnosis of Parkinson's disease and his involuntary movements. [NAME] has a history of falls. Due to his involuntary movements, [NAME] has been noted to slide out of bed. He currently has a low bed and double mattresses.Interventions:8/25/25 - bed in lowest position.8/25/25 - Encourage call light usage.8/25/25 - floor mat at bedside when in bed.8/25/25 - keep environment free from clutter.8/25/25 - Keep personal belongings within reach.8/25/25 - provide adequate lighting.10/23/25 - bolster on mattress. Hospice provided.11/10/25 - personal alarm on resident.R5's Health Status note dated 9/16/25 at 12:43 AM documents UPON MIDNIGHT Rounding Resident noted in his room, laying on the bathroom floor, on his Right side. Upon assessment (indwelling) Cath detached from Resident's Penis, a large amount of blood noted on the floor, and penis. Resident states he doesn't know where he was going or what he was trying to do at the time of Fall. Resident denies hitting his head. Resident states he is not so much in pain Resident's Bed was still in the lowest position and safety mat was in place. Resident was Mechanical lifted from the floor to his Bed. V/S: BP 128/82 HR 97 t 97.4F R 20 PERRLA (Pupils Equal Round Reactive to Light Accommodation), RESIDENT was a&o X2-3. 911 was called at 12:03AM, RES WIFE AND DAUGHTER NOTIFIED AT 12:04AM, MD NOTIFIED AT 12:05AM,EMS ARRIVED AT 12:15 AND RESIDENT WAS TRANSPORTED TO (Regional Hospital) AROUND 12:20AM.No care plan intervention noted for this fall.Facility's Fall Investigation dated 9/16/25 at 12:43 AM documents Found on floor. Laying on bathroom floor. No injuries noted. Assessment/Documentation. Care Plan updated. Neuro checks initiated. Notified immediate supervisor. Sent out for further evaluation, resident noted confusion with uti (Urinary tract Infection) on abt (Antibiotic). Problem Statement: Resident confused with poor safety awareness, and attempting to get out of bed without assistance. Root Cause: Resident confused, with poor safety awareness, and attempting to get out of bed without assistance. Investigative Statements: Nurse: Upon Midnight rounding Resident noted in his room, laying on the bathroom floor, on his right side. Upon assessment Foley Cath. Detached from Resident's penis, a large amount of blood noted on the floor, and penis. Resident states he doesn't know where he was going or what he was trying to do at the time of fall. Resident denies hitting his head. Resident states he is not so much in pain. Resident's bed was still in the lowest position and safety mat was in place. Resident was mechanical lifted from the floor to his bed. V/S: BP 128/82 HR 97 t 97.4F R 20 PERRLA, Resident was a&o x 2-3. 911 called at 12:03AM, Res. wife and daughter([NAME]) notified at 12:04AM, MD notified at 12:05AM, EMS arrived at 12:15 and resident was transported to (Regional Hospital)12:20am.R5's F/U Occurrence Note dated 12/30/25 at 2:00 AM documents Incident Note: Observed lying on floor next to bed and window, on floor mat lying on stomach with arms at side and legs extended. Slow response made eye contact but no verbal response. Moving extremities, no shortening or rotation of legs noted. Transferred from floor to bed via full mechanical lift and 3 assist. More responsive but slow, mumbling speech. Small red area to left cheek bone. Neuro checks initiated. (Indwelling) catheter patent draining dark yellow urine. Call light within reach. Hospice care.No care plan intervention noted for this fall.Facility's Fall Investigation dated 12/30/25 at 2:00 AM documents Fall, Resident room, in bed. Found on floor. On floor mat on stomach. No injuries noted.On 1/23/26 at 3:00 PM, V2, DON stated that some of the falls happened before she was hired. She stated that Care Plan Coordinator is new and learning.Facility's Accidents & Incidents policy dated 7/1/23 documents To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. 4. Investigated and Follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. E. The D.O.N, IDT (Interdisciplinary Team), and /or Designee will conduct an investigation of the accident/incident as well. Findings will be indicated in the appropriate area. The IDT will review within 24 hour or next business day and discuss and attempt to find out root cause and implement an appropriate intervention to attempt to prevent further falls.

Based on interview and record review the facility failed to provide progressive interventions to prevent falls for 2 of 3 (R2, R5) residents investigated for falls in a sample of 25.Findings include:#1.R2's EMR Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 6/23/25 documents a diagnosis of Systemic Lupus Erythematosus, Unspecified; Epilepsy, unspecified, not intractable, without status epilepticus; and Altered Mental Status, unspecified.R2's MDS (Minimum Data Set) dated 11/28/25 documents a BIMS (Brief Interview for Mental Status) score of 9 out of 15. The MDS documents that the resident requires substantial/maximal assistance for roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R2's Care Plan Care Plan dated 7/1/25 documents (R2) is at risk for falls and injuries r/t daily use of anti-hypertensive medications, Narcotic use, and Cardiovascular medications. She is also noted to have tremors, which can impair her mobility and possibly contribute to falls. She has a history of falls with head injuries and displaced dens fracture.Interventions:5/2/25 - Bed in lowest position.5/2/25 - Ensure proper footwear when ambulating.5/2/25 - Instruct resident to avoid sudden position changes.5/2/25 - oriented to room.5/2/25 - provide adequate lighting.5/2/25 - provide/reinforce the importance of sitting on side of bed prior to standing.5/2/25 - Provide/Reinforce use of assistive devices: (specify: reacher, walker, cane, wheelchair, transfer pole, etc.)5/11/25 - (R2) is to have non-skid footwear on while in bed.7/11/25 - non-skid socks on while in bed.8/10/25 - Dycem placed in wheelchair.R2's F/U Occurrence Note dated 8/17/25 at 7:15 AM documents Incident Note: unwitnessed fall. CNA (Certified Nursing Aid) found (R2) on the floor @715. (R2) states she was not standing she was washing her face and tried to put her face towel on the dresser, but the wheelchair slid from under. I did a full head to toe assessment on (R2) with ROM (Range of Motion). She hit the right side of head and blood was on her hand, floor and towel. Denies any pain. V/S (Vital sign) (blood pressure) 115/75 P. (pulse)85 R. (respirations) 18 temp.(temperature) 97.6 O2. (oxygen saturations) 96%. Pt. (patient) A&O (alert and oriented) X 2. transferred to bed with two nurses and two CNA. pt stable. called 911. contacted POA. @740. Ambulance arrived @750. Contacted MD @751. Contacted DON (Director of Nursing) @ 752 left VM (voicemail).No care plan intervention noted for this fall.Facility Fall Investigation dated 8/17/25 at 7:15 AM documents fall, resident room, sitting. Fall caused by patient intent or behavior. Laying on ground. Resident just got up out of bed and was sitting the wheelchair. Assessment/Documentation, Fall Assessment Completed, Neuro checks initiated, routine safety checks, notified immediate supervisor, first aid initiated, Do not move, call bell in reach with instruction. Resident was sent to ED (Emergency Department) for further evaluation. Problem Statement: Resident attempting to get out of wheelchair. Root Cause: Resident attempting to get out of wheelchair. Investigative Statements: Nurse: unwitnessed fall. CNA found (R2) on the floor @ 7:15. (R2) states, she was not standing she was washing her face and tried to put her face towel on the dresser but the wheelchair slid from under. I did a full head to toe assessment on [NAME] with ROM. She hit the right side of head and blood was on her hand, floor, and towel. Denies any pain. V/S 115/75 R 18 temp. 97.6 O2. 96% Pt. A&O X 2. Transferred to bed with two nurse and two CNA. Pt stable. Called 911. Resident: Resident stated she wasn't trying to get out of bed and walk, she was reaching over to put something away.R2's Health Status note dated 1/14/26 at 2:13 PM documents res (resident) leaning forward in w/c and fell forward out of chair, hit head on leg of STS (Sit to Stand), MD here and states to send to ER for Eval (Evaluation).No care plan intervention noted for this fall. Facility's Fall Investigation dated 1/14/26 at 3:00 PM documents Fall, resident room, sitting. Fall caused by patient intent or behavior. Resident went from chair to floor. No injuries noted. Assessment/Documentation, Fall Assessment completed, neuro checks initiated, notified immediate supervisor. Resident witnessed hit head and sent to ED per MD for further evaluation, education to staff to lay resident down immediately after meals. Problem Statement: Resident is A&O x 2, poor safety awareness, BIMS 9, intention of getting out of the w/c. Root Cause: Resident is A&O x 2, poor safety awareness, BIMS 9, intention of getting out of the w/c so she could get to bed. Investigative Statements: Nurse: res leaning forward in w/c and fell forward out of chair, hit head on leg of STS, MD here and states to send to ER for eval. Resident: resident stated she fell and that she wanted out of her chair. Witness: This nurse was walking past room and witnessed resident scooting to edge of wheelchair and pushed self out of chair and fell to floor hitting head on based of sit to stand. Resident was assessed and stated her head hurt. Floor nurse notified POA and MD. Resident to be sent to ED for further evaluation.#2.R5's EMR undated documents that the resident was admitted to the facility on [DATE].R5's EMR dated 8/22/25 documents a diagnosis of Parkinson's Disease without Dyskinesia, without mention of fluctuations, encounter for palliative care, and Malignant Neoplasm of Unspecified Renal Pelvis.R5's MDS dated [DATE] documents a BIMS score of 12 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, chair/bed to chair transfer, and tub/shower transfer. The MDS documents that the resident has an indwelling catheter.R5's Care Plan dated 8/26/25 documents [NAME] is at risk for falls and injuries r/t side effects of his psychotropic and opioid medication use. He is also at risk due to his diagnosis of Parkinson's disease and his involuntary movements. [NAME] has a history of falls. Due to his involuntary movements, [NAME] has been noted to slide out of bed. He currently has a low bed and double mattresses.Interventions:8/25/25 - bed in lowest position.8/25/25 - Encourage call light usage.8/25/25 - floor mat at bedside when in bed.8/25/25 - keep environment free from clutter.8/25/25 - Keep personal belongings within reach.8/25/25 - provide adequate lighting.10/23/25 - bolster on mattress. Hospice provided.11/10/25 - personal alarm on resident.R5's Health Status note dated 9/17/25 at 12:43 AM documents UPON MIDNIGHT Rounding Resident noted in his room, laying on the bathroom floor, on his Right side. Upon assessment (indwelling) Cath detached from Resident's Penis, a large amount of blood noted on the floor, and penis. Resident states he doesn't know where he was going or what he was trying to do at the time of Fall. Resident denies hitting his head. Resident states he is not so much in pain Resident's Bed was still in the lowest position and safety mat was in place. Resident was Mechanical lifted from the floor to his Bed. V/S: BP 128/82 HR 97 t 97.4F R 20 PERRLA (Pupils Equal Round Reactive to Light Accommodation), RESIDENT was a&o X2-3. 911 was called at 12:03AM, RES WIFE AND DAUGHTER NOTIFIED AT 12:04AM, MD NOTIFIED AT 12:05AM,EMS ARRIVED AT 12:15 AND RESIDENT WAS TRANSPORTED TO (Regional Hospital) AROUND 12:20AM.No care plan intervention noted for this fall.Facility's Fall Investigation dated 9/17/25 at 12:43 AM documents Found on floor. Laying on bathroom floor. No injuries noted. Assessment/Documentation. Care Plan updated. Neuro checks initiated. Notified immediate supervisor. Sent out for further evaluation, resident noted confusion with uti (Urinary tract Infection) on abt (Antibiotic). Problem Statement: Resident confused with poor safety awareness, and attempting to get out of bed without assistance. Root Cause: Resident confused, with poor safety awareness, and attempting to get out of bed without assistance. Investigative Statements: Nurse: Upon Midnight rounding Resident noted in his room, laying on the bathroom floor, on his right side. Upon assessment Foley Cath. Detached from Resident's penis, a large amount of blood noted on the floor, and penis. Resident states he doesn't know where he was going or what he was trying to do at the time of fall. Resident denies hitting his head. Resident states he is not so much in pain. Resident's bed was still in the lowest position and safety mat was in place. Resident was mechanical lifted from the floor to his bed. V/S: BP 128/82 HR 97 t 97.4F R 20 PERRLA, Resident was a&o x 2-3. 911 called at 12:03AM, Res. wife and daughter([NAME]) notified at 12:04AM, MD notified at 12:05AM, EMS arrived at 12:15 and resident was transported to (Regional Hospital)12:20am.R5's F/U Occurrence Note dated 12/30/25 at 2:00 AM documents Incident Note: Observed lying on floor next to bed and window, on floor mat lying on stomach with arms at side and legs extended. Slow response made eye contact but no verbal response. Moving extremities, no shortening or rotation of legs noted. Transferred from floor to bed via full mechanical lift and 3 assist. More responsive but slow, mumbling speech. Small red area to left cheek bone. Neuro checks initiated. (Indwelling) catheter patent draining dark yellow urine. Call light within reach. Hospice care.No care plan intervention noted for this fall.Facility's Fall Investigation dated 12/30/25 at 2:00 AM documents Fall, Resident room, in bed. Found on floor. On floor mat on stomach. No injuries noted.On 1/23/26 at 3:00 PM, V2, DON stated that some of the falls happened before she was hired. She stated that Care Plan Coordinator is new and learning.Facility's Accidents & Incidents policy dated 7/1/23 documents To provide staff with guidelines for investigating, reporting, and recording Accidents and Incidents. 4. Investigated and Follow up Action: A. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. E. The D.O.N, IDT (Interdisciplinary Team), and /or Designee will conduct an investigation of the accident/incident as well. Findings will be indicated in the appropriate area. The IDT will review within 24 hour or next business day and discuss and attempt to find out root cause and implement an appropriate intervention to attempt to prevent further falls.

Based on observation, interview,and record review, the facility failed to properly store and discard expired medication. This failure has the potential to effect all 48 residents residing in the facility. Findings include: On [DATE] at 9:40 AM the facility's 100 Hall Medication Cart was inspected. The medication cart contained the following: R19's opened and labeled multi dose Aspart insulin Pen. The multi-dose vial was labeled with open date of [DATE]. R19's open and labeled multi dose Glargine insulin pen. The multi-dose vial was labeled with open date of [DATE]. On [DATE] at 9:45 AM V5, Licensed Practical Nurse, verified that the multi dose vials were open and in use. V5 stated that when opening an insulin pen the resident's last name and open date is placed on the multi dose pen. V5 stated that they only 30 days to use the insulin when opened. V5 stated that R19's Aspart and Glargine was discontinued in January and the insulins should have been removed from the cart and destroyed. On [DATE] at 9:50 AM the facility 200 hall medication room was inspected. The refrigerator located in the medication room contained the following: An opened box of Bisacodyl 10mg Suppository, with expiration date, ,d+[DATE]. R199's bottle of Glycerin suppositories with expiration date ,d+[DATE]. On [DATE] at 9:50 AM V5, LPN, stated that the Bisacodyl are stock medication and are used for everyone as long as they don't have an allergy. V5 stated tht R199 died in January and this medication should have been removed from the refrigerator and destroyed. On [DATE] at 3:15 PM V2, Director of Nursing, stated that she would expect that expired medication be destroyed. V2 stated that she would expect that any discontinued medication and medication of a deceased resident would be taken out of circulation and destroyed. The Resident's Census and Conditions of Resident, CMS 671, dated ,d+[DATE]//2025, documents that the facility has 48 residents living in the facility. The facility's Medication Storage policy, dated [DATE], documents PURPOSE: To provide guidance to facility nursing staff on the proper storage of medication. POLICY INTERPRETATION AND IMPLEMENTATION 4. Drug containers that have missing, incomplete, Improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date.

Based on interviews, observations, and record reviews the facility failed to date nasal cannulas, oxygen humidification containers and nebulizer administration equipment for 5 out of 5 residents (R24, R19, R30, R7, R37); reviewed for respiratory care in a sample of 41. Findings include: 1.R24's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, fracture of the lumbar vertebra, pulmonary hypertension, heart failure and chronic kidney disease. R24's Minimum Data Set (MDS) dated [DATE], documented she was moderately cognitively impaired and at the time did not require oxygen. R24's Care Plan last updated 4/15/25 documented no care plan for oxygen use. R24's orders dated 4/14/25 at 2:00 PM, documented oxygen at 4 LPM (liters Per Minute). R24's orders dated 1/17/25 at 10:00 PM, documented change oxygen tubing every week, every night shift, every 7 days. R24's orders dated 4/13/2025 at 12:46 PM, documented 3 ml(milliliters) inhale orally every 6 hours as needed for shortness of breath or wheezing. On 4/14/25 at 9:46 AM and 11:54 AM as well as on 4/15/25 at 10:44 AM, R24's oxygen NC (nasal cannula) tubing with humidification container and nebulizer equipment was not dated. 2.R19's face sheet dated she was admitted to the facility on [DATE] with diagnosis of, in part, polyneuropathy, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. R19's MDS dated [DATE] documented she is cognitively intact and requires oxygen therapy. R19's Care Plan last revised 4/16/25, documented no care plan for oxygen use. R19's orders dated 1/23/2025 at 6:00 PM documented oxygen at 4 LPM via NC continuous. R19's orders dated 1/23/2025 at 8:00 PM documented change oxygen tubing every week. On 4/14/25 at 9:46 AM and 11:54 AM and 4/15/25 at 10:44 AM, R19's oxygen humidification bottle was dated 4/3/25 with no date on her NC tubing. 3.R7's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, type two diabetes mellitus, and congestive heart failure. R7's MDS dated [DATE] documented she was cognitively intact and required oxygen therapy. R7's Care Plan dated 3/12/24 documented she has oxygen therapy. R7's orders dated 10/28/2024 at 6:00 PM documented oxygen at 2 LPM via NC continuous. R7's orders dated 3/4/2024 at 8:00 PM documented change oxygen tubing every week. On 4/15/25 at 8:00 AM, R7's oxygen humidification was dated 4/7/25 with no date on her NC tubing. 4.R30's face sheet documented she was admitted on [DATE] with diagnosis of, in part, type two diabetes mellitus, heart failure and hypertension. R30's Care Plan last revised 2/24/25, documented no care plan for oxygen use. R30's MDS dated [DATE] documented she was cognitively intact and did not require oxygen use at that time. R30's orders dated 4/8/2025 at 3:30 AM documented oxygen at 2L(liters)/NC to keep saturations above 90. On 4/14/25 at 9:52 AM, R30's oxygen NC tubing did not have a date labeled. 40650 5. On 4/15/2025 at 7:30 AM, R37 was taking a nebulizer treatment of Albuterol Sulfate. R37's nebulizer treatment mouthpiece, medication cup dispenser and tubing had a date on it of 3/8/2025. On 04/15/2025 at 10:32 AM, R37 had oxygen flowing at 3 liters per minute via nasal canula but there was no date on the oxygen tubing or humidifier bottle. R37 then stated that her oxygen tubing was changed on 3/30/2025. R37's MDS, dated [DATE], documented that her cognition was intact and that she receives oxygen therapy. R37's Physicians Order Sheet, dated 4/15/2025, documented diagnoses of Chronic Obstructive Pulmonary Disease. It continued to document, Change (nebulizer) tubing weekly every night shift, every 7 day(s). It also documented, Change oxygen tubing every week at bedtime every 7 day(s). It continued to document an order for Albuterol Sulfate Inhalation Nebulization Solution (2.5 (milligrams)/3 (milliliters) 0.083% (Albuterol Sulfate) 2.5 (milligrams) inhale orally every 4 hours as needed. For inhale of 2.5 milligrams (every 4-6 hours PRN for bronchospasm rinse mouth out with water after each use. R37's physician order sheet continued to document an order for Oxygen at 3 (liters per minute) via (nasal canula) continuous. R37's April 2025 treatment administration record did not document that her oxygen tubing was changed on 4/12/2025. R37's Care Plan, undated, documented, Give medications as ordered by physician. Monitor/document side effects and effectiveness. It continued, OXYGEN SETTINGS: (oxygen) via (nasal canula) (at) 3 (liters) continuously. Humidified. On 4/15/25 at 3:41 PM, V6, licensed practical nurse (LPN) stated she thinks the oxygen tubing, humidification and nebulizer equipment should be changed out weekly or monthly, but midnights complete that task so she's not sure; they should all be labeled. On 4/16/25 at 8:59 AM, V15 (LPN) stated the NC tubing, oxygen humidification containers and nebulizer equipment should all be changed out and dated weekly. On 4/16/25 at 9:34 AM, V9, registered nurse (RN) stated the NC tubing, oxygen humidification containers and nebulizer equipment are supposed to be labeled and dated so we know when it was changed; night shift is supposed to be doing that once a week. On 4/15/25 at 3:40 PM V2, director of nursing (DON), stated R19's oxygen humidification container was dated 4/3/25 and R24's oxygen tubing, humidification container and nebulizer equipment do not have dates either. V2 stated the oxygen tubing, humidification container and nebulizer administration equipment should be dated and changed weekly. The facility's Oxygen Administration Policy dated 7/1/23 documented the procedure for oxygen administration included to care plan oxygen use, label humidifier with date opened, and tubing will be changed and dated weekly.

Based observation, interview and record review, the facility failed to perform hand hygiene after touching clothing, hair and cellular phone during meal service for 18 of 18 (R1, R3, R4, R5, R10, R11, R12, R13, R16, R22, R26, R27, R29, R32, R34, R36, R38, R40) residents reviewed for infection control in a sample of 41. Findings include: On 04/14/2025 at 12:40 PM, V8, Certified Nurse Assistant (CNA), was in the dining room, was touching hair and face, with her bare hands. Then without performing hand hygiene, V8 was pouring cups of coffee for the residents. V8 then served the coffee to R34 then to R10 and then to R40. Then the meal service began, and V8 touched her glasses and rubbed her nose, and then without benefit of hand hygiene, passed meal trays to R32 and R29. V8 was waiting on the meal trays from the kitchen, she touched her glasses and nose again, and retrieved the meal trays for R4 and R12, and without benefit of hand hygiene, distributed those meal trays. She then cut R12's meat. V8 returned to the kitchen and did not perform hand hygiene, took lunch trays to R3 and then to R34. V8, without benefit of hand hygiene, carried a bowl of mashed potatoes, by the rim with her fingers to R10. V8, without the benefit of hand hygiene, made a cup of coffee for R12 and took it to him. V8 then returned to the kitchen opening, where the ABHR dispenser was, did not use it or perform hand hygiene any other way and retrieved meal trays for R26 and R13 and passed out those meal trays and cut up R13's meal. V8 did not perform hand hygiene and retrieved the meal trays for R1 and R11, passed their meal trays to them and then went and got a cup of coffee and gave it to R1. V8 returned to the kitchen opening, waiting for more meal trays, took her cellular phone out of her pocket, and was touching her screen of her cellular phone. Then the kitchen had 2 more meal trays ready for her to pass and without benefit of hand hygiene, she took R5's meal to him and assisted him with set up and then took R40's meal tray to her. V8 returned to the kitchen opening and retrieved R38's and R36's meal trays and delivered those to the residents without benefit of hand hygiene. She then went back to the kitchen opening and while waiting on more meal trays, she was touching her scrub shirt. She was given R27's meal to take to him and without benefit of hand hygiene passed R27's meal to him. V8 severed R22's meal tray to her and then sat down and assisted R16, with his meal. V8, CNA did not perform hand hygiene during the whole meal service. On 4/24/2025 at 1:30 PM, the alcohol based hand rub dispenser at the kitchen opening was operational with product. On 04/16/2025 at 09:20 AM, V19, Certified Nurse Assistant, (CNA) stated that she would wash her hands using the Alcohol Based Hand Rub available at the kitchen door in between passing trays to residents if she touches her hair or clothes during meal tray pass. On 04/16/2025 at 09:25 AM, V11, CNA, stated that he washes his hands in between passing meal trays to the residents and if he touches his clothes, hair or cell phone he will wash his hands. On 04/16/2025 at 09:30 AM, V3, CNA, stated that she washes her hands when passing meal trays to each resident and that she doesn't carry her cellular phone when at work. The facility's policy, Hand Hygiene, Hand Washing, undated, documented, K. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . It continues, O. Before and after assisting a resident with meals .

Based on interview and record review, the facility failed to provide notice of Medicare non coverage to 3 for 3 (R24, R99, and R100) residents reviewed for beneficiary notices in a sample of 43. Findings include: On 4/14/2025 at 8:41 AM an electronic mail was sent to V2, Director of Nurses with the Beneficiary Notice- Resident discharged Within the Last Six Months, worksheet to be filled out. On 04/15/2025 at 04:06 PM, an electronic mail was sent to V2, Director of Nurses, with R24's, R99's and R100's, Skilled Nursing Facility Beneficiary Protection Notification Review forms to be filled out. On 04/16/2025 at 11:26 AM, V1, Administrator, stated that she did not have R24's, R99's and R100's Beneficiary notices but she did have 1 on the list and that was R101. On 4/16/2025 at 12:56 PM V1 sent an electronic mail that stated, We are unable to locate any more of the list. I am so sorry. The facility's, Form Instructions for the Notice of Medicare Non-Coverage (NOMNC),undated, documented, When to Deliver the NOMNC: A Medicare provider or health plan ( Medicare Advantage plans and cost plans collectively referred to as Plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. the NOMNC must be delivered at least two calendar days before Medicare covered service end or the second to last day of service if care not being provided daily.

Based on observation, interview, and record review the facility failed to follow physician's orders for a resident with a rash for 1 of 3 residents (R3) reviewed for pharmacy services in a sample of 4. Findings include: R3's Face Sheet documents he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, aphasia, Parkinson's disease and dementia, no skin rash diagnosis was documented. R3's Skin Inspection assessment dated [DATE] rash continues to BUE (bilateral upper extremities), BLE (bilateral lower extremities) and torso, 11/9/2024 current skin concerns: back/upper arm clearing rash, tx (treatment) in place, 11/16/2024 current skin concerns: rash to torso, arms and thighs. R3's Nurse's Notes, dated 11/18/2024, documents, Resident seen by MD this afternoon new orders to D/C (discontinue) Clopidogrel and start Triamcinolone and Clotrimazole topically BID (twice a day.) Follow up in 1-2 weeks. R3's Physician's Order Sheet (POS), dated 11/18/2024 through 11/27/2024 documents no physician's order for Triamcinolone or Clotrimazole BID. R3's Treatment Administrator Record (TAR), dated 11/18/2024 through 11/27/2024 documents no Triamcinolone or Clotrimazole was administered. On 11/27/2024 at 11:30 AM V2, Director of Nurses (DON) stated on 11/18/2024 the nurse notified the physician that they needed clarification on the dosage for the Triamcinolone and Clotrimazole and the communication fell through, so the medications were not ordered and therefore the nursing staff have not administered the medications per physician's orders. V2 stated she got the medication dosage clarified today and the medications will be delivered to the facility within the next 8 hours. V2 expected all physician's orders to be followed and to follow up with clarification of medications within the same shift. On 11/27/24, at 10:07 AM V8, Certified Nurse Aide (CNA) was showering R3 and he had a red raised rash on back and abdomen and legs all over. V8 stated they use (brand named) soap, and she puts regular lotion on his skin but nothing else, physician prescribed lotion is applied by the nurse. The Facility's Physician Orders Policy, initiated 7/1/2023 documents the purpose of this policy is to establish uniform guidelines in the receiving, recording, and processing of physician orders. This facility will obtain, process, and implement physician orders given by a licensed physician and received by a licensed nurse. It is the responsibility of the Director of Nursing/designee to ensure that all licensed healthcare workers within the facility to know the physician order process. The Facility's Medication Orders Policy, initiated 9/17/2019 documents when recording orders for medications, specify the type, route, dosage, frequency, strength, and rationale of use for the medication ordered.

Based on observation, interviews and record reviews, the facility failed to ensure there was an air gap in the ice machine between the floor sewage drain and the ice machine and there were no signs of water damage from sewage lines and or/pipelines. This has the potential to affect all 45 residents living in the facility. Findings include: On 5/1/2024 at 8:33 AM, the ice machine was in the dining area. Behind the ice machine there was water present on the floor. Behind the machine there were also 2 orange cones with the words wet floor that were placed behind the machine. On 5/1/2024 at 8:39 AM, Behind the ice machine there was a white pipe that went into another pipe into a drain. The pipe was going directly into the drain, and no air gap was observed. The air gap was not twice the diameter of the water outlet from the fixture and the fixture's flood-level rim and there was the potential for backflow or back siphonage. The white pipe was also covered with black spots covering the entire pipe, and was wet with moisture. On 5/1/2024 at 8:55 AM, on the walls behind the ice machine, the walls were protruding, and appears patchy clusters of raised areas on the drywall with black specks. The area affected was approximately five feet in length and four feet in width and covered the entire area behind the ice machine. The large pipes coming out of the back of the machine behind the ice machine were also covered with black spots with moisture present. The dry wall was not smooth, and was puffy in appearance. On 5/1/2024 at 9:00 AM, V28, Dietary Manager, stated, I am not sure why it is wet back there or why the area has the orange cones. I think it is from the ice melting. On 5/3/2024 at 9:19 AM, V22, Environmental Health Director, stated, Those orange cones behind the ice machine are put there by dietary staff not by me. They are always behind the ice machine. We use different cones for wet floors. I am not sure why the floor is wet but it has been like that for a while. I could not say exactly how long. It has been a few weeks. Again, I don't do anything with that area. On 5/3/2024 at 9:24 AM, V25, Cook, stated, Those cones have been there for awhile. We get water back there. I am not sure how long it has been like that. On 5/3/2024 at 9:45 AM, V25, [NAME] President of Operations Maintenance, stated, There was water behind the ice machine. I believe with the temperature of the outside wall and the temperature of the actual ice makes it is causing moisture to cling to the surface. I am going to have staff scrap the area, repair the walls from the moisture damage and hit it with some products to reduce the moisture and prevent future moisture. When I got back there and pulled things out the air gap was not to code, and I will address that as well. We will incorporate some new panes behind them as well so they can be wipes and are cleanable. On 5/3/2024 at 10:02 AM, V28, Dietary Manager, stated, The ice machine that is in the dining room is the only ice machine in the building. We use the ice for all meal preparations and meal services, passing out ice, and water coolers. On 5/3/2024 at 10:31 AM, V1, Administrator, stated, We do not have a policy on air gaps but we follow all state and local ordinances. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 4/30/2024, documented that the facility had a census of 45 residents.

Based on interview and record review, the facility failed to adequately develop an ongoing infection control program that adequately collected data to calculate and analyze infection rates and failed to operationalize infection control policies to adequately define infection control practice in the facility. This has the potential to affect all 45 residents living in the facility. Findings Include: On 5/2/2024 at 10:22 AM, an infection control log was provided but did not have any dates or organisms listed or documented. On 5/2/2024 at 10:33 AM, V2, Director of Nursing (DON), stated, I was just hired and just finished taking the ICP (Infection Control Preventionist) course. I am new to this position, and this is the only surveillance I have. I will look and see what else I can find. I do not have a book, but I will call corporate and see what she has. A second list of Infection control log was provided and contained two and half pages. Not all urinary tract infections had organisms documented and were not provided when requested. There were 10 Urinary Tract Infections documented on the log but only two of ten had documented organisms. The Facility Infection Control Program Policy issue, dated 09/15/2020, documented, Purpose to provide guidelines and guidance for all staff regarding the facility established infection control program that investigates, controls and prevents infections. Surveillance for nosocomial infections will be done to provide a format for the surveillance of infections occurring within the facility. The facility will establish and maintain the program in order to provide a safe and sanitary environment, and to help prevent the development and transmission of disease and infection. Infections will be investigated, controlled, and prevented, and isolation precautions will be determined on an individual basis. The Infection Report Form will be kept on those residents who are receiving antibiotics or have an infection. Data will be compiled, and a report completed monthly. Data will be discussed during the QA Meeting. The Infection Control Coordinator will track and trend infections and ensure proper training of staff and ongoing interventions to prevent the spread of infections. Infection Surveillance: the collection of data on nosocomial infections that is used primarily to plan control activities, educational programs and to prevent epidemics. An important reason for collecting and analyzing data is for the early detection and prevention of infectious disease outbreaks. Procedure for infection surveillance: surveillance data will be collected on ongoing basis. Recording, reviewing, analyzing, and reporting of infection case data will be done monthly, quarterly, and annually to detect trends. Surveillance data shall be used for planning control efforts, detecting epidemics, directing in-service education, and identifying individual resident problems for intervention. Analysis of surveillance data will include at least the following elements on each infection to detect clusters and trends: date of onset, body site, geographic location, and appropriate culture information. Data collection: Continuous collection of data is necessary to determine what an infection is, when it is present, and whether it is nosocomial in origin. Data may incorporate the number of infections, type of infections, and related issues which may be present. Monthly reports will include: the incidence of all types of infections. The incidence of community acquired infections. Rates for various types of nosocomial infections. Predisposing infectious organisms in types of nosocomial infections. Any recommendations made regarding isolations or cross infections. The infection control log should be updated on an ongoing basis. The Long -Term Care Facility Application for Medicare and Medicaid form, dated 4/30/2024, documented the facility had a census of 45 residents.

Based on interview and record review, the facility failed to ensure the residents were given the correct antibiotics for the organism causing infection for 4 of 4 residents (R8, R25, R31 and R150) reviewed for antibiotic stewardship, in the sample of 33. Findings include: 1. R25's Progress Notes, dated 03/28/2024 at 11:01 AM, documented, Received call from ER (emergency room ), reports has UTI (urinary tract infection) starting on Macrobid at ER (emergency room ) and script being sent to (Pharmacy). Placed call to family to update on results of ER visit. R25's Progress Notes, dated 04/04/2024 at 9:55 PM, documented, ABT (antibiotic) completed this shift. No adverse reactions noted. Continue encouraging fluids. Denies any s/s (signs or symptoms) of UTI such as burning, pain, and frequency. R25's Physician Order Sheet (POS), dated 3/1/2024 to 4/30/2024, documented, Nitrofurantoin microcrystal capsule 100 milligrams (mg), give 1 capsule by mouth every 12 hours for UTI Prophylaxis for seven days. R25's Lab Report, collection date 3/28/2024 and verification date 3/29/2024, documented, Mixed genital flora isolated. These superficial bacteria are not indication of a urinary tract infection. R25's Medication Administration Record (MAR), dated April 2024, documented, Nitrofurantoin microcrystal capsule 100 milligrams (mg), give 1 capsule by mouth every 12 hours for UTI (urinary tract infection) for 7 days. Start date 3/28/2024. On 5/2/2024 at 10:00 AM, a Culture and Sensitivity Report (C&S) was requested, and no C&S was provided for R25. 2. R150's Progress Notes, dated 04/20/2024 at 10:49 AM, documented, Resident cont. (continues) ABT (antibiotic) for tx (treatment) of UTI (urinary tract infection), no adverse effects noted. R150's POS, dated 4/19/2024, documented an order for cefdinir oral capsule 300 mg, give 1 tablet by mouth two times a day for UTI for six days. R150's MAR for April 2024, documented that R150 received for cefdinir oral capsule 300 mg, give 1 tablet by mouth two times a day for UTI for six days. R150's Progress Notes, dated 04/28/2024 at 8:59 PM, documented, Remains on antibiotic for UTI. No adverse effects noted. Able to make needs known. Resident denies s/s of UTI this shift. Able to make needs known. R150's Lab results from local hospital, that was collected on 4/16/2024, documented that a urine culture was taken but did not document any culture or sensitivity for the use of cefdinir. The facility was unable to provide a culture and sensitivity (C&S: a lab test to attempt to grow bacteria, viruses, or fungi and then test which medications will effectively work to stop the infection) for R150 when requested. On 5/3/2024 at 9:32 PM, V2, Director of Nursing, stated, My expectations are that anytime any resident is started on antibiotics we have a culture and sensitivity for it and the organism was identified before any antibiotic was given. A lot of times, the hospitals will not send us the C & S and we will have to follow up. I just started this position in April. We also have some issues with the hospice too. 34964 3. R8's Physician Order Summary, dated 5/2/24, documented, 9/2/22: Keflex Capsule 250 MG (Cephalexin) Give 250 milligrams (mg) by mouth in the morning related to Personal History of Urinary Tract Infections. It also documented that this antibiotic was not discontinued until 3/21/24. R8's Medication Administration Records, dated 5/2023 to 3/2024, documented that R8 received Keflex 250 mg every day while she was in the facility for past year. R8's Progress Notes and Lab results, dated 5/2023, were reviewed, and there was no documentation for a diagnosis of UTI nor was there any abnormal urinalysis found. 05/03/24 at 09:43 AM, V2, Director of Nursing, stated that she talked to the physician and got R8's Keflex order discontinued, and she was started on UTI-Stat pm 3/21/24 to help prevent UTIs. 4. R31's Physician Order Summary, dated 4/1/24 to 5/1/24, documented, 4/3/24: Acyclovir 400 mg by mouth every 12 hours for UTI for 5 days and Cefdinir 300 mg by mouth every 12 hours for UTI for 5 days. R31's MAR, dated 4/1/24 through 4/30/24, documented that R31 received all ordered doses of her Acyclovir and Cefdinir from 4/4/24 to 4/8/24. R31's Urinalysis Culture results, dated 4/2/24, documented, Urine Culture Final; Result: Mixed genital flora isolated. These superficial bacteria are not indicative of a urinary tract infection. No further organism identification is warranted on this specimen. The antibiotic Stewardship Policy, revision date of 12/13/2023, documented, Antibiotics are powerful tools for fighting and preventing infections. However, widespread use of antibiotics has resulted in an alarming increase in antibiotic resistant infections and a subsequent need to rely on broad-spectrum antibiotics that might be more toxic and expensive. In addition to the development of antibiotic resistance, antibiotic use is associated with an increased risk of Clostridium difficile infections and adverse drug reactions. Since antibiotics are frequently over or inappropriately prescribed, a concerted effort to decrease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. Antibiotics stewardship consists of coordinated resident safety and the reduction of adverse events. First line treatment recommendations. There are no definitive practice guidelines that specifically address treatment of UTI in elderly patients in the LTCF (Long term care facility). Prescribers will base treatment recommendations on the following factors: facility specific culture and antibiotics sensitivity data.

Based on interview and record review, the facility failed to implement the their policy regarding pneumococcal immunizations and failed to administer both pneumococcal vaccines in the series according to accepted standards of practice for 4 of 6 residents (R23, R36, R45 and R48) reviewed for pneumococcal immunization. This failure resulted in R48 and R36 not being fully immunized against pneumonia and both were admitted to the hospital with [REDACTED]. Findings include: The facility Pneumococcal Pneumonia Vaccination Policy, dated 12/9/2019, documents, in part, Purpose: To reduce the overall incidence of pneumococcal pneumonia by providing the pneumococcal pneumonia vaccines to residents [AGE] years or older and to others at high risk. The Policy documents All residents admitted will be screened to determine eligibility for the pneumococcal pneumonia vaccines (Pneumococcal Conjugate Vaccine - PCV13 and Pneumococcal [MEDICATION NAME] Vaccine - PPSV23). A physician's orders [REDACTED].g. (for example) those [AGE] years and older, those with chronic illness such as lung, heart, or kidney diseases, [MEDICAL CONDITION] cell [MEDICAL CONDITION], or diabetes, those with a weakened immune system). The Policy documents Procedure for residents who have previously received the Pneumococcal Pneumonia Vaccine (PPSV23). 1. The resident or legal representative is provided education regarding the benefits and potential side effects of the vaccination. 2. The resident or legal representative completes the Vaccination Consent. 3. If addition vaccination is determined to be appropriate, follow the Pneumococcal Pneumonia Guide for vaccination recommendations. 4. Follow High Risk Revaccination Guide for those residents in high risk groups. The Policy documents Procedure for residents who have not previously received the Pneumococcal Vaccine or who are uncertain if the Pneumococcal Pneumonia Vaccine was received: 1. The resident or legal representative is provided education regarding the benefits and potential side effects of the vaccination. 2. The resident or legal representative completes the Vaccination Consent. 3. If additional vaccination is determined to be appropriate follow the Pneumococcal Pneumonia Guide for vaccination recommendations. 4. Follow High Risk Revaccination Guide for those residents in high risk groups. According to CDC's Advisory Committee on Immunization Practices (ACIP), the following new recommendations were released June 26, 2019. PCV13 is a shared decision between residents and their provider, for all immunocompetent adults> 65 who have not previously received the vaccine. All adults > 65 should receive a dose of PPSV23 ([MEDICATION NAME] 23). The two vaccines should not be co-administered but should be given at least 1 year apart. Pneumococcal Pneumonia Guide, undated, documents, NO vaccinations received. (Then) Adults [AGE] years of age or older who have not previously received any pneumococcal vaccines should receive PCV13 followed by a dose of PPSV23 greater or equal to twelve months later. If a dose of PPSV23 cannot be given during this time window, it should be administered later. PCV13 and PPSV23 should not be administered on the same day. For some immunocompromised residents (See High Risk Pneumococcal Revaccination Guide) the PPSV23 should be given greater than 8 weeks after receiving the PCV13. UNCERTAIN if any vaccination was received. (Then) Adults [AGE] years of age or older who have not previously received any pneumococcal vaccines or whose previous history is unknown should receive a dose of PPSV23 greater or equal to twelve months later. For some immunocompromised residents (See High Risk Pneumococcal Revaccination Guide) the [MEDICATION NAME] 23 should be given greater or equal to 8 weeks after receiving the Prevnar13. UNABLE TO DETERMINE if PCV13 or PPSV23 was received. (Then) Adults [AGE] years of age or older whose previous history of obtaining PCV13 or PPSV23 is unable to be determined should receive a dose of PCV 13 first, followed later by a dose of PPSV23 greater or equal to twelve months later. For some immunocompromised residents (See High Risk Pneumococcal Revaccination Guide) the [MEDICATION NAME] 23 should be given greater or equal to 8 weeks after receiving the Prevnar13. RECEIVED PCV13 (Then) Adults [AGE] years of age or older that received a dose of PCV13 may receive a dose of PPSV23 greater or equal to twelve months later. If a dose of PPSV23 cannot be given during this time window, it should be administered later. RECEIVED PPSV23. (Then) Adults [AGE] years of age or older who have not received PCV13 and who have previously received one or more doses of PPSV23 should receive a dose of PCV13. The dose of PCV13 should be given greater or equal to 1 year after receipt of the most recent PPSV23 dose. RECEIVED BOTH PCV13 & PPSV23. (Then) See attached table for those that meet the requirement for an additional vaccine. PCV13 = Prevnar13 PPSV23 = [MEDICATION NAME] 23. Above are the recommendations of the Center for Disease Control (CDC) for all adults [AGE] years of age or older. Review of the Centers for Disease Control and Prevention (CDC) publication with a review date of 9/18/19 titled Adults: Protect Yourself with Pneumococcal Vaccines specified Many adults may be at increased risk for pneumococcal disease.Two vaccines provide protection against this serious and sometimes deadly disease.Each year in the United States, pneumococcal disease kills thousands of adults. Thousands more end up in the hospital because of pneumococcal disease. It can cause severe infections of the lungs (pneumonia) blood stream (bacteremia) and lining of the brain and spinal cord (meningitis).However, some can be deadly, especially for adults [AGE] years or older: Pneumococcal pneumonia kills about 1 in 20 older adults who get it (and) pneumococcal bacteremia kills about 1 in 6 older adults who get it. Vaccines are the best way to prevent pneumococcal disease.When the bacteria spread into other parts of the body, it can lead to (pneumonia, bacteremia, and meningitis). These illnesses can be deadly, especially for: Adults [AGE] years or older, people with chronic health conditions (and) people whose immune systems are weakened by disease or medicine (immunocompromised) .Pneumococcal disease is contagious.Pneumococcal bacteria spread from person to person through coughing, sneezing, and close contact. People can carry the bacteria in their nose and throat without being sick and spread the bacteria to others. Review of the new immunization guidelines dated June 2019 TABLE 2. Policy options* for use of pneumococcal vaccines in adults aged [AGE] years presented for a vote and considerations by the Advisory Committee on Immunization Practices (ACIP), June 2019 revealed. BOX. Considerations for shared clinical decision-making regarding use of 13- valent pneumococcal conjugate vaccine (PCV13) in adults aged [AGE] years PCV13 is a safe and effective vaccine for older adults.The remaining risk is a function of each individual patient's risk for exposure to PCV13 serotypes and the influence of underlying medical conditions on the patient's risk for developing pneumococcal disease if exposure occurs. The following adults aged [AGE] years are potentially at increased risk for exposure to PCV13 serotypes and might attain higher than average benefit from PCV13 vaccination, and providers/practices caring for many patients in these groups may consider regularly offering PCV13 to their patients aged [AGE] years who have not previously received PCV13: Persons residing in nursing homes or other long-term care facilities. 1. R48's Admission Record documents R48 was admitted on [DATE] and is [AGE] years old. This Admission Record also documents R48 has [DIAGNOSES REDACTED]. R48's Health Status Note, dated 9/26/2019 at 10:31 AM, documents, POA (Power of Attorney) updated on flu vaccine consent; she agrees and wants mom to have pneumococcal pneumonia vaccine also. R48's Vaccination Consent, signed 9/28/2019, documents that the resident and family were given information regarding the Pneumococcal vaccination and the family/resident wanted to be vaccinated. R48's Pneumococcal Vaccine record, undated, documents consent was given from family to facility on 9/26/19 for R48 to receive Prevnar 13. On the bottom of the record was documented that facility asked Medical Doctor and Medical Doctor noted she did not need. There was no documentation the Medical Doctor was asked or gave a date when the Prevnar13 vaccination was given to R48. R48's Health Status Note, dated [DATE] at 2:15 AM, documents R48 was gurgling and experiencing crackles in her lungs. The Note documented her oxygen saturation levels were 78%. The Health Status Note, at 2:50 AM documented she was sent to local hospital via ambulance. R48's Health Status Noted, dated [DATE] at 6:24 AM, documents, res (resident) admitted to local hospital dx. (diagnosis) pneumonia. R48's Local Hospital History and Physical Report, dated [DATE], documents, R48 had community acquired pneumonia based off chest x-ray. The Report documented she was receiving antibiotic and breathing treatments to treat her pneumonia. R48's Health Status Note, dated [DATE] documented she was readmitted to the facility. On 02/20/20 at 3:53 PM, V11, Medical Director, stated, (R48) is not my patient but is in my group and I can see here she had the Pneumonia vaccine 11/3/1998. On 2/25/2020 at 8:55 AM, V14 Licensed Practical Nurse/ Infection Control Nurse, stated, On admission when the families come in and do paperwork (V15 Social Service Director) goes over the vaccine consent and education with the families and they mark what vaccine they want or don't want. All the boxes should be marked with what vaccine they want, or they don't and if the family or resident know when a vaccine was given. (V15) then gives that consent to the nurse. The nurse will call the doctor for clarification of when a vaccine was given or to get an order for [REDACTED]. Last year I asked (V2, Director of Nurses (DON)) if we should be offering pneumonia vaccines yearly and she never got back to me. Last year I did put a log together about who was vaccinated and with what because (V16 the corporate nurse) told me to do it and fax it to her. I did that, but nothing ever came of it and it wasn't implemented. If the admitting nurse does the vaccines wrong, there is no one following up to ensure the vaccine was given. There is no tracking device in place for when vaccines are due or who had what. The policy does not document how the vaccines will be tracked or documented. On 2/25/2020 at 8:55 AM, V14 Infection Control Nurse, stated, In the case of (R48), the nurse should have confirmed with the doctor a date of vaccination and then questioned restarting the series since it has been [AGE] years since she was vaccinated. 2. R36's Admission Record Sheet, undated, documented she was born on [DOB]and was admitted to the facility on [DATE]. The Admission Record documents she has [DIAGNOSES REDACTED]. R36's Patient Visit Information, from a local emergency department, dated 0[DATE], documents that R36 was diagnosed with [REDACTED]. R36's Radiological Report, dated 0[DATE], documents Technique: (Posterior/ Anterior) and lateral views of the chest were obtained. It continues to document, Impression: 1. Mild right basilar opacities which could represent atelectasis and/or pneumonia. 2. Very small bilateral pleural effusions. R36's Pneumococcal Pneumonia Immunization record, dated 03/11/13, documents that the resident did not want the be vaccinated but had been vaccinated in August 2012. R36's Immunization record, print date of 2/20/2020, documents that the resident received [MEDICATION NAME] dose 1 on 8/30/2012. There is no documentation/tracking that R36 was offered or received the PPSV23 for the prevention of pneumonia. 3. R23's Vaccination Consent, dated 6/14/2018, documents that R23's Power of Attorney (POA), consented for R23 to receive the Pneumococcal Pneumonia vaccine. R23's Admission Record, undated, documents R23's date of birth is [DOB] and she was admitted on [DATE]. It continues to document her [DIAGNOSES REDACTED]. R23's Immunization record, print date of 0[DATE], does not document that R23 received the pneumococcal pneumonia vaccine. On 02/20/2020 at 11:00 AM, V2, Director of Nursing (DON), stated (R23) did not receive the pneumonia vaccination because it was probably overlooked but now it has been ordered. 4. R45's Face Sheet, print date of 02/20/2020, documents that R45 was initially admitted [DATE], has [DIAGNOSES REDACTED]. R45 was born on [DOB] and is [AGE] years old. R45's Immunization Consent, dated 09/20/2018, did not have any documentation that R45 consented or declined the Pneumonia vaccination. R45's Immunization Record documents that R45 did receive a Pneumonia Vaccination on 11/21/2005 but has not had any addition vaccinations in Pneumonia Vaccination series since then. There was no documentation/tracking in R45's medical record that R45 was offered the PPSV23 vaccination. On 2/20/2020 at 9:30 AM, V2 DON, stated, I can only give what the Doctors orders. We ask the Doctor what vaccine to give and give what he orders. No, we have not been going back and re-approaching residents about the new pneumonia protocol. On [DATE] at 2:57 PM, V2, DON, stated, Last year we started a vaccination log, but nothing was done with it. If you need to know if someone has been vaccinated, you pull it up under immunizations in the computer. So, when a resident comes in, they are questioned whether they want the vaccination or if they have had it. V2 stated that we attempt to call the doctor and find out if they have had it or not. Then we get an order and proceed with what the doctor tells us. There is no follow up on initial contact with Doctor regarding what vaccine had been received and if they needed the other. On 02/25/2020 at 11:35 AM, V15, Director of Resident Services (DRS), stated, On admission, the POA and/or resident is educated on the risk and benefits of vaccinations and this information is in the admission packet that is given to them. Copy of the signed Vaccination Consent form is given to the nurse on the hall where the resident will reside. The Vaccination Consent form has a place where the resident or POA marks that they have been educated and that is scanned in and the original goes in the chart. On 02/25/2020 at 9:30 AM, V8, Licensed Practical Nurse (LPN), stated, (V15, DRS) will get the consent for the (pneumonia) vaccine from the resident or the family. The nurse will call the residents doctor for the order or to find out when the resident had it last. We put it on the progress note to let the other nurses know we have a call out to the doctor. We do not have a tracking system in place if they (the resident) to be re-vaccinated or when the 2nd one is due. On 02/20/20 at 3:53 PM, V11 Medical Director, stated, It is very hard to track everyone's vaccines. There is not a central system for it. I expect the facility to follow their policy on the pneumococcal vaccine. As a physician, I would like everyone over 65 to have the Prevnar 13 and then the [MEDICATION NAME] 23 a year later as the CDC guidelines recommends. As to how the staff remind the doctors or how we track there is a lot of nuts and bolts in that, but I do agree they should at least be offered the [MEDICATION NAME] 23. At 4:40 PM, V11 stated that the facility should follow their policy for pneumococcal pneumonia vaccination but unable to say that if this resident had received the updated vaccination, then she would have not gotten pneumonia. He continued to state that the pneumonia R36 has was probably [MEDICAL CONDITION]. On 2/25/2019 at 2:00 PM, a concurrent interview with V2 and V3 Vice President of Operations was conducted regarding monitoring and tracking and the pneumococcal vaccine policy. V2 stated, Nobody has brought it to our attention that a monitoring tracking system wasn't in place for immunizations. I know now because I have been doing an audit. V3 stated, The new system is (V14 LPN/Infection Control) will get all the consents from (V15) and handle the whole immunization process. As far as the policy being updated that is (V16's Corporate Nurse) job she is the infection control nurse. I feel the tools are there for tracking we just need to make sure the right person is doing it and it isn't going through so many hands.

Based on interview, observations and record review, the facility failed to adequately assess, develop and implement a Range of Motion (ROM) program for 1 of 15 residents (R35) reviewed for ROM limitation services in a sample of 31. This failure resulted in R35 developing limitations in bilateral knees and right wrist with no services provided. Findings include: 1. R35's Contracture Risk assessment dated [DATE] documented R35 to be at high risk for contracture development. R35's Care Plan, dated 1/2/18, did not document range of motion services were being provided to R35. R35's Minimum Data Set (MDS), dated [DATE], documented R35 had no limitation in range of motion and no services were provided. The MDS documented R35 had severe cognitive impairment and required extensive assist of two staff for transfers. On 2/21/18 at 11:05 AM, R35 was sitting in his room with his son, V13. When asked if he had any concerns, V13 stated R35 was going to start seeing therapy as his hand is starting to do this dropping his right hand at the wrist. On 2/21/18 at 2:10 pm, V9 and V3, Certified Nurse's Aides (CNAs) entered R35's room to toilet him. V9 and V3 applied the mechanical lift sling and R35 was transferred via a mechanical lift. R35 did not stand up straight and did not straighten his legs as he was lifted the mechanical lift. R35's feet were extremely swollen. V9 and V3 provided no cues or encouragement to R35 to stand straight and bear weight during the transfer. V3 and V9 stated R35's one hand and started to curl in and they do exercise him and have him move his hands and fingers when they work. R35's held his left hand in an inward curved position but could open some when asked. The (MONTH) physician's orders [REDACTED]. PROM (Passive Range of Motion) and wrist drop splint. On 2/27/18 at 2:00 PM, V24 OT Assistant (OTA) stated she was recently asked by nursing to evaluate R35 for wrist drop. V24 stated she understood that this came on very rapidly and she has recommended a splint but has not determined a schedule yet for it since she's just starting it. V24 was asked about range of motion and whether he had limitations lower extremities stated he definitely has limitations in his knees and added that she had seen him a year or so ago and couldn't remember if she recommended ROM or not. When asked about the Contracture Risk assessment identifying him as high risk stated she thought that was correct as she would consider him at risk due to his immobility. On 2/27/18 at 1:30 PM, V15 Registered Nurse/Restorative Nurse stated she does Contracture Assessments on admission and quarterly but was unable to describe what the purpose to the assessments was. V15 stated Once they start showing some stiffness or limitations, she refers them to therapy. V15 didn't respond when told V24 OTA stated R35 definitely has limitations in his knees but added that she assessed R35 in (MONTH) and didn't notice any stiffness or anything with his legs when she did range of motion. V15 stated she has no training or certification in Restorative/Rehabilitation. The Contracture Prevention Program dated 1/15/11 documented the Objective as To maintain residents at the highest level of physical functioning possible, to stimulate circulation and prevent [MEDICAL CONDITION], to prevent fixation of a joint for long periods of time, and to prevent atrophy of muscles. Under procedure, the policy documented A resident that is determined to have a contracture or the potential for a contracture may be referred to the Physical Therapist (PT) for assessment and development of a program. It is the responsibility of the nursing staff to obtain a physician's orders [REDACTED]. The policy also documented The plan of care established by physical therapy or nursing when a contracture is present or the resident is at risk for developing a contracture may include goals, positioning aids, treatment plans and potential for improvement. The policy documented Those individuals having limited ROM and fair to good potential for resolution may be placed in a therapy or restorative/rehabilitation program and Any current resident that is beginning to show signs of stiffness should be brought to the attention of nursing staff for possible referral to the therapist and development of an appropriate program. The policy documented a Contracture Prevention Plan may include, but are limited to in part Encouraging and assisting the resident to perform passive and active optimal joint function to prevent deformities and stimulate circulation and build endurance, Splints by be applied per physician's orders [REDACTED].

Based on interview and record review the facility failed to supervise to prevent falls for one of five residents (R1) reviewed for falls in the sample of 15. This failure resulted in R1 being left alone on the toilet, falling and sustaining a right femur fracture. Findings include: R1's 1/2017 Physician order [REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 3 which indicates severe impairment. R1's MDS documents that R1 requires extensive assistance of one person for toileting. R1's MDS, dated [DATE], documents that R1 requires limited physical assistance of one for toileting. R1's Care Plan, initiated 2/5/13, documents that R1 is at risk for falls related to the need for assist with activities of daily living and mobility, poor cognition, decreased safety awareness, attempts to transfer and walk alone, use of high risk medication, incontinence, and anxiety. The facility's Occurrence Report, dated 4/6/16 at 5:02 PM, documents that R1 was observed sitting on the floor next to the bed on her buttocks with legs extended, arms at sides. The root cause identified for R1 was she attempted to toilet self without assistance documented by E2, Director of Nursing (DON). The intervention documented on the form was to monitor toileting schedule again and continue with current interventions. R1's Care Plan was updated 4/6/16 with the interventions to establish voiding pattern, prompt and assist to the bathroom, anticipate need for toileting upon rising and assist to the toilet as indicated. The Occurrence Report, dated 4/12/16 at 3:35 PM, documents R1 attempted to self ambulate and lost balance/slid. The root cause identified by E2 documents R1 attempted to ambulate after opening occupied bathroom door-stated R1 denied needing to toilet-was noted to have removed one shoe and had a sock on one foot and sock and shoe on the other. Recommendations on the Occurrence Report document therapy to screen, and review continence tracking to see if a voiding pattern can be identified. R1's Care Plan was updated with the intervention to monitor for and assist with non skid footwear. The Occurrence Report, dated 6/4/16 at 6:28 PM, documents the Certified Nurses Aide (CNA) saw resident sitting on the floor. The root cause identified by the DON documents that R1 forgot to ask for assist, attempted to self transfer and fell . The form documents autolock brakes added to the wheelchair. R1's Care Plan was not updated with progressive interventions after this fall to prevent recurrence. The Occurrence Report, dated 7/13/16 at 12:04 PM, documents resident found on left side on floor, laceration to bridge of nose, forehead, and left outer eye, and was sent to hospital for evaluation. The root cause identified by E2 documents R1 forgot to ask for assistance and fell when ambulating back to bed after toileting. The recommendation toileting program initiated to decrease risk for fall. R1's Care Plan interventions about toileting again. The Occurrence Report, dated 8/27/16 at 8:04 AM, documents that the CNA found R1 sitting on the floor. Witness statement by CNA documents that took R1 to the bathroom, turned off the chair alarm and when came back R1 was on the floor. R1's Care Plan was not updated with progressive interventions after this fall to prevent recurrence. R1's Care Plan intervention added, Do not leave (R1) alone without her alarm. R1's Morse Fall Scale documents a score of 70 (high risk being a score of 46 or higher) on 4/29/16, a score of 80 on 6/26/16, a score of 65 on 7/13/16, a score of 80 on 8/27/16, a score of 55 on 9/9/2016 and a score of 80 on 12/3/16. On 1/12/17 at 3:00 PM, E2 stated that R1 did receive a fracture at the facility, because a CNA left R1 on the toilet. E2 stated that R1's toileting plan was changed. On 1/13/17 at 1:50 PM, E2 stated R1 had received a laceration from a fall and was assisted with toileting after that fall. E2 stated that on 8/27/16 that a CNA turned off R1's alarm while R1 was on the toilet, and left R1 on the toilet, and went to answer another call light. E2 stated R1 fell and received a fractured to her femur. E2 stated the CNA is no longer employed at the facility. The facility's Policy Fall Assessment, Risk Identification and Management Policy, dated 3/20/2012, documents it is the policy of the facility to assess each resident's fall risk on admission. The Policy documents all staff providing care to the resident will have access to the care plan and interventions.