Every finding on record at Taylorville Care Center

Based on observation, interview and record review the facility failed to follow physician's orders for one (R2) of 4 sampled residents reviewed for wound treatment.Findings include:R2's Undated Face Sheet documents he was initially admitted to the facility on [DATE] and has diagnoses including: cellulitis of right lower extremity, edema, disorder of the skin and subcutaneous tissue and heart failure. R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents he is cognitively intact and has one venous/arterial ulcer present. R2's Physician's Order Sheet (POS) dated 4/1/2026 right lower extremity (inner calf) cleanse with wound cleanser, apply gentamycin sulfate 0.1% ointment with calcium alginate with silver to bed of wound then cover with large border gauze daily and PRN (when needed) for soiling/dislodgement. Apply ace wrap during day upon rising. R2's Care Plan addresses skin breakdown on right lower extremity but doesn't address the physician's order to ace wrap it. On 4/14/2026 at 3:07 PM R2 was observed sitting up in wheelchair in his room. R2's right lower extremity was wrapped with an ace bandage. R2 stated he has a venous ulcer on the back of his right calf and his right foot that he has dealt with for a long time and staff do his treatment on it daily but they don't always ace wrap his right lower leg as they should, he tells the nurse to but they don't listen to him. On 4/15/2026 at 9:00 AM R2 was observed sitting up in his wheelchair in the dining room. R2 stated the nurse already did his wound treatments this morning 5 hours ago. R2 showed his right lower extremity didn't have an ace bandage on and shrugged his shoulders and stated the nurse didn't put it on. On 4/17/2026 at 8:10 AM V9, Licensed Practical Nurse (LPN) stated she administered treatment to R2's right lower extremity early in the morning on 4/15/2026 and she forgot to apply the ace wrap then she remembered and she got side tracked taking care of other residents and forgot to apply the physician ordered ace wrap. On 4/15/2026 at 9:20 AM V2, ADON stated R2 has chronic venous ulcers on his right lower extremity, and he refuses to elevate his lower extremities to reduce the edema. V3 stated R2 is assessed by a wound physician weekly and he ordered R2's right lower extremity to be ace wrapped after wound treatment to reduce edema. V3 stated she didn't know why the nurse didn't apply the ace wrap to R2's right lower extremity. V3 stated she expected staff to follow all physician's orders including to apply ace wraps and she also expects staff to be following the facility wound policy. The Facility's Wound Management Program revised, 1/20/2023 documents it is the policy of (facility) to manage resident skin integrity through prevention, assessment, implementation and evaluation of interventions. Physician orders should be obtained and followed for each resident.

Failures at this level required more than one deficient practice statement. A-Based on observation, interview and record review the facility failed to provide supervision and ensure residents at high risk for elopement were not able to leave the facility without the facility being aware the resident has left for one of five residents (R4) reviewed for elopement in the sample of 13. This failure resulted in R4 eloping from the facility on 7/25/2025. R4 was observed wandering in a ditch and found by a community member not affiliated with the nursing home. This community member contacted the assisted living facility who in turn notified the facility and asked if a resident was missing. The facility was unaware that (R4) had eloped. Due to R4's poor safety awareness, poor judgement, and need for ongoing supervision, this failure could result in serious harm, serious injury, impairment and/or death. This past non-compliance occurred from 7/25/25 through 7/28/2025. B. Based on observation, interview and record review the facility failed to ensure equipment was in proper working order during transfers for 2 of 3 residents (R1 and R2) reviewed for mechanical transfers in the sample of 13. This failure resulted in R1 and R2 both being transferred with a mechanical lift and the slings ripped causing both residents to fall. Both residents were sent to the hospital. R2 substantiated a hairline fracture to her pelvis, black eye, bruised forehead and cheek, and required two sutures. R1 sustained three skin tears to his left arm with discoloration.Findings include: a. The Immediate Jeopardy began on 7/25/2025 when R4 eloped from the facility at around 4:15 PM. R4 was observed wandering in a ditch and found by a community member not affiliated with the nursing home. This community member contacted the assisted living facility who in turn notified the facility and asked if a resident was missing. The facility was unaware that (R4) had eloped from the facility. The facility was notified of the Immediate Jeopardy on 1/28/26. The surveyor confirmed by observation, interview, and record review, that the immediacy was removed, and the deficient practice was corrected, on 7/28/2025. On 1/29/2026 during this survey the door alarm, went off on ten times form 9:30 AM to 1:30 PM. The door alarm went off at 9:39 AM, 10:03, 10;11 AM, 10:18 AM, 10:23 AM, 12:06 PM, 12:11 PM, 12;23 PM, 12:45 PM, and 1:11 PM. On 1/15/2026 at 1:51 PM, V1, Administrator stated, We did have an elopement back in July. (R4) got out of the building. R4's Photo is in the green book at the nurse's station document, Elopement Book and was identified by the Facility as an elopement risk. R4's Physician Order Sheet (POS) for July 2025 documents a diagnosis of Unspecified Dementia w/o (without) behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Unspecified Dementia with/Agitation, Depression, Metabolic Encephalopathy and Hypotension. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has a wander/elopement alarm that is used daily. R4 was severely impaired for cognition for activities of daily living. R4 is independent with ambulation and requires minimal assistance with care. R4's Care Plan edited on 11/26/2025 documents, Resident is at risk for injuries d/t (related to) exit seeking behaviors: attempts to exit the building unattended: Resident had an elopement on 7/25/25. Problem Start Date: 05/03/2024 Behavioral Symptoms: exhibit wandering/exit seeking behaviors and at risk for elopement. I currently have a (wander management system) on. I am known for packing my things and attempting to leave the building. Long Term Goal Target Date of 2/28/2026 documents, I will be free from wandering through next review date. R4's Elopement assessment dated [DATE] documents R4 is ambulatory of independent in wheelchair location, resident is cognitively impaired, poor decision-making skills, and or pertinent diagnosis. Has a history of wandering unto unsafe areas and has a (wander management system). Resident is at risk for elopement. R4's Progress Notes dated 7/25/2025 at 4:30 PM, Residents POA (Power of Attorney) and MD (Medical Doctor) notified of resident leaving the facility, safely returned to facility via a caregiver vehicle. Residents VS (vital signs) WNL (within normal limits). Skin checks negative for any new skin disruptions of baselines,(wander management system) checked for effectiveness. (Care giver was not from the facility but rather was from the assisted living facility). On 1/15/2026 at 1:02 PM, V17, Certified Nursing Assistant (CNA) stated, (R4) got out of the facility a while ago. I can't tell you how long she was gone or how she got out of the building. I know she did not have any injuries when she returned. The assisted living next to us notified us that someone was walking around and we found it to be (R4). We did not know (R4) had gotten out. I can't tell you how she got out and/or how long she was gone. The alarms did go off earlier and we did a head count and (R4) was there. I don't remember why the alarms were going off and I don't remember them going off again. We got a call from the (assisted living) asking us if a resident got out and that's when we found out (R4) had gotten out. I do not remember any resident telling me (R4) had gotten out of the door. Statement by V17, dated 7/25/2025 documents, I took two residents out for their smoke break. These two residents starting telling me that another resident was pushing on their wheelchair to try and get out the door. After I found out a resident had gotten out the door the two residents told me she had gotten out the door. (This statement does not document the names of the residents.) Statement by V22, Assisted Living Staff documents, A man came to the front desk (assisted living) to tell me there was a lady that just went through the ditch in front of the parking lot. He was worried she came from our building. I came outside to see her walking down the road. I got into my truck to get to her she was on the side of the road, and she didn't know where she was, or her name. I put her in my truck and took her to (assisted living) to see if we could find out. Called (Facility), they came over the (assisted living) to see if she belonged to their building. She did so I drove her over to the (Facility). She was closer to the front door to drop her off. On 1/16/2026 at 10:31 AM, V22 stated, I remember the day I found the resident from the (facility). It was a very hot day and originally when I was notified by a man, I do not know his name, but he stopped by here because he said he was worried because there was a woman who looked confused that was in the ditch I thought it was one of our residents. I got in my truck because I could see the resident walking down the road. When I approached her, she was very confused, and she did not know her name, and I was worried that she got overheated. I could not tell you how long she had been outside, but she looked pale as if she had been outside for some time. I brought her back here and gave her some water to try and cool her down, and I knew she was not one of our residents, so I called the (facility) to see if they were missing any residents. At that time, they were not aware of any residents that were missing. Some of their staff came over her and identified her as being their resident. So I took her in my truck back to the (Facility). Investigation Notes from R4's elopement on 7/25/2025 documents, (V18, Family of R6) stated (R4) did not follow behind them when they went outside. Residents (R8) and (R9) over sitting inside by smoker door and (R4) kept trying to push them out the door; they asked her to stop. (V17) took smokers out at around 4:15 PM. On 1/27/2026 at 12:52 AM, R8 stated she remembers (R4) was trying to push her and go outside but she is not supposed to go outside. She told the nurse. She does not remember (R4) ever going outside or seeing her leave through the gate by the gazebo by herself. She found out later (R4) got out, but this was when it was hot outside, but she did not see her get out and if she would have, she would have told somebody. Statement from R8 dated 7/26/2025 documents, (R9) and I were seated at patio door waiting to go outside. (R4) was trying to push (R9's) WC (wheelchair) out of the way and through the door. I went to get (V19, Licensed Practical Nurse). She came and removed (R4) from the area. We were taken out then to smoke. I did see (R4) come through the door to the outside but not after that. Statement from R9 dated 7/28/2025 documents, She did push me out the door a little. The door alarm sounded. The nurse hollered and said 'you can't go out.' The nurse brought her away. Did not see (R4) go out the door into the courtyard. Did not see (R4) in the courtyard while smoking. (V7), (R8) and myself were outside. On 1/27/2026 at 11:09 AM, R9 stated, I remember (R4) because she does not look like she is strong enough to push you, but she does have some strength. This was in the summer I believe. (R4) kept trying to push me and (R8) because she was trying to get outside. I went and got the nurse because I know she is not supposed to go outside without any staff. I never saw her go outside. I heard later she had gotten out, but I am not sure how she got out. Statement from V21, Former Assistant Director of Nursing (ADON) dated 7/25/2025 documents, (V7, CNA) the CNA was sitting at the nurse station when I walked by during med (medication) pass and said that someone called from the (assisted living) said they may have one of our residents. We have to go over there right now. (V7) and I immediately went through the patio door and over to the (assisted living). We saw (R4) in a truck with one of the staff from (assisted living). Staff from the (assisted living) said she walked over there, and they put her in their truck and called us. (V7) and I came back and met them at the front door and assisted (R4) to building. On 1/27/2026 at 12:31 PM, V21, Former Assistant Director of Nursing (ADON) stated, I remember when (R4) got out. This was back in the summer. I was on the C hall passing out my medications. The door alarm was sounding, and I went to the front desk to see what was happening. The door alarm will go off if the red button is not pushed before opening the door. Anytime we do not know what set off the alarm and or who went out we are supposed to do a head count. I know the DON was working the A hall and I was working the C hall and all of my residents were present. I did a head count and everyone on my hall was there. Later on, we got a call from the (assisted living) and they said they may have one of our residents. (V7) and I went over there, and it was (R4). We had done a head count earlier and nobody was missing. We are not sure how (R4) got out and I am not sure if anyone knew if she had gotten out. R4's Investigation Report dated 7/28/2025 documents. Administrator & Social Service Director spoke with (V18, Family member of R6) whose husband is here at the facility. She visits daily and often takes (R6 out to the patio area to visit. Staff reports that (V18) does know the code to the patio door and she can recite that to us during our conversation. (V18) stated that she is uncertain whether (R4) came out of the patio door when she was assisting her husband out to the patio. She believes that she wouldn't have let her out but is unsure. Family and staff report that (V18) does have memory loss and becomes more confused throughout the day. Side note in different handwriting documents (wander management system) going off on return to building. On 1/27/2026 at 12:47 PM, V18, Family member of R6 stated, I know back when it was warm they were asking me questions about if I had ever let anyone out. I think someone got out that was not supposed to get out. When it is warm, which is not now (R6) likes to go outside and sit by the gazebo. I would take him out and we would sit outside together. I did know the code and would take (R6) out. I never let anyone else go out with us or open the door for any resident. Sometimes there would be residents already outside smoking. I never saw any resident leave the area without staff and or leave through the gate. Statement from V13 (Certified Nursing Assistant, CNA) and V24 (CNA) documents, were on C wing when the alarm went off around 4:30 PM, Said they needed a head count on all the halls, were clear on the C wing, come to find out a resident on the A hall had gotten out. On 1/27/2026 at 2:58 PM, V13 stated, It has been some time since R4 got out. I remember a door alarm went off and I did a head count and all of my residents were here. If someone gets out the front door or the side door the alarms will go off with a (wander management system) and on the door it is supposed to always go off. I know (R4) got out and nobody knew how she got out. On 1/29/2026 at 10:25 AM, V19, Licensed Practical Nurse (LPN) stated, I remember vaguely when (R4) got out. I know earlier (R8) and (R9) were complaining about (R4) trying to push them in their wheelchair so I went and got (R4) and took her back to her room. There was a lot of stuff happening that day. I was looking for a kitchen employee. I remember the door alarms going off and doing a head county. Everyone on my hall was present. Then later when I was looking for the kitchen staff, I saw a truck pull up and drop off (R4). She had left the building, and nobody knew she was missing. V19's Statement dated 7/25/2025 documents, I (V19) walked out deliver door near kitchen, and was walking around the facility looking for an employee. When I was walking up the front door a pickup truck pulled up with resident in her front seat. I assisted resident out of the vehicle and into the building. I looked over her resident body/skin Vitals etc, gave drink of water. When assisting resident into front door (wander management system) started to alarm. Resident was in place to ankle. Write up by V1 documents, Approx 4pm: (V19) Licensed Practical Nurse (LPN) states she was in bathroom and heard front door alarm sounding. She went to the door and could not see anyone. She left alarm sounding and went out the door, checking perimeter to ensure no resident was outside. She did not determine why alarm was sounding and directed staff to start a 'head count' per policy. The (Weather History & Data Archive) website documents outside temperature on 7/25/2025 at 3:52 PM, 89 degrees Fahrenheit (F), and at 4:52 PM 89.0 F for the town where the Facility is located. 1/27/2026 at 1:34, V8, Medical Director stated, his expectation are residents with wandering tendencies should be monitored/supervised; exit doors for (wander management system) on residents should alarm and prevent unnoticed departures. Risk: Exposure to 89 F could cause dehydration, confusion, and possible harm or injury. The Facility Missing Resident Policy with a revision date of November 2017 documents, It is the policy of (Facility) that reasonable precautions are taken to minimize the risks of resident elopement attempts. Reasonable precautions include, but are not limited to: door alarms, personal door alarm activation devices, staff intervention, staff education regarding response to door alarms, and individual resident intervention. It is the policy (Facility) to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the event that a resident is deemed missing. Maintenance to check operations of all facility door alarms daily when on duty. Nurses to check door alarms each shift. Key pad coded door codes will be changed as needed by maintenance Kitchen door and all other hazardous doors are to be closed and locked at all times when staff not present. Staff to be in-serviced at orientation on door alarm policy and procedure. All alarms will be set at all times.Immediate response from staff when alarms are activated to secure situation and reset alarm. Once an alarm is signaled and if there is no witnessed cause of the signal, a resident search will be conducted. Each charge nurse is responsible to assure each resident is accounted for. All staff must respond and identify all residents. Once all residents are accounted for an all-clear announcement will be made. Should a resident be identified as missing, the policy and procedure for missing resident is initiated. The Immediate Jeopardy that began on 7/25/2025 was corrected/removed on 7/28/2025 after the facility took the following actions to correct the noncompliance prior to the start of current survey: Resident returned to facility safely, skin assessment and vital signs completed upon. Resident placed on 15-minute checks, (wander management system) checked for proper functioning, code to patio door changed, and all door alarms checked for proper functioning. 7/25/2025. All residents could be affected by deficient practice. Measures put in place include staff education re: elopement policy, DON/ADON to audit (wander management system) on MAR (Medical Administration Records /TAR (Treatment Administration Records 5x/week x 3 weeks and monthly x 3 months. R3, R4, R10, R11, and R12's Care Plan, Elopement Assessments, MAR and TAR were all reviewed and document they were being checked and documented. Audits were being completed as described with no issues, Code yellow book reviewed by SSD (Social Service Director) to ensure completeness. Care plans for residents at risk for elopement reviewed and updated as needed. Code yellow drills performed weekly x 4 weeks on each shift. Administrator to review audits to ensure compliance. Trends reported to QA (Quality Assurance) committee review with any identified deficiencies to have further corrective action implemented as needed. Completed on 7/26/2025. Code Yellow book was located at the nurse's station and all residents identified as high risk for elopement photo was in the book and a description of the residents was present in the book. Book was reviewed on 1/29/2026. Inservice dated 7/28/25 documents all staff were in-serviced by V1 re: resident supervision, redirecting exit seeking residents, alarms response, no sharing of door codes with non-staff members. 58 signatures. Additional 6 names of new employees starting after 7/28/25 were documented as receiving the training before working on the floor. All staff working on 1/29/2026 were verified as receiving the trainings. This task was documented as being completed on 7/28/2025. b. 1- On 1/13/2025 at 11:28 AM, R2 was in the dining room sitting in her wheelchair. R2 has a yellowish purple faded bruise to her right forehead the size of medium size apple, a black faded yellow, purple bruise black eye to her right eye and band aid covering a small yellowish purple bruise that is exposed around the band-aid on her right cheek. R2's Physician Order Sheet for January 2026 documents a diagnosis of Paraplegia, unspecified; anxiety disorder, unspecified; Congenital hydronephrosis; Disorder of the skin and subcutaneous tissue, unspecified Irritable bowel syndrome, unspecified; Other neuromuscular dysfunction of bladder Note: neurogenic bladder; Scoliosis, unspecified; Spina bifida, unspecified Morbid (severe) obesity due to excess calories; Body mass index [BMI]40.0-44.9, adult. R2's Vitals dated 1/7/2026 documents R2 weighed 190.0 pounds, and her BMI (body mass index) was 45.08. Manufacturer directions for the mechanical sling documents this is within the guidelines for a safe transfer. R2's Minimum Data Set (MDS) MDS dated [DATE] document R2 was cognitively intact for decision making of activities of daily living. R2 has no impairment on her upper or lower extremities, she uses a wheelchair and is dependent on staff for chair/bed transfer: the ability to transfer to and from a bed to chair (or wheelchair) in which staff completed all the activities for the resident for transfers. R2's Care Plan Category under Pain with a created date of 1/10/2026 documents, Resident has pain/risk for pain related to recent pelvic fracture/chronic right hip dislocation following a fall. Under ADL's (Activities of Daily Living) Functions and dated 1/09/2026: Staff to ensure to utilize a mesh shower sling when transferring resident after a shower. Resident has bilateral lower extremity paraplegia from the waist down and requires a (mechanical Lift) for transfers. On 1/13/2025 at 2:00 PM, R2 stated, I was born with scoliosis and spina bifida. I have never been able to walk. They have to use a (mechanical lift) to transfer me. There is a sling on the machine, and something was wrong with the sling because it broke when they were moving me, and I fell from the air and fractured my pelvis. (V1, Administrator) came and told me she would investigate, and she said (V14, Laundry Supervisor) does inspections on the slings. I saw a picture of the sling and it was broken on one side on both the top and bottom. How could both sides break at the same time if there was not something wrong? They were transferring me from my shower chair back to my bed that day. There were two CNA's present in the room. I weigh around 195 pounds. When I was up in the air for about a minute the sling snapped and down I went. (V6) caught my head otherwise I am not sure what would have happened if I had hit my head. I have two stitches in my check and the bruising on my face and the fracture of my pelvis. I am afraid to be transferred now, and I know I need to get up and down. It's scary because it should have never happened to begin with. There was another man on my hall (R1) and he was being transferred and the sling broke on him too. This was about six months ago. Allegedly they got rid of all of those slings and got new ones. But, then why did it break again on me? I don't want anyone else to get hurt either. R2's Progress Notes dated 1/9/2026 at 4:45 PM, This writer was down A wing starting med pass when staff was heard yelling someone come quick, hurry. This writer began going to the yelling voices. A visitor of another resident pointed this writer down C wing. Upon coming to this resident's room, CNA (Certified Nursing Assistant) (V6) was on the floor with this resident, holding a towel to residents right side of her face. CNA (V7) was standing by resident's head talking to resident. Residents' legs were partially under her bed, with her right leg on top of the right leg of the (mechanical Lift), her left shoulder blade on top of the left leg of the (mechanical Lift), and the sling that had been under this resident for transfer was snapped and was hanging from the (mechanical) lift. This writer noted large amount of blood and yelled up the hall for someone to call 911. This writer, and CNAs (V6) and (V7) stayed with resident. Staff was able to safely remove the (mechanical lift) out from under the resident. A pillow was placed under resident's head, all the while pressure maintained to resident's right face. Resident alert and oriented x4, complains of pain to the right side of her face. Noted resident's right eye and area surrounding where pressure being applied to already be discolored. ROM (range of motion) WNL (within normal limits) for this resident. Resident stated to both the CNAs and this writer that she was ok. Resident continued to talk with staff. Call placed to residents POA (power of attorney) to notify of incident and of resident being transferred, and a call placed to (V5, MDS Coordinator) and on call manager to come to the facility for this incident. Upon EMS arrival, resident was placed on a lift blanket and transferred from the floor to the stretcher via EMS (Emergency Medical service) personnel. EMS pulled the towel back from resident's face and revealed what appeared to be a puncture/laceration to right cheek. Resident was able to communicate with EMS, who began conducting a more thorough cognitive exam. Resident left facility to go to (Emergency Room) at approximately 5pm. (V8, Medical Doctor) was notified as well as (DON).On 1/13/2026 at 2:28 AM, V7, CNA stated, I was working the day (R2) fell from the (mechanical lift). (V6, CNA) came and got me and asked me to help transfer (R2). (R2) had just came back from the shower. Her sling was underneath her. We were transferring her from the shower chair to her bed. I was at the foot of her bed and (V6) was at the head. Once (R2) was in the air (R2) was crooked and I went to swing her around and the straps just snapped and (R2) fell. It happened so quickly. We did not pull on the straps or test them beforehand because the sling it was already underneath (R2).Statement dated 1/13/2026 from V7 documents, On 1/9/2026 I was helping (V6) transfer (R2) with the (mechanical lift) to her bed after her shower. Hooked her up (V6) guided her front, I was at the foot of the bed guiding her feet when the sling broke making her fall to the right side of her head, she was bleeding, (V6) kept pressure to her head as she landed hitting the (mechanical lift) legs. I could not get around to help. I yelled for a nurse like 'Now' (V4) came to assess the fall then yelled someone call 911. Then (V4) and I pulled the (mechanical lift) out from her. (R2) was talking to us the whole time. 911 arrived and took over.On 1/14/2026 at 1:34 PM, V6, CNA stated, (R2) was in the shower chair and normally after her showers (R2) likes to go to bed. After her shower I got (V7) CNA, and we hooked up (R2), and the straps were on correctly, but when she was in the air the stitching on the loops came undone and (R2) went down. It happened so fast, and I grabbed her head as she was falling and (R2) hit her face on the base of the (mechanical lift) and it started bleeding. I yelled for help and (V4) arrived and I put a pillow behind (R2's) head and kept pressure on her face/cheek until the EMS arrived. I did not inspect the sling that morning because it was already underneath (R2). Normally, laundry inspects the slings after they are washed, and they inspect and document. I personally only experienced issues with the sling breaking with (R2) but I am aware of (R1's) sling also breaking during a transfer. This was a regular sling underneath (R2).R2's Initial Report dated 1/9/2026 (R2), a [AGE] year old female resident who resides at (Facility) with a history of paraplegia due to spina bifida, scoliosis depression, anxiety. Due to diagnosis, resident requires total assist from staff via (mechanical lift) for transferring. At approximately, 4:45 PM, on Friday, January 9, 2026, resident was given a shower, following the shower, 2 staff CNA's were transferring resident back to bed from the shower chair using the (mechanical lift) in resident's room. During the transfer, the (mechanical lift) sling loops came unattached, causing (R2) to fall, CNA was able to protect head from striking the floor. The CNA in room yelled for help from other staff and immediately held pressure to (R2's) right side of face where there apparated to be a laceration. Nurse (V4, LPN) immediately arrived to room to assess. (R2) remained conscious, alert and orientated, vital signs remained stable. EMS (emergency Medical Services) was called, staff remained with resident until arrival of EMT's (emergency medical team). Resident was taken to hospital for evaluation. Resident's son was notified of incident at this time as well and PCP (Primary Care Provider). Facility later received phone call from ED (emergency department) for evaluation. R2's Hospital Records dated 1/9/206 at 5:10 PM, documents, chief complaint: Fall. Location of injuries right cheek, right periorbital area and head. Occurred at nursing home. Occurred 4:50 PM on 1/9/2026. Pt (patient) arrives per EMS (Emergency Medical Services), States the strap of the (mechanical lift) broke and patient fell face first. Patients face hit the base of the (mechanical lift). Pt (Patient) has pain to right side of face. Pt has bruising and swelling under R (right) eye. Pt has a small lac (laceration) on R (right) cheek. R2's Radiology Report dated 1/9/2026 documents, Acute nondisplaced fracture through the anterior right ilia wing. b. 2 - R1's POS documents a diagnosis of Unspecified dementia, mild, with mood disturbance; Constipation, unspecified; Pressure ulcer of left heel, unstageable; Laceration without foreign body of left upper arm, initial encounter; Generalized anxiety disorder; Depression; and Pain.R1's MDS dated [DATE] document R1 was severely impaired for cognition for activities of daily living. R1 has no impairments and uses a wheelchair and is dependent on staff for chair/bed transfer: the ability to transfer to and from a bed to chair (or wheelchair). Dependent: A helper completed all the activities for the resident.R1's Medical Records document R1 is currently on hospice.R1's Care Plan: Under Falls: Resident is at risk for falls due to: age related comorbidities. Start date 3/30/2024. Problem: I am cognitively impaired due to: Dementia, BIMS (Brief Interview for Mental Status) score previously was staff and remains staff due to nonsensical answers which is severely impaired.R1's Progress Notes dated 7/31/2025 at 11:02 AM, Resident was being transferred by CNA (certified nursing assistant) & this nurse from his bed to the wheelchair to get up for lunch. Resident was in sling and properly fitted in, sling straps and hooks were intact with no noted fraying or breaks. When CNA lowered sling down to place in wheelchair the sling straps to the left side straps part of the sling snapped, dumping resident backwards. This nurse assisted resident to the floor breaking the fall by easing resident to floor as the right-side straps part of the sling and hooks were still intact on the lift. Resident did not hit his head, has no c/o pain, alert, orientated to baseline. Resident has 3 skin tears to the left arm and discoloration. Resident has a red spot to the left cheek where he bumped this nurse's knee when going down. Pillow placed under resident's head and sheet under arm to stop bleeding. EMS (Emergency Medical Service) called and they assisted resident to stretcher with a blanket sling. Resident has been sent to (Hospital) for an evaluation. POA (Power of Attorney) & MD (Medical Doctor) has been notified. R1's Progress Notes dated 7/31/2025 at 11:14 AM, Writer called to resident room and found resident on the floor. ADON (Assisted Director of Nursing) and CNA were getting resident up for lunch and using (mechanical lift) and sling broke causing resident to go to the floor. Resident skin tear on left arm resident also c/o (complained of) shoulder pain. Writer called 911 and also contacted son and left message. Ambulance here and transferred resident to (hospital) for evaluation. DON (Director of Nursing) and administrator aware of resident on floor.On 1/15/2025 at 10:07 AM, V2, Director of Nursing stated, When (R1) fell during his transfer I was not working as the Director of Nursing. I only know there was something with the sling. I don't remember anything else and was not part of the management team at that time.On 1/13/2026 at 2:32 PM, V9, Licensed Practical Nurse stated, I was not working when (R2) fell but I was working awhile back when they were transferring (R1) and his (mechanical lift) strap broke and he fell but he was okay. The strap broke and he fell.Employee Witness Statement by V11, CNA dated 7/31/2025 documents, (V21, ADON) and myself were transferring (R1) to his w/c (wheelchair) with the (mechanical lift) when 2 of the straps on the (mechanical lift) sling snapped and he landed on the floor fell mostly on his shoulder. On 1/14/2026 at 10:39 AM, V14, Laundry Supervisor stated, We in laundry are supposed to inspect every sling and throw away any sling that is damaged. I know we were not documenting in the log like we were supposed to and I did get written up for it. I guess it broke again and somebody fell during a (mechanical lift because the sling broke). I work five days a week. On 1/29/2026 at 1:33 PM, V1, Administrator stated (R1) did fall during a transfer and the sling broke. After (R1) fell from his sling we checked with laundry to make sure they were inspecting the slings, not using bleach on them and that they everyday they are supposed to check the slings, throw them out if they are damaged and document the sling condition. After (R2) fell we re-educated laundry again. No other interventions were put in place expect in-serving staff. The lift was a Invacare reliant 450.The (Mechanical Lift) Manufacture Instructions documents, Bleached, torn, cut, frayed, or broken slings[TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for one of three residents (R2) reviewed for abuse in the sample of three. Findings include:1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and nicotine dependence.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired and ambulated via wheelchair and walker.R1's Care Plan initiated 9/25/25 documents, Inappropriate sexual behavior - resident touched another female resident's genital area.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including malignant carcinoid tumor of the bronchus and lung.R2's MDS dated [DATE] documented R2 was moderately cognitively impaired and ambulated via wheelchair and walker.R2's Care Plan initiated 8/21/25 documents R2 is at risk for abuse and neglect per assessment.The Facility's Initial Report sent to Illinois Department of Public Health (IDPH) on 9/20/25 documents a nurse walked by R1 and R2 while they were waiting to go outside to smoke and observed inappropriate touching by R1.On 10/8/25 at 11:30 AM, V1, Administrator, stated she was on vacation when the allegation of R1 touching R2 was made, so the corporate office filed the report.On 10/8/25 at 11:40 AM, V5, Regional Director of Operations, stated V3, Assistant Director of Nursing (ADON), reported to her that there was a resident-to-resident sexual encounter between R1 and R2 while V1 was on vacation. V5, Licensed Practical Nurse (LPN), reported it, and the staff investigated. V5 was walking by while residents were waiting to go out and there was inappropriate touching of R2 by R1. Apparently the touching was outside of the pants and R2 did not mind, but with their cognition levels V5 told the Facility to separate them with one on one observation until V1 came back and a long term plan could be developed. V5 stated the touching in that area was still inappropriate, and if the residents wanted to pursue a consensual relationship the facility would have to go through the proper steps.The Facility's 9/20/25 Written Statement by V4, Licensed Practical Nurse (LPN), documents, At 4 PM this writer was walking to the bathroom through the DR (Dining Room) where I saw (R2) and (R1) sitting very close together near the patio door. Writer approached them and I saw that (R1) had his right hand in between (R2)'s legs and was rubbing her genital area. She (R2) was allowing him (R1) to do so; she (R2) voiced no opposition. Writer advised (R1) to keep his hands to himself; (R1) verbalized understanding. Writer brought (R2) to the nurse's station for closer observation while I called the nurse on call, (V3). Both res (residents) were placed on q (every) 15 min (minute) checks. (V3) is notifying appropriate parties. Skin check completed.On 10/8/25 at 1:35 PM, V4 stated she was walking through the dining room and R1 and R2 were sitting very, very close together, so she wondered what was going on. R1 had his right hand between R2's legs outside her pants and was playing with her genital area. V4 believes it was consensual, but inappropriate for them to be doing that in the dining room in front of everyone.R1's Progress Note by V3 on 9/20/25 at 5:31 PM documents V4 reported to V3 that R1 was seen sitting next to the door to the patio gazebo area waiting to smoke. R1 was sitting next to R2 and was allegedly seen with his hands inside R2's pants and inappropriately touching her private parts.On 10/8/25 at 1:20 PM, V3 stated she was on call when V4 reported the allegation between R1 and R2. V4 told her she walked through the dining room and saw R1 and R2 sitting in the smoking area. R1 had his hands on the inside of R2's pants.R1's Progress Note by V2, Director of Nursing (DON) on 9/22/25 at 5:00 PM documents V2 followed up and further investigated situation from 9/20/25. V4 witnessed and stated R1's hand was outside R2's pants touching the genital area. R2 did not remember what happened, but after a few questions, V2 asked R2 if she was ok with what had happened. R2 smiled and said, Ya! R1 stated, The lady said to cut it out and We were hugging and touching around too much. R1 remembered what had happened. This was a mutually wanted act. R1 and R2 have been noticed talking to each other more recently and holding hands a few times.On 10/8/25 at 2:47 PM, V2 stated she was on vacation when this allegation took place. R1 and R2 had been talking and going out to smoke together. V4 stated she saw R1 with his hand between R2's legs near the smoker's door. V2 thinks R1 and R2 have the capacity to consent, but both have confusion at times. When R2 was interviewed, she smiled and said what happened was ok. R1 was embarrassed and said they were maybe touching around a little too much and the nurse told him to cut it out.The Facility's Final IDPH Report dated 9/26/25 documents an investigation was conducted, and two residents were involved in altercation of inappropriate behavior. R1 rubbed genital area outside of R2's clothing. On 10/8/25at 1:10 PM, V1 stated she does not think the facility has a policy on consensual relationships and was not sure how that process would work.On 10/9/25 at 9:45 AM, V1 stated she expects the Facility to follow its abuse policy.The Facility's Abuse Prevention Program Policy revised 10/29/22 documents sexual abuse is non-consensual sexual contact of any type. Residents have the right to engage in consensual sexual activity. If the facility has reason to suspect the resident does not have the capacity for consent, the facility must take steps to ensure the resident is protected from abuse and must evaluate the resident's capacity for consent.

Based on observation, interview and record review, the Facility failed to employ a Director of Food and Nutrition. This has the potential to affect all 67 residents living in the Facility. Findings include: On 8/12/25 at 9:00 AM, during the initial kitchen inspection, there was no dietary manager in the Facility.On 8/12/25 at 9:08 AM, V7, Cook, stated she was unsure whether the Facility has a dietary manager and suggested checking with V1, Administrator.On 8/12/25 at 9:16 AM, V1 stated the previous dietary manager recently quit without notice, and they do not currently have a dietary manager.On 8/12/25 at 2:20 PM, V6, Dietary Aid, and V7 were working alone in the kitchen. They stated they have not had any supervision by management today.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated he visits the Facility three times a month and has not been asked to perform any additional duties since they have been without a dietary manager.From 8/12/25-8/15/25, no certified dietary manager was observed in the Facility.On 8/15/25 at 9:16 AM, V1 stated she expects the facility to follow its food service policies.The Facility's Undated Structure and Organization Policy documents, A qualified food service manager supervises the daily functions of the Food and Nutrition Services Department. The food service manager is a full-time person, qualified by training and experience. This person is responsible for the daily planning; food procurement, storage, preparation, distribution and service of food under safety and sanitation conditions; as well as the supervision, training, and scheduling of the kitchen staff.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility.

Based on observation, interview and record review, the Facility failed to follow its facility approved menu. This has the potential to affect all 67 residents living in the Facility.Findings include:The Facility's Weekly Menu documents the following will be served for lunch on 8/14/25: cornflake chicken thigh, hashbrown casserole, whole baby carrots, roll, dessert, and beverages.On 8/14/25 at 12:50 PM, V10, Medical Records, was serving lunch from the steam table in the kitchen. The items being served included fried chicken, baked potato, baked beans and a cookie.On 8/14/25 at 1:08 PM, V10 stated carrots were on the menu for both lunch and supper, so she decided they would just have the carrots tonight. She did not check with the Registered Dietitian (RD) to make sure menu changes were acceptable.On 8/15/25 at 8:50 AM, V25, RD, stated it is important to follow Facility menus, and the carrots should not have been omitted from the meal.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow dietary policies.The Facility's Menus and Food Preparation Policy revised December 2016 documents, Meals shall be prepared according to the facility approved menu. Changes to a menu or recipe based on geographic preferences or resident preferences shall be approved by the registered, licensed dietitian to the residents.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility.

Based on observation, interview, and record review, the Facility failed to provide meals at scheduled times and offer snacks, including at bed time. This has the potential to affect all 67 residents living in the Facility.Findings include: On 8/13/25 at 9:00 AM, during the Resident Council group meeting, R4, R24, R45, and R46 all stated the Facility has not been providing snacks.On 8/13/25 at 11:58 AM, V6, Dietary Aid, stated he does not know anything about snacks and has never passed them out before.On 8/13/25 at 12:04 PM, V13, Certified Nursing Assistant (CNA), stated dietary should be bringing a snack cart to the nurse's station, but it has not been done for the past month or so.On 8/13/25 at 12:07 PM, V12, CNA, stated snacks are not being passed in the Facility. She stated they used to take a cart with snacks and drinks to offer to each resident, but they do not do that anymore.The Facility's Meal Times documents breakfast is served at 7:00 AM, lunch is served at 12:00 PM, and dinner is served at 5:00 PM daily.On 8/12/25 at 1:12 PM, the last resident tray was served. V7, Cook, stated they are usually done serving earlier, but the deviled eggs took longer to make.On 8/13/25 at 1:20 PM, V1, Administrator, stated all residents should receive a lunch meal by 12:30 PM.On 8/14/25 at 1:08 PM, the last resident lunch tray was served.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated evening snacks should be offered to residents, especially residents with diabetes, to ensure they do not go too long without eating.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow the Facility's dietary policies.The Facility's Meal Service & Snack Times Policy revised December 2016 documents, Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. An H.S. (bedtime) snack shall be provided by Dietary and offered to the residents by nursing. Additional snacks shall be provided between meals as ordered by the physician or per resident's request. The Dietary Department shall be responsible for food preparation for all meals and snacks. Snacks shall be provided at: 10 a.m., 2:30 p.m., and 7:00p.m. Dietary shall deliver nourishments to the nursing units. Nursing shall be responsible for distribution of snacks.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility.

Based on observation, interview and record review, the Facility failed to ensure foods were stored and prepared in a manner that prevents foodborne illness. This has the potential to affect all 67 residents living in the Facility.Findings include:On 8/12/25 at 9:00 AM, V6, Dietary Aid, was unloading clean dishes that had just run through the dish machine and putting them away on shelves. V6 dropped a plastic cup on the floor, picked it up, and put it back in the crate containing clean dishes. V6 continued to unload dishes until all glassware was placed on shelves. V6 stated he did not know what happened to the cup that fell on the floor. V6 stated dietary staff do not have to check sanitizer levels or temperatures on the dish machine. On 8/12/25 at 9:05 AM, in the dry storage room, there was a dented can of beef ravioli on a shelf with several other cans. V7, Cook, stated there is no separate place where dented cans are stored. On 8/12/25 at 9:08 AM, next to the three-compartment sink, there was a clear container with a white powdery substance inside. The container was not covered, labeled or dated, leaving the contents open to air. V6 stated the white powder is thickener.On 8/12/25 at 9:10 AM, in the standing freezer, there was a box of uncooked chicken tender fritters stored directly above boxes of cauliflower and roasted turkey breast. There was a box of bacon stored on the shelf directly above boxes of waffles and pancakes. V6 stated there is no specific location for storing uncooked meat, she just tries to separate it by breakfast, lunch and dinner.On 8/12/25 at 9:12 AM, in the walk-in refrigerator, there was a box of pasteurized shell eggs stored on a shelf directly above a box of 2% milk. There was a container labeled applesauce and 5/8. There was a pitcher half full of orange liquid with no label or date. On 8/12/25 at 1:12 PM, food temperatures were obtained from the steam table after the last resident tray was served using a metal calibrated thermometer. The ham salad measured 55 Fahrenheit (F). The pureed ham salad measured 68 F. The pureed deviled eggs measured 71 F.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated he is unsure if dietary staff have been checking the temperatures of food before serving, but the temperatures of the ham salad and eggs were not good due to potential for foodborne illness. He stated uncooked animal proteins should be stored on the lower level to reduce risk of contamination.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow dietary policies.The Facility's Undated Food Safety Requirements Policy documents, It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food.The Facility's Food and Supply Storage Policy revised January 2012 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Plastic containers with tight-fitting lids will be used for storing flour, sugar, bulk cereal, dried vegetables, etc. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. All foods will be covered, labeled, and dated.The Facility's Cleaning and Sanitation - General Policy revised January 2012 documents, Any utensil or dishware that falls on the floor before use will be washed, rinsed, and sanitized before it is used. Food will be maintained at proper internal temperatures. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility.

Based on interview, observation, and record review, the Facility failed to provide residents with palatable and safe temperature meals for 8 of 8 residents (R4, R20, R24, R27, R28, R43, R45, R46) reviewed for food and nutrition services in the sample of 33.Findings include: On 8/12/25 at 10:20 AM, R20 stated the food lacks flavor and is never at the right temperature.On 8/12/25 at 10:24 AM, R28 stated the Facility's food is just not good. It is always cold, and the toast is hard.On 8/12/25 at 10:40 AM, R43 stated the food quality could be better. On 8/12/25 at 10:50 AM, R27 stated the food is cold and tastes bad.On 8/13/25 at 9:00 AM, during the Resident Council group meeting, R4, R24, R45, and R46 all stated the kitchen and food quality have really gone downhill.On 8/12/25 at 1:12 PM, food temperatures were obtained with a metal calibrated thermometer after the last resident tray was served. The ham salad measured 55 Fahrenheit (F). The pureed ham salad measured 68 F. The pureed deviled eggs measured 71 F.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated the temperatures of the ham salad and deviled eggs were not good.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow food service policies.The Facility's Menus and Food Preparation Policy revised December 2016 documents, Food shall be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs. Food and drinks served shall be palatable, attractive and at a safe and appetizing temperature.

Based on observation, interview, and record review, the Facility failed to provide food in a form that meets individual needs for 4 of 4 residents (R9, R40, R44, R51) reviewed for food and nutrition services in the sample of 33.Findings include: On 8/14/25 at 1:08 PM, R40 was sitting in the dining room feeding himself lunch. There was a baked potato with the skin on his plate. He picked up the skin of the potato with his fingers and attempted to take a bite. V10, Medical Records, stated she just finished serving lunch, and the residents on mechanical soft diets received baked potatoes with skin.R40's Diet Order starting 12/13/24 documents regular, mechanical soft diet.R44's Diet Order starting 11/18/24 documents regular, mechanical soft diet.R51's Diet Order starting 7/16/25 documents no added salt, mechanical soft diet.R9's Diet Order starting 11/13/24 documents regular, mechanical soft diet. On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated mechanical soft diets should not have potato skins. He stated they could have mashed potatoes, diced potatoes, or potatoes with the skin removed, but residents on mechanical soft diets should not have the skins. On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow their dietary policies.The Facility's Consistency Modified Diets Policy revised December 2024 documents, The following diets are modified in texture to promote ease of chewing and swallowing. The mechanical soft diet is used for patients/residents with limited chewing ability, and vegetable options include canned vegetables, well-cooked, soft vegetables, and finely chopped fresh vegetables, as tolerated.The Facility's Menus and Food Preparation Policy revised December 2016 documents, Food shall be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs.

Based on interview and record review the facility failed to promote dignity and to treat residents in a respectful manner during care for 3 of 10 residents (R1, R2, and R4) reviewed for dignity in a sample of 10. Findings Include: R2's face sheet, print date of 4/30/25, documented R2 has diagnoses including flaccid hemiplegia affecting left dominant side and dysphasia following cerebral infarction, hypertension, hyperlipidemia, epilepsy, and arthritis. R2's MDS (Minimum Data Set), dated 3/22/25, documented R2 is cognitively intact, is dependent on a wheelchair and assistance for mobility, and is dependent on facility staff for hygiene needs including showers. R2's care plan, undated, documented category: psychosocial well-being, I am considered at risk for abuse/neglect per assessment with approaches including address all complaints/concerns promptly with grievance policy and procedure. Category ADLS (activities of daily living), resident needs limited to extensive assistance for activities of daily living related to CVA (cerebral vascular accident), flaccid on left side with approaches including transfer with assistance of 2 and a full body mechanical lift. R2's care plan also documented R2 is receiving restorative programs with goals to maintain present level of functioning. On 4/28/25 at 12:52 PM R2 stated he had an issue with a CNA (Certified Nurse Assistant) when she gave him a shower a few weeks ago. R2 stated the CNA used a hoist to transfer him onto the shower chair, the hoist hurt his private parts, she was rough, she acted like he had no rights, and she stated he does not have any rights. R2 stated his mom reported this to management but no one from management has talked to him about the incident. R2 then stated the CNA is (V11). On 4/28/25 at 1:15 PM V6 CNA stated she recently heard R2 say he doesn't like V11 to give him showers because she hurt him the last time, she gave him one. On 4/28/25 at 2:17 PM V1, Administrator, stated the facility does have a CNA named (V11). V1 then stated we did a write up on her about (R2) on C hall because his mom called and stated he had a bad experience with her during his shower. I didn't report it because there was no allegation of abuse when his mom called our Social Service Director. V1 stated V9, Social Service Director, spoke to R2's mom (V12) and V12 told her R2's privates were pinched from the sling. V1 then provided surveyor with a facility employee disciplinary form, dated 4/18/25, that documented employee (V11), summary of incident: resident states employee was being rough during shower. He states he asked several times for her to be easier with his genitals. Resident no longer wishes to have employee in his room or to provide care or to give shower. Employee educated on proper peri care/shower technique. This form documented signatures (all dated 4/18/25) by V1, V2 (former Director of Nursing), and V11. On 4/28/25 at 2:36 PM V9, Social Service Director, stated R2's mom (V12) called her and mentioned R2 was upset about the care he received during a shower, that the shower transfer sling had pinched his private area, and V12 requested that the CNA (V11) not shower R2 anymore. V9 said she did not document this in the facility grievance book, nor did she discuss this issue with R2 because she gave the information to the Administrator (V1). On 4/28/25 at 2:45 PM V1, Administrator, stated she did not interview R2 nor the other CNA working with V11. V1 then stated she did not investigate R2's allegation against V11. On 4/28/25 at 2:50 PM R2 stated the day V11 gave him a shower he informed V11 the transfer sling was hurting his privates, she did not reposition him or do anything to ease his discomfort, and that it felt like all his body weight was putting pressure on his testicles during the shower. R2 stated he was on the shower chair, it felt like the sling was not applied properly, he repeatedly told V11 that he was hurting, and V11 ignored his statements. R2 stated after the shower V11 did not dry him off and he was put to bed soaking wet. R2 stated no facility employees including management came and spoke to him about the incident, no nurses looked him over after the incident, so he told his mom (V12) and she called and reported it to someone at the facility. R2 stated he feels it was abuse and he will not allow V11 to care for him again. On 4/28/25 at 2:58 PM V10 CNA stated about 2 weeks ago R2 told him V11 had him sitting on his scrotum and she didn't reposition him when he told her it was hurting. On 4/28/25 at 3:37 PM V12, R2's mother, stated she called the facility's Social Service Director (V9) two weeks ago on 4/14/25 and informed her (V9) of her son's (R2) concerns with how he was treated by the CNA (V11) during his shower on 4/11/25. V12 stated R2 told her V11 was rough and rude, his private area was pinched, he was hurting during his shower, and the CNA (V11) would not reposition him. V12 stated R2 also told her V11 did not dry him off after his shower and she put him to bed soaking wet. V12 stated R2 informed her of the incident during her visit with him on 4/13/25. On 4/30/25 at 9:35 AM V9, Social Service Director, stated R2's mom, V12, did say V11 was rough with R2 during his shower. V9 stated she did not speak to R2 about his concerns because she took it to V1, Administrator, to follow up on. On 4/30/25 at 9:42 AM V11, CNA, stated the last time she gave R2 a shower was a couple of weeks ago on a Friday. V11 stated R2 normally speaks to her during care but he did not on this day, and she tried to speak with him throughout the shower, but he just cursed in response. V11 stated R2 never complained of pain during the shower. V11 stated she informed R2's nurse of his behavior during the shower. V11 stated she was never suspended pending an investigation of R2's allegation. On 4/30/25 at 11:15 AM V1, Administrator, stated she does not have any statements from R2, any other residents, nor staff other than the one on the write up that was given to V11. V1 then confirmed the facility did not complete an investigation of R2's allegations of V11 being rude and rough with him during a shower. 2. R1's, face sheet, print date of 4/30/25, documented R1 has diagnoses including congestive heart failure, atrial fibrillation, hypertension, atherosclerotic heart disease, and type 2 diabetes mellitus. R1's MDS, dated [DATE], documented R1 is moderately cognitively impaired although during interview with surveyor R1 was alert and oriented. This MDS also documented R1 requires partial to moderate assistance with showering indicating R1's helper/CNA does less than half the effort as R1 is able to complete most of his own shower. R1's care plan, undated, documented R1 is needs limited assistance for activities of daily living and is receiving restorative programs in order to maintain his present level of function. On 4/28/25 at 1:05 PM R1 stated he has had issues with the way (V11) CNA gives him showers. R1 stated we don't like the way she does things; she shows no respect to us, she has not abused me in anyway, she just doesn't show any respect. 3. On 4/28/25 at 1:08 PM R4 stated (V11) is not abusive, she just doesn't let us do as much as we can for ourselves when she showers us. She just does it. R4's MDS, dated [DATE], documented R4 is cognitively intact and independent with ADLS including showers. R4 ' s face sheet, print date of 4/30/25, documented R4 has diagnoses including congestive heart failure, depression, hypertension, and atherosclerotic heart disease. R4 ' s care plan, undated, documented R4 requires supervision for activities of daily living prn (as needed) and is independent with transfers,

Based on interview and record review the facility failed to report an allegation of verbal and physical abuse to the State Agency for 1 (R2) of 3 residents reviewed for abuse in the sample of 10. Findings Include: R2's face sheet, print date of 4/30/25, documented R2 has diagnoses including flaccid hemiplegia affecting left dominant side and dysphasia following cerebral infarction, hypertension, hyperlipidemia, epilepsy, and arthritis. R2's MDS (Minimum Data Set), dated 3/22/25, documented R2 is cognitively intact, is dependent on a wheelchair and assistance for mobility, and is dependent on facility staff for hygiene needs including showers. R2's care plan, undated, documented category: psychosocial well-being, I am considered at risk for abuse/neglect per assessment with approaches including address all complaints/concerns promptly with grievance policy and procedure. Category ADLS (activities of daily living), resident needs limited to extensive assistance for activities of daily living related to CVA (cerebral vascular accident), flaccid on left side with approaches including transfer with assistance of 2 and a full body mechanical lift. On 4/28/25 at 12:52 PM R2 stated he had an issue with a CNA (Certified Nurse Assistant) when she gave him a shower a few weeks ago. R2 stated the CNA used a hoist to transfer him onto the shower chair, the hoist hurt his private parts, she was rough, she acted like he had no rights, and she said stated he does not have any rights. R2 stated his mom reported this to management but no one from management has talked to him about the incident. R2 then stated the CNA is (V11). On 4/28/25 at 2:17 PM V1, Administrator, stated the facility does have a CNA named (V11). V1 then stated we did a write up on her about (R2) on C hall because his mom called and stated he had a bad experience with her during his shower. I didn't report it because there was no allegation of abuse when his mom called our Social Service Director. V1 stated V9, Social Service Director, spoke to R2's mom (V12) and V12 told her R2's privates were pinched from the sling. V1 then provided surveyor with a facility employee disciplinary form, dated 4/18/25, that documented employee (V11), summary of incident: resident states employee was being rough during shower. He states he asked several times for her to be easier with his genitals. Resident no longer wishes to have employee in his room or to provide care or to give shower. Employee educated on proper peri care/shower technique. This form documented signatures (all dated 4/18/25) by V1, V2 (former Director of Nursing), and V11. On 4/28/25 at 2:36 PM V9, Social Service Director, stated R2's mom (V12) called her and mentioned R2 was upset about the care he received during a shower, that the shower transfer sling had pinched his private area, and V12 requested that the CNA (V11) not shower R2 anymore. V9 said she did not document this in the facility grievance book, nor did she discuss this issue with R2 because she gave the information to the Administrator (V1). On 4/28/25 at 2:45 PM V1, Administrator, stated she did not interview R2 nor the other CNA working with V11. V1 then stated she did not investigate R2's allegation against V11. On 4/28/25 at 2:50 PM R2 stated the day V11 gave him a shower he informed V11 the transfer sling was hurting his privates, she did not reposition him or do anything to ease his discomfort, and that it felt like all his body weight was putting pressure on his testicles during the shower. R2 stated he was on the shower chair, it felt like the sling was not applied properly, he repeatedly told V11 that he was hurting, and V11 ignored his statements. R2 stated after the shower V11 did not dry him off and he was put to bed soaking wet. R2 stated no facility employees including management came and spoke to him about the incident, no nurses looked him over after the incident, so he told his mom (V12) and she called and reported it to someone at the facility. R2 stated he feels it was abuse and he will not allow V11 to care for him again. On 4/28/25 at 3:37 PM V12, R2's mother, stated she called the facility's Social Service Director (V9) two weeks ago on 4/14/25 and informed her (V9) of her son's (R2) concerns with how he was treated by the CNA (V11) during his shower on 4/11/25. V12 stated R2 told her V11 was rough and rude, his private area was pinched, he was hurting during his shower, and the CNA (V11) would not reposition him. V12 stated R2 also told her V11 did not dry him off after his shower and she put him to bed soaking wet. V12 stated R2 informed her of the incident during her visit with him on 4/13/25. On 4/30/25 at 9:35 AM V9, Social Service Director, stated R2's mom, V12, did say V11 was rough with R2 during his shower. V9 stated she did not speak to R2 about his concerns because she took it to V1, Administrator, to follow up on. On 4/30/25 at 9:42 AM V11, CNA, stated the last time she gave R2 a shower was a couple of weeks ago on a Friday. V11 stated R2 normally speaks to her during care but he did not on this day, and she tried to speak with him throughout the shower, but he just cursed in response. V11 stated R2 never complained of pain during the shower. V11 stated she informed R2's nurse of his behavior during the shower. V11 stated she was never suspended pending an investigation of R2's allegation. On 4/30/25 at 11:15 AM V1, Administrator, stated she does not have any statements from R2, any other residents, nor staff other than the one on the write up that was given to V11. V1 then confirmed the facility did not complete an investigation of R2's allegations of V11 being rude and rough with him during a shower. On 4/30/25 at 12:53 PM V1, Administrator, stated she did not report R2's allegation about V11 being rough with him during a shower. On 4/30/25 at 12:56 PM V15, Director of Operations, stated R2's allegations against the CNA (V11) should have been reported and investigated. The facility's Abuse Prevention Program policy, dated 9/29/22, documented abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. It continues, 8. External Reporting of Potential Abuse: Initial reporting of allegations. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a. Must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the event that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. It continues, d. Five-day final abuse investigation report. Within 5 working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health.

Based on interview and record review the facility failed to operationalize their policy to conduct an investigation of allegations of physical and verbal abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 10. Findings Include: R2's face sheet, print date of 4/30/25, documented R2 has diagnoses including flaccid hemiplegia affecting left dominant side and dysphasia following cerebral infarction, hypertension, hyperlipidemia, epilepsy, and arthritis. R2's MDS (Minimum Data Set), dated 3/22/25, documented R2 is cognitively intact, is dependent on a wheelchair and assistance for mobility, and is dependent on facility staff for hygiene needs including showers. R2's care plan, undated, documented category: psychosocial well-being, I am considered at risk for abuse/neglect per assessment with approaches including address all complaints/concerns promptly with grievance policy and procedure. Category ADLS (activities of daily living), resident needs limited to extensive assistance for activities of daily living related to CVA (cerebral vascular accident), flaccid on left side with approaches including transfer with assistance of 2 and a full body mechanical lift. On 4/28/25 at 12:52 PM R2 stated he had an issue with a CNA (Certified Nurse Assistant) when she gave him a shower a few weeks ago. R2 stated the CNA used a hoist to transfer him onto the shower chair, the hoist hurt his private parts, she was rough, she acted like he had no rights, and she said stated he does not have any rights. R2 stated his mom reported this to management but no one from management has talked to him about the incident. R2 then stated the CNA is (V11). On 4/28/25 at 1:05 PM R1 stated he has had issues with the way (V11) CNA gives him showers. R1 stated we don't like the way she does things; she shows no respect to us, she has not abused me in anyway, she just doesn't show any respect. R1's MDS, dated [DATE], documented R1 is moderately cognitively impaired although during interview with surveyor R1 was alert and oriented. On 4/28/25 at 1:08 PM R4 (R1's roommate) stated (V11) is not abusive, she just doesn't let us do as much as we can for ourselves when she showers us. She just does it. R4's MDS, dated [DATE], documented R4 is cognitively intact. On 4/28/25 at 1:15 PM V6 CNA stated she recently heard R2 say he doesn't like V11 to give him showers because she hurt him the last time, she gave him one. On 4/28/25 at 2:17 PM V1, Administrator, stated the facility does have a CNA named (V11). V1 then stated we did a write up on her about (R2) on C hall because his mom called and stated he had a bad experience with her during his shower. I didn't report it because there was no allegation of abuse when his mom called our Social Service Director. V1 stated V9, Social Service Director, spoke to R2's mom (V12) and V12 told her R2's privates were pinched from the sling. V1 then provided surveyor with a facility employee disciplinary form, dated 4/18/25, that documented employee (V11), summary of incident: resident states employee was being rough during shower. He states he asked several times for her to be easier with his genitals. Resident no longer wishes to have employee in his room or to provide care or to give shower. Employee educated on proper peri care/shower technique. This form documented signatures (all dated 4/18/25) by V1, V2 (former Director of Nursing), and V11. On 4/28/25 at 2:36 PM V9, Social Service Director, stated R2's mom (V12) called her and mentioned R2 was upset about the care he received during a shower, that the shower transfer sling had pinched his private area, and V12 requested that the CNA (V11) not shower R2 anymore. V9 said she did not document this in the facility grievance book, nor did she discuss this issue with R2 because she gave the information to the Administrator (V1). On 4/28/25 at 2:45 PM V1, Administrator, stated she did not interview R2 nor the other CNA working with V11. V1 then stated she did not investigate R2's allegation against V11. On 4/28/25 at 2:50 PM R2 stated the day V11 gave him a shower he informed V11 the transfer sling was hurting his privates, she did not reposition him or do anything to ease his discomfort, and that it felt like all his body weight was putting pressure on his testicles during the shower. R2 stated he was on the shower chair, it felt like the sling was not applied properly, he repeatedly told V11 that he was hurting, and V11 ignored his statements. R2 stated after the shower V11 did not dry him off and he was put to bed soaking wet. R2 stated no facility employees including management came and spoke to him about the incident, no nurses looked him over after the incident, so he told his mom (V12) and she called and reported it to someone at the facility. R2 stated he feels it was abuse and he will not allow V11 to care for him again. On 4/28/25 at 2:58 PM V10 CNA stated about 2 weeks ago R2 told him V11 had him sitting on his scrotum and she didn't reposition him when he told her it was hurting. On 4/28/25 at 3:37 PM V12, R2's mother, stated she called the facility's Social Service Director (V9) two weeks ago on 4/14/25 and informed her (V9) of her son's (R2) concerns with how he was treated by the CNA (V11) during his shower on 4/11/25. V12 stated R2 told her V11 was rough and rude, his private area was pinched, he was hurting during his shower, and the CNA (V11) would not reposition him. V12 stated R2 also told her V11 did not dry him off after his shower and she put him to bed soaking wet. V12 stated R2 informed her of the incident during her visit with him on 4/13/25. R2's shower sheet, dated 4/11/25, documented V11 CNA did give R2 a shower on 4/11/25. On 4/30/25 at 9:35 AM V9, Social Service Director, stated R2's mom, V12, did say V11 was rough with R2 during his shower. V9 stated she did not speak to R2 about his concerns because she took it to V1, Administrator, to follow up on. On 4/30/25 at 9:42 AM V11, CNA, stated the last time she gave R2 a shower was a couple of weeks ago on a Friday. V11 stated R2 normally speaks to her during care but he did not on this day, and she tried to speak with him throughout the shower, but he just cursed in response. V11 stated R2 never complained of pain during the shower. V11 stated she informed R2's nurse of his behavior during the shower. V11 stated she was never suspended pending an investigation of R2's allegation. On 4/30/25 at 11:15 AM V1, Administrator, stated she does not have any statements from R2, any other residents, nor staff other than the one on the write up that was given to V11. V1 then confirmed the facility did not complete an investigation of R2's allegations of V11 being rude and rough with him during a shower. On 4/30/25 at 12:56 PM V15, Director of Operations, stated R2's allegations against the CNA (V11) should have been reported and investigated. The facility's Abuse Prevention Program policy, dated 9/29/22, documented abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. It continues, 4. Establishing a resident sensitive environment; the facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Grievance/Concern Identification and Follow-up: Resident and family concerns will be recorded, reviewed, addressed, and responded to using the facility's concern identification procedures. Residents and families will be informed of the facility's grievance policy and procedures process. An essential element of customer satisfaction is a timely response back to the family or resident to concerns expressed. The reported concerns from residents and families, and the facility response, will be reviewed on a regular basis by the facility Quality Improvement committee to assure that individual concerns are being addressed and to assess any patterns that might indicated needed changes in the facility practices. It continues, 5. Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. Supervisors shall immediately inform the administrator of all reports of incidents, allegations, or suspicion of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation. 6. Protection of Residents: The facility will take steps to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress and will immediately take appropriate steps to remediate the non-compliance and protect residents from additional abuse. It continues, c. Employees of the facility who have been accused of abuse, neglect, or mistreatment will be removed from resident contact immediately until the results of the investigation have been reviewed by the administrator or designee. Employees accused of possible abuse, neglect, or misappropriation of property shall not complete the shift as a direct care provider to the residents. 7. Internal investigation of abuse, neglect or misappropriation allegations and response: a. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. b. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. c. Any other incident or pattern involving reasonable cause to suspect abuse, neglect, or misappropriation will result in an abuse investigation.

Based on interview and record review, the facility failed to report injury of unknown origin for one of four (R2) residents, reviewed for reporting, in a sample of 5. Findings include: The facility's policy, Abuse Prevention Policy, dated 9/29/2022, documented, A. Must ensure that all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours . 1. R2's Minimum Data Set (MDS) dated [DATE], documented that her cognition was severely impaired. R2's Physician's order sheet, dated 2/2025, documented diagnosis of dementia and atrial fibulation. It also documented orders for Adult Low Dose Aspirin (aspirin) 81 mg tablet, delayed release 1 tab oral, once a day and Eliquis (apixaban) 2.5 mg (milligram) tablet twice a day. R2's Care Plan, dated 6/11/2024, documented, Approach: Protect resident from injury/trauma. It continues, Approach: Observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis). R2's Care Plan, dated 2/26/2024, documented, Approach: Report any suspected of abuse/neglect to administrator immediately. R2's Progress note, dated 02/02/2025 at 02:09 PM, V2, ADON, documented,[Recorded as Late Entry on 02/04/2025 02:11 PM] While giving meds to resident this afternoon, writer noticed light bluish V shaped bruise to resident's upper right forehead. Writer investigating possible cause, interviewing all staff. Resident independent and with confusion, resident not sure what happened when asked about bruise. R2's Progress note, dated 02/03/2025 at 01:01 PM, V3, LPN, documented, Not acting her normal self. Had to be feed. Would not even open her mouth for meds. (medications) Stares off. Episodes of crying. No verbal response. Noted bruise to forehead. (V10, R2's Physician) notified and will send to ER (emergency room ). POA notified. (Local Ambulance) called. Call report to hospital. R2's Skin integrity events, dated 2/2/25, documented, PHYSICAL OBSERVATION: Location of Bruise and Size of Bruise right upper forehead 3cm (centimeter) x 3cm at biggest parts V shaped. It continues, Activity during Bruise Occurrence Dressing Other - Residents tends to rest head on table at time causing indentions, It continues, Notify MD/NP/PA (Physician/Nurse Practitioner/Physician Assistant) immediately by phone or beeper for any of the following. Bruising of unknown origin. R2's Local Ambulance run sheet, dated 2/3/2025, documented, Mental status: Pt (patient). has history of dementia and is alert to self. It continues, HEENT: (Head/Ears/Eyes/Nose/Throat) Old contusion noted on Pt. face proximal to the forehead. Dried blood noted in both nostrils of nose, Nursing home staff is unsure of what happened or why the bruising and blood was present when asked. It continues, Old bruising was noted on Pt. head proximal to the right side of forehead, dried blood was noted in both of Pt. nostrils. Pt. was asked by EMS (Emergency Medical Systems) crew if anything was hurting her. Pt. continued crying and stated that she did not want to tell on anyone. R2's Local hospital, History and Physical, dated 2/3/2025, documented, ENT: (Ears/Nose/Throat) normal. Nose normal. (Bruise to the midline forehead. Dried blood in the anterior right nares). It continues, History of Present Illness: [AGE] year old female with a past medical history of dementia systolic heart failure, CKD (Chronic Kidney Disease) stage 3, depression, hypertension, CAD (Coronary Artery Disease), Afib on Eliquis, GERD (Gastro Esophageal Reflux Disease) restless legs syndrome. At baseline patient is pleasantly confused who presented to emergency room for ECF for altered mental status. Nursing home staff report onset of alteration today. Patient is not able to feed herself, take her medication or responding to questions which she normally does. EMS noted bruise on forehead and patient withdraws to touch. emergency room contacted (State Agency) due to EMS is concern of elder abuse. On 2/6/2025 at 8:50 AM, V2, Assistant Director of Nurses stated that she noticed on 2/2/2025 a light bluish V shape bruise to R2's right side of her forehead and it was approximately 3cm x 3cm. She continued to state that on 2/3/2025 that morning she had seen R2 and she did not have dried blood in her nostrils. She continued to state that she was still investigating R2's bruise she was still interviewing staff about it and they did not know at the time about what had happened. V2 stated when asked who reports injuries of unknown origin or reportables to the State Agency, she stated that either the administrator or she does but she did not report R2's bruise to her forehead. On 2/6/2025 at 10:00 AM, V1, Administrator, stated that on 2/2/2025 R2 had blood in her nose and on her stuffed animal and she was speaking with the family and they weren't concerned about it since she is on a blood thinner. Asked V1 if she reported, to the State Agency, she stated that R2 was not sent to the hospital for the bruise to her right side of her forehead and she was sent because she had a change in her level of consciousness probably because of her urinary tract infection and her cat scan's all came back normal.

Based on interview, observation and record review, the Facility failed to prevent, identify, obtain orders and monitor pressure ulcers for 2 of 3 residents (R14 and R71) reviewed for pressure ulcers, in the sample of 44. This failure resulted in R14 going from 4/15/2024 until 4/30/2024 without treatment for or monitoring of a stage 3 facility acquired pressure ulcer. Findings include: 1. R14's Braden Score for predicting Pressure Sore Risk, dated 5/9/2024, documents that R14 is constantly moist, chairfast, and has very limited mobility to makes changes in body positioning. It further documents that R14 is at moderate risk for pressure ulcer development. R14's Progress Notes, dated 4/15/2024, documents, CNA (Certified Nurse Assistant) brought it to my attention during bed check that resident has an open area on her left buttock. The area was cleaned, and ointment was put on the area. It does not document if the physician was notified, the wound was measured, or an order was obtained. R14's Wound Summary Report, dated 5/1/2024-6/6/2024, documents that R14 acquired a stage 3 pressure ulcer to R14's left buttock, that was not present upon admission. If further documents, that it was identified on 4/30/2024. R14's Wound Management Detail Report, dated 4/30/2024, documented that the area was a stage 3 pressure ulcer and measured 2 x 1.5 x 0.1 centimeters. There were no other measurement listed prior to this measurement completed by V2, Director of Nurses (DON). R14's Progress Notes, dated 4/30/2024, documents, Resident with area to left inner buttock, see wound management entry for measurements and details. Treatment order inserted for Medi honey, calcium alginate and border gauze dressing daily and PRN. Treatment applied by writer at this time. Offloading and frequent repositioning to be continued as resident is total assist and (mechanical) lift. MD (Medical Director) and POA (Power of Attorney) updated. R14's Minimum Data Set (MDS), dated [DATE], documents that R14 is dependent on staff for rolling left to right and is always incontinent of bowel and bladder. R14's Care Plan, dated 10/12/2022, documents that R14 has full bowel and bladder incontinence and the goal is that R14 will remain free from skin breakdown due to incontinence. It further documents, My nurse will provide a head to toe skin assessment daily. It continues, CNA staff will also observe for new or developing areas during routine care and with scheduled bathing. On 6/6/2024 at 11:04 AM, V2, DON, stated that R14's wound was first identified on 4/15/2024, but V2 was not made aware of it until 4/30/2024 when a CNA showed her. V2 stated the order obtained on 4/30/2024 was the first order received for the wound and the first time it was measured. On 6/10/1024 at 12:01 PM, V2 stated, I would have expected the nurse who found the open area to call the doctor, get an order and I would have seen her on wound rounds. 33112 2. On 6/4/24 at 1:58 PM, V4, Assistant Director of Nurses (ADON), stated that she just completed R71's pressure ulcer dressing. The right foot dressings, right inner thigh, left gluetal fold, and right upper buttocks were observed, in place and dated 6/4/24. V4 stated all are treated with medihoney and border gauze dressings. On 6/6/24 at 9:07 AM, V7, CNA and V20,CNA both donned gowns and gloves and entered R71's room to transfer R71 from the wheelchair to the bed. R71's incontinent brief was removed and a skin check was done. R71's left buttock gluetal fold area has a pressure ulcer about the size of a dime. The wound bed is dark pink with a small open area in the center. R71's right upper buttocks has pressure ulcer the approximate size of nickel. The wound bed is dark pink with a small open area in the center. Neither of these pressure ulcers have a dressing on them. R71's right foot has three dressings (inner ankle, left outer heel, and medial foot) in place that are dated 6/6/24. The right foot has no pressure ulcers. R71 was positioned on his back leaning to the right side with a blanket between his knees, and a pillow under his left side. R71's left foot was positioned over his right inner heel where the pressure ulcer is located. R71 did not have heel boots on. R71 was covered up and given the call light. On 6/6/24 from 9:07 AM - 11:55 AM, R71 has remained in the same position without the benefit of offloading based on 15 minute observations. On 6/6/24 at 11:55 AM, V2, DON, and V4, ADON, entered R71's room. Both were wearing gowns and gloves. V4 removed the old dressing on the right medial foot, sprayed it with wound cleanser, applied medi-honey to a bordered gauze and placed the gauze on the pressure ulcer. The pressure ulcer is the approximate size of a dime, the wound bed is 100% slough, and the peri-wound is light pink in color. V4 removed the old dressing from the right outer heel. The pressure ulcer is approximately 3 centimeter (cm) x 2 cm. The wound bed is 95% slough. The peri-wound is light pink in color. V4 cleansed with wound cleanser, applied medi-honey to a bordered gauze and placed the gauze on the pressure ulcer. V4 then removed the dressing to the right outer ankle. The pressure ulcer is the approximate size of a dime. The wound bed is yellowish slough. The peri-wound is light pink in color. V4 cleansed with wound cleanser, applied medi-honey to a bordered gauze and placed the gauze on the pressure ulcer. V4 never changed gloves between the 3 pressure ulcer changes. R71 was rolled over onto his right side. The left gluetal fold pressure ulcer did not have a dressing on it. R71's incontinent bed pad was wet with urine. The pressure ulcer is approximately the size of a dime. The wound bed is dark pink with a small open area in the center. V4 placed medi-honey on a bordered gauze pad and placed it on the pressure wound. V4 failed to cleanse the wound before applying the treatment. At this time, V4 was questioned if she was going to treat R71's right upper buttocks, V4 stated, I think that is healed. V4 was informed that the wound was open this morning. V4 stated, It has been closed for awhile now. V4 was informed that the pressure ulcer dressing was observed with her on 6/4/24, V4 stated, That's right it did have a dressing on it. R71's right upper buttocks has pressure ulcer the approximate size of nickel. The wound bed is dark pink with a small open area in the center. V4 cleansed the wound with wound cleanser, applied medi-honey and then a bordered gauze. On 6/6/24 at 12:05 PM, V2 and V4 both were questioned why R71 does not have heel protectors on, V2 stated, He used to have a pair. I don't know where they are. I will get him a pair. V2 and V4 both agreed that the way R71 lays in bed his left foot lays directly over the right heel pressure ulcer and he should be turned every 2 hours. R71's Face Sheet, undated, documents that R71 was admitted on [DATE] with diagnosis of Hypertension, Type 2 Diabetes Mellitus, Unspecified Open Wound to right foot, and need for assistance. R71's MDS, dated [DATE], documents that R71 is moderately cognitively impaired, dependent on staff for toileting, and dependent on staff or requires maximum assistance from staff for all mobility. R71's Braden Scale for predicting pressure ulcers, dated 4/24/24, documents that R71 is at moderate risk of developing pressure ulcers R71's Physician Orders, dated 5/23/24, documents, Right Ischium-Cleanse and apply medi honey and border gauze daily and PRN (as needed) for soiling/dislodging. Once A Day Bedtime 06:00 PM - 06:00 AM. R71's Physician Orders, documents, Left Buttock-Cleanse, apply calcium alginate with silver and border gauze Daily and PRN for soiling/dislodging. Once A Day. Bedtime 06:00 PM - 06:00 AM. Start date of 04/20/2024. Discontinue Date of 06/03/2024. R71's Physician Orders, dated June 2024 reviewed 6/6/24 at 9:30 AM, fails to document a current order for treatment to R71's left upper buttocks. R17's Physician Orders, documents, Right Distal Medial Foot- Cleanse, apply medi honey and cover with border gauze daily and PRN for soiling/dislodging. Once A Day. Morning 06:00 AM - 02:00 PM. Start date of 5/8/24. R17's Physician Orders, documents, Right lateral Ankle- cleanse, apply medi honey, cover with border gauze daily and PRN for soiling/dislodging. Once A Day. Morning 06:00 AM - 02:00 PM. start date of 5/8/24. R17's Physician Orders, documents, Right Medial Heel-Cleanse, apply medi honey and cover with border gauze daily and PRN for soiling/dislodging. Apply pressure reducing boots. Once A Day. Morning 06:00 AM - 02:00 PM. start date of 5/8/24. R17's Physician Orders, documents, Right Ischium - Cleanse and apply medi honey and border gauze daily and PRN for soiling and dislodging. R17's Pressure Ulcer Detailed Report, dated 6/5/24, documents that R71's Right ankle lateral pressure ulcer measures 1.3 centimeters (cm) length (l) x 1.4 cm width (w) x 0.3 cm depth (d), with light serous exudate and the pressure ulcer is improving. R17's Pressure Ulcer Detailed Report, dated 6/5/24, documents that R71's Right Medial Heel pressure ulcer measures 1.8 cm l x 1 cm w x 0.1 cm d with light serous exudate and the pressure ulcer is improving. R17's Pressure Ulcer Detailed Report, dated 6/5/24, documents that R71's Right Buttock Ischium pressure ulcer measures 1 cm l x 1 cm w x 0.1 cm d with light serous exudate and the pressure ulcer is improving. R17's Pressure Ulcer Detailed Report, dated 6/5/24, documents that R71's top of foot Distal, Medial pressure ulcer measures 1.5 cm l x 1.2 cm w x 0.2 cm d with light serous exudate and the pressure ulcer is improving. R17's Pressure Ulcer Detailed Report, dated 5/30/24, documents that R71's left buttock pressure ulcer is healed. The facility Wound Management Program, dated 2/26/21, fails to document a procedure on dressing changes, replacing dressings that are missing, cleansing the wound before treatment and turning and positioning. .

Based on observation, interview, and record review, the facility failed to remove expired medication and glucose control solution from refrigerator and medication cart and date multi dose insulin pens after opening. This failure has the potential to affect all 69 residents residing at the facility. Findings include: 1.On 06/03/24 at 09:40 AM, during the inspection of the medication room refrigerator, it contained a vial of Tuberculosis (TB) solution observed to be open and there was no date noted on the box or the vial. V8, Licensed Practical Nurse (LPN) said the TB solution is used on everyone in the facility and the vial should be disposed of 30 days after opening. On 06/03/24 at 09:45 AM, there was a bottle of Azithromycin oral suspension 200mg (milligrams) per 5ml (milliliter) observed in the refrigerator that did not have a name or date on the bottle. The directions on the bottle states it should be destroyed after mixing use within 10 days. There was a 5ml multi dose vial of Influenza vaccine 2023-2024 opened with no open date on the bottle or box and had an expiration date of May 28th, 2024. On 06/03/24 at 09:53 AM, there was floor stock Bisacodyl medicated laxative suppositories with an expiration date of 12/2023 was observed in the refrigerator that had seven out of 12 suppositories left in the box. V8 verified they were expired. She said if there is no name on the suppositories then they are floor stock. 2.On 06/03/24 at 09:56 AM, B Hallway medication cart was inspected and contained the following: - Lantus insulin Pen for R63 with no opened date. - Lantus insulin Pen for R16 with no opened date. - Lantus insulin Pen for R43 with no opened date. On 06/03/24 at 09:56 AM, V8 verified there were no open dates on the insulin pens, and she stated they should be destroyed after 28 or 30 days. She said some are 28 days and some are 30 days. On 06/03/24 at 11:05 AM, C hallway medications cart was inspected and contained the following: - Aspirin 325 mg (milligram) enteric coated tabs with the expiration date of 4/24 were observed in the cart. - (Brand Name) Glucose control solutions were observed in the cart. The level 2 solution was observed to have an expiration date of 01/17/2023 and the level 3 solution was observed to have an expiration date of 01/18/2023. On 06/03/24 at 11:11 AM, V9, Registered Nurse (RN) stated he isn't sure when the quality control checks are done on the glucometers, he said he just knows they aren't done on day shift. V9 verified the expiration dates on the solution bottles and box. On 06/10/24 at 11:55 AM, V1, Administrator stated she would expect the Director of Nursing (DON), or Assistant Director of Nursing (ADON) would be checking the refrigerator for anything expired, medications unlabeled, and for the resident's insulin pens to have an open date on them. On 06/10/24 at 01:10 PM, V2, Director of Nursing (DON) she would expect the nurses to put the date on the insulin pen after opening it. She said TB solution is good for 30 days after it is opened. V2 said she has been checking the medications room for expired meds and when the night nurse has time, she will do it. The facility's Storage of Medications, revision date of 05/01/2018, documents Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medications supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. It further documents Expiration Dating C. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips once opened, require an expiration date shorter than the manufacturer's expirations date to insure medication purity and potency. It also documents D. 2) Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medications are: In a multi-dose injectable vial An ophthalmic medication An item for which the manufacturer has specified a usable life after opening. E. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating. It also documents H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. The Long Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 06/03/24, documents that the facility has 69 residents living in the facility.

Based on observation, interview, and record review, the facility failed to properly store and label foods with open dates, secure hair during meal preparation and service, and utilize hand hygiene to prevent food contamination and/or borne illness. This failure has the potential to affect all 69 residents residing at the facility. Findings Include: 1.On 06/03/24 at 09:13 AM, the standup freezer was inspected and contained: - An open box of frozen pancakes with no open date and the inner bag with the pancakes in it was not sealed. - One box of maple sausage links with a date of 4/16 (arrival date) that was open, and the inner bag was not sealed in any way. There were two boxes of maple pork sausage links dated 5/14 (arrival date) in the freezer that were open and in the inner bag was not sealed or secured/tied up. On 06/03/24 at 09:20 AM, the walking refrigerator was inspected, and it contained: - A gallon of milk that was open with no open date on it. - On one of the shelves there was a bundle of celery that was not in any kind of bag or storage container and the there was an open box of lettuce, and the inner bag was not sealed. On 06/03/24 at 09:23 AM, the deep freezer in the storeroom was inspected and contained: - A large container of strawberry cheesecake ice cream that was open with no open date on it. On 06/03/24 at 09:23 AM, V10, Dietary Manager said he didn't date the ice cream when he opened it. He said came in another box that had multiple containers of ice cream in it and they just took it out. 2.On 06/03/24 at 11:50 AM, V11, Cook, had a beard. V11 was wearing a hairnet, but he did not have on a beard guard. On 06/03/24 at 11:55 AM V12, Dietary Aide had her hairnet on but did not have it covering her bangs. V13, Dietary Aide had on her hairnet, but she had hair hanging out all around her face and neck. 3.On 06/03/24 at 11:58 AM, V11, Cook washed his hands got a pair of gloves from the box but did not put them on. He proceeded to place lids on the food that was on the steam table, removed aluminum foil from food that was on the steam table and covered them with lids. He then put on the gloves he had gotten form the box a few minutes earlier and donned them. He then removed the lids covering the food, moved plates from on top of the steam table lower so he was able to reach them and began to serve the food. On 06/03/24 at 12:09 PM, V13, Dietary Aide went into the refrigerator and retrieved a gallon of milk. V13 then got a pair of gloves out of the box and donned them with no hand hygiene done prior to putting on the gloves. V13 began to set up meal trays and liquids for the residents. On 06/03/24 at 12:11 PM V11 was observed going back to the storeroom to get a resident a bag of chips with his gloves on then came back and started serving food with the same gloves and no hand hygiene was done. On 06/03/24 at 12:17 PM, V11 walked over in the dishwashing area, touched the wall, walked around the other end of the kitchen, back over to the serving area, and then began to serve food with no hand hygiene or glove change done. On 06/03/24 at 12:18 PM, V13 was observed opening the microwave meal and putting in the microwave for a resident with her gloves on then came back over to the food prep area and with the same gloves on filled a cup with ice. Then at 12:20 PM she removed the meal from the microwave with the same gloves and placed it on a tray. At 12:21 PM, she removed her gloves, got more trays, got new gloves, and donned them without doing any type of hand hygiene. On 06/10/24 at 11:15 AM, V10 stated he would expect the kitchen staff to always have their hairnets on and it should be covering all their hair. He said he would expect anyone with a beard to have their beard covered also. V10 stated he would at the very least expect someone who was working with the food then goes to the back to get something for a resident to do hand hygiene (hand sanitizer) and change their gloves before starting to serve trays again. V10 stated he would expect an open box to be dated with the open date and the inner bag to be twisted and tied off, so the food doesn't fall on the floor. On 06/10/24 at 12:00 PM, V1, Administrator, stated she would expect the kitchen staff to have their hairnets on and if they have a beard to have it covered up with something even if it is with a facemask upside down. She would expect any open food in the freezer to have an open date on it and for the bag to be tied up and not be left open. The facility's Cleaning and Sanitation policy, revision date of January 2012, documents Policy: The kitchen will be maintained in a clean and sanitary condition. The state and/or federal food code will be maintained on file within the food service department and will be the basis of all sanitation and food safety practices. Procedure: 1. The best way to prevent contamination of food or food surfaces is to frequently wash hands. Hands should be washed before starting work, after coughing or sneezing, after handling garbage, picking up an article off the floor, after using the toilet, after smoking, after handling soap and detergents, after touching your hair or face and after all breaks. Thorough hand washing is done using soap and warm water and scrubbing hands together vigorously (20 seconds) and then rinsing them well. Dry hands with a paper towel and turn faucets off using the paper towel instead of clean hands. 2. Hairnets or hair coverings will be worn at all times. It further documents 9. Unused food will be covered, timed, labeled, and dated with their content. All potentially hazardous unused food or leftovers will be cooled following the Two-Stage Cooling Method. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 06/03/24, documents that the facility has 69 residents living in the facility.

Based on observation, interview, and record review the facility failed to ensure wheelchair brakes were locked,a gait belt was utilized during transfers, and smoking was supervised for 4 of 7 residents (R38, R58, R61, R63), reviewed for accidents, in a sample of 44. Findings include: 1. R63's face sheet, dated 6/6/24, documented R63 was admitted on [DATE] with diagnoses of cerebral infarction, diabetes, unspecified abnormalities of gait and mobility, and CHF (congestive heart failure). R63's MDS (Minimum Data Set) dated 4/30/24 documented R63 has moderate cognitive impairment and requires partial/moderate assistance with bed to chair and chair to toilet transfers. R63's fall risk assessment, dated 6/2/24, documented R63 is at high risk for falls. R63's care plan, undated, documented that R63 is at risk for falls. The facility's Fall Prevention Protocol, signed by R63's POA (Power of Attorney), dated 4/30/24, documented, The program consists of the following: 1. Risk assessments are done on all residents to determine what assistive devices may be needed to help promote safety. It continues, make sure that wheelchairs are locked before resident gets up or sits down. On 6/6/24 at 10:25 AM, V14, CNA (Certified Nurse Assistant), and V24, CNA, transferred R63 out of her recliner and into her wheelchair. V24 placed a gait belt around R63's waist and V24 and V14 lifted R63 to a standing position. V24 and V14 then transferred R63 into her wheelchair. V24 and V14 failed to lock R63's wheelchair causing the wheelchair to move backwards during the transfer. V24 and V14 then transferred R63 onto the toilet. V24 and V14 did not lock R63's wheelchair prior to transferring her onto the toilet. 2. R38's face sheet, dated 6/6/24, documented that R38 was admitted to the facility on [DATE] with diagnoses of right above the knee leg amputation, CHF (congestive heart failure), peripheral vascular disease, osteoarthritis, muscle wasting and atrophy. R38's MDS, dated [DATE], documented that R38 is severely cognitively impaired and requires substantial/maximum assistance with transfers. R38's fall risk assessment, dated 5/15/24, documented R38 is at moderate risk for falls. R38's care plan, undated, documented that R38 is at risk for falls related to above knee amputation and history of right-side weakness related to old CVA (cerebral vascular accident). On 6/6/24 at 10:55 AM, V14, CNA and V15, CNA, placed a gait belt around R38's waist and then transferred R38 from her wheelchair onto the toilet. V14 and V15 failed to lock the wheelchair on both sides causing the wheelchair to move back during the transfer. On 6/6/24 at 10:58 AM, V14, CNA and V15, CNA, then lifted R38 off the toilet and then transferred R38 into her wheelchair. V14 and V15 both failed to lock the wheelchair causing the wheelchair to move back during the transfer. On 6/10/24 at 9:45 AM, V1, Administrator, stated that she would expect the CNA's to lock the wheelchairs prior to transferring residents. On 6/10/24 at 9:52 AM, V15, CNA, stated they are supposed to lock both sides of the wheelchair before transferring a resident. On 6/10/24 at 9:57 AM, V6, CNA, stated that she always locks the wheelchair before transferring a resident into it or out of it. On 6/10/24 at 12:20 PM, V31, Corporate Nurse, stated that the CNA's are trained to lock the wheelchairs when transferring residents. The facility's Validation of Competency form, undated, documented, 3. While preparing the resident for transfers, are safe techniques demonstrated by: a. removing the leg rests. b. locking wheelchair wheels (if resident is moving to a wheelchair). The facility's fall prevention protocol, undated, documented make sure that wheelchairs are locked before resident gets up or sits down. 40701 3. On 6/3/2024 at 10:15 AM, R58 stated that she is allowed to smoke unsupervised and keep her cigarettes and lighter. At this time, there was a pack of cigarettes and lighter on R58's bedside table. R58's Care Plan, undated, documented, Problem: I wish to smoke cigarettes and have been assessed. Approach: Nursing to keep cigarettes and lighter/matches in safe area. R58's Smoking Risk Assessment, dated 2/12/2024, documented that R58 is a safe smoker and to follow facility policy. On 6/4/2024 at 12:56 PM, V17, Social Service Director (SSD), stated, Smoking assessments are supposed to be done quarterly. The last one was done in February. I am in charge of updating the care plan too. (R58's) care plan says she is supposed to be supervised but she is pretty independent, so I will update it. On 6/4/2024 at 3:20 PM, V17, stated, I don't really like any one to be unsupervised, but I revised the Care Plan. On 6/6/2024 at 10:10 AM, there were two cartons of cigarettes observed on R58's bed. On 6/6/2024 at 11:03 AM, V3, Activity Director, stated R58 keeps her cigarettes and lighter in her room. R58's Care Plan, dated 6/4/2024 documents, I am alert and able to smoke independently per assessment. The Facility's Smoking Policy and Procedure, undated, documented, Purpose: To ensure all residents are safe while smoking. It continues, Smoking materials, including electronic cigarettes must be secured at the nurses' station when not in use, unless otherwise specified. It further documents, Residents who are determined by the care plan team to be able to smoke without supervision may smoke at will in the designated smoking area. Smoking materials will be returned to the nurse's station and will not be kept in the residents room, unless a secured area or mechanism is available in the residents' room. 33112 4. On 6/6/24 at 9:47 AM, V33, CNA, brought R61 to his room. V33, locked the wheelchair and placed R61's walker in front of him. V33 told R61 to stand up. V33 placed her arm under R61's right underarm and was pulling him up to stand. V33 then with her left hand grabbed the back of his pants and pulled him up more. R61 was turned and placed in the recliner. R61 had a difficult time to stand and was once up he was very unsteady on his feet. V33 failed to use a gait belt for the transfer. On 6/6/24 at 1:50 PM, V33 was questioned as to why she did not use a gait belt while transferring R61, V33 stated, Last week his daughter helped me transfer him and she told me that he stood really well. We did not use a gait belt on him that time. R61's Face Sheet, undated, documents that R61 was admitted on [DATE] with diagnoses of Alzheimer's Disease and Dementia. R61's Minimum Data Set, dated dated [DATE], document that R61 is cognitively impaired, always incontinent of bowel and bladder is dependent on staff for toileting, dependent on staff for stand to chair transfer, and transfer to toilet. The facility policy, Gait Belt Use, dated 7/2014, documents, It is the policy of (the facility) that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee.

Based on observation, interview, and record review, the facility failed to remove soiled linens to prevent cross contamination, perform hand hygiene before donning and doffing of gloves, provide a clean barrier for supplies, and keep supplies clean to prevent the spread of infection for 6 of 17 residents (R14, R26, R60, R61, R62, R71) reviewed for infection control in the sample of 44. Findings include: 1. On 6/6/24 at 9:47 AM, V33, Certified Nurse's Aide, CNA, brought R61 to his room and transferred from his wheelchair to his recliner. R61's back of his pants was saturated. R61 stated that his pants were wet. V33 looked and confirmed they were wet and told R61 that she would tell his aides that he needed to be changed. V33 failed to remove the wet soiled incontinent pad in the wheelchair. On 6/6/24 at 10:30 AM, V20, CNA, and V33 entered R61's room to toilet him. V33 put on gloves without hand hygiene. R61 was transferred from his recliner to the bathroom. R61's incontinent pad in the recliner is wet with urine. R61's back of pants were saturated from the knee up to the waist band. V20 put on gloves without hand hygiene. After completing care, R61 was transferred back to his wheelchair onto the soiled incontinent pad from earlier. The soiled incontinent pad from the recliner was never removed. On 6/10/24 at 1:39 PM, V1, Administrator, stated that she does expect the soiled linens to be changed, hand hygiene performed before putting on gloves, and after removing them. 2. On 6/6/24 at 10:00 AM, V7 CNA and V20 brought R62 to her room to toilet her. V7 and V20 donned gloves without hand hygiene before. R62 was transferred to the toilet. R62's incontinent brief was pulled down. It was dry. R62 urinated on the toilet. R62 was stood back up. V20 wiped R62 with toilet tissue and her brief and pants were pulled up. R62 was transferred back to the wheelchair and then into her recliner. V20 removed her gloves and then operated the remote control for the recliner for R62's comfort. 3. On 6/6/24 at 11:55 AM, V2, Director of Nurses, (DON) and V4, Assistant Director of Nursing, ADON, entered R71's room. Both were wearing gowns and gloves. V4 provided pressure ulcer treatments to 5 different pressure ulcers on R71. V4 placed the gauze pads, wound cleanser, and the medi-honey directly on R71's bed. V4 at one point of the treatments placed all the supplies on a soiled incontinent pad. On 6/6/24 at 4:00 PM, V1, Administrator, stated that the supplies should always be placed on a clean surface. On 6/10/24 at 10:52 AM, V4, was questioned why she did not put down a clean barrier for R71's pressure ulcer treatment supplies, V4 stated, I just took this position three weeks ago. I came from a hospital. V4 was questioned if the supplies were just for R71 or if they were put back into the treatment cart, R71 stated, They are the treatment carts supplies. The policy Infection Control, dated 7/2017, documents, It is the policy of (facility) to make every effort to prevent the spread of infection in the facility. It continues, 4. Staff will use proper glove and hand washing technique. 5. Staff will use proper linen handling technique. The policy Handling of Laundry and Bedding, Soiled, dated 3/24/2020, documents, 3. Deposit soiled briefs or under pads in specially designated laundry hampers or waste containers. The policy Wound Management Program, dated 2/26/21, fails to document the use of a clean surface barrier. 44556 4. On 06/04/24 at 08:16 AM, V8, Licensed Practical Nurse (LPN) did not perform any hand hygiene prior to getting R14's medications ready to give. V8 then gave R14 her medications she went back to the medications cart and no hand hygiene was done. 5. On 06/04/24 at 08:19 AM, V8, LPN did not do any type of hand hygiene prior to getting R26's medications pulled up to give. After getting the medication ready R26's was no longer in. On 06/04/24 at 08:27 AM, after giving R26 her medication V8 did not do any type of hand hygiene. 6. On 06/04/24 at 08:50 AM, V4, Assistant Director of Nursing (ADON) proceeded to take R60's blood sugar. She cleansed R60's right pointer finger with an alcohol pad, used a new lancet, stuck R60's finger, and attempted to get enough blood for the test strip. After placing the blood on the test strip, the machine then did not read the strip. V4 removed her gloves went out the med cart to get another lancet to prick R60's finger. V4 applied clean gloves without doing any hand hygiene and then pricked R60's finger again after cleansing it off. She applied blood to the test strip and the glucometer again had an error. V4 went to the medication cart again with her dirty gloves on and came back with the bottle of test strips and the same gloves on. V4 then obtained R60's blood sugar. V4 removed her gloves cleaned up the discarded lancets and test strips from R60's over the bed table, left the room, disposed of the trash, and started working on the computer with no hand hygiene observed. No hand hygiene was observed being done. On 06/10/24 at 11:55 AM, V1, Administrator said she would expect hand hygiene to be done between each resident during a medication pass. On 06/10/24 at 01:10 PM, V2, Director of Nursing (DON) stated she would expect the nurses to perform hand hygiene in-between each resident's meds (medications) and after giving medications. On 06/10/24 at 01:15 PM, V8, LPN stated hand hygiene should be done at least every third or fourth resident especially if you touch the resident you need to wash your hands. The facility's Handwashing policy, revision date of December 2020, documents Policy: It is the policy of this facility that all staff thoroughly cleanses hands with friction, soap, and water to control infection and reduce transmission of organisms. Procedure: Hands should be thoroughly washed before and after providing resident care. Proper handwashing techniques must be followed at tall times. It further documents 8. Hand antiseptic/hand sanitizer as a supplement or alternative to the use of soap and water when hands are not visible solid.

Base on interview and record review, the facility failed to notify the Physician of high blood sugar results and a newly acquired pressure ulcer for 2 of 17 residents (R14, R51) reviewed for Physician notification in the sample of 44. Findings include: 1. R51's Face Sheet, undated, documents that R51 was admitted on [DATE] and has diagnoses of Type 2 Diabetes mellitus, Depression and Anxiety. R51's Minimum Data Set (MDS), dated [DATE], documents that R51 is cognitively intact. R51's Physician Orders, documents, Humulin 70/30 U-100 Insulin suspension; 100 unit/mL (milliliter) (70-30); amt (amount): 65; subcutaneous Once A Day Evening 03:00 PM - 06:00 PM. Discontinue date of 6/8/24. R51's Physician Orders, documents, Humulin 70/30 U-100 Insulin suspension; 100 unit/mL (70-30); amt: 70; subcutaneous Once A Day Morning 06:00 AM - 10:00 AM. Discontinue date of 6/8/24. R51's Physician Orders, dated 6/8/24, documents, Humulin 70/30 U-100 Insulin suspension; 100 unit/mL (70-30); amt: 70; subcutaneous Once A Day Evening 03:00 PM - 06:00 PM. R51's Physician Orders, dated 6/8/24, documents, Humulin 70/30 U-100 suspension; 100 unit/mL (70-30); amt: 75; subcutaneous Once A Day Morning 06:00 AM - 10:00 AM. R51's Physician Orders, dated 7/20/23, documents, Accu Check Special Instructions: Call MD if <70 or >260 Twice a day; Morning 6:00 AM - 10:00 AM, Evening 3:00 PM - 6:00 PM. R51's Blood Sugar Log, dated 5/8/24 - 6/4/24 documents 21 times that R51's blood sugar was over 260. R51's Progress Notes from 5/8/24 - 6/4/24 failed to document V32 (R51's Physician) being notified of high blood sugars. On 6/6/24 at 1:50 PM, V22, Registered Nurse (RN), stated, (R51) does have orders to call the doctor if his blood sugar is over 260. It should be documented in the progress notes that the Doctor was notified. I will tell you, I don't call the Doctor much because 260 is not that high. If it is high then I will call him. V22 was questioned what she considered high, V22 stated, 300 but that isn't an excuse we should be calling the doctor if it is ordered. On 6/10/24 at 12:40 PM, V8, Licensed Practical Nurse (LPN) stated, I do call V32 (R51's Physician) when his blood sugar is high. I would chart it in the progress notes. It has been quit awhile since I have notified him though. On 6/10/24 at 12:35 PM, V4, Assistant Director of Nurses (ADON), stated, Sometimes I will call (R51's Doctor) and let him know that R51's blood sugar is high and sometimes I forget. If I did call, I would chart it in the progress note. On 6/10/24 at 12:43 PM, V32, R51's Physician, stated, I was not aware that R51 blood sugars were running high. It is really sad. I went in to do rounds on Saturday (6/8/24) and asked for them to print me a print out of his blood sugars. He is consistently running high and I was unaware. I increased his insulin for both doses on Saturday since I found this out. It didn't cause him harm it just slows things down. 40701 2. R14's Braden Score for predicting Pressure Sore Risk, dated 5/9/2024, documents that R14 is constantly moist, chairfast, and has very limited mobility to makes changes in body positioning. It further documents that R14 is at moderate risk for pressure ulcer development. R14's Wound Summary Report, dated 5/1/2024-6/6/2024, documents that R14 acquired a stage 3 pressure ulcer to R14's left buttock, that was not present upon admission. If further documents, that it was identified on 4/30/2024. R14's Wound Management Detail Report, dated 4/30/2024, documents that the area was a stage 3 pressure ulcer and measured 2 x 1.5 x 0.1 centimeters. There were no other measurement listed prior to this measurement completed by V2 (Director of Nurses). R14's Progress Notes, dated 4/15/2024, documented, CNA (Certified Nurses Aide) brought it to my attention during bed check that resident has an open area on her left buttock. The area was cleaned, and ointment was put on the area. It does not document if the physician was notified, the wound was measured, or if an order was obtained. R14's Progress Notes, dated 4/30/2024, documented, Resident with area to left inner buttock, see wound management entry for measurements and details. Treatment order inserted for Medi honey, calcium alginate and border gauze dressing daily and PRN (as needed). Treatment applied by writer at this time. Offloading and frequent repositioning to be continued as resident is total assist and (mechanical) lift. MD (Medical Director) and POA (Power of Attorney) updated. On 6/6/2024 at 11:04 AM, V2 stated that R14's wound was first identified on 4/15/2024, but V2 was not made aware of it until 4/30/2024 when a CNA showed her. V2 also stated that the order obtained on 4/30/2024 was the first order received for the wound and the first time it was measured. On 6/10/1024 at 12:01 PM, V2 stated, I would have expected the nurse who found the open area to call the doctor, get an order and I would have seen her on wound rounds. Change in a Resident's Condition or Status Policy, dated 11/16, documented, Procedure: i. Instructions to notify the physician of changes in the resident's condition.

Based on interview and record review, the facility failed to prevent verbal abuse for 1 of 17 residents (R51) reviewed for abuse in the sample of 44. Findings include: On 6/3/24 at 11:12 AM, R51 stated, Not to long ago an aide came in to give me a bed bath. She took the tub of water and poured it directly on me. I have never had a bed bath like that before. I told her that and she didn't seem to care. Then on Friday around noon she had came in here. I had asked her to do something and she didn't want to. I admit I should not have said it but I told her You work for me. She came back with No I don't work for you. I work for the company. I did not like that. She then left my room and while she was out in the hall I heard her tell the other aide He is such an axxxxxe. She shouldn't be saying that to others. R51 was questioned about who the aide was, R51 stated, I don't know her name. She is newer. She is a larger woman with curly black hair. I am not sure if she is African or a mixed race but she has darker skin tone. R51 was questioned if he told anyone about these incidents, R51 stated, I told my wife but not any workers. On 6/3/24 at 11:50 AM, V1, Administrator, was notified of the allegations of abuse. On 6/3/24 at 3:45 PM, V1 stated that she had started an investigations into the allegations of abuse. On 6/4/24 at 11:58 AM, V1 stated, I have spoke with (R51) and (V18, Certified Nurses Aide, CNA). They both told the same story. (R51) did not want to get out of bed for a shower. He has a treatment that goes on his back. The aides told him that his back needed to be washed before the nurse could put the treatment on. Since he did not want to get up they gave him a bed bath. He was rolled over and with the wet washcloths she (V18) wrung them out over his back. She did not pour the bucket of water over him. (R51) told me the same thing. When I asked him specifically if she threw a bucket of water on him he said no she wrung the rags but what is the difference. (V18) admitted when she was leaving the room that she told the other aide He is being an axxxxxe. She was not able to work yesterday and she is currently suspended. I did report the allegation of abuse to the IDPH. On 6/10/24 at 12:09 PM, V1, stated that the final report is due today and it not completed yet. V1 stated that she is going to substantiate the allegation of abuse. V18's written statement related to R51's abuse allegation, dated 6/3/24, documents, Under my breathe, or so I thought. I told the other aideThis is why I didn't want to do him yet. He's acting like an axxxxxe. He heard me and wanted management. So I got the nurse (V8) and told (V4, Assistant Director of Nurses) exactly what happened. R51's Face Sheet, undated, documents that R51 was admitted on [DATE] and has diagnoses of Type 2 Diabetes mellitus, Depression and Anxiety. R51's Minimum Data Set, dated dated [DATE], documents that R51 is cognitively intact. The Abuse Prevention Policy, dated 9/29/22, documents, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. It continues, mistreatment means inappropriate treatment or exploitation of a resident. It continues, 5. Internal Reporting Requirements and Identification of Allegations: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. It continues, 7. Internal investigation of abuse, neglect or misappropriation allegations and response. a. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. b. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation.

Based on observation, interview and record review, the facility failed to provide supervision for residents who require supervised leave and have the potential for elopement for 2 of 2 residents (R5 and R8) reviewed for supervision to prevent accidents in the sample of 11. This failure resulted in R8 leaving the facility unsupervised, being found by a citizen walking on the road a block from facility at 10:48 PM. This failure has the potential to affect all 71 residents in the facility. This failure resulted in R5 leaving the facility being found on the ground by local police department at 9:08 PM, .6miles from the facility. The Immediate Jeopardy began on 4/28/2024 when R5 exited the facility without staff supervision and being found by the local police .6 miles from the facility on the ground. V1, Administrator, was notified of Immediate Jeopardy on 5/16/2024 at 10:02 AM. The surveyors confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 5/23/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training of staff. Findings include: 1. R5's face sheet undated documents admitted [DATE] with diagnoses of Parkinsonism, unspecified, Diabetes mellitus due to underlying condition without complications, Chronic obstructive pulmonary disease, unspecified, Hyperlipidemia, unspecified, Chronic thromboembolic pulmonary hypertension, Insomnia, unspecified, 2019-nCoV acute respiratory disease (History of), Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R5's Minimum Data Set, dated dated dated [DATE] documents R5 is moderately cognitively impaired and needs supervision with Activities of Daily living. R5's progress noted dated 04/28/2024 at 10:03 PM by V3 (Registered Nurse) documents the following: At 9:08 PM, Local Police called to ask if a resident was missing from the facility. V2 (Registered Nurse) was unaware of any missing resident but stated that we would do room checks and call back if we were. At 9:13 PM, prior to CNAs being able to conduct room checks, Local Police called back to ask if we had R5 as a resident. Dispatcher explained that police observed the R5 fall onto his backside near a local park, where he was walking towards the downtown area with his walker. At approximately 9:30 PM, Local Police arrived at the facility with R5, who explained that his brother-in-law passed away, and so he wanted to go see his nieces to make sure they were ok. Further investigation reveals that at approximately 8pm, R5 was observed shaving with an electric razor in his room by a V4, Certified Nursing Assistant, CNA. Prior to this, during dinner, R5 suggested to V4 that a family member was going to pick him up in the evening, and V4 suggested that R5 communicate with his nurse on duty. Per the nurse working that hall, the resident made no mention of his intentions to leave, and he was given his evening medication prior to leaving, per the nurse responsible for his hall. The situation was reported to V14, and then spoke with V1, the Administrator, via phone, to explain the situation. 15-minute bed checks have been initiated. A thorough assessment of R5 reveals no injury. On 4/30/2024 at 12:30 PM R5 stated that he walked out the front door the other night. R5 stated he was confused and was trying to find his sister. R5 stated that he had to sat down on the road because his legs were hurting so bad. R5 stated there was no sidewalk so I just walked on the road. R5 stated he left about 8:15 PM and was gone about an hour. R5 stated it was kind of dark out when he left. R5 stated he knows to press the button on the front door to get out. R5 stated he told one of the CNAs that he was going to leave. R5 stated he signed out in the book that he was leaving. On 4/30/2024 at 1:00 PM it was noted that the resident sign out book contained an undated document with R5's name and time on it. On 5/1/2024 at 9:55 AM V4 stated she was the CNA on R5's hall on 4/28/2024 on second shift. V4 stated that she was the only CNA on that hall that night. V4 stated that there were only 3 total CNAs on second shift for 72 residents that evening. V4 stated that she saw R5 in his room between 7-730pm shaving. V4 stated she thought this was unusual, so she asked him what he was doing. V4 stated that R5 said he was going to leave that his sister was coming to get him. V4 stated that she thought this was odd that R5's sister would be coming to get him at this time of night. V4 stated that she walked by R5's room about 7:45PM- -8pm and R5 was sitting in his recliner chair. V4 stated she was down another hallway helping another CNA lay down residents that required two assist to get into bed and was told that R5 had gotten out of the building and the police were bringing him back. On 4/30/2024 at 10:00 AM, V2, Registered Nurse, stated that on 4/28/2024 he was at the end the end of the hallway and the phone kept ringing, so he went to answer it and it was the local police department. V2 stated the police department asked if they were missing any male residents. V2 stated he responded, 'Oh God I hope not but we are severely understaffed so I will have to check with the CNAs. V2 stated that just a few minutes later the police called back and asked if R5 was our resident. V2 stated I stated 'yes' and they said they witnessed him at the park fall to his bottom and they assisted him up. Police asked if someone could come get him and I stated no we don't have enough staff. R5 returned to facility via police vehicle and was pleasant and uninjured. V2 stated he was not sure how R5 had gotten out of the building but that R5 is pretty steady on his feet with his walker. On 5/13/2024 at 11:38am V10, Social Services Director, stated that there is only one resident that is allowed to leave independently and that all other residents need to be supervised to leave. Local Police Department, dated 5/1/2024, documented the address of where R5 was located on 4/28/2024. Electronic Mapping application documented that R5 was 0.6 miles from the facility on 4/28/2024 using the address provided by the local police department on 5/1/2024. 2. R8's face sheet undated documents admitted [DATE] with diagnoses of congestive heart failure, unspecified dementia, psychotic disturbance and anxiety and depression. R8's Minimum Data Set (MDS) dated [DATE] documented R8 is moderately cognitively impaired. MDS documents that R8 needs supervision with walking 150feet. R8's elopement evaluation dated 2/13/2024 documents that R8 is ambulatory, is a new resident who is questioning the need to be here, doesn't understand why she is here, and that elopement care plan was not initiated. On 5/13/2024 at 2:33 PM V13, Certified Nursing Assistant, CNA, stated that R8 had tried to get out the front door about 4:00 pm on 5/11/2024 and V13 was able to re-direct her back away from the door. V13 stated that she told V2, Registered Nurse, about it. V13 stated that around supper time that same evening the alarm for door B went off and R8 had attempted to exit door B again. V13 stated that R8 was easily directed again back into facility. V13 stated that when she was leaving around 10:00 PM that R8 was near the breakroom door and V13 encouraged R8 to go back to the nurse's station. On 5/14/2024 at 9:00 AM V5, CNA, stated that R8 was wandering into other residents' rooms on the date of 5/11/2024. V5 stated that one of the residents was yelling get out of here and that V5 entered the room to find R8 in there and re-directed R8 out of the room. On 5/14/2024 at 8:50 AM V2, Registered Nurse, RN, stated that on the evening of 5/11/2024, R8 had went up to the front door when V13, CNA was leaving and V13 re-directed R8 back to the nurse's station. V2 stated that R8 is not normally that confused. V2 stated that R8 doesn't typically exit seek. V2 stated that R8 is pleasantly confused. V2 stated that R8 is independent with ambulation and her walker within the facility. V2 stated he is not aware of any door alarms going off because of R8 on that evening. V2 stated he does not know the protocol for what to do if a resident is actively exit seeking. V2 stated it very difficult for staff to monitor residents due to low staffing numbers on second and third shifts. V2 stated door alarms, resident personal alarms and the front door alarms go off multiple times in a shift and staff become fatigued to them. R8's Progress Note, dated 05/11/2024 at 11:39 PM, written by V23, Licensed Practical Nurse, LPN documents a call was made to the facility stating a resident was walking down Houston Street with a walker. Some staff immediately started doing a head count and other staff went outside. At 10:48 PM as V23 and some staff was out front looking, 2 cars pulled up into parking lot. One car had the R8 inside and the other car had the R8's walker. V23 assessed resident, no concerns noted. R8 stated she was going home and said she left out the door and pointed to the back door on B-wing. V1 notified. V14, DON, notified. POA called and V23 left message. V23 last seen resident at about 10:10 PM. walking down B-wing with her walker. On 5/14/2024 at 10:51 AM, V23, LPN, stated that R8 was wandering up and down the halls when V23 came on shift. V23 stated that R8 had walked up to the front door and was re-directed back to the nurse's station with a snack. V23 stated that R8 then walked back down the B hallway towards her room this was about 10:30 PM. V23 stated that around 10:50 PM one of the CNAs answered the phone and the caller asked if the facility was missing anyone that they had seen someone walking down the street in all black with a walker. V23 stated a staff member went to the front door and a citizen pulled up with R8 in the car. V23 stated that the citizen stated that R8 was two streets over when she saw R8. V23 stated that R8 stated that she went out B door. V23 stated that staff opened door B and the alarm did not go off so they called the maintenance man and blocked the door so no one else could get out of it. V23 stated that the staff shut the lights off at shift change. V23 stated she is not aware of the policy for exit seeking residents but was told what to do after R8 go out of the building. Facility provided Event Report dated 5/11/2024 documents event date as 5/11/2024 at 11:26 PM. This document documents R8 was found about approximately one block north of the facility, R8's mental status as confused and other-possible urinary tract infection. On 5/14/2024 at 2:00 PM observations of the outdoor environment noted the sidewalk outside exit door B contains contained sloped areas and uneven sidewalk. The street in front of facility is found to be uneven, contains loose gravel in areas and numerous potholes. The street does not have a sidewalk and ditches are noted to be deep. On 5/14/2024 at 12:20 PM V14, Director of Nursing, DON stated that R8 was more confused than her normal on the night of 5/11/2024. V14 stated that R8 typically goes to her room after supper and stays there the rest of the night. V14 stated that around 10 PM R8 was given snacks and then R8 walked back down towards her room (down B hall). On 5/13/2204 at 1:00 PM V14 stated that on the evening of 5/11/202,4 R8 said she was going home when R8 was found outside. On 5/13/2024 at 8:35 AM V1, Administrator, stated that R8 was found outside the building by a citizen this weekend. V1 stated that R8 told the staff that she went outdoor B, and the staff said the alarm did not go off. V1 stated they depend on the door alarms to tell us if someone is exiting. On 5/14/2024 at 10:06 AM V1 stated that around 11:00 PM R8 was brought back to facility by a citizen driving by the facility. V1 states R8 was found by this person at the 4-way intersection standing next to the stop sign. V1 stated that the citizen put R8 in her personal car and drove her back to the facility. V1 stated that this citizen called the facility and asked if the facility was missing anyone. V1 stated that 3 aides when out to the car and assisted R8 into the building. V1 stated that R8 has had exit seeking behavior that night before this occurred. V1 stated R8 exited building out B door and that staff said the alarm was not sounding. V1 stated We don't know how she got out because no alarms were sounding. V1 stated the door alarms were not working correctly. V1 stated she was not aware of R8 exiting out B door earlier in the shift. V1 stated that the Door B alarm was not working. V1 stated 15-minute checks were initiated after R8 was found outside, wander guard applied, and all exit doors were all checked that night. On 5/14/2024 at 10:24 AM V24, Maintenance Director, stated that he received a call from the facility on 5/11/2024 around 11PM and said that door B was not alarming. V24 stated he arrived at the facility and went to check door B. V24 stated that door B has two alarms on it, one that can only be cancelled with putting the code in the keypad and one that is battery operated. V24 stated the lights in the hallway were shut off and he noticed that the exit light above door B was not lit up and that the keypad was not lit up. V24 stated he pushed Door B open, and no alarm sounded, so he checked the battery-operated alarm and replaced the battery on it. V24 stated that alarm then sounded when he opened the door. V24 stated that he discovered that the keypad alarm to that door is disabled when the hall lights are shut off. V24 stated he checks the door alarms for proper functioning every week and that door B worked fine on Tuesday of this week. V24 stated that the keypad alarm is connected to the alarm panel at the nurse's station and sounds an alarm at the nurse's station. V24 stated that he does not have the battery-operated alarms on any kind of checks and does not regularly check batteries on theses alarms. On 5/15/2024 at 8:47 AM V24 shut light off down A hall and opened exit door with no alarm sounding. V24 stated that he was not aware of the door alarm not sounding when door A was opened while the lights are off. V24 stated that door A does not have a backup battery alarm attached to it. On 5/15/24 at 5:40 AM, V31, CNA, stated, On of my coworkers did a bed check on her. She gave her a bag of chips and then (R8) went back to her room. Later I answered the phone and the person asked if we were missing someone. I said I don't think so but let me check. She told me it was a lady, wearing all black, and she had a walker. I let my coworker (unidentified) know about the call. It took us about 5 minutes, and we figured out that it was (R8). I let the caller know and they brought her back. (R8) stated that she was fine, went out the back door, and didn't fall by the grace of God. She does exit seek. We try to redirect her. We will get her a snack. We will bring her up to the nurse's station and she sits with us. On 5/14/24 at 6:00 PM, V34, CNA stated that she did not know the B hall exit door was turned off when the lights were turned off and a battery powered alarm was secondary. V34 further stated that the lights are usually turned off around 9:00 PM. On 5/15/24 at 5:40 AM, V31, CNA, stated that she did not know the B hall exit door was turned off when the lights were turned off and a battery powered alarm was secondary. On 5/15/24 at 5:45 AM, V32, CNA stated that she did not know the B hall exit door was turned off when the lights were turned off and a battery powered alarm was secondary. On 5/15/24 at 9:00 AM, V4, CNA, stated that she did not know the B hall exit door was turned off when the lights were turned off and a battery powered alarm was secondary. On 5/15/2024 at 9:42 AM, V1 stated that V24 made her aware last night that door A hall exit door does not alarm when lights are off and door is opened. On5/14/2024 V13 stated that the staff shut the lights off on the hallways around shift change 10pm On 4/14/2024 at 3:35 PM V10, Social Service Director, stated she was not aware that the exit door B alarm did not work when the lights are shut off. On 5/14/2204 at 3:42 PM V3, Licensed Practical Nurse stated that she was not aware that the door alarm did not work down hall B when the lights are off. On 5/14/2024 at 3:35pm V1 stated she knew earlier this week that the exit door B alarm did not work when the lights are off. On 5/14/2024 at 3:40pm V27, CNA, stated that she was not aware that door B alarm did not sound when the lights are off on the hallway. On5/14/2024 at 3:40pm V28, CNA stated she knew on Sunday 5/12/2024 that the alarm on door B did not work when the lights are shut off, but that maintenance came in and fixed it so that it works now. On 5/14/2024 at 3:30 PM V25, CNA stated that he was not aware that the exit doors on the hallway do not alarm when the lights are shut off on the hallway. On 5/14/2023 at 3:00pm V14, DON, stated she was not aware that door B alarm did not work when the lights are turned off. On 5/13/2024 1:00pm V1 stated that on 5/11/12024 when R8 got out the Door B alarm was not sounding and that the staff trust the alarms to tell them when a resident is exiting. On 5/15/2024 at 8:47 AM paper sign taped to wall next to light switch states DO NOT SHUT LIGHTS OFF (even at night) on hall A and Hall B. On 5/14/2024 at 10:24 AM V1 and V24 stated they do not have a policy on checking exit doors. On 5/13/2024 at 10:45 AM V10, Social service Director, stated that they really don't have any systems in place to monitor doors, that doors have alarms, and everyone should be aware. V10 stated everyone should be aware of re-directing residents that are attempting to exit doors. V10 stated it is that way for all shifts. V10 stated that if the resident tells the CNA they are leaving the CNA should tell the nurse so the nurse can prepare meds for leave if needed. V10 stated that cognitively impaired residents are assessed upon admission and quarterly for exit seeking. V10 stated that if residents experience wandering/exit seeking behavior between quarterly assessments the floor staff are to document that behavior. V10 stated if the resident is found to be exit seeking the resident will get a wander guard. V10 stated the wander guard alarm is only on the front door but all other exit doors have alarms. V10 stated that R8 walks with a walker and has had no previous exit seeking behavior. On 5/14/2024 at 10:06 AM V1 stated that if staff were aware of R8 actively exit seeking that she expects staff to monitor her more closely. V1 stated that she defines monitoring as making sure that R8 is here, that they know her whereabouts and possibly initiated 15-minute checks. On 5/14/2024 at 12:20 PM V14 stated that she expects staff to keep residents who are exit seeking, in view at all times and put wander guard alarm on them. On 5/15/2024 at 11:01 AM V26, R8's Physician, stated that the elopement on 5/11/2024 of R8 shouldn't have happened, that she was not even aware of R8's elopement until Sunday 5/12/2204 when the facility called to report R8's increased confusion and V26 sent R8 to the hospital. V26 stated that R8 has significant dementia and R8's safety is at risk because the street in the front of the facility is very busy. V26 stated she expects the facility to have systems in place to supervise R8 so that R8 does not exit facility unsupervised. Facility provided policy dated 1/2018 titled Elopement prevention policy documents that door alarms will be checked daily by maintenance for function. This document states the facility will provide a safe and secure environment for the resident. On 5/2/2024 at 9:00am V1, Administrator, stated she expects her staff to supervise residents and know if they are leaving the building. The facility's matrix, dated 5/1/2024, documented that there were 71 residents residing in the facility. The Immediate Jeopardy that began on 4/28/2024 was removed on 5/16/2024. When the facility took the following actions to remove the immediacy. 1.) V24, Maintenance Director, contacted the Door Alarm company, and the technician was onsite on 5/15/2024. The corridor light switch to A and B hall that controlled door alarm power and lights down A and B hallway was removed to prevent the power to door alarm from being disengaged. 2.) Door backup power system identified as not being on circuit for the generator. Electric Company on site on 5/16/2024 to connect door alarm power to generator panel. 3.) V24, Maintenance Director, and Door alarm company technician checked all doors to ensure they were working properly and that alarms sounded as designed on 5/15/2024. 4.) Facility elopement policy reviewed and updated 5/16/2024 to have doors check daily. V24, Maintenance Director, will check door alarms per facility policy daily. Nurses will check door alarms at the beginning of every shift. 5.) All residents were re-assessed for accuracy on 5/16/2024 by V1 (administrator), V14 Director of Nursing, V40, Assistant Director of Nursing, and V10 Social Service Director, to identify residents who are at risk for elopement including residents that require supervised leave. Assessments were completed for all residents who have been identified as at risk based on the completed assessments. Revision to all identified residents' care plans to include person-centered interventions. 6.) Facility elopement policy reviewed and updated by V42 Regional Director and V1 Administrator on 5/16/2024 regarding residents at risk for elopement and what staff are to do if residents display exiting seeking behaviors or verbalize the desire to leave. 7.) V24, Maintenance Director, educated by V1 Administrator on checking door alarms daily to ensure they are in good working order on 5/16/2024. 8.) Nursing staff educated by V14 Director of Nursing and V40 Assistant Director of Nursing on checking door alarms at the beginning of every shift to ensure they are in good working order on 5/16/2024 or prior to their next scheduled shifts. 9.) All staff working in the facility were in serviced on safety and supervision of residents, code yellow/missing resident, work order process, elopement and door alarm checks by V14 Director of Nursing and V40 Assistant Director of Nursing and V1 Administrator on 5/16/2024 or prior to their next scheduled shifts. 10.) Education to Licensed staff in the facility on completion of elopement observations and implementation of appropriate intervention if at risk by V14 Director of Nursing and V40 Assistant Director of Nursing and V1 Administrator on 5/16/2024 or prior to their next scheduled shifts. 11.) All staff will be trained during the orientation and quarterly for 1 year regarding missing resident policy and door alarm response procedure.; Ensure all staff are trained in these new policies and procedures. 12.) The facility will implement compliance adherence during quarterly QA meetings. The facility provided an abatement plan on 5/16/2024 at 11:50am to remove the immediacy. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 5/16/2024 at 1:15pm. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 5/16/2024 at 1:50pm and the survey team accepted the abatement plan on 5/16/2024 at 2:15pm. The immediate jeopardy was determined to not be removed on 5/16/24 upon review of the implementation of the facility's abatement plan. The surveyor confirmed through observation, interview, and record review that the facility did not implement staff in serviced and knowledge of Code Yellow, elopement. The survey team returned on 5/23/24 and verified that the immediate jeopardy was removed. The surveyor confirmed through observation, interview, and record review that the facility re in-serviced staff and confirmed knowledge of Code yellow, elopement procedures.

Based on observation, interview and record review, the facility failed to use alternatives to bed rails, and assess and monitor for risks including injury and entrapment related to the use of bed rails for 3 of 3 residents (R7, R10 and R6) reviewed for bedrails in the sample of 11. This failure resulted in an Immediate Jeopardy when R7's right arm was caught in the bedrail during care resulting in R7's fractured arm and decline in R7's overall physical condition. In addition, R10 was observed several times with her arm through the right bedrail on her bed. R10's documented history of dementia with behavior disturbances, hallucinations, and psychiatric history put R10's entrapment of her right arm through the bedrail at an increased risk of injury. The Immediate Jeopardy began on 4/21/24 when during care, R7's right arm was caught in the bedrail and R7 sustained a closed distal fracture to R7's right humerus. R7 had a known history of grabbing the siderail with a death grip. R7's Care Plan documents to ensure bed rails are padded to prevent injuries. R7's Assessment did not address any risks related to bed rail use. V1, Administrator, V12, Director of Nursing, V10, Social Service Director, V43, Regional Director of Operations and V44, Regional Clinical Director was notified of the Immediate Jeopardy on 5/21/24 at 11:43AM. The surveyor confirmed by observation, record review, and interview that the Immediate Jeopardy was removed on 5/23/24, but noncompliance remains at Level Two while the facility continues to educate all staff and evaluate the effectiveness of the in-service training. Findings include: 1. R7's undated Face sheet documents R7 was readmitted on [DATE] with a diagnoses of dementia, primary osteoarthritis right and left knee, age related osteoporosis, dorsalgia, unspecified hearing loss, history of falling, dependence on wheelchair, contracture of muscle, multiple sites, contracture, left and right hip, left and right knee, unspecified fracture of shaft of humerus, right arm, sequela, and dysphagia. R7's Physician Order Report dated 11/19/2018-5/13/2024 does not document an order for bedrails. R7's Progress Notes dated 4/21/24 at 5:21PM documents: staff called writer to res (resident) room stating that while changing and dressing res before dinner, she hooked her arm in the bed rails when turning and there was a pop. Writer went to assess and found res laying in the bed on her left side, there is a large area between the right shoulder and right elbow to be raised about 2 inches. Res is able to move fingers. Does not appear to be in pain; does not appear to be in distress. Ambulance was called and res is being send to ER for eval and tx (treatment). Writer left message for POA as there was not answer. Writer spoke with emergency contact and informed of above. He states he will meet res at ER. Ambulance provider en route to transport. R7's Minimum Data Set, dated dated dated [DATE] documents R7 has short- and long-term memory problems, Brief Interview for Mental Status is left blank, and severely impaired decision making. The MDS documents R7 uses wheelchair with no impairment to upper extremities and impairment on both sides of lower extremities and is dependent upon staff for activities of daily living. R7's MDS further documents R7 requires substantial/maximal assistance for rolling left and right. R7's Care Plan dated 4/18/24 documents an approach start date of 10/6/2022 I prefers to have upper bilateral 1/4 rails up while I am in bed to reduce anxiety so I can assist myself when I am able with turning and repositing. The Care Plan further documents an approach start date of 10/5/2022 Siderails: 1/4 up x2 to enable bed mobility. I lay on the very edge of my bed. I even scoot down past my rails or with my head down towards the foot board. On 7/8/2022 an approach to talk to me while providing care. There are no risk versus benefits documented for the use of R7's. The 4/21/24 Approach documents to ensure bed rails are padded to prevent injuries (Day of injury). R7's Most recent side rail Assessment, dated 1/6/24, documents type of slide rails indicated: both to allow for increased bed mobility, safety risk with use of side rails none. There is no side rail assessment for the quarterly 4/2/24 reporting period. R7's Progress Notes dated 4/21/24 documents R7 went out to hospital per family preference after R7 had hooked her arm in the bed rails when turning and there was a pop and returned on 4/22/24 with a closed displaced fracture on the shaft of the right humerus. R7's emergency room Radiology report dated 4/21/24 documents: History: Patient rolled in bed and arm caught in rail. Obvious deformity. Findings: There is an overriding apex laterally angulated midshaft fracture of the humerus. The proximal humerus is not visualized in entirety given the patients limitation with positioning. Distal humerus on a single view is grossly unremarkable. Impression: Suboptimal position given patients body habitus however there is a overriding angulated midshaft humeral fracture. R7's emergency room record documents R7 was treated for a closed displaced transverse fracture of the shaft of the right humerus and received 2mg (milligrams) Morphine IVP (intravenous push), 50mcg (micrograms) Fentanyl IVP and Zofran 4mg IVPR. R7 was sent back to the facility with hydrocodone/acetaminophen liquid 10mg/325mg/15ml, take ten (10) ml orally every 6 hours for 3 days. R7's Facility Reported Incident Report dated 4/22/24 documents, the caregiver stated that they were providing incontinent care and depressing the resident to go to the dining room for dinner. The resident's arm had slipped between the siderail and her mattress. The CNA (Certified Nurse's Assistant) stated they heard a pop from residents' arm. Upon immediate assessment by the RN, a 2 cm raised area was noted between the resident's right shoulder and R7's elbow. R7 displayed no signs of pain or discomfort during assessment. MD was notified of incident and orders were received to send to ER for further assessment of resident injury. R7's Power of Attorney was notified and stated would meet resident at the ER. The ambulance was then called for transport. R7 returned to the facility at approximately 9:00PM with diagnosis of a closed, displaced fracture of the shaft of her RT (right) humerus. R7 had a splint in place an new orders for pain medication. R7 received pain medication while she was in the hospital. R7 has a follow up appointment with Ortho MD in 1 week. R7's Witness documentation, undated include an undated statement from V25, CNA documents I (V25) checked and changed her (R7) by myself. (V34, CNA) was walking by when I asked for help for the transfer. We started transfer with (V34) on residents left and I was on her rights. I had her cradled with her arm around me when we went to lift up and we heard a snap. V34 went and got nurse. R7's Witness documentation dated 4/21/24 written by V34 documents I was asked by (V25) to help transfer a resident to her wheelchair. We had her on the side of the bed about t transfer when the arm she had around V25 (her right) grabbed for the siderail, but her arms was stuck, and we heard a pop. We immediately laid her down while V25 supported her arm, and I went and got a nurse. R7's Witness documentation, undated, statement from V41, CNA documents I walked in with the nurses saw residents' arm. I said I would assist with getting her (R7) in a gown because the nurses were on the way to send her out to hospital. R7's Progress Notes dated 4/27/24 documents pain medicine given with morning med administrations, as pain was evident upon repositioning. R7 did eat some breakfast and drank some med pass with meds. R7's Progress Notes dated 4/28/24 documents pain medicine given with morning med administration, as pain continues to be evident upon repositioning. R7's Progress Notes dated 4/30/24 documents .splint intact to RUE. Noted edema to right arm. R7's Progress Notes dated 4/30/24 documents .medicated for pain this am, splint in place. arm swollen and discolored . R7's Progress Notes dated 5/2/24 and 5/4/24 documents R7 arm remains edematous and discolored. R7's Progress Notes dated 5/5/24 documents: Tylenol given for slight temp tonight. R7's Progress Notes dated 5/6/24 documents R7 not responding as normal. BP (blood pressure) 117/62, P (pulse) 104. Daughter notified of change in condition. R7's Progress Notes dated 5/7/24 documents at 1:20PM, R7 still not responding well. Holding food and drink in her mouth. Decision made to keep resident here and just keep R7 comfortable. At 7:39PM, Progress Notes continue R7 condition appears to be declining. No response to verbal or tactile stimuli. Vitals stable. No s/s of discomfort noted. Daughter leaving at this time. To call if any changes. R7's Progress Notes dated 5/8/24 documents R7 continues to be unresponsive. Family members here this morning. R7 is unable to accept anything by mouth. Family was asking for pain medication, so writer went into room and discussed in detail why Hospice is worth consideration in this scenario. Family said they would reach out if they wished to discuss further. R7's Progress Notes dated 5/8/24 at 12:21PM, documents writer went and spoke with family about Hospice. They would like to go ahead and move forward with hospice. They would like to keep her comfortable as much as possible. Writer is working on faxing information and getting and order from the Dr. for hospice. R7's Physician Order Sheet documents on 5/8/24: hospice to eval and treat. R7's Progress Notes dated 5/8/24 at 6:58PM, R7 admitted to hospice. R7's Visit Note Report dated 5/8/24 documents: Hospice start of care. R7's Visit note further documents: indicate clinical evidence of advancing illness: change in level of consciousness, decline in systolic blood pressure relative to baseline, decreasing oral intake, recent decline in functional status, worsening vital signs. Indicate existing equipment/supplies present in the home (mark all that apply): bedrails, hospital bed, Hoyer lift, overbed table oxygen concentrator. Narrative: R7 is a [AGE] year-old female patient residing at facility coming on to service with the primary diagnosis of Alzheimer's disease secondary diagnosis of dementia co morbidity to include right humorous fracture. R7 was diagnosed with dementia and Alzheimer's approximately 5 years ago, however 2 weeks ago, patient had a fracture of her right humorous that could not be fixed surgically. R7 was returned to the nursing home. R7 has had a steady decline since patient has been NPO (nothing by mouth) for the past 2 days. Minimally responsive upon admission, R7 is now comatose, R7 lungs clear with rapid shallow respiratory rate of 40. Absent bowel sounds, heart sounds are unable to be heard. Blood pressure, unable to be taken. R7 has bilateral lower extremity mottling up to her knees from her toes. R7 had a BM (bowel movement) time 2 today, severe temporal wasting noted, patient place on 3 liters of oxygen per nasal cannula . R7's Progress notes dated 5/8/24 at 10:06pm documents R7 transitioned at 1916 with family by her side. Hospice nurse was called who then called the coroner. Granddaughter was on the way to facility so writer told hospice nurse she would call when family was ready. Funeral home was then called at 2120 and picked up at 2149. On 5/14/24 at 2:40 PM, V25 CNA, was questioned how the injury to R7's right arm occurred. V25 stated that R7 was extremely contacted with her knees bent up and her spine was like a C shape. V25 stated that he had provided incontinent care for R7. V34 CNA came in and was going to assist me with transferring her to her wheelchair. I was holding onto R7's knees because she was extremely contracted, and she was on her back. R7 had her right arm above her head, and she was holding onto the side rail. While V34 had her back turned putting on gloves. R7 then reached and pulled herself with the left arm onto the opposite side rail very quickly and then we heard a pop. V25 was asked again to explain how this happened. V25 stated that it happened very quickly. He stated that he was not sure and his explanation of what happened changed multiple times. V25 was questioned about his written statement and why his written statement did not match his explanation of events. V25 became very nervous, began sweating, stating he was beginning to have a panic attack, because the event was just so horrible, he is having PTSD (post-traumatic stress disorder) flash backs. V25 then stated that he was told to lie on his written statement of events because everyone knew that he transferred her using a dead man lift (a lift where 2 people are used, each put an arm under R7's arm and the knee.) to transfer her. V25 stated that he felt it was much safer for her because with movement she would grab onto anything she could get her hands onto. V25 stated she would grab the mechanical lift straps, one time she got one strap unhooked, she would flip around and almost throw herself out of it. V25 stated that the facility did not want to get him in trouble that is why he was told to lie. V25 stated that she was not hurt during transfer because they had not started the transfer yet because he was waiting for V34. During this conversation, V25 continued to be upset, exhibit shallow breathing, sweating and turning red. The interview was stopped to get V25 assistance for his panic attack. After the interview, it still remained unclear as to exactly what happened to R7 because R25's recollection of events kept changing. On 5/14/24 at 6:00 PM, V34 CNA stated, Before supper I was helping (V25) get R7 ready for supper. She always grabs the side rail. She was on her back. She puts her arm through the side rail but we were getting ready to sit her up so we could transfer her. V25 had (R7) up to about a 30-to-40-degree angle. She wasn't all the way up yet. I was at the foot of the bed. I looked down for a second. I was fixing my pants or my shoe. I then heard a pop. I guess she threw her arm in there and moved and then it popped. I did not have my back turned. I was not putting on gloves. (R7) always uses the dead man carry lift to transfer. She is just unsafe for the full mechanical lift. She moved around so much, and she would grab onto anything. I was told that Physical Therapy made her a dead man lift. On 5/14/24 at 2:50 PM, V14, Director of Nurses, stated, (V25 and V34) told me they were changing (R7), and she got a hold of the side rail and then she rolled, and the arm popped. (R7) was a (full mechanical lift) with 2 people. I never heard they were dead man lifting her. I would not be ok with that. On 5/17/24 at 9:59AM V14, Director of Nursing stated she wasn't here when R7's fractured arm occurred. V14 stated she was told that R7 was in bed and two staff members were changing R7 and when they went to turn R7, they heard a pop. V14 stated R7 was known to grab rails even when she was sleeping and had a death grip on the side rails. V14 stated she guessed there was risk of R7 having side rails with her grabbing them and not letting go was injury or entrapment. V14 stated she was unaware that V25, CNA was told to lie on the incident report. V14 stated she expects the risk versus benefits to be assessed and documented. On 5/21/24 at 9:20AM, V1, Administrator stated she did not interview anyone else for R7's investigation and she probably should have. V1 stated she just believed what staff said. On 5/13/24 at 10:25 AM, V14, Director of Nurses, stated R7 was [AGE] years old, total care and had been that way for a while. V14 was questioned if she knew R7's admitting diagnosis for hospice since she was recently admitted to hospice and past on 5/8/24, V14 stated, I don't know but since the break she just went downhill. On 5/13/24 at 3:00 PM, V18, Registered Nurse (RN), stated, (R7) was total care and dependent on staff. I was here when her arm was broken. The CNA came running to me stating We need you. We think her arm is broken. She was lying on her left side. It was evident that her arm was broken. They told me that it happened while getting her up. She had a habit of wrapping her arms around the side rail. I think it was for security. I think her arm was caught in the side rail. I called her family and 911 immediately to get her to the hospital. I honestly can't say if her fracture exacerbated her death. On 5/14/24 at 9:10 AM, V2, RN, stated, I have never known (R7) to wrap her arms around the side rails. She would grab onto them. I think the CNAs might have gotten too forceful in removing her hand or it happened while turning her in bed. Ever since I have worked there, (R7) has always been picked up by 2 staff on each side of her. She was very light and contracted. A (mechanical lift) has never been used on her. I think a lift would have been more dangerous because the way she grabbed, flipped, and her contractures. R7 had been stable for the past 6 months. She came back from the hospital with pain. It was very painful for her. She did have Norco for the pain which helped. She very quickly declined, went on hospice, and passed away. I was afraid we would not get her on hospice fast enough to even help her. On 5/15/24 at 5:15 PM, V2 stated that R7 had 1/4 side rails when the fracture happened, and the side rails remained on her bed after her return. V2 stated that when R7 returned from the hospital she was in a lot of pain. On 5/16/24 11:25AM V39, Certified Nurse Assistant (CNA) stated she cared for R7 and knew her well. V39 stated R7 has always had side rails on her bed and is not aware of any alternative to the side rails that have been tried. V39 stated she put mesh padding on side rails once by herself because R7 always had a death grip on side rails, but R7 was still able to get through to grab the side rails so it didn't last long. V39 stated R7 always found her way to grab the side rails. V39 stated because R7 had a death grip on the side rails you needed to verbally cue her multiple times, take your time with her. V39 stated she felt R7 was scared with rolling and that's why she always was hanging on side rails. V39 stated everyone in the building except one resident has side rails. V39 stated there has been no other interventions put in place prior to side rail use. On 5/16/24 at 11:40AM, V18, Registered Nurse stated she cared for R7 routinely and the side rails have been on her bed as long as I can remember, and she has worked here for years. V18 stated there have been no alternative to side rail that was attempted that she is aware of. V18 stated R7 rolled around on her. V18 stated R7 was always hanging on the bedrail all the time. When asked if R7 was at risk for entrapment in the side rail, V18 stated she guessed it could happen to anybody- then stating, I'm sure that could happen. On 5/16/24 at 1:37PM, V28, CNA stated R7 had side rails up the whole time she was here and had a firm grip. V28 stated R7 was a 2 person Hoyer lift. V28 stated there were no alternatives to help turn and reposition R7 but that covers were put on and didn't help, R7 found her way around them to grab side rails. On 5/17/24 at 10:19AM, V1, Administrator stated R7 was being provided care from V25, CNA and when they rolled R7, V25 was cradling R7 and R7's arm was over V25's head and they heard a pop and R7 's arms had been caught in the side rails while positioning her. V1 stated R7 used the side rail and held on for dear life and that staff would sometimes have to pry R7's hands off the siderail. V1 stated knowing R7's history, staff should put a pillow or something to prevent R7 from grabbing side rails during care, or in a perfect world, put the side rail down while providing care. V1 stated she was not aware that V25 told the survey team that he was instructed to lie about his written statement and what happened with R7 and that they should know better than that.V1 stated there are known risk associated with side rails use such as entrapment and the facility is only approved for quarter rails and V1 expects assessments for side rails to be accurately and completely filled out. V1 further stated she expects staff to intervene when a resident arms or legs are in a siderail. On 5/15/24 at 10:38 AM, V1, Administrator, stated that R7 does not have a Side Rail Assessment and has never had a Side Rail Assessment completed. V1 further stated that a resident should have a Side Rail Assessment upon Admission and then quarterly. 2. R10's undated Face sheet documents R10 was admitted on [DATE] with a diagnoses dementia with other behavioral disturbances- with hallucinations polyosteoarthritis, age related physical debility, history of fall, mixed receptive-expressive language disorder. R10's Physician Order Report dated 4/21/2024-5/13/2024 does not document an order for side rails. R10's Progress Notes dated 3/1/24 at 1:50PM documents R10's medical doctor notified of increased agitation/hallucinations during the evening ad night. R10 noted to scream that someone is in her room trying to kill her and take her things. Noted to throw things in her room. Comes out to hall yelling for help to get them out of her room. R10's Minimum Data Set, dated dated dated [DATE] documents R10 has short- and long-term memory problems, Brief Interview for Mental Status was unable to be completed, moderately impaired decision making, and the ability to understand others is coded a 2: sometimes understands. The MDS documents R10 has behavior symptoms directed towards others and that R10's current behavior status as a two (2): worse. The MDS further documents R10 uses a walker and wheelchair with no impairment to upper extremities and impairment on both sides of lower extremities and is independent with rolling left and right in bed. R10's Care Plan dated 3/28/24 documents to keep environment free of clutter and obstacles to reduce risk of injury with a start date of 4/30/24. R10's Care Plan further documents behaviors symptoms: resident exhibiting problems as seen by making disruptive sounds, hallucinations and delusion, pressure ulcer/injury: ensure proper body alignment when in bed or chair to reduce pressure, activity of daily living function status: start date 10/12/22 siderails: 1/4 rails up as per doctors' orders for safety during care provision to assist with bed mobility. Observe for injury or entrapment related to side rail use. I need to have 1/4 siderails x2 up to assist me with getting around my bed. R10's Most recent Side Rail assessment dated [DATE] documents type of side rails indicated: both to allow for increased bed mobility, safety risk with use of side rails none. There is no side rail assessment for the quarterly 4/2/24 reporting period. On 5/16/24 at 1:45PM, R10's door was shut. Upon entry with V28, CNA, and V39, CNA, R10 was observed to be laying in her bed and her right arm was through the right-side rail. R10's body was adjacent to the side rail and the side rail was all the way up to R10's shoulder. R10 began moving and extending her right arm to point at an object in her room though the side rail. V28 stated they keep R10's door shut all the time because she hallucinates and yells out. R10 stated she didn't have lunch and that people were trying to kill her. V28 went and got R10 ice cream and redirected R10 multiple times to move her (R10's) arm through the side rail to hold the ice cream. On 5/17/24 at 7:53AM, R10 was in her bed with her right arm through the side rail up to her shoulder eating breakfast with her right hand. R10 requested staff assistance and this surveyor went to get V2, Registered Nurse. V2 checked on R10 and R10 was confused about where her stuff was. When asked if R10 was normally positioned with her right hand through the side rail, V2 stated that he had seen R10 like that before. V2 stated the side rails would be a risk for R10 due to her cognition and psychiatry/behavior history and that any object is a risk to her, stating R10 has pulled all the baseboards off, and it wouldn't surprise me if she had a drawer pulled apart even. During this time, it was noted R10's baseboards were gone. On 5/16/24 at 3:10PM R10's side rails were measured at 17 3/4 inches wide and 3 1/2 inch tall, and the bottom portion as 22 3/4 inch wide and the top 3 1/2 inch wide. On 5/17/2024 9:46AM V40, Assistant Director of Nursing stated she just took this position and started 5/13/24. V40 stated every occupied bed in facility has siderails and thinks they are 3/4 rails. V40 stated risk of having side rails could be getting stuck in between, ones that can't or are not independent, and that limbs and head can get stuck. V40 stated she is not aware of alternatives to the side rails due to just starting. On 5/17/24 at 9:59AM V14, Director of Nursing she expects the risk versus benefits to be assessed and documented. V14 stated she came from the hospital, so she didn't realize you needed an assessment for side rails. V14 stated R10 has a lot of psych issues and is schizophrenic and she expects staff to move R10's or any residents arm out of the side rail if they saw that. V14 further stated R10 can get agitated but she expected staff to redirect R10 and assist R10 to scoot over in bed away from side rail. On 5/17/24 at 10:19AM, V1 Administrator stated there are known risk associated with side rails use such as entrapment and the facility is only approved for quarter rails and V1 expects assessments for side rails to be accurately and completely filled out. V1 further stated she expects staff to intervene when a resident arms or legs are in a siderail. V1 stated R10 does whatever she wants and sometimes it is hard to redirect her, but she still expects staff to ensure she is safe. V1 state the side rails are a risk to R10. On 5/21/24 at 3:45PM, V1 stated the facility reassessed R10 for side rails use and according to their assessment R10 should have never had side rails on to begin with. On 5/16/24 at 9:30 AM, V1, stated that she is unable to locate a side rail policy. V1 stated, I have had 4 people working on it since yesterday afternoon and they still cannot locate one. On 5/17/2024 9:35AM V1 was asked again if the facility had a side rail policy and V1 stated they do not have a policy on siderails. The facility provided an abatement plan on 5/21/2024 at 1:20pm to remove the immediacy. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 5/21/2024 at 1:40pm and the survey team accepted the abatement plan on 5/21/2024 at 3:35pm when the facility took the following actions to remove the immediacy: 1. V24, Maintenance Director completed bed gap measurement and assessment for entrapment zones per FDA guidance for all residents' beds with side rails. All bed rails were in compliance on 5/21/2024. 2. V24, Maintenance Director completed side rail audit to ensure they are compatible with bed on 5/21/2024. 3. V14, Director of Nursing and V10, Social Service Director audit of side rails used as a restraint or enabler with completed pre restraint assessment form, side rail assessment form, side rail usage assessment and side rail consent on all residents to ensure least restrictive alternatives on 5/21/2024. 4. V14, Director of Nursing and V10, Social Service Director audit and update care plans for residents using side rails regardless of used as enabler or restraint and for any other residents with restraints other than side rails. Care plans include medical symptoms justifying use of restraint, type of restraint used, frequency, durations, circumstances for when it is to be used, interventions to address potential or actual complications from restraints use such as increase incontinence, decline in ADLs or ROM, increased confusion agitation or depression completed on 5/21/2024. 5. V14, Director of Nursing and V10, Social Service Director audit completed of physician orders for side rails and correct as needed to include medical symptom being treated, type of restraint, frequency of releasing the restraint completed on 5/21/2024. 6. V43, Regional Director and V44, Regional Director reviewed and updated Bed Rail Maintenance and Installation and Entrapment Prevention, Restraint Reduction Program, Restraint Policy, and Restraint Usage Guide. 7. Education to clinical staff currently in the facility on 5/21/2024 conducted by V1, Administrator, V14, Director of Nursing and V10, Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide. 8. Education to V24, Maintenance Director completed on 5/21/2024 by V56, Corporate Director of Environmental Services. Education Plan: 1. Education to clinical staff currently in the facility on 5/21/2024 conducted by V1, Administrator, V14, Director of Nursing and V10, Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide. 2. Education to all clinical staff prior to next working shift conducted by V1, Administrator, V14, Director of Nursing and V10, Social Services Director on Restraint Policy, Restraint Reduction Program, and Restraint Usage Guide. Education to V24, Maintenance Director completed on 5/21/2024 by V56, Corporate Director of Environmental Services. QA component: 1. V24, Maintenance Director will complete bed gap analysis quarterly and whenever new enabling or restraint device applied. 2. V14, Director of Nursing will complete audit of small sample of resident daily x 1 week, 2x a week x 2 weeks and weekly for 3 months to ensure resident safety with enablers or restraints, care plan current, physician orders current and appropriate documentation in place. 3. V1, Administrator will review audits weekly to ensure compliance. The immediate jeopardy was determined to not be removed on 5/22/24 upon review of the implementation of the facility's abatement plan. The surveyor confirmed through observation, interview, and record review that the facility did not implement appropriate measurements of Zone 1 of the siderails. The survey team returned on 5/23/24 and verified that the immediate jeopardy was removed. The surveyor confirmed through observation, interview and record review that the facility appropriately measured zone 1 in the siderails. 33112 3). R6's Resident Face Sheet, undated, documents that R6 was admitted on [DATE] with diagnoses of Dementia with Anxiety and Weakness of the Left Side. R6's Minimum Data Set, dated dated [DATE], documents that R6 is severely cognitively impaired, is dependent on staff for all mobility, activities of daily living, does not ambulate and does not have a pressure ulcer. On 5/15/24 at 9:00 AM, V4 Certified Nurses Aide (CNA), stated that on 5/1/24 she transferred R6 to bed by herself and did not hit R6's leg on the side rail. On 5/16/24 at 9:30 AM, V1, Administrator, stated that R6 did have 1/4 side rails on before she went to the hospital, R6 did not have a Side Rail Assessment before the side rails were place, R6 does not move in bed, and the family wanted the side rails on the bed. R6's Side Rail Use and Risk Assessment, dated 5/7/24, documents that R6 has bilateral 1/4 length side rails. Reason for Use: Resident or Legal Representative request for side rails. Purpose of side rail(s) being used for a resident who is immobile and can not voluntary get out of bed because of physical limitations. Unmarked. Resident has medical symptom(s) contributing to use of side rail(s) Unmarked. Resident factors impacting side rail use: Requires assist with transfers. Select other methods used besides side rails: None of the bed. Resident / Family/ Resident Representative Information Consent Information: Risk factors is not checked.

Based on interview and record review, the facility failed to notify the Physician of a change of condition and delay in diagnostics for 1 of 3 residents (R6) reviewed for physician notification in the sample of 11. This failure resulted in delay of treatment and pain management for R6's right distal femoral fracture. Findings include: R6's Resident Face Sheet, undated, documents that R6 was admitted on [DATE] with diagnoses of Dementia with Anxiety and Weakness of the Left Side. R6's Minimum Data Set, dated dated [DATE], documents that R6 is severely cognitively impaired, is dependent on staff for all mobility, activities of daily living, and does not ambulate. R6's Progress Note, dated 05/02/2024 at 02:00 PM, which was recorded as Late Entry on 05/03/2024 06:59 PM, documents, CNA (Certified Nurse Aide) reported swelling and tenderness noticed in residents right knee, reported to writer and floor (V18, Registered Nurse /RN) received and inserted order for knee xray. R6's Progress Note, dated 05/03/2024 at 05:30 PM, documents, Resident right knee and hip xray results received this afternoon, faxed (V29, R6's Physician) and notified (V22, R6's Power of Attorney/POA) of results, being osteoarthritis, and probable distal femoral fracture. (V30, V29's Nurse) states received results at office but (V29) had left office for day. Residents family would like resident sent to ED (Emergency Department) eval (evaluation) for another xray, eval and pain management. Writer called (local ambulance service) and (local hospital). taking resident to ED at this time with family following, paperwork sent with EMS (Emergency Medical Services). R6's Progress Note, dated 05/04/2024 03:26 AM, documents, ER (emergency room ) nurse called to inform writer that resident is being admitted for pain management and right femur fracture. The local Hospital Clinical Report, Registration Date of 5/3/24, documents, History of Present Illness: Chief complaint; right lower extremity pain. This started yesterday and is still present. Patient is a [AGE] year old female with past medical history of dementia/ nonverbal/ non ambulatory. (full mechanical lift) presenting from (the facility) with complaints of right lower extremity pain that started yesterday some time with no known injury. There was an outpatient x-ray done which showed a possible distal femur fracture. There is no known repeated fall or trauma. It documents She does endorse a lot of pain with movement of right extremity or any movement. On 5/13/24 at 1:38 PM, V16, CNA, stated, On 5/2/24 (Thursday). She (R6) was screaming in pain and holding her leg when we (V16 and V19, CNA) tried to get her up and dressed for the day. We were trying to put her pants on and once it got to her shins she started screaming. We left in her in bed. When we provided care for her during the day, she would grab leg and scream out. On 5/13/24 at 3:00 PM, V18, Registered Nurse (RN), stated, During change over from the night shift to my day shift, night shift stated that there was a little red spot and swelling on (R6's) knee. I went with (V19, CNA) I think, and I assessed her leg. She had a little swelling to her knee and quarter size red spot. I touched it and she didn't flinch. The day shift CNAs did not mention anything to me about her showing signs of pain. The evening shift 2 PM to 10 PM let me know that she was in pain. I told them to just leave her in bed and I called the Dr for an order for an X-ray. I called (the X-ray company) and they told me they would come in the morning because they were busy. She was wincing in pain at the time with movement. I did call (V22, R6's Power of Attorney (POA)) and let her know. She actually came in and looked at her knee and agreed to monitor and get X-ray in the morning. She has scheduled Ibuprofen for pain. I honestly don't know if it helped her or not. I honestly did not think that it was as bad as it was. Especially an impacted fracture, that is a lot of trauma. That is why I didn't send her to the emergency room for an X-ray. On 5/14/24 at 11:15 AM, V19, CNA stated I worked with (R6) on 4/30/24 and she was fine. I was off on 5/1/24. When I came back on 5/2/24 in report I got that she had a red mark on her right knee. I and (V9, CNA) got (R6) dressed and up for breakfast and she was fine. I didn't notice that she was having pain. After breakfast around 9 AM - 10 AM, we went to lay her back down and change her. She was making noise. I could tell she was in pain. I have worked with her enough to know her. I asked if she was in pain, and she said yes. Her knee was a little swollen. I let the nurse (V18) know. She told us to lay her down and keep an eye on it. She said that she was going to check on it too. Me, (V19), and (V17) all went to get her up for lunch. She acted like she was in more pain, and it was more swollen. I then refused to get her up. I told (V18). At supper she was still in pain. She was moaning and making noises, so we left her in bed. I left at 6 PM. On Friday she was the same. She got her X-ray around 10:45 AM. On 5/14/24 at 12:53 AM, V9, CNA, stated, On 5/2/24 I worked with either (V17 CNA) or (V20 CNA.) We were getting people up for breakfast and she was yelling 'ow'. Her knee was huge. If we stopped touching it, she would stop. I went and told the nurse (V18) On 5/14/24 at 2:55 PM, V14, Director of Nurses (DON), stated, On Wednesday 5/1/24 night, I was told by (V35 Licensed Practical Nurse/LPN) that (R6) had swelling and redness to the right knee and when (V35) assessed the knee (R6) would react. On 5/2/24, (V35) passed it onto (V18) the day nurse. (V18) came to me that (R6's) knee was swollen and that she had gotten an order for an Xray. The next morning (5/3/24) they came and took the Xray. I got the results in the afternoon. I notified (V22, R6's POA) of the probable fracture. I faxed the results to the doctor and called the doctor's office, but the nurse said he was gone for the day. (V22) came in shortly after that and she wanted to see if we could get something for pain control. Her other daughter came in (V15) and wanted her sent to the hospital for pain control and another Xray. I called for transport and sent her to the hospital. (V22) was concerned because the night before (5/2/24) she had visited and (R6) was yelling out in pain when moved and (V22) was worried it was the right hip. She had contacted me and requested a hip xray on Thursday, so I put in an order for a hip Xray to be done too. V14 was questioned as to why the physician was not notified in delay of Xray and having increased pain, V14 stated, I didn't think about it but yes the Doctor should have been notified. On 5/15/24 at 5:30 AM, V31, CNA, stated that she worked on 5/1/24 the 10 PM to 6 AM shift. V31 stated on her first bed check with R6 she noticed that was red marks to the middle of the right-side rib area, the left knee, and the right knee. At this time there was no swelling. V31 stated on the second bed check, the red mark on the rib area and left knee were gone. V31 stated the right knee was red but not hot to the touch. V31 stated at this time, R6 did not seem to be having pain. By the time the 5/2/24 day shift came in, R6's right knee was swollen and hot to the touch. V31 stated R6 was yelling out with pain with movement. V31 stated I then worked again on Thursday 5/2/24 night shift. R6 was in a lot of pain when she was rolled and provided incontinent care. The right knee was red and still swollen. On 5/16/24 at 9:30 AM, V1, Administrator, stated that the Physician should have been made aware of the R6's increased pain and the delay in Xray. On 5/16/24 at 3:02PM, V45, Medical Doctor, stated he knows he got a called on R6's fracture leg and we sent R6 to the ER and thought that the ER found it (fracture). V45 stated he can't remember the details, and this is the first kind of injury he's aware of. V45 stated he can't remember when he knew about R6's pain increasing but his (V45) reaction would be to send R6 to the emergency room . V45 stated the first V45 had heard of R6's fracture was from the ER, or maybe from his nurse or had a message to send R6's in, and that V45 couldn't recall. The facility policy Change in a Resident's Condition or Status, dated 11/16, documents, d. A significant change in the resident's physical / emotional / mental condition psychosocial status to either life threatening conditions or clinical complications. It continues, g. A need to transfer the resident to a hospital / treatment center.

Based interview and record review, the facility failed to timely treat an injury of unknown origin for 1 of 1 resident (R6) reviewed for quality of care in the sample of 11. This failure resulted in R6's ongoing pain and delay of treatment for a fractured leg. Findings include: R6's Resident Face Sheet, undated, documents that R6 was admitted on [DATE] with diagnoses of Dementia with Anxiety and Weakness of the Left Side. R6's Minimum Data Set, dated dated [DATE], documents that R6 is severely cognitively impaired, is dependent on staff for all mobility, activities of daily living, and does not ambulate. R6's Progress Note, dated 05/02/2024 at 02:00 PM, which was recorded as Late Entry on 05/03/2024 06:59 PM, documents, CNA (Certified Nurse Aide) reported swelling and tenderness noticed in residents right knee, reported to writer and floor (V18, Registered Nurse /RN) received and inserted order for knee xray. R6's Physician Order Report, dated 2/29/24 - 5/13/24, documents, Start Date 5/2/24. XRAY right knee 2 views AP (anteroposterior) LAT (lateral). Mobile r/t (related to) advanced age and immobility. Dx (diagnosis); Pain, swelling. R6's Physician Order Report, dated 2/29/24 - 5/13/24, documents, Start Date 5/3/24. Rt (right) Hip: Special Instructions: Right Hip Xray-pain. Portable due to advanced age and immobility. Dx: Pain. The facility acquired X-ray, dated 5/3/24, documents, Impression: Probable distal (away from body) femoral (thigh bone) fracture with effusion (fluid collection) presumably acute (recent onset). R6's Progress Note, dated 05/03/2024 at 05:30 PM, documents, Resident right knee and hip xray results received this afternoon, faxed (V29, R6's Physician) and notified (V22, R6's Power of Attorney/POA) of results, being osteoarthritis, and probable distal femoral fracture. (V30, V29's Nurse) states received results at office but (V29) had left office for day. Residents family would like resident sent to ED (Emergency Department) eval (evaluation) for another xray, eval and pain management. Writer called (local ambulance service) and (local hospital). taking resident to ED at this time with family following, paperwork sent with EMS (Emergency Medical Services). R6's Progress Note, dated 05/04/2024 at 03:26 AM, documents, ER (emergency room ) nurse called to inform writer that resident is being admitted for pain management and right femur fracture. The local Hospital Clinical Report, Registration date of 5/3/24, documents, History of Present Illness: Chief complaint; right lower extremity pain. This started yesterday and is still present. Patient is a [AGE] year old female with past medical history of dementia/ nonverbal/ non ambulatory. (full mechanical lift) presenting from (the facility) with complaints of right lower extremity pain that started yesterday some time with no known injury. There was an outpatient x-ray done which showed a possible distal femur fracture. There is no known repeated fall or trauma. It documents She does endorse a lot of pain with movement of right extremity or any movement. The Hospital Radiology Report, dated 5/3/24, documents, Exam: CT (Computed Tomography) of the right knee. Impression: There is a mild impaction type fracture of the lateral (outside) femoral (thigh) condyle (the end of the thigh bone which connects to the knee). R6's Hospital Discharge Summary, dated 5/7/24, documents, Non weight bearing on Right lower extremity, right knee immobilizer for 6 weeks recommended per orthopedics while in Emergency Department. On 5/13/24 at 1:38 PM, V16, CNA (Certified Nursing Assistant), stated, (R6) is dependent on staff for all cares. She transfers with a (full mechanical lift). I work the day shift 6 AM to 2 PM. On 4/30/24 she was fine. I was off on 5/1/24. When I came back on 5/2/24 (Thursday), she was screaming in pain and holding her leg when we (V16 and V19 CNA) tried to get her up and dressed for the day. We were trying to put her pants on and once it got to her shins she started screaming. The knee was extremely swollen. I went and told the nurse. I don't remember who it would have been the nurse on A hall (V18, Registered/RN). I work a lot. We left in her in bed. When we provided care for her during the day, she would grab leg and scream out. I think they sent her out by Friday. On 5/13/24 at 2:34 PM, V13 CNA, stated, (R6) requires total care. She has minimal speech. I believe it was Thursday (5/2/24) that I worked with her. She would make facial grimaces with cares. We were told to leave her in bed. Her knee was swollen with a small bruise that was forming. On 5/13/24 at 3:00 PM, V18, Registered Nurse (RN), stated, During change over from the night shift to my day shift, night shift stated that there was a little red spot and swelling on (R6's) knee. I went with (V19, CNA) I think, and I assessed her leg. She had a little swelling to her knee and quarter size red spot. I touched it and she didn't flinch. The day shift CNAs did not mention anything to me about her showing signs of pain. The evening shift 2 PM to 10 PM let me know that she was in pain. I told them to just leave her in bed and I called the Dr for an order for an X-ray. I called (the X-ray company) and they told me they would come in the morning because they were busy. She was wincing in pain at the time with movement. I did call (V22, R6's Power of Attorney (POA)) and let her know. She actually came in and looked at her knee and agreed to monitor and get X-ray in the morning. She has scheduled Ibuprofen for pain. I honestly don't know if it helped her or not. I honestly did not think that it was as bad as it was. Especially an impacted fracture, that is a lot of trauma. That is why I didn't send her to the emergency room for an X-ray. On 5/14/24 at 11:15 AM, V19, CNA, stated, stated, I worked with (R6) on 4/30/24 and she was fine. I was off on 5/1/24. When I came back on 5/2/24 in report I got that she had a red mark on her right knee. I and (V9, CNA) got (R6) dressed and up for breakfast and she was fine. I didn't notice that she was having pain. After breakfast around 9 AM - 10 AM, we went to lay her back down and change her. She was making noise. I could tell she was in pain. I have worked with her enough to know her. I asked if she was in pain, and she said yes. Her knee was a little swollen. I let the nurse (V18) know. She told us to lay her down and keep an eye on it. She said that she was going to check on it too. Me, (V19), and (V17) all went to get her up for lunch. She acted like she was in more pain, and it was more swollen. I then refused to get her up. I told (V18). She went down and assessed it. She said that she was going to get an X-ray. At supper she was still in pain. She was moaning and making noises, so we left her in bed. I left at 6 PM. On Friday (5/3/24) she was the same. She got her X-ray around 10:45 AM. On 5/14/24 at 12:53 AM, V9, CNA, stated, On 5/2/24 I worked with either V17 CNA or V20 CNA. We were getting people up for breakfast and she was yelling ow (sic ouch). Her knee was huge. If we stopped touching it, she would stop. I went and told the nurse (V18), and she came down and looked at it and said she would notify the doctor. The next thing I know is she was sent out. We didn't get her up for any meals. On 5/14/24 at 2:55 PM, V14, DON (Director of Nursing), stated, On Wednesday 5/1/24 night, I was told by V35 Licensed Practical Nurse (LPN) that (R6) had swelling and redness to the right knee and when (V35) assessed the knee (R6) would react. On 5/2/24, (V35) passed it onto (V18) the day nurse. (V18) came to me that (R6's) knee was swollen and that she had gotten an order for an Xray. The next morning (5/3/24) they came and took the Xray. I got the results in the afternoon. I notified (V22, R6's POA) of the probable fracture. I faxed the results to the doctor and called the doctor's office, but the nurse said he was gone for the day. (V22) came in shortly after that and she wanted to see if we could get something for pain control. Her other daughter came in (V15) and wanted her sent to the hospital for pain control and another Xray. I called for transport and sent her to the hospital. (V22) was concerned because the night before (5/2/24) she had visited and (R6) was yelling out in pain when moved and (V22) was worried it was the right hip. She had contacted me and requested a hip xray on Thursday, so I put in an order for a hip Xray to be done too. V14 was questioned as to why the Doctor was not notified in delay of Xray and having increased pain, V14 stated, I didn't think about it but yes the Doctor should have been notified. On 5/14/24 at 6:30 PM, V22, R6's Power of Attorney, stated, I had been notified that my mom had a red area and a swollen knee. I was told they were going to get an Xray. My sister (V15) and I went in to see her the evening on 5/2/24. Her right knee was red and super swollen. It was sore to the touch. She would yell and grimace with touch and or when she was moved. My sister and I went to change her. She started yelling. I asked her if it was her hip and she said hip. I let (V14) know that I would like an Xray of the hip. Friday (5/3/24) I was notified that it was a probable fracture. I then requested that she be sent out to the hospital for pain control and evaluation. On Wednesday, when I saw her, I didn't think fracture. I was thinking maybe an abscess or cellulites. I didn't think she need to go to ER (emergency room ) then. On 5/15/24 at 5:30 AM, V31, CNA, stated that she worked on 5/1/24 the 10 PM to 6 AM shift. V31 stated on her first bed check with R6 she noticed that was red marks to the middle of the right-side rib area, the left knee, and the right knee. V31 stated at this time there was no swelling. On the second bed check, the red mark on the rib area and left knee were gone. V31 stated the right knee was red but not hot to the touch. V31 stated at this time, R6 did not seem to be having pain. By the time the 5/2/24 day shift came in. The right knee was swollen and hot to the touch. R6 was yelling out with pain with movement. I then worked again on Thursday 5/2/24 night shift. V31 stated R6 was in a lot of pain when she was rolled and provided incontinent care. V31 stated the right knee was red and still swollen. On 5/15/24 at 9:00 AM, V4, CNA, stated, On 5/1/24 the evening shift we were short staffed. We had 3 CNAs for the building. Around 4:30 PM or 5:00 PM, (V13 CNA) and I got R6 up using the full mechanical lift. Her family came in and fed her dinner. I ended up putting her to bed around 8:30 PM - 9:00 PM. She seemed normal. She doesn't speak much. She wasn't moaning or anything. I did use the (full mechanical lift) to transfer her to bed. I did it by myself. We only had 3 people in the building. I just wanted to get her to bed. The transfer went well. I didn't hurt her. She didn't bump anything. She didn't hit the side rails. On 5/16/24 at 9:30 AM, V1, Administrator, was questioned if she believed R6's Physician should have been notified of increased pain and that the Xray would not be taken until 5/3/24 morning, V1 stated that the Physician should have been made aware of the increased pain and the delay in Xray. On 5/16/24 at 3:02PM, V45, Medical Doctor, stated he knows he got a called on R6's fracture leg and we sent R6 to the ER and thought that the ER found it (fracture). V45 stated he can't remember the details, and this is the first kind of injury he's aware of. V45 stated he can't remember when he knew about R6's pain increasing but his (V45) reaction would be to send R6 to the emergency room . V45 stated the first I heard of R6's fracture was from the ER, or maybe from his nurse or had a message to send R6's in, and that V45 couldn't recall. The facility policy Change in a Resident's Condition or Status, dated 11/16, documents, d. A significant change in the resident's physical / emotional / mental condition psychosocial status to either life threatening conditions or clinical complications. It continues, g. A need to transfer the resident to a hospital / treatment center.

Based on interview, observation, and record review, the facility failed to assess, measure, document, obtain orders for, prevent the development and worsening of pressure ulcers, and provide pressure ulcer treatment following nursing standards for 1 of 3 residents (R6) reviewed for pressure ulcers. This failure resulted in R6 sustaining a new pressure ulcer and 2 previous pressure ulcers worsening. Findings include: R6's Resident Face Sheet, undated, documents that R6 was admitted on [DATE] with diagnoses of Dementia with Anxiety and Weakness of the Left Side. R6's Minimum Data Set, dated dated [DATE], documents that R6 is severely cognitively impaired, is dependent on staff for all mobility, activities of daily living, does not ambulate and does not have a pressure ulcer. R6's Physician Order Report, dated 2/29/24 - 5/13/24, documents, Start date 5/7/24. Left buttocks - cleanse and apply medi honey with calcium alginate and cover with border gauze and PRN (as needed) for soiling / dislodging. Once a day. R6's Physician Order Report, dated 2/29/24 - 5/13/24, documents, Start date 5/7/24. Right buttock - Apply skin prep to area daily for protection. Once a day. R6's Physician Order Report, dated 2/29/24 - 5/13/24, fails to document any order for R6's pressure ulcers before 5/7/24. The Physician Order Report, dated 5/14/24, documents, Start date 5/14/24. Left buttocks cleanse and apply hydrocolloid 3 times a week and PRN for soiling / dislodging. Start date 5/14/24. Right buttock Cleanse and apply medi honey, calcium alginate and cover with bordered gauze daily and PRN for soiling / dislodging Once a day. R6's April 2024 and May 2024 Medication Administration Record documents that R6 had open areas during a skin check on 4/30/24, 5/1/24 and 5/2/24. R6's Wound documentation fails to document any wounds or pressure ulcers before 5/7/24. R6's Focused Observation, dated 4/30/24, documents, Have you reviewed/added Wound Management for any Alterations in skin? Answered yes. This Focused Observation fails to document what the alteration is the skin is. The Facility Wound Summary Report, dated 5/7/24, documents, R6 has a DTI (Deep Tissue Injury) to the Right Buttock measuring 2 x 1 and it has been present for 8 days. R6 also has a Stage II Pressure Ulcer on the left buttock measuring 1 x 1 x 0.1 which has been present for 8 days. R6's Wound Management Note, dated 5/13/24, documents, First observation of area by wound Dr (doctor) (V36, Wound Doctor). Present on re admit from hospitalization . Area with stage 3 ulcer of 1.5x1.5cm (centimeter), hydrocolloid to be applied 3 x (times) a week, with surrounding periwound purple/maroon DTI altogether measuring 10 x 7.5 cm. Area 60% dermis, 20% granulation tissue, 20% skin. Treatment orders in place, offloading and frequent repositioning. Resident on Low air loss mattress. This Wound Management Note fails to document the size, the appearance, and Stage of the Right Upper Buttock. On 5/14/24 at 10:10 AM, V14, Director of Nurses, entered R6's room to provide pressure ulcer treatment. With R6 lying on her left side, R6's buttocks were exposed. R6 has a pressure ulcer to the right upper buttock/ coccyx area The area is approximately 2.5 inches (inches) wide by 1 in. long. The top of the pressure ulcer which is approximately half of the pressure ulcer is light brown in color and appears to be hard thickened skin. The other part of the pressure ulcer is a light purple color area which has begun to flake off. The left outer lower buttock has 2 pressure ulcers both are the approximate size of a nickel. Both pressure ulcers wound beds are red and have bloody drainage. The periwounds are both slightly reddened. On 5/14/24 at 10:12 AM, V14 stated that the old dressings were just removed because R6 was provided incontinent care. the left outer lower buttocks pressure ulcer was first identified now and it was not present yesterday evening when (V36) made rounds. On 5/14/24 at 10:12 AM, V14 washed hands, donned gloves, sprayed wound cleanser on a 4 x 4 gauze pad, and cleanse all three pressure ulcers with the same gauze pad in a swiping motion. V14 removed gloves, performed hand hygiene, applied a hydrocolloid dressing over the left lower buttocks pressure ulcers. V14 then applied medihoney, calcium alginate, and a foam dressing to the right upper buttocks/ coccyx wound. V14 removed gloves and preformed hand hygiene. R6 does have a low air loss mattress in place. On 5/13/24 at 1:38 PM, V16, Certified Nurse Aide (CNA), stated, (R6) had a small open area on her butt before she went to the hospital. I can't remember what cheek. We were putting Calazamine cream on it. On 5/14/24 at 8:52 AM, V14, Director of Nurses, stated, I was unaware that R6's had an open area before she went to the hospital. If I had known about it I would have got an order for it. On 5/13/24 at 2:34 PM, V13, CNA, stated, (R6) had a small pressure ulcer on her butt when she went to the hospital. Now that she is back it has gotten a lot worse, so apparently she isn't getting turned properly. On 5/13/24 at 3:00 PM, V18, Registered Nurse (RN), stated, (R6) did have a pressure ulcer on her coccyx. I know we were treating it. I think with honey and calcium alginate but I am not sure. I am not sure why there isn't an order. If I see an open area I let the wound nurse know about it. On 5/14/24 at 11:15 AM, V19, CNA, stated, (R6) did have a pressure ulcer on her buttocks. We were putting zinc cream on it. There was not a dressing just the cream. It was about the size of you fingertip. She had it a little while before she went to the hospital. On 5/14/24 at 12:53 PM, V9, CNA, stated, (R6) did have a small open spot on her buttocks before she went to the hospital. On 5/15/24 at 6:30 PM, V22, R6's Power of Attorney, previous facility Director of Nurses, stated, (R6) did have a pressure ulcer on her buttocks before she was put in the hospital. I am not sure what they were treating it with. My last day of work there was 4/19/24 and at that time her buttocks was just red. It was not open. On 5/16/24 at 9:30 AM, V1, Administrator, stated that R6 should have had pressure ulcer orders before she went to the hospital. V1 stated that the wound doctor measured all three of the wounds as one. V1 stated the pressure ulcers have gotten worse since she came back from the hospital which is probably caused by not turning and repositioning. On 5/16/24 at 9:40 AM, V14 stated that the wound doctor measurements reflect her documenting all 3 wounds as one. V14 stated that she does not have individual pressure ulcer measurements or assessments at this time and the pressure ulcers have worsened since 5/7/24. The policy Wound Management Program, dated 1/20/23, documents, c. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it, Skin Protocol or New Skin Condition Protocol. d. The new area will be noted on the 24 hour report. It continues, f. The nurse will measure the area; call physician to obtain appropriate treatment order, call the guardian / family member to inform him / her, document the area on the T.A.R. (Treatment Administration Record), and initiate the treatment. It continues, All wounds will be reported weekly in their electronic health record. 8. It is important that wounds are assessed correctly to differentiate between pressure and non pressure wounds. The Documentation is to include: a. Pressure Wound Report i Resident name ii. Room and Bed # iii. Resident admitted iv. Resident location (hall number and letter) v. Site vi. side vii. On set date viii. Origin ix. Stage x. Odor xi. Eschar / Slough xii. Drainage xiii. Drainage amount xiv. Size xv Pressure reducing devices xvi. Change since last assessment xvii. Treatment conditions.

Based on interview and record review, the facility failed to provide pain management for 1 of 3 residents (R6) in the sample of 11. This failure resulted in R6 being in pain from a sustained leg fracture without pain control for 2 days. Findings include: R6's Resident Face Sheet, undated, documents that R6 was admitted on [DATE] with diagnoses of Dementia with Anxiety and Weakness of the Left Side. R6's Minimum Data Set, dated dated [DATE], documents that R6 is severely cognitively impaired, is dependent on staff for all mobility, activities of daily living, and does not ambulate. R6's Physician Order Report, dated 2/29/24 - 5/13/24, documents, Start Date 2/29/24. Aleve tablet; 220 mg (milligram): 1 oral. Special Instructions: BID (twice daily) PRN (as needed). R6's Physician Order Report, dated 2/29/24 - 5/13/24, documents, Start Date Motrin IB (ibuprofen); tablet 220 mg; amt (amount): 2; oral. Dx: Pain. Four times a day. R6's May 2024 Medication Administration Record M documents that R6 had a pain scale of 4 (on the 1 to 10 pain scale which indicates 1 is low pain and 10 being the worse pain) on 5/3/24 and R6 did not receive any PRN pain medication. This same MAR documents that R6 did not have any pain on 5/1/24 and 5/2/24. R6's Progress Note, dated 05/02/2024 02:00 PM, which was recorded as Late Entry on 05/03/2024 06:59 PM, documents, CNA (Certified Nurse Aide) reported swelling and tenderness noticed in residents right knee, reported to writer and floor (V18, Registered Nurse (RN)) received and inserted order for knee xray. R6's Progress Note, dated 05/03/2024 05:30 PM, documents, Resident right knee and hip xray results received this afternoon, faxed (V29, R6's Physician) and notified (V22, R6's Power of Attorney (POA)) of results, being osteoarthritis, and probable distal femoral fracture. (V30, V29's Nurse) states received results at office but (V29) had left office for day. Residents family would like resident sent to ED (Emergency Department) eval (evaluation) for another xray, eval and pain management. Writer called (local ambulance service) and (local hospital). taking resident to ED at this time with family following, paperwork sent with EMS (Emergency Medical Services). The local Hospital Clinical Report, Registration Date of 5/3/24, documents, History of Present Illness: Chief complaint; right lower extremity pain. This started yesterday and is still present. Patient is a [AGE] year old female with past medical history of dementia/ nonverbal/ non ambulatory. (full mechanical lift) presenting from (the facility) with complaints of right lower extremity pain that started yesterday some time with no known injury. There was an outpatient x-ray done which showed a possible distal femur fracture. There is no known repeated fall or trauma. It continues, She does endorse a lot of pain with movement of right extremity or any movement. On 5/13/24 at 1:38 PM, V16, Certified Nurse's Aide (CNA), stated that R6 would scream out with pain with care. On 5/13/24 at 2:34 PM, V13 CNA, stated, (R6) requires total care. She has minimal speech. I believe it was Thursday (5/2/24) that I worked with her. She would make facial grimaces with cares. We were told to leave her in bed. On 5/13/24 at 3:00 PM, V18, Registered Nurse (RN), stated, During change over from the night shift to my day shift, night shift stated that there was a little red spot and swelling on (R6's) knee. I went with (V19, CNA) I think, and I assessed her leg. She had a little swelling to her knee and quarter size red spot. I touched it and she didn't flinch. The day shift CNAs did not mention anything to me about her showing signs of pain. The evening shift 2 PM to 10 PM let me know that she was in pain. I told them to just leave her in bed and I called the Dr for an order for an X-ray. She was wincing in pain at the time with movement. She has scheduled Ibuprofen for pain. I honestly don't know if it helped her or not. I honestly did not think that it was as bad as it was. Especially an impacted fracture, that is a lot of trauma. That is why I didn't send her to the emergency room for an X-ray. On 5/14/24 at 11:15 AM, V19, CNA, stated, When I came back on 5/2/24 in report I got that she had a red mark on her right knee. I and (V9, CNA) got (R6) dressed and up for breakfast and she was fine. I didn't notice that she was having pain. After breakfast around 9 AM - 10 AM, we went to lay her back down and change her. She was making noise. I could tell she was in pain. I have worked with her enough to know her. I asked if she was in pain, and she said yes. Her knee was a little swollen. I let the nurse (V18) know. She told us to lay her down and keep an eye on it. Me, (V19), and (V17) all went to get her up for lunch. She acted like she was in more pain, and it was more swollen. I then refused to get her up. I told (V18). At supper she was still in pain. She was moaning and making noises, so we left her in bed. I left at 6 PM. On Friday she was the same. On 5/14/24 at 12:53 AM, V9, CNA, stated, On 5/2/24 I worked with either V17 CNA or V20 CNA. We were getting people up for breakfast and she was yelling 'ow'. Her knee was huge. If we stopped touching it, she would stop. On 5/14/24 at 2:55 PM, V14, DON (Director of Nursing), stated, On Wednesday 5/1/24 night, I was told by (V35 Licensed Practical Nurse/LPN) that (R6) had swelling and redness to the right knee and when (V35) assessed the knee (R6) would react. On 5/2/24, (V35) passed it onto (V18) the day nurse. (V18) came to me that (R6's) knee was swollen and that she had gotten an order for an Xray. The next morning (5/3/24) they came and took the Xray. I got the results in the afternoon. I notified (V22, R6's POA) of the probable fracture. I faxed the results to the doctor and called the doctor's office, but the nurse said he was gone for the day. (V22) came in shortly after that and she wanted to see if we could get something for pain control. Her other daughter came in (V15) and wanted her sent to the hospital for pain control and another Xray. I called for transport and sent her to the hospital. (V22) was concerned because the night before (5/2/24) she had visited and (R6) was yelling out in pain when moved and (V22) was worried it was the right hip. She had contacted me and requested a hip Xray on Thursday, so I put in an order for a hip Xray to be done too. On 5/14/24 at 6:30 PM, V22, R6's Power of Attorney, previous facility Director of Nurses, stated, I had been notified that my mom had a red area and a swollen knee. I was told they were going to get an Xray. My sister (V15) and I went in to see her the evening on 5/2/24. Her right knee was red and super swollen. It was sore to the touch. She would yell and grimace with touch and or when she was moved. My sister and I went to change her. She started yelling. I asked her if it was her hip and she said hip. I let (V14) know that I would like an Xray of the hip. Friday (5/3/24) I was notified that it was a probable fracture. I then requested that she be sent out to the hospital for pain control and evaluation. On 5/15/24 at 5:30 AM, V31, CNA, stated that she worked on 5/1/24 the 10 PM to 6 AM shift. On her first bed check with R6 she noticed that was red marks to the middle of the right-side rib area, the left knee, and the right knee. At this time there was no swelling. On the second bed check, the red mark on the rib area and left knee were gone. The right knee was red but not hot to the touch. At this time, R6 did not seem to be having pain. By the time the 5/2/24 day shift came in. The right knee was swollen and hot to the touch. R6 was yelling out with pain with movement. I then worked again on Thursday 5/2/24 night shift. R6 was in a lot of pain when she was rolled and provided incontinent care. On 5/16/24 at 9:30 AM, V1, Administrator, was questioned if she believed R6's Physician should have been notified of increased pain, V1 stated that the Physician should have been made aware of the increased pain. On 5/16/24 at 3:02PM, V45, Medical Doctor, stated he knows he got a called on R6's fracture leg and we sent R6 to the ER and thought that the ER found it (fracture). V45 stated he can't remember the details, and this is the first kind of injury he's aware of. V45 stated he can't remember when he knew about R6's pain increasing but his (V45) reaction would be to send R6 to the emergency room . V45 stated the first I heard of R6's fracture was from the ER, or maybe from his nurse or had a message to send R6's in, and that V45 couldn't recall. The policy Pain Prevention and Treatment, dated 10/2017, documents, Procedure: 1. Each resident will be assessed for pain using the Pain Screen including an appropriate Pain Rating Scale upon admission and at least quarterly. Residents who are not able to communicate verbally or have cognitive deficit that precludes them from answering yes/no questions will be screened using the Pain Observation Screen including the FLACC (face, legs, activity, cry, consolability) scale.

Based on observation, interview and record review, the facility failed to investigate falls and implement progressive interventions to prevent additional falls for 5 of 13 residents (R11, R26 R41, R52, R60) reviewed for falls in the sample 36. This failure resulted in R26 and R60 sustaining fractured hips and requiring hospitalization . Findings include: 1. On 5/26/22 at 2:15 PM, V32, Certified Nurse's Assistant (CNA), and V27, CNA, attempted to transfer R26 out of her wheelchair (w/c) to bed to perform catheter care. R26 was sitting in her w/c, slumped over at her waist, and refused to get out of her chair despite several attempts and encouragement from CNAs. V32 stated R26 is usually agreeable to laying down after supper and they provide catheter care at that time. V32 stated they will reapproach R26 again in a little bit to see if she is agreeable to getting out of her chair. R26's Face Sheet documents her diagnoses to include Type 2 Diabetes Mellitus, Hypertension, [CONDITION(S)], Major Depressive Disorder, History of Falling, Unspecified Dementia Without Behavioral Disturbance, Difficulty in Walking, Not Elsewhere Classified, Unsteadiness on Feet, Other Abnormalities of Gait and Mobility, and Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites. R26's Minimum Data Set (MDS), dated [DATE], documents she is severely cognitively impaired and requires extensive assist with bed mobility and transfers. The MDS documents she is dependent for locomotion on and off the unit. R26's Fall Risk Evaluation, dated 5/17/22, documents a score of 13, indicating she is at increased risk of falls. R26's Care Plan dated 4/3/20 documents: I am at risk for falls related to previous fall, cognition, unsteadiness. The care plan lists the following falls: 10/04/21 Fall from recliner attempting self-transfer; 12/13/2021 slide from chair; Fall 1/17/22; Fall 1/27/22, Fall 3/1/22; Fall 3/28/22; Fall 5/8/22 fall from w/c. R26's Un-Witnessed Fall Report, dated 10/4/21 at 7:15 AM, documents: This writer was outside of resident's door. Heard a loud noise, resident yelling for help. Upon entering the room noted resident laying on her left side with her head up against the nightstand. Recliner was tipped forward. Small amount of blood on the floor. Resident unable to give description. Resident assisted back to the recliner after PROM (Passive Range of Motion) completed. Area above left brow cleansed with soap and water. Steri-strips applied over approximately 0.5 cm (centimeter) superficial laceration. Neuro checks started. R26's Care Plan was updated on 10/4/21 with new intervention: Therapy to screen to establish transfer status. R26's Unwitnessed Fall Report dated 12/13/21 at 8:00 PM documents: CNA came to nurses' station to let nurse know that resident slipped out of her w/c onto the floor. When writer approached resident's room, resident was laying on her right side, legs out in front of her, wheelchair behind her against the bathroom door and resident was in front of her bed. When writer asked resident what happened she stated, I don't know. Resident denied any pain, denied hitting her head at all. Writer, CNA and gait belt assisted resident back into her w/c. Resident then received a shower and writer checked resident body for any marks. Resident has no marks on her from fall. Vitals were obtained and resident is on fall neuros due to fall being unwitnessed. Resident was wearing non-slip socks. R26's Care Plan did not have any progressive interventions added following this fall on 12/13/21. R26's Unwitnessed Fall Report, dated 1/17/22 at 8:00 PM, documents, Writer called to resident's room. Resident was noted to be lying on her left side on bathroom floor with feet near the toilet, walker near the sink. Resident yelling out, no injury noted at time of assessment. Resident assisted to sitting position with no c/o (complaint of) injury, assisted to standing with 3 staff assist. Resident able to walk back to her recliner at this time without difficulty. Resident unable to give a description. R26's Care Plan did not include any progressive interventions added following this fall on 1/17/22. R26's Unwitnessed Fall Report, dated 1/27/22 at 5:15 PM, documents, Writer was called down to resident room, resident was laying on the floor on her right side, head towards the wall, feet towards her recliner. When asked resident what happened she stated, 'I don't know.' Writer asked resident about any pain, she stated 'my back'. Performed ROM (range of motion) on all extremities. No c/o pain voiced at this time. Resident rolled over to her back, assisted to a sitting position, and then to a standing position and then into her wheelchair with assistance of 2 staff members and a gait belt. Writer did a full assessment, no new areas noted. Started resident on neuros. Denies hitting her head. Called POA (Power of Attorney) and faxed MD (Medical Doctor). Under Resident Description the report documents, Resident has been complaining of pain in her back for weeks according to POA. There were no progressive interventions added to R26's Care Plan following this fall 1/27/22. R26's Witnessed Fall Report, dated 3/1/22 at 8:09 AM, documents, Was called to room per CNA who witnessed fall. Noted (R26) on floor in door frame of bathroom facing her bed. CNA reported that while she was taking another resident to her room, she noted (R26) in a semi-standing position in front of the toilet. She attempted to get to her but before she could, (R26) fell to ground landing on her buttock and then rolled to right side. Resident description, I was trying to go pee and I just fell . (R26) was assessed for injury. ROM checked and within normal limits. Vital signs were taken. (R26) was assisted off floor by 3 staff members and placed on toilet. There were no progressive interventions added to R26's Care Plan after this fall on 3/1/22. R26's Unwitnessed Fall Report dated 3/28/22 at 8:30 PM documents, Writer was coming up the hall when writer heard a crash followed by a yell for help. When writer arrived to nurses' station, resident was noted to be on the floor lying on her right arm. She denies any pain, no injury noted upon assessment. She was wearing non-skid socks and states that she was trying to 'get up and go'. Had been toileted 1 hour prior to incident. Lighting was appropriate for situation. Resident was assessed, no injury or pain reported on assessment. A new intervention was added to R26's Care Plan following this fall: Monitor me for needs when in halls or at nurses' station. R26's Serious Injury Incident Report, dated 5/8/22 at 4:30 AM, documents, There were no witnesses to the incident. Administrator originally indicated resident was not capable of communication, however, resident can communicate but resident is not a good historian. On 5/8/22 at approximately 4:30 AM CNA entered (R26's) room to find her on the floor with her arm under her head, on her left side at the foot of her bed. (R26) was assessed at the time of the incident, but not found to have injuries and denied pain. On 5/10/22 resident reported pain and physician notified and x-rays ordered. (X-ray company) notified and results were received on the morning of 5/11/22 indicating a femoral neck fracture. Physician ordered (R26) to be sent to (hospital) to be evaluated by orthopedic physician. Surgery was performed on 5/17/22. Investigation into the fall on 5/9/22 by the IDT (Interdisciplinary Team) revealed the CNA had just gotten (R26) up and put her into her w/c and left her sitting in her room. Resident often wheels herself around in her w/c, and it appeared resident wheeled herself beside her bed, as her w/c was found close to her bed. Staff believe resident was attempting to put herself back in bed, due to the early morning hour. IDT determined resident should be allowed to sleep in if desired. ADON (Assistant Director of Nursing) interviewed (R26) before she was transferred to the hospital and (R26) did not have any recollection of any incident, or that she was even hurt at the time, and wondered why she was being sent out. Review of the circumstances did not indicate neglect or abuse and fall interventions will be reviewed when resident returns from the facility and therapy will evaluate (R26) for treatment and education. Initial report had a typo in the dates of complaints of pain, as medical reflects no pain reported until 5/10/22 when the physician was called. A new intervention was added to R26's Care Plan on 5/10/22: I am not to be gotten up before 5:00 AM, but the care plan was not updated with R26 having sustained a hip fracture and surgery to repair it. 2. On 5/27/22 at 9:05 AM, V17, CNA, and V22, CNA, transferred R52 from her w/c to her bed. R52 was noted to have a quarter sized dry scab to her left forehead. After she was in bed, a skin check was performed and R52 had bruises to her right hip and buttock. V17 stated the scab, and the bruises were from when R52 fell a couple of weeks ago and had to be sent to the hospital because she had a brain bleed. V17 stated R52 had fallen out of bed. V17 stated R52 cannot turn herself in bed but sometimes she does scoot herself. V17 stated they usually have a floor mat on the floor if someone falls out of bed, and they keep the bed in the lowest position when the resident is in it. She stated they have not put a floor mat down for R52 yet; she stated she got R52 up this morning and there was not a floor mat on the floor. After R52's care was completed, V17 put a wedge cushion under R52's right side, with R52 facing the left side of the bed, which was facing open door. The right side of the bed was against the wall. The wedge cushion would have prevented R52 from scooting against the wall but would not have impeded R52 to scoot to the left and out of bed. R52's Face Sheet documents her diagnoses to include Traumatic Subdural Hemorrhage Without Loss of Consciousness (5/10/22), Major Depressive Disorder, Hypoxemia, Unspecified Dementia with Behavioral Disturbance, Anxiety Disorder, History of Falling, Muscle Wasting and Atrophy, Muscle Weakness, and Other Abnormalities of Gait and Mobility. R52's MDS, dated [DATE], documents she is severely cognitively impaired and requires extensive assist of 2 staff to transfer and for bed mobility. R52's Care Plan, dated 12/14/18, documents: I am at risk for falls r/t (related to) decreased mobility, weakness, anxiety, cognitive loss, secondary to depression, dementia, muscle weakness. Fall from bed 5/9- laceration to head and to hospital with subdural hematoma There was no updated intervention after R52's fall on 5/9/22. The first intervention after R52's fall on 5/9/22 was initiated on 5/23/22 as wedge pillow in bed to decrease ability to roll out of bed. R52's Serious Injury Report, dated 5/9/22 at 5:00 AM, documents, (R52) was noted to be on floor by nurse at 5:00 AM when walking down B Hall. (R52 was on the floor laying on her left side with her hand above her head, with head facing toward the floor. R52 appeared to have fallen out of bed. R52's head was bleeding. Ambulance was called and (R52) was transferred to (local hospital), then transferred from there to another hospital for treatment and observation. Investigation into fall was initiated. Staff caring for resident were interviewed. CNAs had completed the 4:00 AM bed checks on B Hall at approximately 4:45 AM with R52 being the last resident checked on B Hall. Prior to leaving the room, the caregivers had positioned her on her right side, facing the wall, and she was well positioned when they left the room. Resident is known to be mobile in bed and CNA described her as quite the wiggle worm. Resident has a low bed. All caregivers (nurses and CNAs) believe R52 wiggled herself to the edge of the bed and on the floor. Upon return to the facility, R52 was evaluated by therapy and a positioning cushion was implemented in hopes of helping resident position self in bed. This intervention is being monitored by staff. R52's hospital records include a CT report, dated 5/9/22 at 5:36 AM, which documents, under Impression: 1. New right-sided [MEDICATION(S)] hematoma overlying the lateral right frontal lobe. R52's Physician Progress Note, dated 5/21/22, documents: Reason for visit: Follow up. The progress note documents, She (R52) recently had that bad fall and had a bleed that initially was thought to be an [MEDICATION(S)] hematoma but I think in [NAME] (2nd hospital) they determined it more likely was subdural. On 5/26/22 at 12:41 PM, R52's Care Plan was reviewed with V4, Minimum Data Set/Care Plan Coordinator (MDS/CPC). V4 stated she has not gotten around to updating R52's care plan since she returned from the hospital. 3. On 5/24/22 at 11:20 AM, R60 was standing up in front of his wheelchair (w/c). V4, MDS/CPC, was coming up the hall and directed R60 to sit back down and then propelled him in his w/c to the dining room for lunch. R60's call light was on at the time he was observed standing up. The MDS nurse offered him toileting, but he declined. On 5/24/22 at 1:20 PM, V24, R60's wife, reported R60 fell in January (1/18/22) and broke his hip and stated he also had a fall this past Sunday (5/22/22) and was sent to the emergency room (ER), but did not have any injuries other than a few scabs. R60's Face Sheet documents he was initially admitted to the facility on [DATE] with the diagnoses of Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing (10/22/21), History of Falling (10/22/21), Other Abnormalities of Gait and Mobility, [CONDITION(S)], Unspecified Dementia Without Behavioral Disturbance, and Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites. The Face Sheet included an additional diagnosis, dated 1/28/22, of Periprosthetic Fracture Around Other Internal Prosthetic Joint, Initial Encounter. R60's MDS, dated [DATE], documents R60 is severely cognitively impaired with both long and short term memory problems. Per the MDS, R60 requires extensive assist from 2 staff for transfers (care plan documents he needs 1 assist) and limited assist with walking. R60's Fall Risk Evaluation, dated 5/9/22, documents a score of 20, indicating he is at risk of falls. R60's Witnessed Fall Report, dated 1/12/22 at 11:15 AM, documents, CNA reported that resident 'went to his knees during care.' Abrasion to left knuckles noted and band aid applied. Resident description, 'He is unable to give description. He stated he hit his head, but CNA reports she saw the incident and he didn't hit his head. R60's Care Plan, dated 10/25/21, was not updated with a progressive intervention after this fall. R60's Unwitnessed Fall Report, dated 1/18/22 at 11:05 PM, documents, Writer was sitting at nurses' station when a loud crash was heard down the hallway. Resident had gotten up by himself and walked to hallway when he lost his balance and fell landing on his right side. Fall was not witnessed and hallway dark at time of occurrence. Resident had not been incontinent of urine or bowel and denied need for either. Writer noted that right wrist has open laceration and resident yelling out in pain while writer was assessing site. Resident also grabbing at hips and grimacing. EMS (Emergency Medical Service) notified of need for transport. Spouse, MD (Medical Doctor), on call nurse and ER (emergency room ) nurse all notified of fall and given report of incident. Resident unable to give description. Under Other Info the report documents: Resident has been getting up frequently without assistance and has had increased behaviors lately. R60's Progress Note, dated 1/19/2022 at 4:08 AM, documents, Writer called and spoke with (nurse) at (hospital's) ER whom reports that resident will be admitted shortly, and that resident has a right femur fracture requiring surgical intervention. Resident will be admitted on ce room becomes available. POA (Power of Attorney) at bedside. R60's Hospital Records include his Hospitalist History and Physical (H&P), dated 1/19/22 at 4:32 AM, which documents, Impression: Right periprosthetic hip fracture: Acute impacted radial head fracture, and Fall. The H&P report further documented, At the time of my evaluation, patient's wife reported that patient has fallen multiple times in the last 5 days. Besides R60's falls on 1/12/22 and 1/18/22, no other falls were documented in his progress notes and no other fall reports for January 2022 were provided by the facility. R60's Care Plan, dated 10/25/21, included an intervention dated 1/18/22, I am becoming more mobile, assist me with ambulation, give frequent reminders to wait for assist before walking on my own. There were no additional progressive interventions put in place after R60 was readmitted from the hospital on 1/28/22. R60's Witnessed Fall Report, dated 2/26/22 at 8:30 AM, documents, Resident fell in dining room at 8:30 AM. Fall was witnessed by two CNAs. Resident could move all extremities. Resident unable to give a description. No injuries observed at the time of incident. R60's Care Plan was not updated with any progressive interventions following his fall on 2/26/22. R60's Progress Note, dated 4/20/2022 at 3:09 PM, documents, Nursing Note Text: Resident was sitting in wheelchair at nurses' station, resident stood up, writer could not get to resident quick enough and resident lost balance and went down on his knees. no injuries noted. writer assessed resident. ROM (range of motion) WNL(within normal limits). resident did not hit his head. resident was assisted back into his wheelchair, and he asked to go to bed. CNA took resident to room to lay down. POA (Power of Attorney) and MD (Medical Doctor) notified of witnessed fall. The facility failed to provide a Witnessed Fall Report for his fall on 4/20/22 indicating this fall had been investigated. R60's Care Plan was not updated with progressive interventions after this fall. R60's Witnessed Fall Report, dated 5/22/22 at 5:37 PM, documents, Writer was sitting at nurses' station and resident was sitting in w/c and stood up and before I could get to him, he fell to the floor, landing on his right side. He did not hit his head. Examined for injuries and resident has skin tears to right elbow and two skin tears on his right lower arm. Swelling to outer right wrist noted. Skin tear to left shin. Resident unable to give description. Examined for injuries and skin tears noted to right elbow and two on right wrist. Skin tear to left shin and raised area on right wrist. Moves lower legs and left arm. Notified (MD) at 3:45 PM and made doctor aware of fall and sending to hospital ER for evaluation. Notified ambulance at 3:50 PM. Notified POA at 3:55 PM. Ambulance here and transported resident per stretcher to hospital. R60's Care Plan was updated on 5/23/22 with the new intervention: obtain labs and urinalysis/ culture & sensitivity (ua/c&s) per MD order and report to MD results. No lab results could be found on R60's EMR (Electronic Medical Record) regarding labs and ua/c&s ordered following his fall on 5/22/22. On 5/26/22 at 2:40 PM, V3, Assistant Director of Nursing, stated, When we did the initial fall huddle for (R60), we discussed doing his labs, but the physician stated he thought they had probably done all that stuff in the hospital when he was sent to the emergency room . We also talked to his wife who is usually here every day, and she had not been in to see him on the day he fell , and she thought him trying to get up might have been a behavior. V3 stated the labs were not done, and they just forgot to go in and update R60's care plan to take the labs off and add that staff are to keep his walker closer to him and encourage him to go to more activities. His wife brought in a new game she thinks he might like, so we are trying to get him to join in games. V3 stated she later checked with the hospital, and they had only done x-rays when he was seen in theER on [DATE] but no labs or ua were done. On 5/26/22 at 12:41 PM, V4 stated she had not done much with R26's Care Plan since she came back after being hospitalized for her hip fracture. V4 stated, I only have two hands. I spend a lot of time on the floor working. When I added some interventions on 1/4/22, I added a lot of new things then so I may not have added anymore. V4 stated she usually hears about falls in morning meeting and tries to update care plans then. V4 stated she does not look at the fall reports before she updates the care plan because she usually hears about the fall before she sees the reports. She stated with the new fall program she is supposed to add something new when a fall occurs. R26's, R52's and R60's fall care plans were reviewed and V4 acknowledged that she did not update their care plans after every fall with progressive interventions. V4 stated, You can only do so much. 4. R11's May 2022 Physician Order Sheet (POS) documents R11 has a diagnosis of pain in left hip, [CONDITION(S)], repeated falls, secondary Parkinsonism, multi-system degeneration of the autonomic nervous system, unsteadiness on feet, difficulty in walking, lack of coordination, muscle weakness, other abnormalities of gait and mobility, muscle wasting and atrophy, fatigue, and need for assistance with personal care. R11's MDS, dated [DATE], documents R11 is cognitively intact, independent with bed mobility, transfer, and personal hygiene, requires supervision and setup with dressing, and requires setup with eating and toileting. R11's Fall Risk Assessment, dated 11/13/2021, documents R11 is at risk for falls. R11's Care Plan with initiation date of 9/1/2021 documents, The resident has had an actual fall with minor injury r/t (related to) poor balance with [CONDITION(S)] diagnosis. The resident will have no serious injuries due to falls by next review. Target date 6/8/22. R11's Unwitnessed Incident Report, dated 12/17/22 at 3:06 PM, documents, Staff called writer to room stating they found (R11) on the floor. Writer entered room and noted that he was sitting by bed upright Indian style. [NAME] was across room by his chair. Resident description: (R11) stated he was coming back from his closet and his right foot 'froze' up. At that point he felt a little dizzy and immediately went down on his right knee. In the process of going down, he sheared his right flank/rib area on the foot board of the bed causing a large abrasion. There is a small abrasion to his right forehead, but he is not certain what he hit his head on. R11's Care Plan documents R11 had a fall on 12/17/2022 with no injury. No new intervention was documented following the 12/17/2022 fall. R11 had a subsequent fall on 1/1/2022. R11's Unwitnessed Incident Report, dated 1/1/2022, documents, CNA came to get writer and stated that resident would like to see nurse and stated that he fell , as well. CNA stated that when she answered his call light resident was sitting in recliner. When writer approached resident room, he was sitting in his recliner. When writer asked resident what happened he stated that he had fallen and hit his head. Writer did not feel any bumps or see any marks on head. Writer did notice a bruise to the back left shoulder. Resident description: I was trying to go to the bathroom. I lost my balance and fell and hit my head. R11's Care Plan documents fall on 1/1/2022 with bruise to left shoulder. No new intervention was documented until 1/18/2022. 5. R41's May 2022 POS documents R41 has a diagnosis of [CONDITION(S)], [CONDITION(S)], and dementia in other diseases classified elsewhere without behavioral disturbance. R41's MDS, dated [DATE], documents R41 is cognitively intact, requires extensive assistance from two or more persons for bed mobility, transfer, dressing and toileting, requires extensive assistance with one person for personal hygiene, and requires setup for eating. R41's Fall Risk assessment dated [DATE] documents R41 is at risk for falls. R41's Care Plan with initiation date of 1/27/2022 documents, I am at risk for falls related to decreased mobility, weakness, cognitive loss secondary to [CONDITION(S)] dementia, [CONDITION(S)]. I will remain free from injury related to fall through next review. Target date 7/28/2022. R41's Unwitnessed Fall Incident Report for 2/4/22 at 2:45 PM documents, Resident was found lying next to his bed face down with his head against his recliner. His slippers were next to him but had not been on. His catheter bag was lying next to him, and his glasses were next to him with one side broken. Resident Description: Resident stated he was trying to stand up to go (urinate) and fell forward and hit his head on the floor. R41's Care Plan documents R41 had a fall on 2/4/2022 with resulting hematoma and laceration. No intervention documented following 2/4/2022 fall. R41 fell again on 2/15/2022 causing abrasion and skin tear. R41's Unwitnessed Fall Incident Report for 2/15/2022 at 10:30 AM documents, Resident was noted on floor in his room. Resident description: Resident states that he was trying to put his basin back in his top drawer of his dresser. He lost his balance and fell backwards. R41's Care Plan was not updated with a new intervention after 2/4/2022 and 2/15/2022 falls until 2/21/2022. On 5/27/2022 at 9:07 AM, V3, Assistant Director of Nursing (ADON), stated, I expect a new intervention following each fall. Once the team decides on the intervention, it is documented in the care plan. The Facility's Falls Prevention Management Policy and Procedure, dated 3/15/2018, documents, It is the policy of (the facility) to have a Fall Prevention Program to assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Fall Prevention Program includes the following components: Immediate change in interventions that were unsuccessful. Care plan incorporates interventions are changed with each fall, as appropriate.

Based on observation, interview and record review the facility failed to timely identify/assess and initiate treatment and provide pressure relief to prevent the formation of/or worsening of pressure ulcers for 3 of 3 residents (R2, R3, R4) reviewed for pressure ulcers in the sample of 5. This failure resulted in R2 developing a facility acquired Stage 3 pressure ulcer to his sacrum which progressed to an unstageable pressure ulcer and R4 developing a facility acquired unstageable pressure ulcer to his right heel. Findings include: 1.R2's Electronic Medical Record (EMR) dated 2/2022 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan dated 2/2/22 documents I am at risk for pressure ulcers or skin breakdown related to decreased mobility and weakness, recent COVID positive with pneumonia, [CONDITION(S)], legally blind, Peripheral Vascular Disease (PVD), Diabetes Mellitus (DM). R2's Care Plan Interventions document Please monitor my skin for redness, irritation, and report to my nurse, Keep skin clean and moisturized. Date Initiated: 2/7/22. Please remind/assist me to turn and reposition every 2 hours and as needed (PRN). Date Initiated 2/7/22. R2's Shower Sheet dated 1/28/22 documents R2 has an old dark spot on his left great toe and has a circle around the coccyx area which documents may be open. R2's Skin assessment dated [DATE] documents, Weekly skin check. Skin intact. Groin red, cream applied. No open areas noted. medical doctor (MD) faxed for treatment (Tx). R2's Skin assessment dated [DATE] documents Stage 3 pressure ulcer to sacrum with measurements 7.0 X 2.5 X 0.25 centimeters (cm). There was no documentation in R2's medical record from 1/28 to 2/4/22 regarding this pressure ulcer. R2's Minimum Data Set (MDS) dated [DATE] documents R2 requires extensive assist of two for bed mobility. R2's Transfer Form to hospital, dated 2/10/22 documents unstageable coccyx ulcer. The National Pressure Injury Advisory Panel website documents an unstageable pressure ulcer as Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. R2's local emergency room documentation dated 2/10/22 includes, Clinical Impression: [CONDITION(S)] ([CONDITION(S)]) with [CONDITION(S)], Acute [MEDICATION(S)] with Hematuria, Low Magnesium, Chronic [CONDITION(S)], Low Potassium, Elevated Glucose with DM2, Acute Renal Injury, obstructive, Sacral Decubitus with Fibrous exudate, 2 scrotal wounds, stage 2, bilateral pedal [CONDITION(S)]. Noted 3-centimeter (cm) X 2 cm open area on left side of scrotum, area cleansed, dried and covered with [MEDICATION(S)]. Also has a 1 cm X 1 cm open area on anterior lower scrotum, area cleansed a [MEDICATION(S)] applied. Patient turned to left side, has dried stool on buttocks and a large dressing on upper to mid buttocks. Dressing removed has a large irregular shaped wound to both sides of buttocks. Wound has minimal redness around outer edges, some yellow discoloration and some black areas noted. Large amount of yellowish tan foul-smelling drainage present. Wound rinsed with normal saline and packed with normal saline soaked gauze and covered with abdominal dressing (ABD). On 2/23/22 at 11:00 AM, V2, Director of Nurses (DON), stated, I would expect a residents pressure ulcer to be identified prior to it being a Stage 3. 2. R4's Electronic Medical Record (EMR) dated 2/2022 documents R4 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Shower Sheet dated 1/15/22, 1/22/22 does not document any skin issues. R4's Shower Sheet, dated 2/7/22, documents, Right heel diagram has a circle around it and documents, not new, came with a spot. R4's Shower Sheet, dated 2/13/22, buttock diagram has a circle around it and documents old'. The Shower sheet did not have any documentation regarding R4's right heel. R4's Shower Sheet dated 2/16/22 documents no abnormalities. R4's Shower Sheet dated 2/22/22 documents no abnormalities and does not include any documentation regarding R4's right heel or his buttocks. R4's Skin Assessments dated 1/14/22, 1/24/22, 1/31/22 all document no skin issues, no open areas. R4's Skin Assessment on 2/4/22 documents laceration to face. R4's Skin assessment dated [DATE] documents right inner buttock pressure ulcer stage 2. R4's Skin Assessment 2/15/22 documents skin tear to right elbow and abrasion to vertebra. R4's Skin Assessment had no documentation regarding R4's right heel or buttocks. R4's Skin assessment dated [DATE] documents Unstageable Pressure Ulcer Right Heel, In House Acquired measurements 1.9 centimeters (cm) X 1.5 cm X 2.0 cm, Eschar (dead tissue) 100%. R4's Initial Wound and Management Summary, dated 2/13/22, written by V9, Wound Doctor, documents, Unstageable (Due to Necrosis) of the Right Heel Full Thickness. Wound Size 2 X 2.5 cm. Surface Area 5.00. Thick Adherent black necrotic tissue (eschar) 100%. Dressing treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations: Elevate legs; Float heels in bed; Off load wound; Reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able. R4's Care Plan dated 1/27/22 documents I am at risk for pressure ulcers or skin breakdown related to decreased mobility, bowel incontinence. 2/23/22 I have an unstageable pressure injury to my right heel and redness to my buttocks. Interventions: Do a daily skin check and notify my family and MD of any new areas. Date Initiated: 1/27/22. Please monitor my skin for redness, irritation and report to my nurse. Keep skin clean and moisturized. Date initiated 1/27/22. Please remind/assist me to turn and reposition every 2 hours and PRN. Treatment as ordered to my right heel. Date initiated 2/23/22. R4's MDS dated [DATE] documents Basic Interview for Mental Status (BIMS) cognition intact. Functional Status: Needs extensive assist of two for bed mobility. On 2/22/22 at 2:10 PM, R4 was lying in his bed on his back, his right heel is resting on the mattress and was not off loaded. At 2:55 PM, R4 was in the same position, right heel is not off loaded. On 2/23/22 at 10:00 AM, R4 was laying in his bed on his back and his right heel was not off loaded. On 2/23/22 at 2:00 PM, V2 was asked if the first time R4's unstageable pressure ulcer was identified was when V9 wound doctor did his initial wound assessment on 2/13/22. V2 stated, (V9) was not in the facility on 2/13/22 he was here on 2/10/22 and identified R4's right heel pressure ulcer then. His document is dated on 2/13/22 because that is when he documented it. Yes, that is when the wound was first identified. On 2/24/22 at 10:25 AM, V11 Licensed Practical Nurse (LPN) looked in R4's EMR to see when R4's pressure ulcer was first identified and stated, I would assume if (V9) came to the facility on [DATE] that is when it was first identified. On 2/24/22 at 12:15 PM, V2 was asked if R4's heel should be off loaded and she stated, What do you mean? V2 was asked again would you expect R4's heel to be floated so it is not resting on the bed, she stated, Yes. 3. R3's EMR documents, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Care Plan dated 10/15/21, Focus: Resident is at risk for impaired skin integrity related to impaired mobility, incontinence. The resident has a stage 2 pressure ulcers to left buttock, right buttock and sacrum. The Care Plan documented Administer treatments as ordered and monitor for effectiveness. Follow facility policy/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/22 at 9:50 AM, prior to watching V11 Licensed Practical Nurse (LPN) provide wound care for R3's pressure ulcers, no dressing was in place to R3's pressure ulcer. The facility Policy and Procedure for Wound Management Program dated June 2020 documents It is the policy of this facility to manage resident skin integrity through prevention, assessment, and implementation and evaluation of interventions. Procedures: 1. The facility is provided with Wound Care Protocols. These are to be utilized to assist in the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility will assess all residents weekly for current skin conditions. a. The charge nurse for each hall will do skin assessments. A schedule will be established to identified room/bed day and shift. b. Any resident that scores very high risk, high risk, or has a wound present will have a skin check documented daily to identify new or worsened areas. d. The weekly skin assessment will be documented on the skin assessment in PCC (Point Click Care). i. Indicate the location of ant identified areas on the body figure. ii. Describe the area(s) on the line provided. iii. Give a detailed description of the area in the common box. e. If any new areas are identified, write a nurse's note describing the area found and the protocol followed to treat it. h. The nurse responsible for treatments will review all daily documentation and review any new areas. i. The nurse will measure the area; call physician to obtain appropriate treatment order, call the guardian/family member to inform him/her, and initiate the treatment. 5. The skin assessment should also be completed whenever a new skin condition is noted. 6. All wounds will be reported weekly in PCC EHR system, using the skin and wound evaluation assessment.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer treatment for 1 of 4 residents (R4) reviewed for pressure ulcers in a sample of 4. This failure resulted in R4's stage II pressure ulcer progressing to unstageable with hospitalization for [CONDITION(S)] and [CONDITION(S)] requiring surgical debridement of the pressure ulcer. Findings include: R4's hospital records, dated 12/2/2021 at 11:53 AM, document WBC (white blood cell count) was 8.7 (normal range 4.0 to 10.8), also documented is Stage II-III decubitus ulcer overlying the coccyx with pale yellow base. Plastic surgery Progress note on this document dated 11/30/2021 at 9:14 PM, documents R4 has a stage II sacral pressure sore that will likely heal without any surgical intervention, no signs of infection, measures 6 by 8 cm (centimeter). R4's Resident Information sheet, dated 12/3/2021, documents R4 was admitted to facility on 12/3/2021. R4's Minimum Data Set (MDS), dated [DATE], documents R4 is an extensive assist with 2 plus person assistance for Bed mobility, Transfers, and Toilet use. R4's initial assessment on admission to the Facility, dated 12/3/2021, documents sacrum pressure stage 2: Partial thickness skin loss with exposed dermis, Present on Admission, Wound Measurements 6.5cm (area) 4.0cm (length), 2.7cm (width) with Depth, no Undermining and Tunneling, Granulation with the presence of slough to the wound bed, no presence of eschar (dead tissue), no evidence of infection, light amount Serous Exudate with no odor noted. Peri wound; Edges Attached: Edge appears flush with wound bed or as a sloping edge, Surrounding tissue; Blanching (whitening of external tissue), Normal in color, No induration, swelling or [CONDITION(S)], normal Peri wound temperature; Orders: Goal of care, healable. R4's Care Plan, dated 12/13/2021 document's (R4) is at risk for pressure ulcers or skin breakdown related to decreased appetite, decreased mobility; (R4) does not like to be repositioned off supine position; Self-Care Deficits As Evidenced by, Need for assistance with Activities of Daily Living (ADL's), at risk for falls, Resident is incontinent of Bowel/Bladder; (R4) has impaired cognitive function/dementia or impaired thought process, initiation date 12/21/21. R4's December 2021 Treatment Administration Record (TAR) documents treatments ordered to start 12/4/2021 and Discontinued on 12/27/2021. Cleanse stage 2 pressure injury with generic wound cleanser and pat dry with gauze. Apply calcium alginate and cover with border gauze every day and as needed for soiling or dislodging one time a day. The TAR documents no treatment done to stage 2 pressure injury 12/4/2021 through 12/20/2021. R4's weekly wound assessment, dated 12/12/2021 documents, Weekly skin assessment, skin warm & dry. Pressure area to sacrum, treatment in place. No measurement of wound noted on this assessment. R4's weekly wound assessment, dated 12/16/2021 documents, Weekly skin check done. Treatment in place to sacrum. R4's weekly wound assessment, dated 12/28/2021 documents, Weekly skin assessment done; pressure injury noted to sacrum area; wound bed black in color; odorous. Writer applied dressing to site. R4's progress notes document's, on 12/9/2021 at 12:53 PM telehealth visit with facility doctor. Ordered labs CBC (complete blood count), BMP (basic metabolic profile), Chem7, LFT (liver function test) and THS to be done on 12/14/2021. R4's progress notes documents, on 12/27/2021 at 4:02 PM, After clarification received-order to begin wet to dry dressing to sacral wound using full strength Dakin's solution. Wound doctor here on 12/23/21 and performed wound cleaning and removing of dead tissues at that time. R4's progress notes documents, on 12/30/2021 at 3:41 PM, writer called wound doctor to update on wound status, writer requesting to begin resident on oral antibiotics. Order was given for [MEDICATION(S)] 100 milligram (mg) twice daily for 14 days. R4's progress notes documents, on 12/30/2021 at 5:05PM, Lab called with a critical WBC 29.9 (indicator of infection), facility physician notified order was received to send to ER (emergency room ). R4's progress notes documents, on 12/31/2021 at 1:23AM, R4 was admitted for [CONDITION(S)], [CONDITION(S)] (inflammation of bone or bone marrow, usually due to infection), R4 will be going to the OR (Operating Room) to determine if wound is [CONDITION(S)], WBC 35. R4's lab report dated 12/14/2021 at 1:24 PM documents, WBC (White Blood Cell Count; indicator of infection) 6.9 (Ref Range 3.5-10.0). R4's lab report dated 12/30/2021 at 3:17 PM documents, WBC (White Blood Cell Count, indicator of infection) 29.9 (Ref Range 3.5-10.0). R4's Hospital record dated 12/30/2021 documents, Surgical Pathology Report 12/31/21, Final Pathologic Diagnosis, soft tissue, sacral tissue, excision, abscess with ulceration; Bone, sacral bone, debridement, [CONDITION(S)] with ulceration. Gross Description: sacral tissue is a 16.2 by 14.1 by 6.3cm aggregate of tan wrinkled skin and underlying green-yellow; sacral bone is a 3.8 by 3.0 by 1.2cm aggregate of tan-gray friable, hard irregular bone fragments. Microbiology- blood reports [CONDITION(S)], Growth of Bacteroides fragilis beta lactamase positive, growth of staphylococcus epidermidis. On 1/19/2022 at 10:30 AM, V2, Director of Nursing (DON), stated that when she saw R4's wound (unsure of the dates) it was greenish in color with small amount of drainage, it was the size of an apple and had some depth. V2 stated that it progressively got worse. V2 stated there are no wound notes from V10, wound care doctor, because they never got put in, but V10 saw R4 once and that was on 12/23/21. V2 stated that she would expect there to be a wound description on every wound assessment and she would expect measurements of the wound on a weekly basis.V2 stated that treatment order was changed on 12/27/21 due to deterioration of the wound.V2 stated that she doesn't know when the deterioration began because it is not documented on wound assessments or progress notes. V2 stated that the missing treatments to R4's pressure ulcer that were not documented 12/4/21 through 12/20/21, she cannot account for due to them not being marked. V2 stated that she cannot say for certain if the treatments were done or not, but if they aren't documented it didn't happen. On 1/19/22 at 3:00 PM, V7, Licensed Practical Nurse (LPN), stated it is all nurse's responsibility to do wound care. V7 stated that when R4 came to the facility, her wound was large, clean with some depth, it was coded a stage 2 pressure sore. V7 stated that she didn't see R4's wound routinely. V7 stated the last 3 to 4 days that R4 was at facility the wound was black and R4's treatments were daily on day shift. V7 stated that skin checks are done weekly and should include length, width, depth, drainage, smell, color, redness, inflammation. V7 stated that the wound had worsened in size, appearance and in drainage. V7 stated that something else should have been done, V7 stated, R4's wound got awful and I feel bad. V7 stated that the best she could tell that if the treatment were done there should be checkmarks and initials in the boxes from 12/4/2021 through 12/20/21 on the TAR. On 1/19/22 at 2:30PM, V9, MDS Nurse, stated that she would expect to be notified if a wound had changed in condition. V9 stated she was never notified of a change in condition to R4's wound. On 1/20/22 at 1:20PM, V11, Hospital Physician, stated that the hospital has no information prior to this hospitalization . V11 stated that the wound size was 14cm in diameter, with dark dry eschar to entire wound. V11 stated that wound had a dark tan malodor, sacral bone palpable. V11 stated that R4's wound was not well treated at time of arrival at the hospital. The Facility's Wound Management Program policy and procedure dated June 2020, documents, Procedures 1. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The facility will assess all residents weekly for current skin conditions. d) The weekly skin assessment will be documented in Electronic Medical Record; i. Indicate the location of any identified areas in the body figure. ii. Describe the area(s) on the lines provided. iii. Give a detailed description of the area in the comment box. 7. The Documentations is to include: vi. Size (cm l x w) (length times width) vii. Depth (cm).

Based on interview and record review, the facility failed to prevent an incident of mental abuse/neglect for 1 of 17 residents (R2) reviewed for abuse in the sample of 17. This failure resulted in R2 being frightened, having nightmares and afraid to use her call light. Finding includes: R2's Face Sheet documents that R2 was admitted to the facility 8/13/21 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set (MDS) dated [DATE] documents that R2 is cognitively intact and requires extensive assistance for toilet use. R2's Progress Notes dated 9/28/21 documents that R2 was started on an antibiotic for a Urinary Tract Infection ([CONDITION(S)]). R2's Progress Notes dated 9/5/21 documents, Continues on [MEDICATION(S)] (antibiotic) for [CONDITION(S)] with no adverse effects noted. Continues to c/o (complain of) frequency and urgency. [MEDICATION(S)] ([MEDICATION(S)]) started. The Facility's Initial Incident Report dated 9/5/21 documents, Incident Category: Abuse. It continues to document that R2 was the resident involved as the victim and that R2 is alert and oriented times 3 (cognitively intact) and is capable of communication. The report documents the staff member involved was V3, Certified Nursing Assistant (CNA) and that V3 was suspended. It further documents the detailed incident summary as, It was reported to the administrator by (V4, Registered Nurse) that (V3) refused to take (R2) to the bathroom when (R2) requested to go. The Facility's Final Incident Report dated 9/10/21 documents the above information involving R2 and V3. The Report documents During the interview with (R2), (R2) stated that on Sunday, (V3) came into her room to answer her call light. (R2) told (V3) that she needed the bedpan. (V3) told her she could only use it every 2 hours. (R2) told (V3) that she could not see the clock. (V3) told her she would check the clock and if it wasn't time, she would have to wait. (R2) also stated that (V3) was getting her up in the morning sooner that (than) (R2) wanted to get up. When I spoke with (V3) regarding this alleged incident, I told her she could write a statement and submit it to me. As to date, she has not made a written statement. She told me it was staff making up allegations toward her. I do not know if (V3) was being abusive intentionally, however, I do know that this is unacceptable behavior on her part, and she has been terminated. Name of person submitting report (V1, Administrator). A written statement, dated Sunday, 9/5/21 at 4:04 PM, written by V8, Certified Nurse's Aide (CNA) on behalf and in the presence of R2 and another staff member for a witness. The statement documents, At 1:30 AM (V3) came in to answer (R2's) light. (R2) needed the bedpan. (V3) told her she could only use it every two hours. (R2) said she couldn't see the clock. (V3) then said she would come in here and check the clock and if it wasn't time, (R2) would have to wait. At 4:30 AM (V3) came in and told (R2) she would be back at 5:00 AM to get her up. (R2) said she didn't want to get up that early because that was too long to sit in the chair. This is not the first time (V3) has come in and told her she was to wait to use the bedpan/bathroom. (R2) is afraid to use the light because she doesn't want (V3) to come in and start in on her. (R2) claims to have peed the bed because she was afraid to use the light. (V3) also told her at her age she should be sleeping more instead of using the bathroom. (V3) has told her several times since she's been here, she has to hold it. Two weeks ago (V3) came in at about 1:30 AM and she was on the phone. (V3) told (R2) she had to wait until she was off the phone. (R2) says (V3) has said so much to her she can't recall all of it but every time, she is mean to her. The document was signed by V8, another CNA as a witness, and R2. A typed statement dated 9/5/21 at 4:50 AM documents, We went in to administer scheduled (Pain medication) to (R2) and assist her with the bedpan. (V10, Licensed Practical Nurse) asked how her night was and the resident stated, 'Not very good'. Asked her what was wrong, resident replied, 'Well I was told I had to get up right now and I would rather not. I'll be sitting up the whole day and it's a little early for me.' I informed (R2) she did not have to get up until she wants to. (R2) stated, 'Well the other girl told me that she was coming in and I had to get up.' We both assured her that she doesn't have to get up until she wants to. Resident also stated, 'She wouldn't let (me) use the bedpan when I needed to. She said I had to wait every 2 hours. I told her I couldn't see the clock. She said I'll tell you when it's time.' Resident was very upset about this. It continues to document that V10 and V11 (Licensed Practical Nurse) assured R2 that she could use the bedpan or bathroom anytime she needs and that what the CNA said was inappropriate and wrong. It further documents that V10 and V11 assured R2 that V3 would not be back in her room and R2 stated, Good, because I don't want her to come back in here. It further documents that at 5:50, as V3 was getting ready to leave, V10 politely told V3 that R2 does not want her in her room anymore and that someone else will have to answer her lights, to which V3 replied, Okay, perfect. It documents that V10 texted V1, V2 Director of Nursing (DON), V13, Assistant Director of Nursing (ADON), and V14, MDS/Care Plan Coordinator. This document was signed by V10 and V11. An additional statement dated 9/5/21 at 5:00 PM documents, I had been passing hall trays for lunch. I brought (R2) her tray and she told me about her night (9/4/21 overnight). Resident stated that the night shift (V3) had told her to hold her pee because she, 'Went pee too much and she needed to wait every two hours.' Resident stated she couldn't wait that she had to go now. She (the resident) had wet the bed and was still upset today (9/5/21). Resident also states that CNA woke her up at 4:30 AM to tell her she had to be up at 5:00 AM. This document was signed by V15, CNA and V16, LPN. On 9/27/21 at 2:30 PM, V7, CNA stated, I didn't witness it (the incident between R2 and V3). I heard about it from V8. (R2) just needed help using the bed pan. It would have only taken 30 seconds to do it. On 9/27/21 at 3:56 PM, V8, CNA, stated, I watched (V3's) hall while she was on break that night. When I answered (R2's) call light, she grabbed her chest and said, 'I'm so glad it's you!' She said she needed to talk to me and told me that (V3) was very rude to her. I told her I would definitely be reporting it. I told the nurses working and they told me to write a statement and put it under (V1's) door. I took a witness with me and wrote word for word what (R2) told me, and she signed it. I guess it wasn't the first time (V3) had treated her that way. People like (V3) don't need to be doing this type of work. (R2) told me she was scared to turn on her call light. (R2) had a [CONDITION(S)] at the time, so she certainly shouldn't have been hold it (urine). (V3) also told (R2) she had to get up at 5 AM. (R2) was in her right mind and it's her right to not have to get up that early. (R2) told me she was having nightmares and was scared to use her call light when (V3) was working, so she just peed the bed. She always told us when she had to use the bathroom, she was continent. After I took (R2) to the bathroom I immediately told (V10) and (V11). It was about 1:30 in the morning. They passed it on to the dayshift nurses. I really did not want to leave that night, so I told the nurses to look out for her (R2). I feel like (V3) should not have been allowed to work after that. I told (V4) the next day and she told me to write the report to (V1). (V3) did finish her shift I think, but I was told (V3) would not be allowed in (R2's) room. (V3) was suspended and then they called her in and fired her. On 9/27/21 at 4:00 PM, V4, Registered Nurse (RN) stated, I heard that (V3) was verbally aggressive with (R2). It was out of line and inappropriate. It should not have happened. It was first reported to (V8). I heard about it in report. By the time second shift got here I had heard the whole story. (R2) had a [CONDITION(S)] at the time and (V3) told her she would have to wait to go to the bathroom. On 9/28/21 at 9:08 AM, V1 stated, I would expect to be called any time, day, or night, with an allegation. If they had called me, I would have removed (V3) from patient care immediately. On 9/28/21 at 1:00 PM, V1, Administrator stated that the incident/interaction between R2 and V3 would be considered abuse/neglect and should have never happened.

Based on observation, record review and interview, the facility failed to identify, assess, evaluate, monitor and treat pressure sores for 2 of 2 residents (R1, R2,) reviewed for pressure ulcers in the total sample of 4. Findings include: 1. R1's Electronic Health Record, (EHR), documents that R1 was admitted to facility on 7/31/20 with a [DIAGNOSES REDACTED]. R1's Care Plan dated 8/03/20 documents: I developed a stage 2 pressure injury to my right buttock after my admission. I remain at risk for development of new areas due to incontinence, limited mobility, and my preference of sitting up in the chair throughout the day during daytime hours. 08/11/2020 Stage 2 pressure ulcer right upper buttock. This wound is distal to another wound on right buttock 08/20/2020 Stage 2 right inferior buttock 08/25/2020 Stage 2 left heel INTERVENTIONS: 08/08/20 Treatment per MD orders to right upper buttock stage 2, (proximal wound). 08/11/20 Treatment per MD orders to right upper buttock stage 2, (distal wound). 08/20/2020 Treatment per MD orders to right inferior buttock stage 2. 08/20/2020 Treatment per MD orders to left heel stage 2. 08/24/2020 2 new open areas on buttock. 4 totals, on buttock, measure and document wound measurements weekly. Notify my Physician and family weekly of wound progress. Wound physician to asses my wound weekly. To follow all recommendations made by MD, (Medical Doctor). Nurse to provide head to toe skin assessment weekly. Care staff will monitor and report any new or open areas noted during routine care or with schedules bathing. R1's Progress Note, dated 8/16/20 documents: Spoke with night shift nurses earlier this AM. They reported that (R1) now has an area to his left heel. They stated, that is moving constantly through the night in bed writhing and constantly in motion. He likely is causing friction, due to frequent moving in bed. R1's Progress Note, dated 8/24/20 documents: Stage 2 blister (intact), noted on left heel. MD and (wife) notified. Will skin prep heel every shift. Currently has an alternating air flow mattress, [MEDICATION NAME], extra protein, Vitamin therapy for wound healing. Spoke with Therapy this evening, to see if they can take a look at a heel float, area measures 3.7 x 4.6. R1's Skin assessment dated , 8/13/20 documents: Right buttocks pressure ulcer 0.5 cm long and 0.3cm in width. Other pressure ulcer 1cm long and 1cm width. R1's Skin assessment dated , 8/20/20 documents: Resident has a stage 3 to the right superior, right inferior, left buttock and right buttock. Resident is receiving treatment to areas. R1's Skin assessment dated , 8/27/20 documents: Resident has a stage 3 to the right superior, right inferior, left buttock and right buttock. MD saw resident on 8/26 and is changing treatment. Resident also has a wound to left heel that is a stage 2 closed blister. R1's Weekly Wound Assessment, dated 9/02/20 documents: Right buttock stage 2 length 3cm x width 2cm and depth 0.1cm. Date acquired 8/11/20. Peri wound tissues slightly reddened but blanching wound edges even. Left buttock date acquired 8/20/20. Stage 2 Right upper buttock (superior). Date acquired 8/8/20. Stage 2 pressure length 0.8cm x width 0.5cm. Right buttock (inferior) date acquired 8/20/20. Stage 2 length 0.8cm x width 0.3cm and depth 0.1cm. Left heel date acquired 8/24/20. Stage 2 pressure. Length 3cm x 4cm width. R1's BRADEN SCALE-For Predicting Pressure Sore Risk, dated 9/28/20, has total score of 13 which represents moderate risk. R1's Minimum Data Set, (MDS), dated [DATE] documents, R1 to be cognitively moderately impaired. R1's MDS documents, that R1 requires extensive assistance, 2-person physical assist with transfers, locomotion on and off unit, dressing and toilet use. R1 is frequently incontinent of bladder and occasionally incontinent of bowel. R1's Physician Order, dated 8/31/20 documents: Apply medi honey to the wound then a calcium alginate dressing to stage 2 pressure ulcer located on right buttock daily Cover with island dressing daily. R1's Physician order [REDACTED]. On 9/26/20 at 10:25AM, V7, CNA arrived to floor after lunch break, 'I've been so busy. V7 CNA stated, A midnight aide stayed over to about 9:00AM today to help me, we have just been short of staff. On 9/26/20 at 10:35AM V4 CNA stated, I've been working by myself for a couple of days now. V4 stated, If we have the staff then we have 2 aides on the floor, if not then just 1. On 9/26/20 at 09:45 AM V8 Certified Nurse Assistant, (CNA), stated, I was working another hall, but that person went to lunch, so I am here covering. On 9/28/20 at 10:35AM, V14 LPN/Wound Nurse, I was hired to be a Wound Nurse and I got to do that job maybe 2 days and since then I have been working as a floor nurse. V14 stated, I usually try to do my dressings after lunch when the resident is laying down. 09/28/20 at 11:00AM V13 CNA stated, It's a mess around here. V13 stated, I think they have called everyone, agency and they don't have anyone. On 9/28/20 at 11:50AM V12 Licensed Practical Nurse (LPN)n stated, I haven't been able to do my job for the past 10 days. V12 LPN stated, So my job is getting farther behind and corporate will not send us any relief. On 9/28/20 at 1:40PM, R1 stated, Nobody wants to help me. On 9/28/20 at 1:41PM V12 and V14, LPN's entered R1's room. V12 asked, R1 to roll over onto his right side. A wet rolled up piece of gauze observed hanging off R1's buttocks. A stage 2 pressure ulcer located on right side of buttocks, pink wound bed, clear drainage. V12 cleaned wound bed and applied new dressing/treatment. R1's left heel was a large round pressure ulcer with necrotic tissue uncovered with no treatment. V14 stated, R1 just came back from hospital. 2. R2's EHR documents that R2 was admitted initially to facility on 6/07/17 and readmission 12/19/19 with a Diagnosis: [REDACTED]. R2's skin assessment dated [DATE] documents: right buttock pressure. Length 2cm x width 2cm. Stage II. R2's skin assessment dated [DATE] documents right buttock pressure. Length 6cm x width 4.2cm and depth 0.8cm unstageable. R2's Weekly wound assessment dated [DATE] documents date acquired 8/28/20 slough tissue present, necrotic tissue present. Length 2.5cm, width 1.5cm and depth 0.5cm. Recommendations- Off-load wound; Reposition per facility protocol; limit sitting to 30 minutes. R2's Wound Care Assessment/Treatment Plan dated 9/16/20 documents, (site1) Stage 4 pressure wound sacrum. Primary dressing frequency BID (twice a day) for 16 days. Wound size length 3cm x width 3cm and depth 05.cm (site2), Venous wound of left leg. Recommendations-Compression hose The facility's 'Weekly Skin Integrity Report, dated 9/16/20 documents: R2 sacrum stage 4 measuring 3cm length, 3cm wide and 0.5cm depth. Treatment start date, 8/28/20 and original date 8/28/20. On 9/26/20 at 10:35AM, R2 was observed sitting in recliner in room On 9/26/20 at 11:50AM, V4 CNA assisted R2 up with gait belt, R2 was unable to straighten legs or put a foot forward. R2 stated, Get some help. V4 CNA then sat R2 down into a wheelchair so that he could have a window visit. R2 was not checked for incontinence. On 9/26/20 at 12:50PM V3 Corporate Nurse and V8 CNA assisted R2 with gait belt from wheelchair back into recliner. R2 was not checked for incontinence. On 9/26/2020 at 2:39PM skin check requested for R2. V4 and V16 CNA's, stood R2 up from recliner and pulled down pant and incontinent brief. A large area of blood mixed with feces observed in incontinent brief. A stage 4 open area about size of a fifty-cent piece observed on R2's sacrum with drainage and no treatment covering wound. V4 CNA stated, I think there is supposed to be a dressing on it. On 9/30/20 at 1:15PM, V17 R2's Doctor stated, I would expect staff to be checking and repositioning residents. V17 Doctor stated, I would expect staff to be applying treatments as ordered. V17 stated, I thought the facility had a wound nurse. V17 stated, I don't want a resident to be sitting in stool. Facility's Policy and Procedure 'Decubitus Prevention and Treatment' dated 6/99 documents: Prevention protocol is considered good nursing care and will not require an order. Goal: No other single fact points to negligent, inadequate nursing care more clearly than the presence of decubitus ulcers. Treatment protocols: Assess need for position change schedule. Initiate if needed. The average turn and position schedule call for a frequency of every 2 hours. The CNA will observe skin daily and or each time resident is changed, dressed, undressed etc. The license nurse will provide care ordered by the Physician and will observe daily.

Based on observation, interview and record review the facility failed to timely assess, respond and provide interventions for 1 of 1 resident (R2) reviewed for shortness of breath. This failure resulted in R2 waiting for over 45 minutes after notifying aide that he couldn't breathe. R2 was sent out to hospital with a [DIAGNOSES REDACTED]. Findings include: 1. R2's EHR documents, that R1 was admitted initially to facility on 6/7/2017 and readmission 12/19/2019 with a Diagnosis: [REDACTED]. On 9/28/2020 at 09:00 AM R2's call light was on. On 9/28/2020 at 09:15 AM V11 Certified Nurse Assistant, (CNA), stated, Yes, I am the only CNA on this hallway. On 9/28/20 at 09:15 AM V11 CNA entered into R2's room. R2 was observed sitting in his recliner. R2 stated, I can't breathe. R2 stated, I just need air. R2 stated, I want to go to hospital. R2 stated, I'm very ill. R2 then opened his shirt showing a large bruise on his right side of chest. V11 CNA stated, I saw that when I got you up this morning. V11 CNA stated, I don't know what happened, I got nothing in report. V11 left the room and returned stating, I told the nurse that R2 can't breathe and about the bruise. On 9/28/2020 at 09:20 AM R2's call light is on. At 09:25 AM V11 CNA in room with R2. R2 stated, I need to go to hospital. I need to see a Doctor. R2 stated, I don't think they can take care of me here. On 9/28/2020 at 9:27 AM V11 CNA, turned off R2's call light and left the room. V11 CNA, then left the COVID unit, no staff present on hall at this time. On 9/28/2020 at 09:29 AM V11 CNA stated, to R2, I know I saw that bruise when I was getting you dressed, and I told the nurse. On 9/28/2020 at 09:42 AM V11 CNA stated, I told the nurse that (R2) was having trouble breathing and that his ribs were hurting and that he wanted to go to hospital. V11 CNA stated, that the nurse stated she would be down in a minute. V11 CNA stated, I don't know what happened to (R2). V11 CNA stated, I got nothing in report about that bruise. (R2) didn't have that Friday. V11 stated, They said he didn't fall. On 9/28/2020 at 10:14 AM V3 Corporate Nurse, (RN), entered COVID Unit. V3 stated, I would expect staff to respond immediately to a resident who states I can't breathe or I need air.V3 then placed a pulse oximetry, (device to measure oxygen levels), on R2's finger indicating an oxygen level of 85% down to 82% then decreased to 79%. V3 then placed oxygen via nasal canula on R2. R2's oxygen level increased to 94% at this time. V3 obtained R2's temperature indicating 99.5. On 9/28/2020 at 10:27 AM V14 LPN stated, (V11) stated, that R2 had a bruise. On 9/28/2020 at 10:27 AM R2, was sent out to local hospital. On 9/30/2020 at 1:15PM V17 R2's Doctor stated, I would expect staff to respond immediately to shortness of breath. V17 Doctor stated, A resident that is short of breath needs an immediate assessment. R2's Progress Note dated, 9/28/2020 documents: Late Entry: Note Text: (R2) resident was noted to be having SOB. SPO2% 82. 2L O2 applied. MD was contacted. Awaiting call back from MD staff decided to send resident to (local Hospital) for evaluation due to condition worsening even with O2. ambulance was contacted for transport as well as POA. R2's Progress Note, dated 9/28/2020 documents: Call placed to (local hospital) to inquire about resident, resident was transferred to another hospital. Writer called hospital to inquire, resident was admitted to their COVID Unit with pneumonia, elevated white count, and elevated BNP. On 9/30/20 at 2:00PM V1 Administrator, (Adm), stated, I don't think we have a policy and procedure for that, but I am still checking and will let you know. On 9/30/20 at 3:00PM V1 Adm stated, I agree with V3 RN, (R2), should have been assessed immediately. V1 Adm stated, We are unable to find a policy and procedure for this incident.

Based on observation, record review and interview, the facility failed to provide timely identification, treatment, monitoring and turning and repositioning to prevent pressure ulcers from developing for 4 of 9 residents (R3, R39, R59, and R64) reviewed in the sample of 34. This failure resulted in R39 and R64 developing facility acquired, unstageable heel pressure ulcers; R59 developing a new, unidentified, unstageable right buttock pressure ulcer; and R3 developing three new, stage two pressure ulcers to the buttocks. Findings include: 1. On 05/18/18, the Admission Nursing Note documented R64 fell at home fracturing left tibia requiring proximal tibia Open Reduction and Internal Fixation (ORIF). The physician's orders [REDACTED]. On 05/18/18, the MDS for R64 documented a BIMS score of 13, cognitively intact requiring extensive to total assist of two staff for bed mobility, transfers, locomotion, dressing and bathing. On 05/18/18, the Braden scale for predicting pressure ulcers documented a score of 12, indicating high risk. The Care Plan, dated 05/21/18, documented interventions for left tibia fracture, in part as, monitor limb for swelling and skin changes, Reposition as necessary to prevent skin breakdown. On 05/18/18, the admission nursing assessment documented R64 was admitted with a stage II left buttock pressure ulcer measuring 1.5 x 0.5 and a stage II pressure ulcer to the right heel measuring 2.0 centimeter (cm) x (by) 1.0 cm. As of 06/19/18, the pressure ulcer on the right heel was healed. On 06/20/18 1:28 PM, V6 and V7, Certified Nurse's Aides (CNAs) were observed during transfer and incontinent care for R64. V6 stated R64 was upgraded from a full mechanical lift to an extensive assist of two staff for transfers with no weight bearing to the left lower extremity. R64 had a surgical dressing observed on the left shin, dated 06/19/18, clean, dry and intact. The left heel was observed to have a large black area measuring approximately 4.0 centimeter (cm) by (x) 3.0 cm and was intact. R64 stated she had been wearing a full leg brace on the left lower extremity and could not move very well and did not turn and reposition the left leg often and developed the heel ulcer. V6 stated R64 was supposed to wear heel boots while in bed, but takes them off regularly because R64 gets too hot. On 06/06/18, a Weekly Wound Assessment documented R64 had developed a pressure ulcer of the left heel. It documented the initial assessment of the facility acquired pressure ulcer of the left heel as a Deep Tissue Injury and unstageable measuring 3.5 cm x 1.3 cm. However, the Weekly Skin report, dated 06/06/18, documented the left heel measurement at 3.5 cm x 1.5 cm. On 06/10/18, the Weekly Skin Report documented the left heel ulcer measuring 3.5 cm x 1.5 cm, no change in appearance. There was no Weekly Wound Assessment completed for 06/10/18. R64's physician's orders [REDACTED]. On 06/16/18, a Weekly Wound Assessment documented R64's left heel ulcer measured 3.0 cm x 1.3 cm. However, the Weekly Skin Report documented on 06/16/18, R64's left heel ulcer measured 3.5 cm x 1.5 cm, unchanged. 2. R3's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview of Mental status as 4 indicating severe impairment. The MDS further documents R3 requires extensive assistance from staff for Activities of Daily Living (ADL's). On 6/22/18 at 11:40 AM, V15, CNA, and V6, CNA, transferred R3 using a full body mechanical lift from bed to wheelchair and then directly took R3 to dining room. At 12:35 PM V15 then removed R3 from dining room and left R3 in hallway outside of room. At 1:35 PM, R3 was observed in wheelchair sitting outside room without the benefit of position change until 2:40 PM. On 6/22/18 at 2:40 PM V4 Certified Nurse's Assistant (CNA) and V17 Certified Nurse's Assistant (CNA) transferred R3 using a full body mechanical lift from wheelchair to bed. V4 then left and V16 Certified Nurse's Assistant (CNA) replaced V4. V16 and V17 then provided incontinent care on R3. V16 began removing R3's pants which were heavily soaked with urine including the sling. R3's incontinent brief was heavily soaked with urine and large amounts of loose yellow stool noted oozing from the incontinent brief to in the inside of R3's pants. R3 had loose stool covering the front and back of the peri area. V16 then began wiping the stool away from R3's buttocks where 3 pressure ulcers with beefy red granulation tissue were observed opened and uncovered. V16 stated, She's (R3) always red. I think the nurse know about those areas. On 6/22/18 at 3:20 PM V18 Licensed Practical Nurse (LPN) stated, I believe that those areas were observed this morning and are being treated. V2 Director of Nursing (DON) stated, Yes we are treating those areas as Incontinence Associated [MEDICAL CONDITION] with ointment. (R3) is always moist. I believe she takes a diuretic (water pill). V18 also stated that duoderms do not work with R3 due to R3 is always moist. R3's EHR (electronic health record) documents, Physician order [REDACTED].N.A's (certified nurse's assistants). Assessments for R3 wounds to buttocks charted on 6/21/18 First Observations left buttock Incontinence Associated [MEDICAL CONDITION] 1.0 cm LENGTH 0.3cm WIDTH GRANULATION TISSUE BEEFY RED right buttock superior LENGTH 1.0cm WIDTH 1.0cm; right buttock inferior pressure ulcer length 0.7cm length 0.7cm. Treatment ointment. Skin Checks with CROPS 1 time per day everyday at bedtime, Document Skin Check with CROPS C-Clear, R-Redness, O-Other, P-Pressure, S-Skin Tear one time a day. 3. On 06/19/18 9:20 AM R39 was sitting up in a specialized wheelchair with R39's head down in a forward position with neck extended forward. At 10:30 AM, R39 was in the same position. At 11:45 AM, R39 was taken from her room to the dining room via wheelchair. No check and change was observed. R39 was in her wheelchair with head down sleeping at the dining table until her food was served at 12:30 PM. At 1:10 PM, R39 was taken to her room and left in wheelchair. At 2:30 PM, R39 still up in wheelchair in room sleeping. On 06/20/18 at 9:00 AM, R39 was up in the wheelchair sleeping. At 10:00 AM, R39 was in the same position. On 06/21/18 at 9:10 AM, R39 was in bed on her back sleeping. At 9:20 AM, V6 and V7, Certified Nurse's Aides (CNA's) gave R39 incontinent care. R39 had reddened deeply creased bottom and was incontinent of urine. R39's right heel had a medium-sized black area measuring approximately 1.5 centimeters (cm) x (by) 2.0 cm with no dressing. There was another open area that was small and brown measuring 0.5 cm x 0.5 cm. R39's Care Plan, dated 04/09/18, documented R39 developed an unstageable deep tissue pressure ulcer to the right heel. Interventions, in part, turn and reposition every 2 hours. On 04/11/18, the physician's orders [REDACTED]. The Minimum Data Set (MDS), dated [DATE], documented R39 was cognitively impaired with a Brief Interview for Mental Status (BIMS) of 3 indicating severely cognitively impaired and required extensive to total assist of two staff for bed mobility, transfers, dressing, toileting and eating. On 06/21/18 at 10:30 AM, V2, Director of Nursing (DON) stated R39 had developed an unstageable pressure ulcer to the right heel and that the area seemed to be drying up. Facility's policy and procedure (undated) documents in part, The facility will provide care and services to: Promote the prevention of pressure ulcer development. The Policy documented Redistribute pressure i.e. repositioning, protecting heels etc. Provide appropriate pressure-redistributing, support surfaces. Provide non-irritating surfaces. 4. The MDS dated [DATE] identifies R59 to have a Brief Interview of Mental Status (BIMS) score of 5 indicating a severe cognitive deficit. The MDS also documents R59 requires extensive assist of two staff for bed mobility, total assist for transfers, and is always incontinent of bowel/frequently incontinent of urine. The Braden Score of 5/7/18 identifies R59 to be a 12 or high risk for pressure ulcer development. R59's Care Plan dated 5/31/18 documents R59 to be at risk for skin breakdown due to incontinence, limited mobility and a recent decline in appetite. The Care Plan documents R59 developed an ulcer on her left elbow 6/5/18. The goal is to maintain or develop clean and intact skin by the next review with interventions for R59 to have arm sleeves to both arms at all times except showering (2/9/17), elbow pads to bilateral elbows (6/5/18), skin checks daily with CROPS, pressure relieving mattress to bed, and turn/reposition every two hours in part. The (MONTH) (YEAR) POS includes an order dated 6/5/18 that documents Cleanse left elbow with wound cleanser; apply collagen particles in wound bed then cut to fit hydrogel AG (Silver) and apply over collagen particles; Cover with absorbent dressing. Wrap with stretch gauze daily one time a day for unstageable ulcer. The Weekly Wound assessment dated [DATE] documents the wound was identified as being a stage II with granulation tissue present (Beefy Red), moist, measuring 1cm (Centimeter) x 0.8cm x 01cm when found. The most recent documentation dated 6/16/18 identifies decline in the wound with it now being unstageable, worsening, with 100% slough present on the wound bed measuring 1.5cm x 1cm. Progress Notes from 6/15/18 to 6/20/18 failed to reflect R59's buttock ulcer and it was not reflected on the weekly skin reports. On 6/20/18 at 11:30 AM, R59 was incontinent of urine and had three cloth incontinent pads under her over a quarter sheet folded turn sheet. R59 had a small open area on right buttock which was a full thickness skin loss. The pressure ulcer bed was sloughy and somewhat dark. On 6/21/18 at 10:40 AM, V9 LPN removed R59's elbow dressing. R59 voiced pain and moaned. The elbow wound was irregular in shape and had full wound bed of slough except one small area of dark tissue at 4 O'clock. The surrounding tissue was red. V9 poured wound cleanser on a gauze pad and gently patted the wound bed several times. She then applied collagen particles with a cotton tipped applicator then applied a hydrogel pad over the wound bed. V9 then covered it with a padded gauze dressing. The wound was not cleansed appropriately. Progress notes dated 6/20/18 at 11:30am document Note Text: CNA reported while turning resident noted area to right hip/buttock. Area assessed noted 1 x 0.5 unstageable area cleansed and duoderm applied for current time while waiting for further orders. Dr (V13) notified and POA left message with. On 6/21/2018 at 10:00 AM, a telephone order was received for R59's buttock ulcer which read cleanse area to right hip with wound cleanser apply duoderm, change every 3 days and prn (as needed), one time a day every 3 day(s) for pressure area. Weekly wound assessment dated [DATE] documents a newly facility acquired pressure ulcer was identified on right hip unstageable, slough present, measuring 1.0 cm x 0.5 cm red periwound, no odor or drainage, with inflammation/induration present. On 6/22/18 at 2:00 PM, V2, Director of Nurse's (DON) stated she was unsure as to why staff did not identify R59's sooner and acknowledged that the ulcer was unstageable when found.

Based on interview, observation and record review, the facility failed to complete adequate assessments including measurement of contractures, failed to assess to determine efficacy of the Range of Motion (ROM) services and failed to provide complete ROM exercises for 4 of six residents (R6, R39, R27, and R47) reviewed for range of motion in a sample of 34. This failure resulted in overall mobility decline in R6 and development of bilateral lower extremities limitations. Findings include: 1. On 6/21/18 at 2:28 PM, R6 was in bed with the head of the bed slightly elevated. V5, Certified Nurse's Aide (CNA) was asked to do passive range of motion exercises (PROM) for R6. V5 got a folded instruction sheet for range of motion out of her pocket and after setting it on the over bed table, explained to R6 that she planned to do range of motions exercises on her. V5 did 3 repetitions (reps) completing flexion/extension and abduction/adduction of R6's right shoulder then moved on to her elbow and did 3 reps on flexion/extension. No range of motion was done on R6's wrist, finger or thumb. V5 then did 3 reps abduction/adduction of R6's right hip, flexion/extension of her right knee with no range of motion done to her ankle or toe joints before stating she (V5) was finished. At 2:33 PM V5 stated she will do the other side the same and will do 15 minutes of range of motion on all the residents she's assigned to. At 2:35 PM, V5 was at the nursing station, having completed R6's Passive range of motion. R6 was alert/cooperative during the process and exhibited no discomfort or resistance. R6's head of the bed remained elevated throughout the exercises. R6's Minimum Data Set ((MDS) dated [DATE] documents R6 has short/long term memory loss with moderate cognitive impairment. The MDS documents R6 has ROM limitations to bilateral lower extremities and receives AROM (Active Range of Motion). The quarterly Restorative assessment dated [DATE] documents R6 to have no contractures and limited range of motion WNL (within normal limits). R6's strength is documented as able to ambulate with assist. A Restorative assessment dated [DATE] documents R6 has no contractures but ROM Deficits of her bilateral lower extremities indicating a decline. The most recent Restorative assessment dated [DATE] documents the same as 12/26/17. R6's Care Plan dated 3/14/18 documents R6 to have a limited physical mobility related to a fall prior to admission. The goal documents R6 will remain free of complications related to immobility, including contractures in part with interventions being a restorative program of active ROM. Interventions included are as follows: 1 - explain tasks, 2 - provide privacy, 3 - initiate AROM (Active ROM) to all extremities with 8-10 reps twice daily, 4 - provide verbal cues and visual demonstration for each exercise and 5 - Stop if pain or discomfort present and notify nurse. The policy/procedure entitled Range of Motion (passive and active) dated 5/2016 documents Range of motion exercises will be implemented for all residents in need and/or as physician orders. The Purpose is documented as to move the resident's joints through as full a range of motion as possible, to improve or maintain joint mobility and/or to prevent contractures. 2. R39's physician's orders [REDACTED]. On 06/19/18 9:30 AM, R39 was observed with head down, neck extended forward. R39 was observed to have foot drop to bilateral feet. There were no observations of staff performing any type of ROM to R39's upper and lower extremities on this day. On 06/21/18 at 9:10 AM, V6 and V20, Certified Nurse's Aides (CNAs) were observed for incontinent care for R39. V6 stated that the CNA's on the floor do not perform any type of ROM and that it's done by the restorative staff. R39 stated she can no longer move her head/neck back to an upright position or move feet/ankles to a normal position due to contractures. R39's Care Plan, dated 02/22/18, documented R39 had limited physical mobility related weakness. The goals listed for R39 was for R39 to remain free of complications related to immobility, including contractures, skin-breakdown and fall related injury. The interventions, in part, are provide gentle range of motion as tolerated with daily care. It also documented R39 was identified as receiving restorative rehabilitation with AAROM program to maintain current level of ROM to all extremities by next review. However, the facility failed to document any baseline ROM measurements to identify any decline. The Care Plan did not identify any interventions regarding R39's bilateral foot contractures (foot drop). 3. R27 was admitted to facility on 9/12/13. R27's Minimum Data Set ((MDS) dated [DATE] documents a Brief Interview of Mental status as 4, indicating severe impairment. The MDS further documents R27 requires extensive assistance from staff for Activities of Daily Living (ADL's). On 6/21/2018 at 2:15 PM V15, CNA, and V4, CNA, provided incontinent care on R27. When completed range of motion was requested, V4 then asked V15 for her ROM (range of motion) paper. V15 removed the paper from her pocket and gave to V4. V4 was unsure what steps to take, staring at the paper and asking V15 how many reps. V15 responded 5 reps. Resident's lower extremities were contracted up half way to thighs. V4 stated, I'm not sure how much I can do with this leg. A rolled up wash cloth was noted in resident's left hand. V15 stated that it is difficult to get the wash cloth in resident's hand because resident's fingers were contracted in towards palm of hand. R27's Care plan dated 02/26/15 documented the resident has limited physical mobility. 3. Initiate PROM exercises to all extremities 8-10 reps twice daily for at least 15 minutes (mins) daily. 4. R47's Minimum Data Set ((MDS) dated [DATE] documents R47 requires extensive assistance from staff for Activities of Daily Living (ADL's). On 06/21/18 at 10:20 AM V15 stated that PROM (passive range of motion) was conducted on R47 once and that 5 reps are given. R47's Care Plan dated 11/05/2014 documents resident has limited physical mobility. The Care Plan Interventions documented Nursing Rehab/restorative Passive Range of motion 3. Initiate PROM exercises to all extremities 8-10 reps twice daily for at least 15 minutes daily.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls and injuries for 2 of 8 residents (R42 and R53) reviewed for falls in the sample of 34. This failure resulted in R42 having multiple falls that included a [MEDICAL CONDITION] and hematoma to the head; and R53 sustaining three fractures within a sixth month period. Findings include: 1. On 06/21/18 at 9:10 AM, R42 was lying in bed on back sleeping. At that time, V6, Certified Nurse's Aide (CNA) stated R42 has had a decline in mental and physical status in the last couple of weeks. V6 stated R42 does not try to get up as much as she did. V6 stated, We now get her up last to go to meals and lay her down first after meals. and stated R42 does not attend activities now. V6 also stated R42 does not use her call light for assistance. An Incident Report, dated 01/08/18, documented R42 was found on the floor on her bottom in her room. The Incident Report documented an intervention as staff was to not leave R42 in her wheelchair in the hallway. On 01/15/18, the MDS documented R42 was sent to an acute hospital for [MEDICAL CONDITION]. On 01/18/18, admission note documented, R42 re-entered the facility after having a left hip hemi-arthroplasty. An Incident Report dated 01/22/18, documented R42 was found on the floor in her room and complained of right hip pain. It also documented R42 had self-transferred from wheelchair to bed and fell . The intervention was to transfer R42 to recliner or bed after meals. Do not leave in wheelchair unattended. An Incident Report dated 03/25/18, documented R42 was found on the floor in the hallway on buttocks and scooting herself on the floor. The report documented R42 was last seen in her recliner in her room. The intervention was to place R42 on 15 minute checks for 24 hours. An Incident Report, dated 4/10/18, documented R42 was found on the floor next to her bed. R42 had suffered a hematoma to the right side of her head. The intervention was to place R42 in a wheelchair and move to nurse's desk. It documented last checked R42 was in bed. An Incident Report, dated 04/13/18, documented R42 was found on the floor in another resident's room with her wheelchair by her side. It documented R42 was last toileted approximately two hours prior. The intervention was to re-educate staff to assist R42 to bed or recliner after meals. An Incident Report, dated 5/2/18, documented R42 was found on the floor at the nurse's station and had struck another resident's wheelchair with her head. The Report documented R42 sustained a hematoma to the head. The intervention was to re-educate staff to assist R42 to the dining room once in her wheelchair. On 04/17/18, the Minimum Data Set (MDS) documented R42 was severely cognitively impaired with Brief Interview for Mental Status (BIMS) and required extensive assist of two staff for bed mobility, transfers and toilet use. It also documented R42 was always incontinent of bowel and bladder and had a balance deficit and could not stabilize self without assistance. The Care Plan, dated 04/10/18, documented R42 was at risk for falls related to confusion and fall with hematoma. The interventions listed, in part as, be sure call light is within reach and encourage resident to use it for assistance and resident not to be left in wheelchair unattended. On 06/22/18 at 10:20 AM, V2, Director of Nursing (DON), stated R42 was a very busy person who got up frequently and attempted to self transfer. V2 stated R42 has had a major decline and is no longer walking. 2. The MDS dated [DATE] (5 day review) documents R53 to have moderate cognitive impairment with short/long term memory deficits. The MDS documented R53 required extensive assist of one staff for bed mobility and minimal assist of one staff for transfer. The MDS documents R53 required staff assistance for all balance opportunities. The Admission Summary dated 11/17/17 documented R53 was admitted to the facility from the hospital following a [MEDICAL CONDITION] ([MEDICAL CONDITION].) R53's Care plan dated 11/29/17 documents R53 to be at high risk r/t for falls (related to) deconditioning, gait/balance problems, poor communications/comprehension, poor safety awareness, dx (diagnosis) of [MEDICAL CONDITION]. The Care Plan continues to document Has a recent extensive history of falls with resulting fracture at hospital, was a very safe individual prior to [MEDICAL CONDITION], and is use to be on the go all the time, resident is up frequently on own, is very busy and does not understand his limitations. The goal is to not sustain serious injury through the next review. Interventions included ensuring proper foot wear, transfer with limited assist of one staff, does not use call light appropriately so check on him frequently, room rearrangement so if the resident attempts to get up his dominant arm is always toward the bed rail, and make sure room and floors are clutter free. On 6/26/18 at 11:10 AM, V2 Director of Nurses (DON) stated R53 fell at the hospital and sustained a fractured wrist so was admitted to the facility with a cast on his arm. An Incident report dated 12/2/17 at 8:00 PM documents R53 fell while ambulating with or without assistive device which was unwitnessed with no apparent injury in the bathroom. The report fails to document whether R53 was suppose to be using an assistive device and whether or not it was actually in place when the fall occurred. There is no information as to where staff were and why R53 was in the bathroom before staff knew R53 was up and mobile. The Details of Corrective Measures taken by Facility documents staff educated to check bathroom frequently due to resident sharing bathroom with another resident who tends to leave linens on floor. However, the report does not identify a causative factor for the fall. The Care Plan fails to reflect any revisions as a result of this fall. On 6/26/18 at 11:10 AM, V2 stated R53's room mate had left his pants on the floor and they think R53 tripped over it. V2 was unable to state as to why R53 would have been all the way into the bathroom before staff was alerted. V2 stated at this time, R53 was in a room half way down A hall. The Incident report dated 1/1/18 at 3:30 AM documented R53 had an unwitnessed fall while ambulating with or without assistive device in his room. The details document resident observed on the floor in room with head resting against bathroom door laying on his back. Assessed for injuries noted skin tears to right and left elbows and to RFA (right forearm.) The report continues to document Resident has poor balance and requires assistance with all ADL's (activities of daily living.) Resident is non-compliant and was observed an hour prior to fall walking to nurses' station with some blankets in his had but again, fails to identify the causative factor of the fall as being unassisted when up. There is no information as to where the staff was or the need for increased supervision. Corrective actions include 15 minute checks and continue to monitor. R53's room was also moved closer to the nurses station. On 1/13/18, the care plan shows a new intervention to rearrange his bed for right side neglect but fails to reflect his need for additional supervision. On 1/29/18 at 12:15 AM, the Incident report documents R53 again as falling (unwitnessed) as ambulating with or without assistive device in the corridor. The Detail of incident documents resident found on floor in middle of hallway lying on his right side. R53 sustained skin tears to right hand. The Corrective Actions section documents facility had care plan with family. There is no evidence the facility identified the causative factor of the fall and revised the interventions in an attempt to prevent R53 from getting up unassisted. The care plan shows only that the care plan meeting was held with R53's family with no other revisions. An Incident Report dated 2/18/18 documents R53 had another unwitnessed fall while ambulating with or without assistive devices in his room sustaining a right knee skin tear. Corrective actions section document continue with current interventions. Will continue to monitor. The Incident Report dated 6/3/18 at 5:00 AM documents R53 fell while ambulating with or without assistive devices in the dining room which was witnessed by a Licensed Practical Nurse. The report documents R53 sustained an abrasion on his face and a deep cut to his right pinky finger. The narrative documents writer heard shuffling in dining room, went to see what it was and saw resident losing his balance with his walker. R53 was transported to the emergency room and diagnosed with [REDACTED]. The care plan fails to reflect any revisions made following this fall until 6/7/18 when a new intervention documents It has already been established that resident gets up on his own due to poor safety awareness. This fall was witnessed and staff member was attempting to reach resident before his fall. All current interventions were in place at time of fall including having walker and having shoes on; and, Due to no other obvious reasons for fall occurring, staff will check orthostatic blood pressure. This was discussed today as possible intervention. There is no intervention that addresses the lack of staff within a reasonable distance and the need for closer supervision. On 6/26/18 at 11:10am, V2 stated R53's fall on 12/3/17 resulted when he got up to the bathroom unassisted. V2 stated R53 sustained a Right Lateral Tibial Impaction fracture during that fall. V2 stated R53 was still on A Hall when this fall occurred. V2 stated R53's fall on 1/1/18 occurred when R53 was on A Hall as well, and that he sustained a closed Right radial [MEDICAL CONDITION] R53 fractured at the hospital prior to admission. V2 stated on R53's fall on 6/3/18, R53 fractured the 5th metacarpel. V2 stated they have no alarms in the building and no restraints and they are unsure as to what else they can put in place to ensure R53's safety and from getting up on his own unassisted. V2 stated R53 currently uses a walker but was unsure as to when R53 started using it, saying R53 was in a wheelchair when first admitted . On 6/19/18 at 9:00 AM, R53 was in low bed which was pushed into the inside corner of the room. R53's curtain was pulled half way closed to the next bed so R53 was unable to be visualized from the hallway. On 6/19/18 at 11:30 AM , V3, CNA, stated R53 gets up on his own although R53 is not supposed to. V3 stated R53 is very quick and has had several falls. On 6/19/18 at 12:40 PM, R53 was sitting at the dining room table. R53's walker was beside him. R53 turned himself in the chair and stood up. No CNAs were close. A housekeeper stopped R53 and cued R53 to not walk until she could find someone. On 6/20/18 at 9:05am, R53 was out of bed and halfway into his bathroom when R53 was noticed by V10, who was walking past R53's room. R53 had gotten himself out of the low bed and ambulated at least 5 feet into the bathroom without the walker that was sitting beside his bed. Again, the curtain to R53's side of the room was pulled halfway across so visualization of R53 getting up was blocked from the hallway. On 6/20/18 at 12:40 PM, R53 again stood up from the dining room table, grabbed his walker and turned to start walking when staff was alert by a visitor. No staff were close by.

Based on interview, observation, and record review, the facility failed to follow manufacturer's recommendations for use of a full body mechanical lift for 2 of 3 residents (R2, R3) reviewed for mechanical lift transfers in the sample of 9. This failure resulted in R3 falling during a transfer and sustaining a bilateral subarachnoid hemorrhage. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R3 has severe cognitive impairment and is totally dependent on staff for all activities of daily living including transfer. The Care Plan, dated [DATE], documents R3 is a mechanical lift with assist of 2 and uses a wheelchair for locomotion throughout the facility requiring total assist of staff. An Incident Report, dated [DATE], documents R3 fell to the floor in her room at 6:33 AM during a full body mechanical lift transfer from her bed to the wheelchair by 2 Certified Nurses Aides (CNAs), E4 and E5. The Report documents while in the sling, the (mechanical) sling strap broke causing the resident to fall to floor. Note laceration c (with) bleeding to the back of the head. EMS (emergency services) called et (and) transferred to ER (emergency room .) The Report documents R3 being transferred to a larger hospital for evaluation and treatment. The Report documents the investigation determined the sling had no fraying, thread breakage, rips or tear that would account for the sling tearing. The Manufacturer's Handbook, dated 2013, documents recommendations for this particular lift that directs staff to position wheelchair and lock wheels before transferring the resident from the bed to the wheelchair. The recommendations also document staff are to ensure the straps are attached correctly after lifting from the bed and before moving the resident toward the wheelchair. The Incident Report does not reflect whether staff did this or not prior to transferring R3. On [DATE] at 1:00 PM, E4 and E5 were interviewed. E4 stated they (E4 and E5) had hooked R3 up and lifted her off the bed. E4 stated she reached over and pulled R3 over from above the bed as she reached back for the wheelchair when she her a pop pop and R3 fell to the floor. E4 stated she did not have the wheelchair locked as they usually pull it underneath the resident as they move the lift over. Both E4 and E5 stated the wheelchair was not positioned or locked prior to lifting R3 from the bed with the mechanical lift. Neither stated they checked the straps once they lifted R3 off the bed and before they moved her toward the chair. E4 stated the strap broke at R3's hips first, then the one by her shoulder causing her to fall and hit her head on the floor. E4 demonstrated at bed side that she was to the side of R3 trying to pull the wheelchair into place when R3 fell . E5 stated she was running the controls of the machine and had pulled the legs of the lift out from under the bed and moved her from over the bed when the straps broke. Neither CNA was in a position to break R3's fall from where they stood and E4 did not have control of R3. E5 stated she has been inserviced on using the full body mechanical lift since the incident occurred with R3. On [DATE] at 9:55 AM, E9, Registered Nurse (RN), stated she was called to the room after R3 fell . E9 stated that when she entered the room, R3 was on the floor with the sling under her, upper body towards the end of the bed and legs over the leg of the lift. E9 stated she saw blood coming from R3's head and immediately called to have her transported to the emergency room . R3's hospital Discharge Records, dated [DATE], document R3 had a bilateral subarachnoid hemorrhage resulting from a fall at the nursing home. R3's Progress notes, dated [DATE], document R3 returned to the facility at 1850 (6:50 PM) with end of life care (Hospice) due to bilateral subarachnoid hemorrhage. R3's Progress notes, dated [DATE], document R3 expired. 2. On [DATE] at 10:56 AM, E5 and E6, CNA, entered R2's room to transfer her to the wheelchair using a mechanical lift. The sling for the mechanical lift had already been placed under R2. E6 and E5 hooked R2's sling to the lift as she lay flat in the middle of the bed and E6 took the controls of the lift. R2 was lifted several inches above the bed then E6 moved her back as E5 turned her around and pulled her over toward the wheelchair which was located at the foot of the bed. The wheelchair wheels were not locked and as E5 took control of R2 by grabbing the sling straps on the back of the sling and moving her over the wheelchair, the wheelchair tipped backwards into E5. E5 moved R2 above the seat of the wheelchair and E6 lowered the sling/R2 into the seat of the wheelchair. Neither E5 or E6 checked the straps once R2 was lifted from the bed nor was the wheelchair positioned and the wheels locked prior to the lift as recommended in the Manufacturer's handbook. On [DATE] at 9:45 AM, E1, Administrator, and E2, Director of Nurses (DON), stated inservicing on mechanical lifts had been done since the incident occurred with R3 even though her fall was caused by the straps breaking. E2 stated E10, Therapy Director, had trained E11, Licensed Practical Nurse (LPN)/Restorative Nurse, and she had started training and doing repeat demonstrations for all CNAs. On [DATE] at 4:20 PM, E11 stated she had been doing some inservicing on the mechanical lift and had approximately 15 more CNAs to do. E11 stated she was unsure about whether to lock the wheelchair or not prior to transferring, but stated she knew the lift itself was not to be locked. On [DATE] at PM, Z3, Supplier of the lift, stated proper positioning for using the particular lift would be to have everything including the wheelchair in position prior to lifting the resident. On [DATE] at 9:45 AM, E10 stated she did inservicing to E11 and some direct care staff, but they have more to do. When asked about positioning and locking the wheelchair prior to lifting residents, E10 stated she tells staff to not lock the lift itself, but you can or don't have to lock the wheelchair. E10 stated it is very important for one person to have control of the resident in the sling at all times referring to have hold of the straps at the back of the sling when the resident is moved from over the bed to the wheelchair. E10 stated she has not looked at the handbook, but had training in this by the manufacturer approximately one year ago. E10 stated they did not focus on wheelchair positioning in a bed to wheelchair transfer, but not locking the lift so the point of gravity is maintained to prevent the lift from tipping. E10 stated again, that a staff member should have control of the resident in the sling at all times.

Based on interview and record review, the facility failed to safely transfer 1 of 3 residents (R1) reviewed for falls in the sample of 8. This failure resulted in R1 sustaining a fracture to her right hip. Findings include: The "Incident Details" documents that R1 fell in the Facility on 9/7/12 at 2:08 PM, "while ambulating with or without an assistive device" and sustained a "Minor Injury - Hematoma". The "Details" document "E5, Certified Nurses Aide (CNA) was transferrring Resident from toilet back to recliner. Resident's foot ran into the bathroom door, she lost balance and fell forward. Resident landed on her right side striking her head onto the floor. Resident has large hematoma noted to back right side of head and a large hematoma noted to right elbow with a small amount of serous drainage noted. Resident made complaints of pain to her head, neck, back and right hip. Order was received to send to emergency room . After further investigation, noted CNA was ambulating resident back from bathroom without a gait belt". R1's "Emergency Center Note", dated 9/7/12, documents "This [AGE] year old female was using her walker and it apparently caught on a door jam and she fell on her right side injuring her right hip, elbow, and striking her right posterior parietal scalp. There was no loss of consciousness but she is on Coumadin and she does have quite a bit of swelling. She has a history of fairly severe COPD and Congestive Heart Failure. She has chronic 4+ edema of her lower extremities. She has chronic renal insufficiency, diabetes, depression, hypertension, and GERD. The hip and pelvis x-ray shows a distal Transcervical fracture of the right femoral neck". Interview with E2, Director of Nursing (DON), on 9/25/12 at 3:30 PM, and E2 stated that R1 required extensive assistance with ambulation. E1 said that E5 failed to utilize a gait belt per the Facility policy when transferring R1 to and from the toilet. The following is documented in a statement written by E5 on 9/7/12: "I did not have the gait belt because I thought she was a supervised resident. The Facility has a few residents that we help without gait belts and I never seen one used on her after they changed her to a Assist 1". R1's Minimum Data Set (MDS), dated [DATE], documents that she requires the extensive assist of two or more staff persons for ambulation and transfers. R1's Plan of Care, with a start date of 8/27/12, documents a "Problem" of "I am at risk for falls due to unsteady gait, weakness, occassionaly incontinent of urine, psychotropic medication usage and oxygen usage". The "Approaches" for this "Problem" include "I am an extensive assist with ambulating. Please use a gait belt when assisting me with transfers and ambulation". .

Based on record review, observation and interview, the facility failed to safely transfer a resident, ensure resident alarm(s) were properly functioning and ensure a resident was safely toileted and ambulated for 3 of 9 residents (R1, R5 and R11) reviewed for falls in the sample of 16. This failure resulted in R1 incurring a right tibial tuberosity fracture during improperly assisted toileting and ambulation. Findings include 1. R1's Occurrence Report, dated 2-12-12, documented "resident (R1) walking back to bed from bathroom and lost her balance." R1' Nurse's Notes, dated 2-12-12, documented R1 was transferred to an emergency room for evaluation. R1's Radiology Department Report, dated 2-12-12,documented "fracture of the tibial tuberosity with minimal avulsion and soft tissue swelling." In an interview of E23, Licensed Practical Nurse (LPN), on 6-29-12 at 10:30a.m., E23 stated R1's walking device "got tangled in a bed side table" when she ambulated R1 from the bathroom to her bed. E23 also stated she assisted and ambulated R1 by herself. R1's Falls Care Plan, target date 8-6-12, documented R1 was at risk for falls d/t (due to), in part, poor balance and dementia. R1's Minimum Data Set (MDS), dated [DATE], documented urinary incontinency, extensive assistance of two plus persons physical assistance with mobility transfer and toileting and impaired moving, walking and turning balance. 2. Per R5's Physician order [REDACTED]. The MDS dated [DATE] and 4/23/12 both document that R5 requires extensive assistance with transfers, has poor balance and is non-ambulatory. The same MDS documents that R5 is moderately cognitively impaired and has poor safety awareness. Review of the facility Resident Care Plan interventions column, with a start date of 3/10/12 documents, "assist of 2 with transfers." On 2/5/12 wheelchair brakes were not checked before the transfer, and during the transfer E16, Certified Nurse Aid (CNA) realized the brakes were not working properly resulting in the wheelchair moving out from under the resident and resulting in a fall. On 3/10 and 3/12 E16 transferred R5 by himself. The Occurrance Report documents that R 5 either "lost her balance, or her legs gave out," resulting in a fall. E16 did not have a second assistant, as required for the transfers. Review of the Facility Occurrence Log for 2012 documents that on all three occasions E16 was the person transferring R5 when she fell . R5 was observed during a transfer on 6/26/12 at 12:50 PM from her wheelchair to the toilet. R5 required the assist of two CNA's and the use of a standing transfer device. During the transfer R5 yelled out that her knees were rolling and were going to give out and stated she was not able to go up any further in the device tolerating it poorly. R5 was not able to assist in supporting her weight during the transfer. E20 CNA stated, she has been this way for a while, she can't help and gets impatient." In an interview with E16 the CNA involved in the falls with R5, stated, "In February, I did not check the chair before I transferred (R5) I just figured the brakes were OK. In March, I looked at the board next to her bed and it still said 1 assist, but after the first fall on 3/10, it did cross my mind that I should have gone and gotten a second person, but I was the new guy and didn't want anyone to think I couldn't do my job. I should have gone to get help." 3. The MDS dated [DATE] identifies R11 to require extensive assist of two staff for transfers and ambulation. The MDS also indicates R11 has deficits with standing balance and moving between surfaces. The June 2012 physician's orders [REDACTED]. According to the care plan dated 4/20/12 identifies R11 to be at risk for falls due to wanting to be able to toilet/walk herself, confusion/forgetfulness, weakness and unsteadiness in addition to receiving an antipsychotic medication. The interventions also indicate R11 is to have a sensor alarm at all times. An Occurrence Report dated 2/4/12, indicates R11 was found on the floor. Her alarm was documented as "not sounding." No explanation was given for the alarm not sounding. On 5/14/12 at 3:06am, the Occurrence Report documents R11 having another fall from her chair which was not witnessed. The incident details recorded indicate the alarm was not working properly and was replaced. R11 was transferred to the emergency room for evaluation and returned with no injuries noted. An Incident Detail dated 5/23/12 at 6:30pm again documents R11 on the floor falling from her chair. The investigation documents R11 slid out the wheelchair to the floor and the alarm was half way out of the chair. The report documents the alarm was not sounding. No injuries were reported. On 5/24/12 at 5:51 am, R11 is again documented as falling from the chair in the dining room. The alarm was sounding but staff were unable to reach her before she slid to the floor. Dycem was placed in the seat of the chair to prevent further sliding. On 6/24/12 at 8:50 pm, R11 was again found on the floor only beside her bed. The alarm was not sounding as it was "close to the edge". On 6/28/12 at 11:50 am, E 21 and E 22 CNA's applied a gait belt on R11 and cued her to stand from her recliner chair at bedside encouraging her to "push off" from the arm of the chair. R11 was slightly unsteady then slowly began to take steps toward the bathroom. The gait belt slid up over her breasts and under her arms. R11 had a sensor alarm in the seat of the recliner which did not sound immediately upon R11 lifting up from it. On 6/28/12 at 11:02 am, E3, LPN, was asked if the facility had a system in place to check if the alarms are functional. E3 stated no but thought they probably needed one. E3 added in interview that the CNA's are suppose to check their own alarms but agreed that several of R11's falls occurred when the alarms were not sounding appropriately.

Based on observation, interview and record review, the facility failed to assess and manage pain for 3(R4, R12, R14), of 10 residents reviewed for pain control, in a sample of 17. This failure resulted in R4 flinching and pulling her leg up during pressure sore treatment with tears in her eyes. R14 exhibited verbal and non verbal signs of pain during a transfer. R12 had increased refusal of therapy due to complaints of pain in lower back and [MEDICAL CONDITION] of her bilateral lower extremities. Findings include: 1. R12's hospital physician progress notes [REDACTED]. Assessment: Lumbar pain and right gluteal pain. Plan: "At this point we will go ahead and give her something like pain shots, like [MEDICATION NAME] 30 IM tonight to try to help some with her pain and discomfort." R12's Hospital physician progress notes [REDACTED]. She is cooperating with Physical Therapy and is progressing. No problems reported. Extremities are now free of [MEDICAL CONDITION]. Under IMPRESSIONS: it is documented, in part, [MEDICAL CONDITION]. Will continue physical therapy and rehabilitation. Bilateral pedal [MEDICAL CONDITION] resolved. Will use Ace wraps prn (as needed). R12's May 2011 Physician order [REDACTED]. The POS shows an order of 4-19-11 for pain assessment. R12's PAIN ASSESSMENT OF 4-19-11 documents R12 had frequent, moderate pain in the past 5 days that did not effect function or daily activities. Pain intensity was assessed at "5" on a scale of 0 to 10. The assessment documents R12 has PRN (as needed) pain medication and verbalizes presence of pain. The section for Pain Summary addressing treatment, effectiveness, failures and preferences is left blank with no documentation. R12's Minimum Data Set (MDS) of 5-3-11 identifies R12 as having no pain and no PRN pain med. R12's Care Plan of 4-28-11 documents R12 may experience pain related to her back and age process. Note written 4-27-11 documents to give 325 mg of Tylenol 1 x only for back pain. Note written on 4-28-11 states Narco 10 mg/375 every 4 hours prn for back pain. Goal is to be free of pain or kept comfortable thru next review. Intervention includes, in part: Give pain medications as ordered and monitor for effectiveness or adverse effects; if don't have relief in pain or it gets worse notify Physician; Nurse will monitor pain every shift and rate on scale of 0 - 10 with 0 being no pain and 10 being the most severe; Monitor for signs and symptoms of pain, assess if R12 is tearful, crying, irritability, guarding, facial grimacing, and change in behavior or withdrawal from activities; Assess for pain or need for pain meds prior to any activity, eg: therapy, dressing changes, range of motion, ect. R12's Care Plan identifies a potential for fluid imbalance. Takes [MEDICATION NAME] with [DIAGNOSES REDACTED]. Encourage to drink all fluids on tray. There is nothing on R12's Care Plan to monitor for [MEDICAL CONDITION]. R12 was observed on 5-17-11 at 12:40PM to be brought to the Dining Room in a wheel chair propelled by staff. R12 was observed asking for a pain pill. R12's feet and legs were very [MEDICAL CONDITION] and extremely red and shiny with [MEDICAL CONDITION] from the knees down. R12' feet were swollen over her shoes. R12's feet were not on her foot pedals and the foot pedal was digging deep into her lower back leg. R12 was complaining that her legs hurt from the foot pedals. Surveyor informed E1, Administrator, of R12's feet position, wheel chair pedals digging into her legs and R12 stating it hurt where the pedals were digging into her legs. E2, Director of Nursing, went to R12 and removed the foot pedals, stating she thought they were too short for R12 and needed extended. At 3:10PM, R12 was observed complaining of lower back pain and asking for a pain pill. At 4PM, R12 was still complaining of pain and asking for pain medication and was told she would have to wait another hour before she was could have another pain pill. R12's SKILLED DAILY NURSES NOTES from of 5-17-11 identifies bilateral pedal [MEDICAL CONDITION] but the part of assessment form [MEDICAL CONDITION] is left blank. (R12 was observed with =4 [MEDICAL CONDITION] from foot pedals digging into her lower back legs.) The space for pain is left blank. (R12 was observed 3 times to complain of pain and ask for pain medication.) The Pain Assessment on R12's Medication Administration Record (MAR) shows no pain on the 6-2 shift. (R12 was observed to complain of pain at 12:45 PM and MAR shows [MEDICATION NAME] was given at 12:40PM.) There is no assessment/rating of pain. R12's MAR shows PRN [MEDICATION NAME] was given 42 times from May 1 thru May 18, 2011. The facility failed to assess R12's pain and the amount of PRN pain medication given. R12 was observed on the morning of 5-19-11 to be in bed sleeping. At 10:20AM R12 stated her legs hurt and she wanted to sleep. At 10:25AM, E17 stated R12 doesn't like to get up in the morning. She has a lot of pain and gets medication that maybe makes her tired. During interview with E17, Certified Occupational Therapy Assistant, on 5-19-11 at 1:30PM, E17 stated R12 will refuse therapy at times. E17 stated they try to encourage her to come to therapy and at times therapy staff will do therapy in R12's room. E17 stated R12 gets pain medication when she request and they will ask the Nurse to give pain medication if she is complaining of pain and also will ask Nursing to give pain med prior to therapy. E17 stated R12's swollen legs and feet could impact her not wanting to walk in therapy. E8, Physical Therapy Assistant, confirmed R12 will not always come to therapy room for therapy. She will do some activity in her room. "There are days when she just doesn't feel up to it." Both Therapist confirmed R12 was at the facility for therapy with intention to go home. E17 stated the goal if for R12 to spend at least 40 minutes in therapy, but sometimes spends less time because she says she is not up to it. On 5-20-11 during meeting with the facility, E2, DON, confirmed R12 needed to be reassessed for pain and management of pain. 2. According to the Minimum Data Set ((MDS) dated [DATE], R4 has short/long term memory deficits with cognitive impairment and is dependent on staff for all activities of daily living (ADLs). The MDS section on Pain is incomplete. The physician's orders [REDACTED]. The current POS includes an order for [REDACTED]. A PAIN assessment dated [DATE] has "unable to answer" checked for pain presence, frequency, effect on function, and activities. Intensity section has a "slash" through it along with a scale. Staff observance of pain has "0" documented for non-verbal signs, complaints, facial expressions and protective body movement. The care plan dated 4/19/11 indicates R4 "may experience pain related to age treated to change as well as discomfort related to" her contractures but includes no goal toward comfort with treatments although the goal is to be free of pain. Interventions include giving pain medications as ordered and monitoring for effectiveness or adverse effects. Interventions also reflect the pain assessment to be completed every shift using a scale of 0-10 with 0 being no pain and 10 being the most severe. The care plan also indicates she is unable to identify her pain but mentions nothing about monitoring pain with non-verbal signs. On 5/18/11 at 9am, R4's pressure ulcer treatment on her left lower ankle was observed being done by. As E21 cleansed the area with normal saline, R4 jerked her leg up in a protective manner as tears welled in her eyes with a frightened look on her face. R4 flinched again when the dressing was applied. According to E21 at the time, R4 always reacts this way to her treatment which is ordered twice daily stating "yes, always flinches" and "It does bother her." When asked about pain medication, E21 stated she didn't know if R4 was getting any pain medication and would find out. Review of the Medication Administration Record (MAR) for May 2011 show no Tylenol being administered at all. In addition, the pain assessments for all three shifts are documented as "0" even though R4 would have her treatment done daily on 7-3 and 3-11 shift. On 5/19/11 at 11:45am, E22, LPN, was in R4's room doing her treatment. She also acknowledged that R4 does pull back when the ulcer on her leg is cleaned and she "knows it hurts her." E22 said she had given R4 some Tylenol an hour before the treatment but couldn't say that it made R4 any more comfortable during the treatment. On 5/20/11 at 9:45am, E2, Director of Nursing indicated she knows R4 has "obvious pain" with her treatment as she saw it herself. E2 also stated the physician was notified and a routine [MEDICATION NAME] order was given to be administered 1 hour before treatments. E2 also indicated that the staff did try Tylenol on 5/19/11 with no relief noted with treatment. The facility failed to adequately identify and monitor R4 for pain with treatments and failed to ensure that pain medication was provided for comfort during treatments. 3. R14's Minimum Data Set (MDS), dated [DATE], documented R14 was a cognitively impaired resident with extensive assistance of two plus persons physical assistance with transfer and mobility. R14's Care Plan, dated 4-18-11, documented a care plan problem of pain with an intervention to monitor for signs an symptoms of pain, verbal and non-verbal. It was also noted R14 was care planned for fall risk with an intervention to provide R14 with proper assistance so "we can perform our task safety together." R14's Occurrence Report, dated 5-6-11, documented staff found a 3.0cm x 3.0cm skin tear, with dried blood, on R14's left outer elbow during care. During observation of R14's transfer, on 5-17-11 at 1:20pm., E14, Certified Nursing Assistant (CNA), and E15, CNA, transferred R14 from wheel chair to bed, R14's left outer elbow observed with a dated and dry dressing surrounded by deep reddened skin tissue around the upper edges of the dressing. During the transfer, R14 held her left outer elbow with her right hand and complained of left outer elbow pain, discomfort and tenderness. During observation of R14's transfer, on 5-18-11 at 8:55a.m., E12, Certified Nursing Assistant (CNA), and E13, Certified Nursing Assistant (CNA), transferred R14 from wheel chair to bed. During the transfer, R14 held her left outer elbow with her right hand and complained of left outer elbow, discomfort and tenderness. R14's chart documented Pain Assessments dated 10-16-10 and 1-19-11. R14's chart did not document a Pain Assessment after her 5-6-11 skin tear. R14's Routine Medications Sheet, dated 5-1-11 to 5-31-11, documented "Pain Assessment--Misc" every shift. It was also noted R14 was rated zero for pain for each shift; however, no entries were documented individualized to R14's 5-6-11 left outer elbow skin tear or her complaints of pain, discomfort and tenderness on 5-17-11 or 5-18-11. R14's Routine Medications Sheets, dated 5-1-11 to 5-31-11, and her Nursing Notes, dated 5-17-11 and 5-18-11, did not documented.

Based on interviews, observations and record review, the facility failed to ensure that 8 (R8, R11, R4, R1,R3, R2, R9, and R14) of 10 residents on the sample of 17 reviewed for pressure ulcers. The facility failed to ensure that all residents were turned and repositioned timely, were provided adequate skin care and assessments to meet their needs. This failure resulted in R4 developing an unstagable pressure ulcer on her lower leg which facility was unaware of and failed to prevent R11 from developing 2 new stage II pressure ulcers. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], R4 has short/long term memory deficits with cognitive impairment and is dependent on staff for all activities of daily living (ADLs). The physician's orders [REDACTED]. The care plan dated 4/19/11 indicates staff are to do daily skin checks, treatments as ordered and turn/reposition every two hours and as needed among other interventions. On 5/17/11 at 9:26am, R4 had a gauze dressing on her left foot, and also had a small open area (stage II) on her inner left buttock. R4 also had two stage II ulcers on her right hip within a golf ball size red area. She had a pressure relieving mattress on her bed, however, also had two cloth incontinent briefs under her. In addition, she had slid down in bed. The nurses notes and/or treatment record did not identify and/or reflect any treatments on either the inner buttock or the right hip. At 11am, R4 was provided incontinent care for bowel movement and urine by E5 and E6, Certified Nurses Aides (CNA's) using no soap or cleanser. Again, open areas were noted on her inner left buttock and right hip with both being brought to the CNA's attention. R4 wasn't turned again until 2 hours and 20 minutes later. On 5/18/11 at 9am, R4's inner ankle pressure ulcer treatment was observed and she was noted to have an additional unstageable pressure ulcer on her inner right ankle which was black, dry and oblong which E21, Licensed Practical Nurse (LPN), stated she was unaware of. E21 was also unaware of the ulcers on R4's right hip. On 5/18/11, R4's right hip areas were assessed at stage II's measuring .2cm x .1cm < 0.1 depth and .5cm x .7cm < 0.1 depth. R4's unstageable on her inner lateral ankle measured 1.3cm x .5cm. 2. The MDS dated [DATE] identifies R11 as requiring extensive assist of 2 staff for bed mobility. The Braden Scale dated 4/19/11 assesses R11 at high risk for pressure ulcer risk. Labs dated 1/24/11 show a low Total Protein 5.9 (normal 6.1-7.9) and [MEDICATION NAME] 2.1 (3.5-4.8). According to the May 2011 physician's orders [REDACTED]. The POS also includes orders for barrier cream. The care plan dated 4/29/11 indicates R11 has a long history of pressure ulcers. Interventions include providing fluids with each intervention, to drink plenty of fluids, use skin barrier to help protect skin, and skin check daily among others. The facility failed to provide treatments as ordered and failed to implement interventions for pressure ulcer prevention. On 5/17/11 at 11:10am, R11 was in bed on his right side. R11 had a crinkled up [MEDICATION NAME] dressing on his coccyx and no other dressing on. His right lower buttock was fire red, appeared [MEDICAL CONDITION] and weepy and had several small open areas present within the red areas. The dressing on was dated 5/16/11. E4 and E5, CNA's stated he was not wet but were going to "clean him up." The CNA's wiped back to front across the red open areas. R11 repeatedly said "ow" "ow" stating "that hurts." No barrier cream was applied. R11 was then dressed and transferred to his recliner. When up, he stated "My butt burns." No rinsing had been done with the regular shower gel. R11 had two incontinent pads on his bed. On 5/18/11 at 9:15am, R11 was transferred to bed. The CNA stated the [MEDICATION NAME] dressing had come off earlier that morning and the nurse had not been down to apply it yet. E 21, LPN did R11's treatments then. E21 stated new areas had been identified on R11 and measured them. Left posterior thigh was identified as a stage II and measured .2 x .2cm, left posterior thigh 1cm x .7cm. Additional measurements include left gluteus .4 x .7cm, right posterior thigh right side .8cm x .4cm, right posterior thigh middle .3 x .2cm and right posterior thigh left side 6cm x 3cm. 3. R14's MDS, dated [DATE], documented R14 was a cognitively impaired resident, incontinent of bowel and bladder, extensive assistance of two plus persons physical assistance with transfer, mobility and toileting and extensive of one person physical assistance with hygiene. R14's Care Plan, dated 4-18-11, documented a care plan problem of moderate risk for pressure sore development. It was also noted to turn and reposition frequently, to keep bed sheets smooth and wrinkle free and a documented healed pressure area on R14's left gluteal. During observation of R14's transfer and incontinent care, on 5-18-11 at 8:55a.m., E12, CNA, and E13, CNA, transferred R14 from wheel chair to bed. R14' adult diaper was observed soiled with urine, her buttock reddened and tissue scared. R14's bed was also observed with a double bed pad in place resulting in uneven raised surfaces and wrinkled bedding. E12 and E13 did not ensure R14's bedding was [MEDICATION NAME] and wrinkle free after providing care and leaving R14's room. 4. R3 was observed, on 5-17-11 from 11:15a.m. to 1:35p.m., at 10 minute intervals 11:15a.m., 11:25a.m., 11:35a.m. to 1:35p.m., without staff offer toileting or turning and reposition. During observation of R3's toileting, on 5-17-11 ar 1:35p.m., E12 and E13 assisted R3 to the bathroom. R3's adult diaper was soiled with urine and R3 stated, on 5-17-11 at 1:35p.m., "Absolutely", when E12 and E13 asked R3 if she needed to "go to the bathroom." R3's buttock observed reddened and creased. 5. R9's MDS, dated [DATE], documented R9 was a cognitive impaired resident, incontinent of bowel and bladder and extensive assistance of two plus persons physical assistance with transfer, mobility and hygiene. The facility's Pressure Ulcer Log, dated 5-11, documented R6 was admitted with a unstable right heel pressure ulcer. R19's Care Plan, dated 11-20-10, documented at risk for skin problems and "float heels et have heel protectors on while in bed." During observations of R9's heels,on 5-17-11 from 10:50a.m. to 11:30a.m. at 5 minute intervals 10:55a.m., 11:00a.m. to 11:30a.m. and 5-19-11 from 7:15a.m. to 9:15a.m. at 5 minute intervals 7:25a.m., 7:35a.m. to 9:15a.m., R9's heels were not floated with heel protectors while he was in bed. 6. R8 who was not offered timely turning and reposition during observation on 5-17-11 from 9:20a.m. to 1:20p.m. At 1:20p.m., R8's buttock were observed deeply creased and reddened when provided care on 5-17-11 at 1:20p.m. And, R2, who was not offered timely turning and reposition on 5-17-11 from 8:45a.m. to 1:45p.m. and observed sitting up in a wheel chair. R2's buttock was observed deeply creased and reddened when provided care, on 5-17-11 at 1:45p.m. R1 was also not timely turned and repositioned during the survey.

Based on interviews, observations and record review, the facility failed to ensure that 1 (R4) of 1 resident in the facility with a gastrostomy tube of 17 sampled residents received necessary services to provide adequate nutrition/hydration to meet her assessed needs including unplannned weight loss. This failure resulted in R4 having a significant weight loss of 5% within a month, exhibiting signs/symptoms of fluid deficit and observed poor positioning. Findings include: 1. According to the Minimum Data Set ((MDS) dated [DATE], R4 has short/long term memory deficits with cognitive impairment and is dependent on staff for all activities of daily living (ADLs). The physician's orders [REDACTED]. The POS also indicates R4 currently pressure ulcers. The care plan identifies R4 to be at nutritional risk for weight loss and risk for aspiration. A hospital history and physical dated 10/25/10 indicates she was admitted with pneumonia and dehydration. The NUTRITIONAL CARE NOTES dated 2/18/11 indicates R4 was readmitted from the hospital for pneumonia." Weight at that time was 106 pounds. According to hospital lab results, R4's [MEDICATION NAME] 2.7 L (normal 3.5-5) and Total Protein 6.2 (6-8.3). The Registered Dietician (RD) recommended gradually increasing Glucerna from 30ml an hour to 50ml an hour with same flush. R4's estimated energy needs at the time: 1200-1500 cal, 58 grams of protein, 1500cc of water. However, R4's feeding was providing less as the RD writes "currently provides 828 calories, 41gm of protein, 1355cc fluids." The 50cc/hour would provide 1380 calories, 61 grams of protein and 1725 cc of fluids. According to the Medication Administration Record, could not handle increase in Glucerna rate to goal of 50 ml/hr." The nurses notes dated 3/2/11 documents "res (resident) noted to have audible congestion. Skin cold and clammy. SPO2 93%." The physician was notified and R4 had a chest Xray done which identified right peripheral infiltrates. The nurses notes do not reflect any assessment toward positioning or how R4 tolerated the tube feeding at the time other than the audible congestion. Observations during the survey on 5/17/11 and 5/18/11 have R4 laying very low in the bed with her head not elevated. The NUTRITION RECOMMENDATION dated 3/12/11 under rationale documents "Resident unable to tolerate ^ (increase) rate to meet energy needs. May benefit from more nutrient dense formula" with the recommendation resulting in the [MEDICATION NAME] HN at 30 ml for 20 hours with flushes 200 cc every 6 hours. The recommendation indicates the same flush amount will be continued. However, the next note dated 3/23/11 documents "Nutrition recommendation signed for diet change to [MEDICATION NAME] HN 30ml... New product ordered by DON (Director of Nursing). Will change as soon as new product arrives." And on 4/1/11, the RD documented the [MEDICATION NAME] would be started that day. Recorded weight on April was 103 pounds according to the weight record, a loss of 3 pounds. On 5/20/11 at 9:30am, E20, RD was asked about the delay in starting the [MEDICATION NAME] and stated it took a while to get the physician's orders [REDACTED]. E2, Director of Nursing stated the facility was having trouble getting the physician to return a response and/or order timely. E2 stated they did not contact the medical director regarding the delay in response but waited until they received it back from R4's physician. On 5/17/11 during initial tour of the facility at 9:20am, R4 was laying on her right side fairly flat in bed. Her tube feeding was running at 30cc an hour per pump. A 1000cc bottle of [MEDICATION NAME] was hanging and had no labeling on it as to time, date or rate of infusion. Her [DEVICE] site dressing was present dated 5/17/11 and was noted to have some drainage present. R4 had been incontinent of very soft black bowel movement and not incontinent of urine. Her mouth, oral cavity in general appeared dry. At 11am, R4 was again observed and the [DEVICE] bottle of [MEDICATION NAME] was labeled with all information except time hung. R4's oral cavity was dry, tongue cratered and white, teeth dry with lips were peeling. On 5/18/11 at 9am, R4 was again noted in bed laying on her right side slid down in bed. The head of the bed was barely elevated. R4's mouth was again noted to be dry, tongue white/cratered and she had dried thick mucus stuck on her teeth and lips. Lips had skin peeling. R4 had a 1000cc bottle of [MEDICATION NAME] hanging labeled 5/17/11 2200 (10pm) at 30cc an hour with 86 cc infused per the pump. As of 11am, R4's mouth still had not been cleaned. The nurses notes for both days fail to reflect these observations. Review of the weekly weights recorded identify a significant weight loss from 103 on 4/3/11 to 102 pounds 4/10/11 to 97 pounds on 4/17/11, 4/27/11, 5/1/11, and 5/4/11 Her weight on 5/11/11 was 100 pounds. The facility failed to identify this as a significant weight loss and notify physician and dietician until it was brought to their attention on 5/18/11. On 5/19/11, the RD provided new recommendations over the phone that included increasing the [MEDICATION NAME] to 40ml per hour with 200cc flushes every hours. A telephone order was written. On 5/20/11, the RD reassessed R4. His assessment indicates that the current amount of [MEDICATION NAME] (30cc.hour) did not meet her nutritional and/or fluid need and currently has developed pressure ulcers along with having a 3 pounds weight loss in 1 month. The note documents his increase in [MEDICATION NAME] to 40cc with nursing assessing her tolerance and wounds. In addition, the RD recommended [MEDICATION NAME] 1 packet twice daily and a pre-[MEDICATION NAME] level.