Every finding on record at The Citadel at Saint Joseph Village

Based on interview and record review, the facility failed to initiate a home health referral upon a residents (R1) discharge from the facility. This applies to 1 of 3 residents reviewed for discharge in the sample of 5.The findings include:R1's electronic face sheet printed on 4/21/26 showed R1 has diagnoses including but not limited to fibromyalgia, non-ST elevation myocardial infarction, presence of aortocoronary bypass graft, chronic pain syndrome, muscle wasting & weakness, major depressive disorder, Bell's Palsy, generalized anxiety disorder, and osteoarthritis.R1's care plan dated 6/9/25 showed, Return to community referral. (R1) does not plan to make the community a long term home (R1) will be assisted with the plan to stay in the community until discharge is practical-associates will support (R1's) plan to stay short term, assist with referrals, as needed, to meet goals for discharge.R1's facility discharge assessment dated [DATE] showed, planned discharge, discharge status: home under care of organized home health service organization, active discharge planning is occurring, referral to local contact agency.R1's nurse practitioner notes dated 6/5/25 showed, The patient was seen for follow-up and discharge planning. The social worker stated the patient is most likely going to be discharged home on June 12th, 2025 discharge disposition: despite patient's good participation in subacute rehab and current improvements, patient needs to continue with outpatient home health, PT (physical therapy) and OT (physical therapy) to improve strength, balance, endurance and mobility in order to maintain as much as possible and as long as possible the independence with ADL's (activities of daily living) as well as to decrease the risk of falls.R1's nursing progress notes dated 6/8/25 showed, During inquiry related to 6/11/25 medical appointment, resident reported that she planned to discharge from facility on 6/10/25 as arranged by her son.R1's nurse practitioner note dated 6/9/25 showed, The social worker informed this provider that the patient no longer wants to be in nursing facility and wants to go home today .discharge disposition: despite patient's good participation in subacute rehab and current improvements, patient needs to continue with outpatient home health, PT and OT to improve strength, balance, endurance and mobility in order to maintain as much as possible and as long as possible the independence with ADL's as well as to decrease the risk of falls.R1's social service progress note dated 6/9/25 showed, (R1) requested to discharge today. She will discharge home with in home PT/OT/Nurse/bath aid with (local home health agency). She also plans on cardiac rehab beginning in July.R1's discharge instructions for care dated 6/9/25 showed, discharged to home, cardiac diet, home exercise program, independent in all ADL's, no services contacted, no physician name, appointments scheduled shows f/u 6/11/25.On 4/21/26 at 2:13 PM, V4 (Occupational Therapist/Therapy Director) stated, When a resident desires to discharge, we recommend therapy services to the facility and then the facility would get the orders and do the referrals for the resident. It's pretty routine that we would at least recommend home health if not recommend outpatient therapy. People don't always accept it and don't stay as long as they used to. (R1) arrived to us after a CABG (Coronary Artery Bypass Graft) and was a 1 person assist for transfers, 1 assist for ADL's, and ambulating short distances with a walker. She did great in therapy and by the time she left here she was dressing, toileting, transferring, and ambulating herself to dining room with a walker due to cardiac precautions. We worked on stairs because she had a few steps to go into her apartment. I recommended cardiac rehab due to her CABG. I did not recommend PT/OT because she wouldn't qualify for both PT/OT and cardiac rehab. I don't know when cardiac rehab was scheduled but I know the referral was in from the cardiologist. We weren't aware of any delay in the cardiac rehab being scheduled. It was a quick discharge, we could have made that referral for PT/OT but I honestly didn't know it was going to be that long before she could get into cardiac rehab. I probably would have made the referral for some PT/OT until she could get into cardiac rehab had I known that it was going to be a few weeks just so she could keep up with her level of functioning and have no deterioration.On 4/22/26 at 8:44 AM, V4 stated, The doctor or nurse practitioner has the final say with the referrals for outside resources upon discharge. If we don't make any recommendations and the provider feels they need something, they will order it and we have no say in it.On 4/22/26 at 9:27 AM, R1 stated, When I left the facility, the social service person told us that they were setting up home health for me for physical therapy and occupational therapy in my home when I discharged . I waited about a week and nobody ever called or showed up, they told me it might take a few days so I waited at least a week if not 2. We called the home health company and they never received a referral so I lost all that time without any therapy and I felt weaker. The home health company didn't seem surprised at all that they didn't receive the referral. I was told I couldn't have both cardiac rehab and therapy services at the same time. I think I started cardiac rehab in the beginning of July.On 4/22/26 at 10:22 AM, V9 (previous social service director) stated she was unable to recall (R1) or her family or any details related to her discharge.On 4/22/26 at 10:58 AM, V12 (home health intake coordinator) stated, We started care for (R1) on 6/23/25 and our care ended on 7/7/25 when she started cardiac rehab. She was getting nursing, physical, and occupational therapy. I do document all accepted and rejected referrals and her name was never received from (facility). I contacted her physician's office on June 18th, 2025 after (R1's son) contacted our office wondering when we were going to start home health for (R1) and I had no idea what he was talking about. I was able to get the order for home health and everything I needed by June 19th and we started care the next week. R1's home health documents dated 6/23/25 showed R1 enrolled in home health services and received nursing, physical therapy, and occupational therapy from 6/23/25-7/7/25.On 4/22/26 at 1:15 PM, V13 (Social Services) stated, I have been working as social services since November 2025. If resident requests to discharge from the facility, I talk to therapy to see how they are doing, talk to nurse practitioner to see if discharge order can be obtained, and then talk to family to see if home health, DME (durable medical equipment), or therapy services are wanted. We have 2 home health agencies that we typically deal with. We fax the referral order and then they reach out to us if further information is needed. They will also reach out to us when they have received the referral so we know things are set up. I try to call if I don't hear anything but I don't always remember. A weekend is a little more difficult to get home health set up. I tell the resident and family that I can get the referral sent but home health won't reach out until the following week because there typically isn't anyone in the office.The facility's policy titled, Transfer or Discharge-Resident-Initiated dated October 2022 showed, Residents may initiate a transfer or discharge from the facility.Documentation: 1. For resident-initiated discharges, the medical record contains: c. documented discussions with the resident or, if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care.

Based on interview and record review, the facility failed to ensure a resident received an ordered low sodium diet. This applies to 1 of 3 residents (R1) reviewed for special dietary needs in the sample of 5. The findings include:R1's Face Sheet showed diagnoses to include heart bypass surgery, myocardial infarction (heart attack), and hypertension (high blood pressure).R1's 5/28/25 Brief Interview for Mental Status score showed she was cognitively intact with a score of 15 out of 15.On 4/21/26 at 9:35 AM, V1 (Administrator) stated the facility had changed ownership after R1 was discharged from the facility (R1 was discharged to home with family on 6/9/25). V1 stated records prior to 10/1/25 went with the previous owners and they were not returning calls. R1's entire medical was requested. On 4/21/26 at 9:50 AM, V1 stated she may have a staff member that has access to the previous electronic health record.On 4/21/26 at 11:45 AM, V1 provided a paper copy of R1's Electronic Medical Record. R1's hospital Discharge Packet (printed 5/27/25, R1's admission date to the facility was 5/28/25) showed an order for a Heart Healthy DASH diet (Dietary Approaches to Stop Hypertension) and No Added Salt Diet. The orders showed, The hospital diet order may be substituted with your facilities equivalent diet description. The discharge packet showed R1 had been admitted to the hospital on [DATE] with a heart attack and then on 5/20/25 underwent coronary bypass graft surgery (heart bypass surgery).The National Institutes of Health website (NIH, Official United States Government Website titled DASH Eating Plan (Last Updated 2/25/26) showed a DASH diet is a .flexible and balanced eating plan that helps create a heart-healthy eating style for life. The DASH eating plan requires no special foods and instead provides daily and weekly nutritional goals. This plan recommends: Eating vegetables, fruits, and whole grains. Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils. Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils. Limiting sugar-sweetened beverages and sweet (sic). Sodium 2,300mg (milligrams)* The plan continued, *1,500 milligrams (mg) sodium lowers blood pressure even further than 2,300 mg sodium daily. The website showed, When following the DASH eating plan, it is important to choose foods that are.lower in sodium.The Mayo Clinic Website titled, DASH diet: Guide to recommended servings (Dated 5/25/23) showed, The DASH diet also limits salt, also called sodium, to between 1,500 and 2,300 milligrams a day.R1's Physician's Orders showed an order for No added salt diet which was started on 5/28/25. The orders then showed a third change on 6/6/25 (9 days after R1 was admitted to the facility) when the diet was altered to DIET: 2-3g (grams, 2,000 to 3,000 milligrams) Sodium; Thin Liquids.On 4/22/26 at 9:26 AM, R1 said I was supposed to be on low sodium and low fat diet. I took a picture of it; the first meal I was served was a big glob of pulled pork with barbecue sauce and fat all through it. It was salty and that was what they served me. I sent the picture to my kids, and I said, 'Can you believe this?' I ate less than half. I knew I wasn't supposed to eat it.On 4/21/26 at 2:22 PM, V7 (Registered Dietitian) stated, at the time of R1's admission, there were two dietary options for sodium restriction; a no added salt diet and a 2 to 3 gram salt diet. V7 stated the no added salt diet is a regular diet with no salt packet provided to the residents. V7 stated, in long-term care, a 2-3 gram salt diet is a low sodium diet. V7 stated the regular menu would exceed 3 grams of salt on most days. V7 stated the 2-3 gram salt diet is more restrictive than the no added salt diet. V7 stated she was not certain what the sodium restrictions were for a DASH diet; however, the facility did not have a DASH diet. V7 stated, she was notified by staff the day following R1's admission that R1 had been served pulled pork the night of her admission and R1's Son was not happy. V7 said, she did go through the menu with R1 and help her make better choices. (Interview concluded at 2:45 PM at the request of V7, who cited a previously scheduled appointment.)On 4/22/26 at 10:28 AM, V7 was shown the hospital discharge orders. V7 stated she would expect staff to enter a no added salt diet because that is what was ordered, and the facility did not have a DASH diet option. V7 stated, The DASH diet is more for when they go home. V7 stated, upon further review of the hospital discharge orders, it is possible the intended order from the hospital was for R1 to be on a DASH diet in addition to a no added salt diet and the No Added Salt diet was not to the exclusion of the DASH diet. V7 stated, if a DASH diet recommendation is less than 3 grams, then the facility's 2-3 gram sodium diet most closely aligns with the DASH diet's sodium restriction. V7 stated the purpose of sodium restriction is to minimize swelling and reduce blood pressure.

Based on observation, interview, and record review, the facility failed to maintain accurate records of controlled medications for seven (R6, R7, R8, R9, R10, R11, R12) of ten residents reviewed for medication management in the sample of 12.The findings include:1.R9's Order Summary Report dated March 12, 2026, shows an order for hydrocodone-acetaminophen (Norco) 5-325 mg give one tablet by mouth every four hours as needed for pain started January 8, 2026.A narcotic count was performed with V4 Licensed Practical Nurse on March 12, 2026, at 11:08 AM. R9's Norco punch card had 14 pills left in it. R9's Controlled Drug Receipt/Record/Disposition Form shows the last dose was administered on March 7, 2026, and there were 15 pills left. (Meaning one pill was missing and not signed out). V4 said she performed a narcotic count with the previous nurse. V4 said one nurse has the sheet and the other nurse has the drawer with the narcotics. V4 said she doesn't know why there is a discrepancy. V4 said she does not remember giving R9 a Norco. On March 12, 2026, at 2:53 PM, V1 Administrator said the facility is still investigating the missing Norco tablet. 2.R10's Medication Administration Record (MAR) dated March 1, 2026-March 31, 2026, shows an order for alprazolam 0.25 mg one tablet by mouth twice daily; give one tablet by mouth every 12 hours as needed.R10's Control Drug Receipt/Record/Disposition Form shows R10 received an alprazolam on March 5, 2026. March 7, 2026, shows a tablet was removed. The nurse documented, For (another resident's initials). Assistant Director of Nursing (ADON) aware. R10's MAR shows that R10 did not receive an alprazolam on March 7, 2026.3. R11's Controlled Drug Receipt/Record/Disposition Form shows a Norco was signed out on March 9, 2026, two times, but no staff member name is signed. R11's MAR shows that R11 did not receive Norco on March 9, 20264. R6, R7, R8, and R12's Controlled Substances sheets were signed off by V4 LPN during this narcotic count performed on March 12, 2026, at 11:08 AM. V4 said she administered the controlled substances to the listed residents but did not sign them off on the control substances sheets. R6, R7, R8, and R12's MARs show the controlled substances were scheduled to be given at 8:00 AM. On March 12, 2026, at 11:55 AM, V5 Registered Nurse (RN) said narcotics are counted at shift change. V5 said if there are discrepancies, then they have to notify the assistant director of nursing or the director of nursing. V5 said one residents' medication should not be used for another resident. On March 12, 2026, at 1:51 PM, V3 ADON said narcotic counts are performing during the oncoming shift change. Two nurses perform the counts. One nurse looks at the book and the other looks in the cart. Medications should be documented as it is given. V3 said the purpose of performing a narcotic count is to prevent drug diversion. The facility's Administering Medications Policy dated December 2017 shows, The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.The facility's Controlled Substances policy dated December 2017 shows, The facility shall comply with all laws, regulation, and other requirements related to handling, storage, disposal, and documentation of schedule II and other controlled substances. Nursing staff must count controlled medication at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observation, interview, and record review, the facility failed to ensure the dishwasher temperature was at an appropriate temperature to sanitize dishes and silverware and failed to maintain the garbage disposal system. These failures have the potential to affect all residents residing in the facility.The findings include:The Resident Census and Condition Report provided by the facility on 3/4/26 showed 88 residents residing in the building.On 3/3/26 at 9:06AM, The dishwasher was draining large amounts of water onto the dish room floor. The water had small amounts of food and wrappers located in it. The dishwasher was started and showed a wash cycle temperature of 144 degrees Fahrenheit. The front of the machine showed a reference wash cycle temperature of 150 degrees Fahrenheit. There was a strong odor of rotting food within the dish room. Surveyor observed the sink with the garbage disposal was full of orange/brown water with food floating in it.On 3/3/26 at 9:19AM, V5 (Dietary Manager) stated, There is a pipe on the back of the dishwasher that falls off every day at a minimum. If it falls off, the water leaks all over the floor. V5 then put the pipe back in place and the water leaking from the dishwasher greatly decreased. V5 stated he is unsure why the dishwasher was not coming up to the appropriate temperature. V5 stated the garbage disposal is clogged and then proceeded to dig what appeared to be coleslaw, french fries, and unidentifiable food out of the garbage disposal system.On 3/3/26 at 12:50PM, V5 stated, The dishwasher should be coming up to 150 degrees as it is a hot water sanitization. If it does not come up to the desired temperature then dishes will not get sanitized properly. If we don't get that pipe fixed, it could remain a hazard for our staff to have water leaking all over the floor.The facility's undated dishwasher manual showed, Minimum water temperature for hot water sanitization 150 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 29 opportunities with 9 errors resulting in a 31% medication error rate. This applies to 4 of 6 (R31, R53, R80, R81) residents reviewed for medication pass.The findings include:1. R31's March 2026 physician's orders showed R31 receives meropenem 1000 milligrams (mg) intravenously every 12 hours for bacterial infection and acetaminophen 650mg at 8AM and 8PM. On 3/3/26 at 03/03/2026 9:30AM, V16 (Licensed Practical Nurse-LPN) administered R31's acetaminophen 650mg (1 hour and 30 minutes past the scheduled administration time).On 3/3/26 at 9:38AM, R31 stated she doesn't think she received her meropenem this morning. V16 stated, I'm an LPN so I can't give it. She's supposed to get it at 6AM. I just can't give it so I have to get time to go get the RN (Registered Nurse) on the other side of the building. V16 then notified the Nurse Practitioner of R31's late medication and informed administration that she needed an RN to administer R31's intravenous meropenem (3 hours and 38 minutes after the scheduled administration time).2. R53's March 2026 physician's orders showed R53 receives memantine 10mg at 8AM and 8PM.On 3/3/26 at 9:41AM, V16 administered R53's memantine 10mg (1 hour and 41 minutes past the scheduled administration time).3. R80's March 2026 physician's orders showed R80 receives ramipril 5mg, rivaroxaban 2.5mg, glipizide 10mg, and gabapentin 300mg at 8AM and 8PM. R80 receives vitamin C 1000mg at 7AM and 4PM.On 3/3/26 at 9:36AM, V16 administered R80's ramipril 5mg, rivaroxaban 2.5mg, vitamin C 500mg, glipizide 10mg, and gabapentin 300mg (2 hours and 36 minutes past the scheduled administration time for R80's vitamin C and 1 hour and 36 minutes past the scheduled administration time for the remainder of R80's medications).On 3/3/26 at 9:52AM, V16 stated, I came in this morning at 6:15AM. I'm not familiar with the residents on this hall as much because I don't work over here often. I feel bad and try to help because there are only 2 aides working this whole unit so I'm trying to help them too. I know my medications were late for a few people, but I don't know what else I could have done to prevent it. 4. R81's March 2026 physician's orders showed R81 receives chlorhexidine mouth rinse at 8AM and 8PM.On 3/5/26 at 8:31AM, V11 (LPN) stated R81's chlorhexidine was unavailable and was unable to find it in her medication cart. V11 stated she reordered the medication on 2/27 so is unsure of why it has not arrived from pharmacy yet.On 3/5/26 at 11:11AM, V2 (Director of Nursing) stated, All medications should be administered within 1 hour before or 1 hour after scheduled time. If the order is at 8AM then they can be given between 7AM-9AM. Anything outside of those times would be considered a medication error for timing. Intravenous antibiotics are especially important to give at the ordered time to ensure a resident receives the full treatment to fight their infection.The facility's policy titled, Administering Medications dated December 2017 showed, Medications shall be administered in a safe and timely manner, and as prescribed.4. Medications must be administered within one hour of their prescribed time, unless otherwise specified.

Based on observation, interview, and record review, the facility failed to prepare pureed foods to the desired consistency. This applies to 8 of 8 residents (R2, R35, R46, R48, R53, R87, R90, R91) reviewed for pureed foods in the sample of 23.The findings include: On 3/3/26, the facility provided a list of residents receiving a pureed diet. R2, R35, R46, R48, R53, R87, R90 and R91 were all residents listed as receiving a pureed diet. On 3/3/26 at 11:10AM, V14 (Cook) prepared the pureed fried steak. V14 poured the meat with a small amount of liquid from the bottom of the cooking pan into the blender. V14 blended the meat to a ground consistency and then poured it into a pan. V14 then prepared the pureed corn by pouring the corn into the blender, blended to a ground consistency, and poured it into a separate pan. Upon completion of blending each item, V14 tasted the items and stated they were both a pureed consistency which should be a smooth consistency and not a paste-like consistency.On 3/3/26 at 12:07PM, R35 stated his food was not pureed. He stated the meat wasn't pureed all the way and there were pieces of meat in it. He said he has a swallowing problem and problems with his teeth. Resident had already left the dining room and was sitting in his wheelchair in the hall. He stated he let the staff know that it wasn't pureed. At 12:10PM, R35's lunch plate observed and he left mashed potatoes with gravy, corn with kernel chunks in it, and meat with chunks in it. R35's food was not a creamy texture and only a few bites were taken from his plate. The ticket next to R35's meal ticket showed he is to have pureed consistency with double portions of meat. R35's ticket was circled to show he chose to have fortified pudding, pureed chicken fried steak with country gravy, garlic mashed potatoes, pureed creamed corn, and pureed frosted spice cake. (The Physician Orders for March 2026 for R35 showed regular diet, pureed texture).On 3/3/26 at 12:17PM, surveyor requested a pureed test tray. The meat was thick and not creamy with small chunks of meat in it. The pureed corn had pieces of corn hull in it. At 12:25PM, V1 (Administrator) came into the conference room and stated the test tray appeared to be mechanical soft. V1 confirmed the pureed diet did not appear pureed. On 3/3/26 at 12:58PM, V15 (Registered Dietician) stated, Pureed foods should not have any chunks in them as this creates a choking hazard for our residents with swallowing difficulties. Food should be blended to a smooth consistency and not like a paste for residents to swallow easily.The facility's Guidelines for Pureed Preparation policy (March 2017) showed the pureed diet provides food with semi-liquid to semi-solid consistency (i.e. pudding-like).The recipe for pureed creamed corn printed on 3/4/26 showed, Place portion of prepared corn in food processor and blend until a smooth consistency.The recipe for pureed chicken fried steak printed on 3/4/26 showed, Place prepared portion of chicken fried steak in food processor with hot broth and blend to a smooth consistency.

Based on observation, interview, and record review, the facility failed to ensure 6 residents (R19, R25, R65, R85, R94, R106) were treated with dignity during mealtimes, and failed to provide assistance with facial hair grooming for 1 resident (R31). These failures apply to 7 of 7 residents reviewed for dignity in the sample of 23.The findings include: 1. On 3/4/26 at 11:34AM, R25, R94, and R106 were seated at the lunch table together. R94 received her lunch tray and began eating her food. At 11:48AM, surveyor observed R94 stop eating. R94 stated, I'm trying to wait so we can all eat together but my food is getting cold. At 11:55AM, R25 stated, We always have to wait a long time after (R94) gets served. I think it's ridiculous. We should all be eating at the same time & she shouldn't have to eat slower because we are waiting. At 11:57AM, V5 (Dietary Supervisor) brought R25 and R106's meal tray. R25 stated that wasn't what she ordered and V5 stated her ticket was lost so they brought her the main meal. V5 returned at 12:10PM to serve R25 her correct meal. (26 minutes passed between the time R25 was served and all residents at the table received their meal.) On 3/4/26 at 11:35AM, R19, R73, and R85 were seated at their lunch table. R73 received her meal tray. At 11:45AM, R19 and R85 were served their lunch meal. R85 stated, She (R73) is already halfway done eating and we haven't even been served yet. I don't like that. We should all eat at the same time so we can enjoy eating together. On 3/4/26 at 11:48AM, R32 and R65 were seated at their lunch table. R32 was served her lunch meal. At 12:06PM, dietary staff began picking up plates from empty tables where residents had finished eating and V14 (Cook) stated she was plating the hall trays for residents in their rooms. V14 stated all residents in the dining room had been served. At this time, surveyor notified V5 that R65 did not get a meal tray brought to his table. (18 minutes after R32 was served her meal.) On 3/5/26 at 8:33AM, V5 stated, I did see the dining experience yesterday and it is unacceptable. I saw residents waiting to eat when their tablemates were eating and that is not okay. I didn't realize it was 25 minutes at times for table mates to get their food. That is 100% a concern and that is not ok. I am trying to work with the dietary staff to get them to realize when residents are all sitting at the same table then they should all be served at the same time. It is a concern for the residents dignity if they are all not served at the same time because we do have some residents who feel left out and like we are intentionally not serving them at the same time. That's not the case but that's how they feel. I did not see that (R85) had not been served food until someone notified me right before you did that, he didn't have a plate. We need to be more accountable for our residents and ensure everyone is served in the dining room before we start plating the hall trays to be delivered. The facility's policy titled, Quality of Life-Dignity dated 2018 showed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality.1. Residents shall be treated with dignity and respect at all times. 2. On 3/3/26 at 11:25 AM, R31 was sitting up in bed. R31 had coarse gray and white facial hair above her upper lip, chin and neck. The surveyor asked R31 if the facility had offered to shave her facial hair. R31 replied, No, I wish they would. I know it needs to be shaved. It's embarrassing. R31 said she usually keeps the facial hair shaved at home, but her facial hair hadn't been shaved since admission to the facility (2/11/26). On 3/4/26 at 8:35 AM, R31 was seated in her electric wheelchair, fully dressed. R31 continued to have numerous, coarse gray and white facial hairs to her upper lip, chin, and neck. R31 said she was going out for an appointment. R31's Face sheet dated 3/5/26 showed R31 was admitted on [DATE] with diagnoses to include, but not limited to multiple sclerosis, diabetes, chronic kidney disease, and hypertension. R31's facility assessment dated [DATE] showed she was cognitively intact and required substantial/maximal assistance with personal hygiene. This assessment defines personal hygiene as the ability to maintain personal hygiene, including combing hair, shaving, applying makeup and washing/drying face and hands. R31's Care Plan initiated 2/11/26 showed R31 required assistance with ADLs (Activities of Daily Living) related to multiple sclerosis. Assist with ADLs was a listed intervention. On 3/4/26 at 1:04 PM, V22 (Certified Nursing Assistant – CNA) said female residents should be offered assistance with shaving on shower days, but we usually don't shave them unless they ask. On 3/4/26 at 3:39 PM, V2 (Director of Nursing – DON) said female residents shouldn't have facial hair unless it is their preference. V2 stated, It's a dignity issue. V2 said the CNAs should offer to shave R31 whenever they notice facial hair and on shower days. The facility's Quality of Life – Dignity Policy reviewed 12/2018 showed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).

Based on interview and record review, the facility failed to provide HS (bedtime) snacks for 6 of 6 residents (R4, R8, R30, R34, R56, R80) reviewed for HS snacks in the sample of 23.The findings include:On 3/4/26 at 10:07AM, a Resident Council meeting was held with R4, R8, R30, R34, R56, and R80. All residents stated the kitchen does not send snacks every day for them. We don't get offered snacks every day. The only time we get snacks is when we request it but we thought they were supposed to come around and offer it. All residents state they would like to at least be offered a snack because it is a long time to wait from dinner time to breakfast the next day.R4, R8, R30, R34, and R80's most recent facility assessments showed no cognitive impairment. R56's most recent facility assessment showed mild cognitive impairment.The resident council minutes for January 2026 showed, Are you offered a bed time snack? No. Residents were encouraged to go ask for snacks when they stated they do not receive a bed time snack.On 3/5/26 at 11:11AM, V2 (Director of Nursing) stated, Snacks are passed with water pass usually but it can be at different times. We don't have a specific snack pass time, we prefer it to be done after breakfast on day shift and on second shift they do it right when they come in so by 4PM or so. I guess I didn't realize that it had to be after dinner when they passed the snacks, but it makes sense if it's supposed to be an HS snack.On 3/5/26 at 11:29AM, V27 (Certified Nursing Assistant) stated, Second shift snacks are passed with water when I first come in for my shift. I didn't know they had to be offered at bedtime.On 3/5/26 at 12:05PM, V1 (Administrator) stated, I just had an in-service 2 weeks ago telling staff when to pass the snacks. There is no reason why they shouldn't be offering snacks to residents at bedtime. We at least need to offer a snack and document whether or not the resident accepts them.The facility's policy titled, Snacks (Between Meal and Bedtime), Serving dated, September 2010 showed, The purpose of this procedure is to provide the resident with adequate nutrition.

Based on observation, interview, and record review the facility failed to ensure a resident had a wheelchair that fit and maintained body alignment and positioning needs for 1 of 1 residents (R60) reviewed for accommodation of needs in the sample of 23.The findings include:On 3/4/26 at 9:03 AM, R60 was sitting in her wheelchair in the common area with her left leg twisted inward. The resident's knees were bent, and the back of her knees were about 1 foot away from the seat of the wheelchair. R60 complained of pain to her left leg and did not look comfortable. V13 (Certified Nursing Assistant - CNA) was asked to observe R60 and V13 stated R60 did not look comfortable in the wheelchair.On 3/4/26 at 9:12 AM, V12 (Restorative Nurse) went with the surveyor to observe R60 in her chair. V12 stated R60's positioning in the wheelchair wasn't good and confirmed that the wheelchair did not appear to fit R60 as it should.On 3/4/26 at 9:15 AM, V6 (Director of Physical Therapy) observed R60 in her wheelchair and stated the wheelchair looked too small for R60 and they could get her a larger one.The Face Sheet dated 3/4/26 for R60 showed diagnoses including Alzheimer's disease, unspecified protein calorie malnutrition, depression, dementia, obstructive and reflux uropathy, chronic atrial fibrillation, anxiety, urinary tract infection, chronic pain, mitral valve insufficiency, disorders of the kidney and ureter, cardiomegaly, and hypertension. The MDS dated [DATE] for R60 showed severe impairment of memory and cognition; functional limitation in range of motion to both lower extremities; mobility device - wheelchair; substantial/maximal assistance needed for rolling left and right in bed; dependent for transfers.The facility's Quality of Life - Accommodation of Needs policy (August 2019) showed the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis.

Based on observation, interview, and record review the facility failed to ensure the elasticated tubular support bandages were in place for 1 of 1 residents (R60) reviewed for quality of care in the sample of 23.The findings include:On 3/3/26 at 2:35 PM, R60 was sitting in her wheelchair with her feet on the floor and grip socks on. R60 did not have any elasticated tubular support bandages (leg wraps) on her lower legs. V10 (Certified Nursing Assistant - CNA) was asked to check and see if R60 had any leg wraps in place and she confirmed R60 did not have any and she was not aware of the resident having any.On 3/3/26 at 2:41PM, V7 (Licensed Practical Nurse - LPN) stated the elasticated tubular support bandages should be done as ordered. V7 stated she thought they were put on by the night nurse. V7 looked in her computer and stated the leg wraps can be put on by either the day or night shift nurse. On 3/4/26 at 9:03 AM, R60 was sitting in her wheelchair in the common area and did not have leg wraps in place. On 3/4/26 at 9:24 AM, V11 (LPN) was asked if R60 was supposed to have any wraps to her legs. V11 checked in her computer and stated R60 is supposed to have them. V11 stated the order showed they were to be applied in the morning and removed at bedtime.On 3/4/26 at 12:52 PM, V2 (Director of Nursing - DON) stated R60 has the elasticated tubular support bandages because she gets dependent edema from sitting in the wheelchair. V2 stated the leg wraps were to be applied in the morning. V2 stated she thought the nurse was the one that applies them and the nurse and CNAs monitor compliance to make sure it is being done. V2 stated they should be signed out on the Treatment Administration Record - TAR when they are being done. V2 reviewed R60's March 2026 TAR and stated they were signed out on 3/4/26 at 6:30 AM by V7 that she put them on. V2 stated they were not signed out by V11 today that they were on and that V11 came to talk to her about it after the surveyor asked her about it that morning.The Face Sheet dated 3/4/26 for R60 showed diagnoses including Alzheimer's disease, unspecified protein calorie malnutrition, depression, dementia, obstructive and reflux uropathy, chronic atrial fibrillation, anxiety, urinary tract infection, chronic pain, mitral valve insufficiency, disorders of the kidney and ureter, cardiomegaly, and hypertension. The Physician Orders dated March 2026 for R60 showed Apply elasticated tubular support bandages to both legs in the morning and remove at bedtime every day and night shift. The order was placed on 9/30/25.The Care Plan dated 12/29/25 for R60 did not show the use of elasticated tubular support bandages.The Progress Notes for R60 were reviewed from 1/1/26 - 3/4/26 and did not show any refusal of care.The MDS dated [DATE] for R60 showed severe impairment of memory and cognition; functional limitation in range of motion to both lower extremities; mobility device - wheelchair; substantial/maximal assistance needed for rolling left and right in bed; dependent for transfers.The facility had a policy for Applying Anti-Emboli Stockings (10/2022) that did not show any information specifically for elasticated tubular support bandages. The stockings and bandages were not the same. There was no policy for elasticated tubular support bandages.The facility's Physician Orders policy (February 2019) showed all orders will be processed and carried out by nursing service personnel as soon as the order has been received.

Based on observation, interview and record review, the facility failed to ensure a resident was positioned safely to prevent a fall for 1 (R4) of 4 residents reviewed for falls in the sample of 23.The findings include:R4s admission record shows she was admitted to the facility on [DATE] with a primary diagnosis of congestive heart failure and a history of falling. The 12/16/25 quarterly resident assessment and care screening documents R4 to be cognitively intact. The same record shows R4 requires partial/moderate assist with rolling right to left. The helper lifts, holds or supports trunk and limb during the movement.R4s 11/30/25 care plan documents her to be a high risk for falls related to functional deficits.The facility's 2/5/26 incident report of a witnessed fall documents R4 fell out of bed during repositioning. She was lowered to the floor gently by the aide. On 3/04/2026 at 12:34 PM, R4 said she had rolled out of her bed about a month ago. The Certified Nursing Assistant (CNA) was repositioning her in bed. She said the CNA rolled her towards the edge of the bed and her feet went over first and her legs shifted. Then she rolled and fell to the floor between the aide and the bed. She said it would have been about a two-foot drop from the bed to the floor. She said at the time, the side rails were not on the bed. She said it was not the first time she had fallen out of bed, there was another incident last year.On 3/4/26 at 12:35 PM, R4 was sitting up in her wheelchair in her room. She had a bariatric bed with bilateral upper rails.On 3/5/26 at 9:01 AM, V24 (CNA) said R4 has always been a 2 assist with rolling her in bed, she recently had bars put on her bed because she rolled out of bed. We use 2 staff for resident safety.On 3/05/2026 at 10:37 AM, V2 (Director of Nursing - DON) said the aide rolled R4 towards herself and when R4s legs were moved over, the momentum of her legs moved her over the edge of the bed shifting her and making her fall off the bed.The facility's 3/2018 policy for falls and fall risk documents a fall is defined as: unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if her or she had not caught him/herself, is considered a fall. A fall without injury is still a fall.

Based on observation, interview, and record review the facility failed to ensure an indwelling catheter drainage bag was maintained below the level of the bladder for 1 of 3 residents (R31) reviewed for indwelling catheters in the sample of 23. The findings include:On 3/4/26 at 8:35 AM, V19 and V20 (Certified Nursing Assistants - CNAs) had the total lift in R31's room. They said they just got R31 up and were getting her ready for her dentist appointment. V20 left the room briefly and re-entered. R31 was seated in her electric wheelchair. V19 lifted R31's catheter drainage bag in the air to place it in the privacy bag. R31's catheter drainage bag was at the level of R31's shoulders (above the level of her bladder) and yellow urine was flowing back toward R31 in the tubing.On 3/4/26 at 12:34 PM, V21, V22, and V23 (CNAs) entered R31's room to transfer her to bed with the total lift. V22 and V23 applied R31's total lift sling to the mechanical lift. V22 said someone will need to hold R31's catheter. V22 removed the catheter drainage bag from R31's electric wheelchair and handed it to V23. R31 was still seated in her electric wheelchair. V23 held R31's catheter drainage bag near R31's shoulder level (above the level of her bladder) while waiting for V21 and yellow urine was backflowing in the catheter tubing.On 3/4/26 at 2:20 PM, V18 (Registered Nurse - RN) was preparing for R31's wound care. V18 removed R31's urinary catheter bag from the side of the bed, lifted it approximately 1-2 feet above R31 and handed it to V27 (CNA). Yellow urine back flowed toward R31 in the tubing. R31's Face sheet dated 3/5/26 showed R31 had diagnoses to include, but not limited to multiple sclerosis, diabetes, chronic kidney disease, hypertension, neuromuscular dysfunction of the bladder, and urinary tract infection. R31's facility assessment dated [DATE] showed she was cognitively intact and had an indwelling urinary catheter.R31's Care Plan initiated 2/11/26 showed R31 required the use of an indwelling catheter related to neurogenic bladder. The care plan included an intervention to keep the drainage bag lower than the level of the bladder.On 3/4/26 at 1:04 PM, V22 (CNA) said the catheter bag is supposed to be kept below the resident's waist to decrease the risk of an infection.On 3/4/26 at 3:39 PM, V2 (Director of Nursing - DON) said the catheter drainage bag should be kept below the level of the bladder to prevent backflow that could cause R31 to get a urinary tract infection.The facility's Urinary Catheter Care Policy reviewed 9/2019 showed the purpose of this procedure is to prevent catheter-associated urinary tract infections. This policy showed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the bladder.

Based on observation, interview, and record review the facility failed to label open tube feeding, ensure a feeding tube dressing was intact, and check placement of a feeding tube prior to using the tube for 1 of 1 residents (R3) reviewed for enteral feeding in the sample of 23. The findings include:On 3/3/26 at 10:07 AM, there was an open bottle of tube feeding sitting on R3's dresser. There was 300 milliliters (ml) left in the bottle. The tube feeding was not labeled when it was opened.On 3/3/26 at 1:19 PM, R3 was laying in bed with his abdomen exposed. R3's feeding tube was slightly pulled out and there wasn't a dressing on his abdomen around the feeding tube. The dressing was twisted with bloody drainage and was hanging down on his tubing. V7 (Licensed Practical Nurse - LPN) was leaving his room and stated she was just cleaning up his room. At 1:24 PM, V7 was asked if she was returning to R3's room and she stated she had already given R3 his bolus of tube feeding at 11:00 AM and his medications had been given so she was done in his room. V7 stated his dressing around his feeding tube is changed by the night nurse but can be done as needed. V7 was asked to observe R3's dressing. V7 went into his room and stated she could change his dressing.On 3/4/26 at 10:30 AM, V11 (LPN) went into R3's room to give him his tube feeding. V11 had a gown and gloves on. V11 flushed R3's feeding tube with water, gave a bolus of 325 ml of tube feeding, and flushed the feeding tube. V11 never checked placement prior to giving the bolus of tube feeding. V11 stated there weren't any orders for her to check placement of his feeding tube. V11 stated she does it sometimes and when she does there is a residual of 25 ml to 50 ml of tube feeding. V11 stated she said R3 recently switched to bolus feedings, and she doesn't think that he is tolerating it. V11 stated there aren't any parameters for his tube feeding to show if he is tolerating it or not. V11 stated she never received any education related to the facility's policy on tube feeding.On 3/4/26 at 12:52 PM, V2 (Director of Nursing - DON) stated the facility does have feeding tube policies. V2 stated they do residual checks for placement prior to tube feeding administration. V2 stated checking the potential of hydrogen - pH is not part of their policy. V2 stated the facility's policies are on the computers and there are copy binders on the unit. V2 stated staff should follow physician orders. V2 stated tube feeding should be labeled when it is opened, and it is good for 24 hours.The Physician Orders dated March 2026 for R3 showed apply split gauze to tube site. Enteral feed - tube feeding Bolus 325 ml five times a day. Monitor for tolerance. Must document in nursing note. Place binder on abdomen so the patient cannot accidentally pull-on tube. Place binder when tube is not being used. Clean external tube site with mild soap daily. Flush tube before and after every use whether it is medication, nutrition etc.The Care Plan for R3 dated 1/29/26 showed the resident has difficulty swallowing related to medical diagnosis of dysphagia and is nothing by mouth with dependency on tube feeding. Let staff check residuals per nursing policy. Monitor tube feeding tolerance. Provide tube feeding as ordered. Tube feeding: Resident is at risk for complications related to tube feeding. Check feeding tube residual as ordered. Check tube placement by auscultating air injection every shift. Keep head of bed raised 30 degrees. Tube feeding as ordered. R3's The Face Sheet dated 3/4/26 showed diagnoses including hypoxic ischemic encephalopathy, asthma, critical illness myopathy, type 2 diabetes mellitus, obstructive sleep apnea, dysphagia, cognitive communication deficit, aphasia, spastic hemiplegia, gastroesophageal reflux disease, iron deficiency anemia, benign prostatic hyperplasia, down syndrome, hyperlipidemia, hypothyroidism, major depressive disorder, anxiety disorder, hypertension, gastrostomy, and bipolar disorder.The facility's Checking Gastric Residual Volume - GRV policy (March 2023) showed the purpose of this procedure to assess tolerance of enteral feeding and minimize the potential for aspiration. Measure GRV with at least a 60 ml syringe. Once target rate and amount of feeding have been reached and are being tolerated, check GRV every 6-8 hours.The facility's Confirming Placement of Feeding Tube policy (March 2023) showed the purpose is to ensure placement of the feeding tube to prevent aspiration during feedings. Observe for changes in residual volume. A. A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach; b. Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus. Post- pyloric/intestinal contents can be bile stained, light to dark yellow or greenish-brown. The person performing this procedure should record the following information in the resident's medical record the date and time the procedure was performed. The name and title of the individual(s) who performed the procedure. All assessment data obtained during the procedure. If the resident refused the procedure, the reason(s) why and intervention taken. The signature and title of the person recording the data.

Based on observation, interview, and record review the facility failed to follow professional standards when starting an intravenous (IV) antibiotic for 1 of 1 resident (R38) in the sample of 23. The findings include:On 3/3/26 at 9:35 AM, V18 (Registered Nurse - RN) prepared to administer IV antibiotics to R38's PICC (peripherally inserted central catheter) line. V18 flushed R38's PICC line with 10 milliliters (ml) of Normal Saline (NS), clamped the PICC line and left the syringe attached to R38. V18 checked the IV antibiotic and stated, This is ampicillin 500 milligrams (mg) and we will run the 100 ml over 60 minutes. V18 opened the IV tubing and spiked the antibiotic. V18 primed the IV tubing with the antibiotic, clamped the white C-clamp and roller clamp. V18 removed the flush syringe from R39's PICC line, cleansed the site with an alcohol swab and attached the IV tubing. V18 opened the clamp on the PICC line site and the roller clamp on the IV tubing. The white C-clamp was still closed on the IV tubing. V18 said the next step was to put the tubing in the pump and set the rate. V18 attempted to place the tubing into the pump and said the white clamp had to go in a specific way. V18 was unable to get the tubing in on the first try. The white C-clamp opened during this failed attempt. The IV antibiotic began to flow freely into R38's PICC line. A steady stream of fluid passed through the drip chamber. V18 did not notice the freely flowing antibiotic and continued to attempt to place the tubing in the IV pump. The surveyor intervened and asked V18 if the antibiotic should be flowing freely. V18 replied, Oh, no. It shouldn't be going that fast. V18 closed the roller clamp on the IV tubing, and the flow of the antibiotic stopped. R38 received approximately 20-30 ml of the 100 ml antibiotic (ampicillin 500 milligrams (mg) in 100 ml of fluid) medication in less than a minute. V18 said the antibiotic should not have been administered so quickly. V18 stated, It stopped as soon as I closed the roller clamp. V18 said she should have had the roller clamp closed when she was placing the IV tubing in the IV pump. V18 said pharmacy enters the appropriate rate for infusion on the label of the medication. V18 said R38's antibiotic label showed that the entire 100 ml should be administered over one hour. R38's Face Sheet dated 3/5/26 showed diagnoses to include, but not limited to chronic kidney disease, urinary tract infection, bladder cancer, dysphagia, disorders of the muscles, lack of coordination, and cognitive communication deficit. R38's Physician Order Sheet dated 3/5/26 showed an order for Ampicillin Sodium 500 mg IV four times a day for an infection in the urine for 10 days. R38's IV antibiotic label dated 3/3/26 showed Ampicillin 500 mg in 100 ml of NS. Infuse 100 ml IV piggyback over 60 minutes every 6 hours for 10 days. R38's Care Plan initiated 2/28/26 showed R38 had a urinary tract infection. One of the interventions was to administer medications as ordered. On 3/4/26 at 3:45 PM, V2 (Director of Nursing - DON) said R38's antibiotic should not have been free flowing while V18 (RN) tried to place the IV tubing. V2 said the nurse should prime the IV tubing and place the IV tubing into the IV pump before the IV tubing is attached to the PICC site. V2 said that prevents the risk of accidentally infusing medication too quickly while trying to place the IV tubing in the IV pump. V2 said some of the nurses have trouble loading the IV tubing into the IV pumps because the white C-clamp must go in a specific direction. V2 said that's why it's so important to make sure the roller clamp is closed to prevent the antibiotic from free flowing. V2 said she's not sure what could happen if R38 received 20-30 ml of Ampicillin in less than a minute. V2 said there's a reason the antibiotics are labeled to run at a specific rate. V2 said the nurses are expected to follow the prescribed rate of administration. On 3/5/26 at 9:36 AM, V26 (Pharmacist) said ampicillin IV is used to treat infectious processes. V26 said the IV room pharmacist calculates the infusion rate and then labels the medication appropriately. V26 said she expected the nurses to administer at the appropriate rate. V26 said R38's ampicillin should be administered through an IV pump and shouldn't have been flowing freely. The surveyor asked what potential side effects could R38 experience from receiving 20-30 ml in less than a minute. V26 said the error would not have been clinically significant. The facility's Continuous Infusion of Medications and Solutions dated July 2017 showed the IV tubing should not be attached to the resident's IV site until the IV tubing inserted into the IV pump and set at the prescribed rate. The policy showed the roller clamp should be closed while loading the IV tubing into the pump and should not be opened until the nurse is prepared to start the infusion.

Based on observation, interview, and record review the facility failed to have respiratory masks covered and stored in a manner to prevent any cross contamination for 3 of 3 residents (R3, R29, and R107) reviewed for respiratory care in the sample of 23.The findings include:1. On 3/3/26 at 10:07 AM R3 had a CPAP (Continuous Positive Airway Pressure) machine with a face mask sitting face down uncovered on the bedside table. The mask was dirty with white substances on the inside of the mask and some tan flakes. R3's nebulizer mask was uncovered on the bedside table, and the inside of the mask was dirty.On 3/3/26 at 2:25 PM, V3 (Assistant Director of Nursing - ADON/Infection Control Preventionist) stated respiratory masks are kept in little black bags next to the machines. This is done for sanitary reasons/infection control.R3's Face Sheet dated 3/4/26 showed diagnoses including hypoxic ischemic encephalopathy, asthma, critical illness myopathy, type 2 diabetes mellitus, obstructive sleep apnea, dysphagia, cognitive communication deficit, aphasia, spastic hemiplegia, gastroesophageal reflux disease, iron deficiency anemia, benign prostatic hyperplasia, down syndrome, hyperlipidemia, hypothyroidism, major depressive disorder, anxiety disorder, hypertension, gastrostomy, and bipolar disorder.The Physician Orders dated March 2026 for R3 showed change nebulizer mask/tubing every week and as needed. Bilevel positive airway pressure/continuous positive airway pressure - BiPap/CPAP on at bedtime and off in the morning. Cleanse mask w/ 0.25% Acetic Acid every morning am after removal.The Care Plan dated 1/29/26 for R3 showed, Respiratory: has potential for difficulty in breathing related to asthma and obstructive sleep apnea. Administer medications/treatments as ordered. Head of bed elevated to prevent Shortness of Breath. Monitor vital signs and lung sounds. Observe for changes in breathing pattern. There wasn't any plan in place for BiPap/CPAP.The facilities CPAP/BiPAP Support policy (March 2023) showed, General Guidelines for Cleaning. Masks, nasal pillows and tubing: clean daily by placing in warm, soapy water and soaking/agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow to air dry between uses.The facility's Administering Medications through a Small Volume Nebulizer (October 2024) showed rinse and disinfect the nebulizer equipment according to facility protocol or. When equipment is completely dry, store in a plastic bag with the resident's name and date on it.2. On 3/3/26 at 10:33 AM, R107 was lying on his side asleep in bed with oxygen on via a nasal cannula. There was a urinal on R107's bedside table with his nebulizer mask laying uncovered next to the urinal.On 3/3/26 at 2:25 PM, V3 (Assistant Director of Nursing - ADON/Infection Control Preventionist) stated respiratory masks are kept in little black bags next to the machines. This is done for sanitary reasons/infection control. V3 stated the masks should not be sitting next to any urinals and there shouldn't be any urinals sitting out. V3 stated this is for infection control. The Face Sheet dated 3/4/26 for R107 showed diagnoses including anoxic brain damage, chronic obstructive pulmonary disease, unspecified severe protein calorie malnutrition, atherosclerotic heart disease, heart failure, hypertensive heart disease with heart failure, hyperlipidemia, dysphagia, and hypertension.The Physician Orders for R107 for March 2026 showed, change nebulizer mask/tubing every week and as needed every night shift every Friday. Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ML), 3 ml inhale orally every 4 hours as needed for shortness of breath or wheezing via nebulizer. The Care Plan dated 2/20/26 for R107 showed, Respiratory: R107 has potential for difficulty in breathing related to chronic obstructive pulmonary disease - COPD. Administer medications/treatments as ordered. R107 is on respiratory therapy for improvement in pulmonary function related to COPD. Administer nebulizer treatment as ordered. 3. On 3/3/26 at 10:36 AM, R29 was sitting up on his bed watching television. There was a urinal with urine in it on R29's bedside table. R29's nebulizer machine and uncovered nebulizer mask was on the bedside table next to his urinal.On 3/3/26 at 2:25 PM, V3 (Assistant Director of Nursing - ADON/Infection Control Preventionist) stated respiratory masks are kept in little black bags next to the machines. This is done for sanitary reasons/infection control. V3 stated the masks should not be sitting next to any urinals and there shouldn't be any urinals sitting out. V3 stated this is for infection control. The Face Sheet dated 3/4/26 for R29 showed diagnoses including chronic obstructive pulmonary disease, pneumonia, atrial fibrillation, heart failure, acute on chronic respiratory failure with hypoxia, disorders of muscle, hyperlipidemia, and hypertension. The Physician Orders for March 2026 for R29 showed, change nebulizer mask/tubing every week and as needed every night shift every Friday. Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML Solution use 1 vial in nebulizer twice daily. The Care Plan dated 2/27/26 for R29 showed, Respiratory: resident has potential for difficulty in breathing. Administer medications/treatments as ordered. Assess respiratory status: rate, depth, pattern, skin color. Head of bed elevated to prevent Shortness of Breath. R29 is on respiratory therapy for improvement in pulmonary function related to chronic obstructive pulmonary disease and chronic respiratory failure. Administer nebulizer treatment as ordered. Administer oxygen therapy as ordered.

Based on observation, interview, and record review, the facility failed to dispose of a residents (R90) expired insulin pen, failed to store narcotics in a manner to prevent medication diversion for a resident (R80). These failures apply to 2 of 2 medication carts reviewed for medication storage.The findings include:On [DATE] at 1:34PM, surveyor reviewed medication cart belonging to V17's (Licensed Practical Nurse-LPN) assignment. R90's insulin aspart pen had an open date of 12/15 and an expiration date of 1/15. V17 stated, We try to keep an eye on the insulin pens to check expiration dates. (R90) hardly ever uses his sliding scale insulin so that's probably why we didn't notice it but it should have been discarded if it's been open for more than 28 days. V17 disposed of R90's insulin aspart pen and obtained a brand new one out of the medication room and stated, I don't know why we didn't replace it if there's a new one here that we should be using. R90's February and March medication administration records were reviewed and showed R90 utilized the insulin aspart pen multiple days while it would have been expired.On [DATE] at 1:39PM, Surveyor completed a narcotic count with V16 (LPN) on her assigned medication cart. R80 had a card of Norco 5/325mg with one of the tabs taped into the card. V16 stated, If someone pops out a medication and then they don't use it we usually just tape it back in so we don't waste it. I can only assume that is a Norco pill, I guess I would have to verify with someone to see if that's what it actually is.On [DATE] at 11:11AM, V2 (Director of Nursing) stated, Insulin pens are discarded after 28 days of opening due to expiration of medication. I think the potency decreases with time opened. Narcotics should be wasted in a drug buster with 2nd nurse witness, should not be taped back into card because it causes the potential for diversion or the medication could get loose or mixed up with other medications.The facility's policy titled, Storage of Medications dated [DATE] showed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility staff failed to follow enhanced barrier precautions - EBP when providing care for a resident with a feeding tube for 1 of 3 residents (R3) reviewed for enhanced barrier precautions in the sample of 23.The findings include:On 3/3/26 at 1:24 PM, R3 was laying in bed with his dressing around his feeding tube twisted with bloody drainage. The dressing was down on the tubing and not secure to his abdomen. At 1:28 PM, V7 (Licensed Practical Nurse - LPN) and V9 (Certified Nursing Assistant - CNA) went into R3's room with gloves on but no gowns on. They repositioned R3 in the bed. V7 removed the old dressing from around R3's feeding tube, did site care, and placed a new dressing. V7 and V9 repositioned R3 in bed. V9 stated R3 was incontinent of bowel movement and said she needed to go and get help. When V9 returned to the room she had V8 (CNA) with her. V7, V8, and V9 were asked about EBP. V7 stated she did not know if R3 was on EBP. V8 stated that a gown, gloves, and face mask is to be worn with care of the feeding tube and close contact care of the resident. V9 stated V8 told her that she needed to wear a gown when they provide care. On 3/3/26 at 2:25 PM, V3 (Assistant Director of Nursing - ADON) stated staff know if someone is on EBP because there is signage on the door. The sign tells the staff what they should wear and when they should wear it. If it is a double occupancy room there is an orange sticker on the name plate of the resident that is on them. Staff also know what they should wear and when to wear it because we have covered it during in-services. V3 read what the sign states and said it would be for close contact care, residents with devices including feeding tubes, dressing changes etc. R3's Face Sheet dated 3/4/26 showed diagnoses including hypoxic ischemic encephalopathy, asthma, critical illness myopathy, type 2 diabetes mellitus, obstructive sleep apnea, dysphagia, cognitive communication deficit, aphasia, spastic hemiplegia, gastroesophageal reflux disease, iron deficiency anemia, benign prostatic hyperplasia, down syndrome, hyperlipidemia, hypothyroidism, major depressive disorder, anxiety disorder, hypertension, gastrostomy, and bipolar disorder. The Physician Orders dated March 2026 for R3 showed an order for Enhanced Barrier Precautions (EBP). The Care Plan dated 1/29/26 for R3 showed resident requires enhanced barrier precautions related to feeding tube. Staff will wear gloves and gowns for device care or use of central lines, urinary catheters, feeding tubes, tracheostomy, colostomy/ileostomy or any wound care. Gown and glove one use only and for only one resident. The facility's Enhanced barrier Precaution - EBP policy (March 2023) showed EBP is indicated during high-contact resident care activities that provide for transfer of multidrug resistant organisms - MDROs with any of the following: Indwelling medical devices, regardless of MDRO colonization status (central lines, urinary catheters, feeding tubes, hemodialysis catheters, tracheostomies, and ventilators). High contact resident care activities include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use EBP requires the use of gown and gloves when performing high contact care resident care activities.

Based on observation, interview, and record review the facility failed to honor resident preferences regarding menu items. This failure has the potential to affect all residents residing in the facility. The findings include:The facility's resident roster provided on 12/6/25 showed 77 residents reside in the facility.On 12/6/25 at 8:39 AM, V3 [NAME] stated bacon used to be provided for the residents prior to the current owners acquiring the building. (New corporation took ownership on 10/1/25.) V3 said, We used to make bacon all the time.I had four residents ask for it this morning.On 12/6/25 at 8:45 AM and 8:47 AM respectively, a walk-through of the facility's walk-in freezer and walk-in refrigerator showed no bacon.On 12/6/25 at 8:53 AM, V2 Dietary Aide stated We do have residents asking for bacon all the time, but we were told the company won't allow it. [V4] is the dietary manager, and he called the company, and they said no bacon. V2 stated R2, R3, R4, and R5 routinely ask for bacon.On 12/6/25 at 1:16 PM, V7 Certified Nursing Assistant (CNA) stated, he has received a lot of complaints about not getting bacon.On 12/6/25 at 1:21 PM, V8 Registered Nurse stated, I have had many complaints from many residents about not getting bacon.On 12/6/25 at 1:35 PM, V9 CNA stated, They don't get any bacon in the morning, and they are not getting meat in the morning. There are a lot of residents complaining about that.On 12/6/25 at 1:00 PM, R3 stated, .Breakfast is a mess, we don't get any bacon, as far as I know there is no bacon. I like bacon, it's the only breakfast meat I want. They say it's too expensive for us and I said that's bull crap, but I didn't say crap. I think I should be allowed to have bacon. All I want is bacon toast and coffee and now I can't get it. I think I pay enough to get that. I know bacon doesn't have any nutritional value, but it tastes good. I think I should be able to make my own choices about what I eat even if it's not the best for me. I'm [AGE] years old; I should get what I want.What they serve us has a big impact on how I feel, I enjoy going and seeing my friends and talking with them and eating a good meal.On 12/6/25 at 9:40 AM, R2 stated the facility no longer makes bacon and they ran out of bread the other day. R2 stated she would like to have her thin cut bacon.On 12/6/25 at 10:09 AM, R4 stated No bacon anymore. I ask for it, and they say they don't have it anymore. I can't remember the last time we had bacon; it's been months. We had sausage for a while, but they stopped that several days ago. We don't get any meat with our breakfast. I think we should be able to get the bacon all the time or at least a couple times a week, now we get nothing.On 12/6/25 at 10:22 AM, R5 stated . there is no bacon.When I first came here, I had bacon every day and now that they (new owners) have taken over I have not had bacon once since they took over. [V1] has been having a series of resident meetings and the food stuff, the food is the main thing we talk about. The rice and beans are cheap, and I just can't eat rice anymore.Eating is one of the few things that we old people have left to enjoy, so we pay the same as we did before, so why can't they serve us the same stuff. Yesterday they served lasagna at lunch, and I got it again at supper time. I got leftover lasagna.We do have an alternative menu. I have no idea how they would do the alternative menu if they don't have bacon, I would really like some bacon once in a while. (R5 pointed to a facility provided alternative menu. Listed on the menu was Egg, bacon, and cheese sandwich for breakfast and for lunch/supper a BLT (bacon, lettuce, tomato sandwich) was listed.)On 12/6/25 at 11:03 AM, V1 Administrator provided the facility's Always Available Menu (aka alternative menu). The menu showed, Egg, Cheese Sandwich and the BLT sandwich was not listed. The alternative menu was otherwise identical in format to the one on R5's wall.On 12/6/25 at 11:03 AM, V1 Administrator stated The alternative menu, it was changed 2 to 3 weeks ago. We can't get bacon. My understanding, [food service provider] does our menus, they said it has no nutritional value and they will not add it to our menus. It used to be available. The residents would like to have bacon.On 12/6/25 at 11:24 AM, V4 Dietary Manager stated So, I was able to get it (bacon) through [food service provider] one time. I asked the food rep (representative) to order it for me, because residents had asked for it. So, I put it out (provided the bacon to the residents), then after that [food service provider] said I couldn't get any longer because it had no nutritional value. So, then I had to remake the menu without the bacon. The only time I have gotten bacon is when it's a part of a recipe and not served independently. It (bacon has no nutritional value) was from my [food service representative] via their dietitian that I was told we could not get bacon. Bacon is a protein; it doesn't have as much nutritional value as other meats. I'm just going off of what I was told. I have conversations with residents where we try and find a solution to their concerns, and its conversations we continue to have. I would absolutely agree that food is big part of their enjoyment in their life. I think if a food item is not the most nutritious, but it brings them enjoyment they should most definitely be allowed to have that food item.On 12/6/25 at 11:50 AM, V5 Registered Dietitian (V5 does not work for the food service provider, and she was not the dietitian who removed bacon from the menu) stated she has worked for the facility for 5 years. V5 stated, Recently the facility was purchased, and we are no longer able to offer them bacon. [V4] attempted to get it but we are not able to serve it. The issue with bacon is one serving size, which is less than an ounce, doesn't have enough protein to count towards the macronutrients for the menu.It does have some value, but 2 pieces of bacon has only 8 grams of protein. There is nothing dangerous with allowing them to have bacon, but it can be pleasurable for the residents. I do see that mealtime is a big part of their enjoyment especially in the long-term care setting. I could see how having bacon or not having bacon could affect the residents either positively or negatively. We are taught that having things in moderation is okay.The facility's Menu from November 30, 2025, through December 27, 2025, showed no bacon on the breakfast menu. The facility's November grievance log showed R10 reported on 11/18/25 Not receiving breakfast meat.The 11/6/25 Resident Council Meeting minutes showed, Concerns expressed around resident rights discussed: Still not getting bacon.On 12/6/25 at 2:10 PM, V1 stated the facility does not have policy that pertains to the menu and resident preferences.

Based on observation, interview and record review the facility failed to ensure a resident (R1), with a urinary catheter in place, was dressed in a manner to prevent a resident injury, failed to ensure facility staff safely managed and positioned a resident's (R2) urinary catheter as the resident ambulated, and failed to ensure a resident (R3) was showered in a manner to prevent a resident fall. This failure resulted in R1 being sent to a local hospital after her skin was lacerated by a plastic clip connected to her urinary catheter as she was being dressed by facility staff. R1 required nine sutures to repair her laceration. These failures apply to 3 of 3 residents (R1, R2, R3) reviewed for resident safety and supervision in the sample of 3. The findings include:1.R1's hospital discharge records showed R1 was discharged to the facility on 7/28/25 for rehabilitation after being hospitalized for right leg cellulitis, lymphedema, pneumonia, and urinary retention. R1 was discharged with a urinary catheter in place due to her urinary retention. R1 was cognitively intact. A facility incident report dated 7/31/25 showed R1 sustained a laceration to her right lower leg as V4 Certified Nursing Assistant (CNA) was attempting to put pants on R1, V4 started to pull the catheter system through the resident's leggings and noticed bleeding. The nurse assessed the resident's laceration and applied a dressing. The wound care nurse and the nurse practitioner then evaluated the laceration and the resident was sent to the ER (emergency room) where she received 9 sutures to the anterior right lower leg. R1's hospital discharge instructions dated 7/31/25 showed R1 was discharged , back to the facility, with a diagnosis of a leg laceration that required nine sutures to repair. R1's skin evaluation form dated 7/31/25 showed R1's sutured, right leg laceration measured 4 cm (centimeters) x 1.5 cm. R1's facility records showed R1 was discharged home on 8/18/25. On 9/2/25 at 8:37 AM, R1 was interviewed via telephone about the 7/31/25 incident. R1 stated on 7/31/25, V4 CNA had just finished helping her shower. R1 was seated in a chair in the shower room. V4 CNA was the only staff present at the time of the incident. R1 stated V4 partially put R1's pants on, up to R1's knees. R1 stated as V4 was pulling R1's urinary catheter bag and catheter tubing through the right leg of R1's pants, that plastic clip (attached to the catheter bag) scraped against my leg and cut me. I told her to stop. She was hurting me. That is when we saw the blood. On 9/2/25 at 9:47 AM, V4 CNA stated, on 7/31/25, she was trying to pull (R1's) catheter up the right leg of (R1's) pants when either the ties or the plastic clip (both attached to the urinary catheter system to hang the catheter bag in place) cut R1's right leg. V4 stated she should have put R1's catheter bag and tubing through R1's pant legs first, prior to pulling up R1's pants, to avoid any contact between R1's skin and her catheter. On 9/2/25 at 10:48 AM, V8 Nurse Practitioner (NP) stated on 7/31/25 she was told the plastic clip attached to R1's urinary catheter cut R1's leg as V4 CNA was putting on R1's pants. V8 stated R1's injury could have been prevented had they put something around the plastic clip to protect (R1's) skin when getting her dressed. V8 stated facility staff could have used a leg bag (urinary catheter drainage bag that attaches directly to a resident's upper leg) to avoid having to pull a catheter bag through R1's pant leg. V8 stated facility staff need to make sure they are protecting a resident's skin especially if the resident's skin is fragile. 2.R2's current care plan showed R2 had diagnoses including encephalopathy, lung cancer, and neuromuscular dysfunction of her bladder. R2's plan showed R2 was at risk for falls as she had a history of falls in the facility. R2 was confused. R2 had a urinary catheter in place to drain her urine. The plan showed facility staff were to ensure R2's catheter bag and tubing were secured in place to avoid any tension on or the pulling of R2's urinary catheter tubing. On 9/2/25 at 9:20 AM, R2 was seated in a high back wheelchair in the facility's therapy room. R2's urinary drainage bag hung from underneath the seat of R2's wheelchair. R2's urinary catheter tubing was noted sticking out of R2's pants, down by her left ankle. At 9:25 AM, V6 Physical Therapy Assistant (PTA) assisted R2 to a standing position with the use of a walker. R2's urinary catheter bag remained attached to R2's wheelchair located behind R2. R2 took a step and began walking with V6 at her side. As R2 took a step with her left leg, R2's urinary catheter tubing was pulled taut and began pulling R2's left leg slightly back as the catheter tubing and drainage bag remained attached R2's wheelchair. At that time, V7 Occupational Therapy Assistant (OTA) began pushing R2's wheelchair behind R2 as she walked, however, every time R2 took a step with her left leg, R2's catheter tubing was pulled taut as the catheter drainage bag continued to hang off R2's wheelchair, behind R2 as she attempted to ambulate. On 9/2/25 at 12:26 PM, V2 Director of Nursing (DON) stated for a resident that has a urinary catheter in place, the standard urinary drainage bag should be changed to a leg bag drainage system to help promote mobility while in therapy and to help avoid any pulling of a resident's catheter tubing. V2 stated if a leg bag is not used, the resident's catheter bag should be hung off the walker as the resident is walked so there is no pull or tension on a resident's catheter tubing. 3. R3's profile record report printed 9/2/25 showed R3 had diagnoses including repeated falls, hearing loss, dementia, and vision loss. R3's fall risk assessment dated [DATE] showed R3 was at risk for falls due to her hearing and vision impairments along with her impaired mobility. R3's Functional Abilities and Goals form dated 8/11/25 showed R3 required substantial assistance from staff when being transferred in the shower or bath. A facility fall incident report dated 8/6/25 showed R3 had an unwitnessed fall in her room as R3 was attempting to reposition herself and fell out of her wheelchair. R3 was not injured. A facility fall incident report dated 8/28/25 showed R3 had a fall in the facility's shower room with V9 Agency CNA present. The report showed R3 lost her balance and was lowered to the shower floor by V9. R3 received no injuries from the fall.On 9/2/25 at 12:30 PM, this surveyor attempted to interview R3 about her fall on 8/28/25 but was unable to complete the interview due to R3's impaired cognition, vision and hearing. On 9/2/25 at 12:00 PM, V9 Agency CNA stated, on 8/28/25, she took R3 into the shower room via her wheelchair. V9 stated, I was told by the staff she was independent. She could get up on her own. I knew she was hard of hearing and couldn't see well. I put her in her wheelchair over the by the toilet in the shower room. She tried to scoot out of her wheelchair to stand up. I kept telling her to sit down. V9 stated she was unsure if R3 was able to hear her or see her at that time. V9 stated when she turned to get the shower chair for R3, located by the shower in the shower room, R3 attempted to stand on her own and her legs buckled. V9 stated she caught R3 as she began to fall and lowered her to the ground. On 9/2/25 at 12:26 PM, V2 DON stated staff should check a resident's care plan and/or their transfer status/resident information report that is located behind every resident's door in their rooms to verify a resident's transfer status and exactly how much assistance a resident needs.

Based on interview and record review the facility failed to ensure residents were treated in a dignified manner for 3 of 3 residents (R1-R3) reviewed for dignity in the sample of 5. The findings include: On 7/21/25 at 9:02 AM, R1 stated, I had a shower last Tuesday (7/15/25). The aide that was with me was on her cell phone the whole time we were in the shower. I don't remember her name. She answered her phone and talked through her earphones. I felt like she wasn't really paying attention to me. I wasn't important. R1's shower records showed R1 did receive a shower on 7/15/25 by V8 Certified Nursing Assistant (CNA). On 7/21/25 at 8:35 AM, R2 stated during her shower on 7/12/25, the CNA that gave her a shower was on her phone. She had her earphones in and her cell phone rang. She answered it (while she was in the shower with R2) and started talking. R2 stated, Why was my bath not more important than her phone call? She has a job because I need help. R2 stated she was unable to remember the name of the CNA that showered her on 7/12/25. R2's shower records showed R2 did receive a shower on 7/12/25 by V9 CNA. On 7/21/25 at 8:45 AM, R3 stated staff are on their personal cell phones all the time. R3 stated she has seen staff on their phone in the hallways and in the main dining room during meals. R3 stated I don't need to much help, but I would not be happy if I needed help, and staff were too busy on their phones. The facility's Resident Council Meeting minutes dated April 2025-June 2025 were reviewed. The minutes showed resident concerns of staff being on their cell phones during work hours was identified during the facility meetings held in April 2025, May 2025, and June 2025. On 7/21/25 at 12:21 PM, V2 Director of Nursing (DON) stated staff are not to be on their cell phones at work and definitely not when providing cares to residents. V2 stated, Staff being on their personal phones at work has been an issue. The facility's Promoting/Maintaining Resident Dignity policy dated 11/2024 showed, It is the policy of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care, directly and indirectly, to residents to promote and maintain resident dignity and respect resident rights. When interacting with the resident, pay attention to the resident as an individual. Encourage conversation that is resident focused and resident centered while providing care or assisting a resident.

Based on interview and record review, the facility failed to safely reposition a resident in bed for one of seven residents (R1) reviewed for safety supervision in the sample of seven. This failure contributed to R1 experiencing multiple fractures which required a hospitalization . This past non compliance occurred from February 7, 2025 to March 8, 2025. The findings include: 1. R1's Face Sheet dated March 17, 2025 shows she was admitted to the facility with diagnoses including fibromyalgia, morbid obesity, spinal stenosis, cervical spine fusion, major depressive disorder, repeated falls, and pain. R1's Care Plan dated August 16, 2019 shows R1 is requiring almost total care by staff. Assist of two people for all transfers. R1's MDS (Minimum Data Set) dated February 3, 2025 shows R1 is cognitively intact. R1 requires substantial/maximal assistance for rolling left and right in bed. R1 has impairments on both sides of upper and lower extremities. R1's Fall Risk assessment dated [DATE] shows she has a significant risk of falling. R1's Departmental Notes dated February 8, 2025 at 1:51 AM shows, Patient was receiving care by CNA (Certified Nursing Assistant), when she rolled to her right side. She stated she could not hold on and fell on to the floor. When this nurse came to assess patient she was observed on the floor laying partially face down with half her body on the bottom of the bedside table. Patient has an injury noted to the left lower leg, bruise to the right lower leg and pain to the left upper shoulder. Range of motion severely limited to left arm related to fall. Patient was sent to emergency room by ambulance via stretcher at 12:30 AM. R1's Hospital Records dated February 8, 2025 shows, Fall at nursing home. Humerus shaft fracture, laceration of leg, pubic ramus fracture. On March 17, 2025 at 9:18 AM, R1 said the CNA was in a hurry the evening of her accident. It was an unnecessary accident. R1 gave the first name of the CNA (V6). R1 said that she was on a low air loss mattress. The girl was throwing me around. I fell on the floor hard. I fractured my left arm in two places and I injured my pelvis. I got stitches in my left leg. I fell to my right side off of the bed. Now I am afraid to be positioned on that side. I went down hard. She was on my left side and she pulled the pad up to help me turn and I rolled off of the bed. They usually use two people to turn me in bed. She was by herself. On March 17, 2025 at 12:36 PM, V5 CNA said she has taken care of R1 in the past. V5 said she has been taking care of R1 for a long time. V5 said she has never seen R1 require one person for assistance. V5 said R1 has always been a maximum assist with two people, even before her fall out of bed. On March 17, 2025 at 2:17 PM, V6 CNA said she was taking care of R1 when R1 fell . V6 said she woke R1 up and asked if she needed to be changed. V6 said she grabbed the pad underneath R1 to help her turn onto her right side. V6 said R1 rolled off of the bed onto the floor. V6 said R1 hit her left side on the bedside table. V6 said she tried to pull R1 back over, but it was too late. V6 said R1 was bleeding from her left leg and complained that her left shoulder was bothering her. V6 said she has taken care of R1 by herself many times before. On March 17, 2025 at 1:33 PM, V3 ADON (Assistant Director of Nursing) said R1 was being taken care of by the CNA when the CNA had R1 roll to the opposite side that the CNA was on and R1 went to the floor. V3 said R1 was transferred to the hospital and had fractures. V3 said prior to R1's fall, R1 was on a low air loss mattress, which means it should be two CNAs taking care of the resident on each side of the bed. V3 said that's facility policy. V3 said two assist due to residents risk of falls. V3 said she interviewed V6 in regards to R1's incident. V3 said V6 was not aware that if a resident is on a low air loss mattress, then two staff should be repositioning the residents. V3 said R1's fall could have been prevented had there been two staff in R1's room. V3 said that R1 was hospitalized for more than one day. R1's Safety Event Manager dated February 8, 2025 shows, Contributory Factors and Issues Leading to this Event: One CNA providing care on an air mattress. Prior to the survey date of March 18, 2025, the facility had taken the following actions to correct the noncompliance: 1. R1 was assessed by nursing staff on February 8, 2025 and sent to the emergency department. R1's Care Plan has been reviewed and updated. 2. Other resident residing in the facility as of February 8, 2025 who have air mattresses have the potential to be affected. These residents will be monitored for proper bed mobility by quality director on or before March 8, 2025. 3. Will ensure all staff is educated on the policy and procedure related to providing care for residents who utilize and air mattress. 4. Nursing staff will be re-educated on providing care for residents who utilize an air mattress by ADON on or before March 8, 2025 or prior to working their next scheduled shift. 5. The policy and procedure bed mobility has been reviewed and is deemed appropriate. 6. Quality Assurance Plans to monitor facility compliance to make sure that corrections are achieved and permanent. 7. Audits will be submitted and reviewed by the QAPI committee for management of ongoing compliance and will continue until otherwise determined by QAPI. 8. The administrator is responsible for ensuring ongoing compliance. Completion dated: March 8, 2025-all staff will be educated on policy and procedure for bed mobility for residents on an air mattress.

Based on observation, interview, and record review the facility failed to provide physician ordered intervention that maintained the patency of a CVC-Central Venous Catheter for 1 of 1 resident (R2) reviewed for parental fluids in the sample of 18. This failure resulted in the occlusion of R2's catheter and the need for replacement. The findings include: R2's Current Minimum Data Set on 12/11/2024 shows, R2 is cognitively intact. On 12/11/24 at10:17AM, R2 pulled up her pant leg to reveal a CVC-Central Venous Catheter in her left upper thigh that had a blue colored locking cap labeled 3.6 milliliters and a red colored locking cap labeled 3.5 milliliters. The clear lumens of the red capped and blue capped catheter had dark red blood in the tubing. At 11:00AM, V21 RN (Registered Nurse) flushed R2's CVC and removed the blood from the two lumens. On 12/10/24 at 11:49 AM, R2 said, I had to get my catheter replaced again due to it being clogged. They are supposed to flush it and are not doing it, so it keeps getting clogged. On 12/11/24 at 10:18AM, R2 said, they flushed my line yesterday, they have not flushed it today. On 12/11/2024 at 10:21AM, V23 (LPN-Licensed Practical Nurse) said, I do not flush R2's femoral catheter. On 12/11/24 at 10:22AM, V21 (RN) said, LPN's do not flush CVC. R2's CVC is flushed with Normal Saline daily and as needed when there is blood in the line. On 12/11/24 at 11:17 AM, V2 (DON-Director of Nurses) said, there is no training for CVC flushing. If the staff are not confident with the procedure they will call the DON. We have a program in our computer system that provides instruction for CVC flushing. Any topic the nurse is uncertain the nurse can look up and it will provide education. R2's Medication Administration Record dated November 2024 shows, Normal Saline Flush 10 milliliter syringe flush CVC with 10 milliliters once daily every day. Start 10/30/2024. November 1st Not Administered. 7th Not Administered by V21 (RN). 8th Not Administered. 9th Not Administered. 10th Not Administered by V4 (LPN). 14th Not Administered. 15th Not Administered. 16th Not Administered. 17th Not Administered. 19th Not Administered. 20th Not Administered. 24th Not Administered. 25th Not Administered. 27th Not Administered. 28th Not Administered. 30th Not Administered. Heparin 500 unit per 5 milliliters Heparin Lock both Ports of CVC with 2.4 milliliters weekly with dressing change. Start date 07/26/24. October 1st Not Administered. 8th Not Administered. 15th Not Administered. 22nd Administered by V24 (LPN). 29th Not Administered. R2's Medication Administration Record dated December 2024 shows, Normal Saline Flush 10 milliliter syringe flush CVC-central venous catheter with 10 milliliters once daily every day at 8:00AM. Start 10/30/2024. December 1 Not Administered. 2nd Administered. 3rd Not Administered. 4th Not Administered. 5th Administered. 6th Not Administered. 7th Administered. 8th Not Administered. 9th Administered. On 12/11/24 at 1:15 PM, V4 (LPN) said, most likely the nurses that documented on 12/02, 12/05, 12/07, 12/09/2024, got click happy, the line occluded on 11/27/24 at 1:33PM, the nurse called the surgeon and was told not to continue flushing it. The nurse on those dates documented doing the flush but the flush was not done, they were, click happy with their documentation. R2's Departmental Notes dated 11/27/2024 at 1:33PM, shows, resident was flushed in AM. 6 milliliter flush due to resistance. Called surgeon which advised no more flushing. Dressing is saturated with blood and feels boggy to touch. Awaiting MD (Medical Doctor) phone call for further instruction. Signed by: (V25 LPN). R2's Central Venous Catheter Placement Narrative by V26 (Medical Doctor) dated 12/09/2024 at 2:30PM, shows, after local anesthesia was obtained, the retention cuff of the existing dialysis catheter was bluntly dissected free. It should be noted that the clear portions of both ports were noted to be completely filled with clot. This was noted on every catheter exchange indicating that this catheter is likely not being flushed and locked properly with being allowed to flow back into the lumen of the catheter where it clots. The catheter was aspirated and cleared of a large amount of soft clot. Contrast was infused which demonstrated some irregularity at the level of the catheter tip. The decision was made to place a slightly longer catheter. The remainder the catheter was removed over a wire. Conclusion: Again, noted is thrombus filling the clear portions of both lumens of the catheter indicating that this catheter is not being flushed and locked with heparinized saline correctly. Blood is being allowed to flow backward within the lumen of the catheter and clotting resulting in obstruction of the catheter.

Based on observation, interview, and record review the facility failed to safely transfer a resident (R1) for 1 of 4 residents reviewed for safety in the sample of 6. This failure resulted in R1 falling, and hitting her head on the oxygen concentrator. R1's head laceration required 6 staples and 2 sutures for closure of the wound, in the emergency department. The findings include: On 9/10/24 at 10:05 AM, R1 was in wheelchair, being pushed to her room by a family member. There was dried blood and 6 stables on the top of R1's head, in her hairline. There was dried blood and scabbing along the staple line. The surveyor asked R1 if her head was sore and how it happened. R1 said her head hurt real bad when it first happened, but it was starting to get a little better. R1 said she has to take pain medication for the pain some days. R1 said on 8/27/24 she had taken a nap after lunch. R1 said she couldn't remember the CNA's (Certified Nurses Assistant) name. (Through investigation CNA identified as V13). R1 said the CNA came in to help her get up. R1 said she sat up on the side of the bed. R1 said V13 did not use a gait belt. R1 said the wheelchair was positioned to her right, parked near the foot of the bed, facing where she was seated. R1 said she stood with the walker in front of her and all she had to do was pivot to the right and sit down in the wheelchair. R1 said V13 was behind the wheelchair when she was pivoting and was not touching her. R1 said she doesn't really know what happened, but she lost her balance and fell forward. R1 said she didn't pass out or anything like that. R1 said she just fell forward and couldn't stop. R1 said she fell face first and hit her head on the oxygen tank (concentrator). R1 said there was blood everywhere and she was so scared. R1 said she went to the emergency room and they put staples and sutures in her head. R1 said sometimes her legs get weak and she loses her balance. R1 said there's a gait belt right there, pointing to a gait belt hanging on the wall, near her closet. R1 stated, I don't know why they weren't using it. They didn't use it before I fell , but they do now. If they don't use it, then I'm supposed to remind them. R1's Diagnosis/History printed 9/10/24 showed diagnoses to include, but not limited to: chronic kidney disease, morbid obesity, anxiety, insomnia, persistent atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, generalized weakness, and other abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed she was cognitively intact; had no behaviors; and required partial to moderate assistance to sit, stand, and transfer from the bed to chair. R1's Care Plan initiated 1/28/24 shoed R1 was at risk for falls due to new surroundings and poor balance. This care plan also showed R1 required limited/extensive assistance of one (staff member) for ADL (Activities of Daily Living) tasks due to weakness and poor balance. The interventions included, but were not limited to: Assist of 1 for all transfers. Use gait belt and walker. R1's Resident Incident Report showed the Fall occurred on 8/27/24 at 4:45 PM. This form showed R1 was transferring from the bed to the wheelchair with the CNA (V13), walker and gait belt. This document showed, (The) patient was in the standing position and turning around to sit in the wheelchair. Patient suddenly leaned forward and fell head first into the oxygen concentrator sitting on the floor next to her bed. CNA unable to stop patient from falling. Laceration noted to frontal area of head/scalp. Excessive bleeding noted. Pressure immediately applied to laceration. Skin tear noted to left forearm - 1.5 cm (centimeters) x 4 cm, skin approximated and dressing applied per protocol . Unable to assess laceration well . transported to ER for evaluation and treatment . R1's Incident Followup Report printed on 9/3/24 showed, .Resident admitted to [local hospital] for (atrial fibrillation with rapid ventricular response). Resident has 2 sutures and 6 staples and plan is to return to facility. On 9/10/24 at 9:22 AM, V7 (LPN - Licensed Practical Nurse) said R1 is alert and oriented. V7 said R1 is aware of what is happening around her and can express her needs. V7 said before R1 fell , therapy had been working with her and she was a super easy 1 assist for transfers. V7 said R1 does get very anxious. V7 said she was working the night R1 fell (8/27/24). V7 said she was not in the room when she fell . V7 said she heard V13 (CNA) yelling out. V7 said she went in the room and R1 was laying on the ground, next to her bed, face first. V7 stated, I think she hit her head on the oxygen concentrator knob. It bled a lot, which added to her anxiety. V7 said R1 just kept begging them to get her up. V7 said R1 was in the hospital a few days and came back with 6 staples and 2 sutures. V7 said R1 also had a half moon shaped skin tear to the left, outer elbow. On 9/10/24 at 10:58 AM, V13 (CNA) said she worked 8/27/24. V13 said she went into R1's room to get her up for dinner. V13 said R1 likes to lay down after each meal. V13 said R1 sat up, she placed the gait belt on her, had the walker in front of R1, and R1 stood up fine and pivoted to the the right. V13 said the wheelchair was behind her legs and all R1 had to do was sit down in the wheelchair. V13 stated, Next thing I know she is falling forward. V13 said she was standing behind R1's wheelchair and did not have a hold of the gait belt when R1 went forward. V13 said R1 hit the oxygen concentrator with her head. V13 said R1 never complained of being dizzy. V13 said there was blood everywhere and she yelled for the nurse. V13 said she couldn't remember exactly what R1 was saying, but remembers her repeating, I'm scared . I fell . V13 said she knows that she's supposed to have her hands on the gait belt at all times to help control the resident's movement, but she was so surprised by the fall. On 9/11/24 at 9:04 AM, V14 (Occupational Therapist/Director of Therapy) said a gait belt should be used any time the staff are transferring or ambulating with a resident. V14 said the gait belt should be properly placed and the staff's hands should remain on the gait belt at all times, during the transfer. V14 stated, You never know what could happen. Their knees may buckle or they lose their balance. V14 said the purpose of the gait belt is to assist the resident with balance and if the resident falls or loses their balance, to help guide the resident slowly to a safe landing. V14 said a resident may still end up on the floor, but the staff guiding them down with the gait belt should decrease the severity of any injuries and possibly prevent an injury from occurring. On 9/11/24 at 12:11 PM, V15 (Nurse Practitioner) said she would expect the facility to safely assist residents with transfers. V15 said she was trained to keep your hands on the gait belt throughout the transfer. V15 said she would expect staff to be using the gait belts properly. V15 said R1's scalp injury was directly related to her fall. On 9/12/24 at 12:22 PM, V2 (DON - Director of Nursing) said the staff should being using gait belts any time they transfer or ambulate a resident. V2 said there are gait belts in every resident room. V2 said the purpose of the gait belt is to assist the resident with balance and to guide them to a safe place if they lose their balance. V2 stated the proper use of a gait belt should help reduce the risk of injury. V2 said the staff hands should be on the gait belt at all times, during the transfer. The facility's undated Safety, Body Mechanics, Transfers and Gait Belt Procedures showed, Purpose: .4. To educate staff in appropriate transfer methods to ensure compliance with individual resident care plans. If the techniques demonstrated are followed, residents will be more comfortable and safe, risk to staff injury will be greatly reduced and work will be performed more efficiently. Procedures: A. Safety: 1. Primary concern is the safety and health of the residents. Residents who are properly transferred by staff help prevent common injuries such as fractures, skin tears, bruises, etc. Resident safety can be accomplished by doing the following: .e. Use a gait belt to assure firm grip on the resident. f. Get in a position so that you are in control .

Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner to prevent injury. This failure resulted in R4 sustaining a fractured femur during a transfer on [DATE]. This applies to 1 of 3 residents (R4) reviewed for falls in a sample of 4. The findings include: R4's Facility Reported Incident dated [DATE] states, Resident, (R4) was lowered to the floor by CNA (Certified Nurses Assistant), (V9), after her knees buckled during a transfer. Resident was sent to (Local Hospital) for further evaluation. Resident returned to the facility with a diagnosis of periprosthetic fracture of the distal femur. R4's Radiographic Image of the knee, right dated [DATE] states, There is a total right knee prosthesis in place. There is a comminuted angulated periprosthetic fracture of the distal femur . On [DATE] at 8:55 AM V9 (CNA) stated, I got her (R4) cleaned up and dressed and we were transferring from the bed to the chair and her legs were giving out so I lowered her to the floor. She sat on her butt on my feet. I was not able to reach the call light so I asked her roommate to push her call light. It took her a minute but then she pushed it. Another CNA came to the door and he saw what happened and went to get the nurse, (V11- Registered Nurse/RN). She (V11) came to the room and assessed her and we got her up. I was able to get my feet out from under her and we lifted her from under her arms and put her in the chair. She was able to kick both of her legs and I heard her say she had some pain but I don't know where. I had never cared for her so I think she was just a 1 assist for transfer. I did not use a gait belt. She was sitting on the edge of the bed and I was standing in front of her. She stood and then she started to shake, almost like she was scared and she became very unsteady. She started to lose her balance so I said it's okay and I lowered her to the floor. I held on to her by her pants and she sat on her butt. On [DATE] at 9:30 AM V10 (Radiologist) stated, It is really hard for me to say what happened. It is all speculation. Per her x-ray (radiography) she had some osteopenia but it is not the most fragile bone. These type of fractures usually happen due to a fall, they do not cause the fall. It looks like there was some twisting motion involved and some energy involved with this fracture pattern. It is a pretty good fracture there. On [DATE] at 10:15 AM V12 (RN) stated, The fall happened before my shift started. (R4) is normally one that doesn't complain of pain and doesn't offer any information. She will answer yes and no questions about her pain. My tactic is to ask, is it tolerable or do you need me to help you with your pain. After breakfast the girls (CNA's) told me that (R4) was sitting in the wheelchair with her knees bent but the right knee was not all the way bent. I noticed after they got her in bed that even the slightest movement or palpation she was wincing, but when she was still she was smiling and seemed very comfortable. Her knee looked disjointed. I asked her if she had pain and she told me no. I gave her what I had for pain- Tylenol. I had already called the NP (Nurse Practitioner) and I called the POA (Power of Attorney) to see if they wanted her sent out. It took about 45 minutes for the transport to arrive and her leg was at about 15 degrees. She couldn't straighten it or bend it more than that. It looked a little greenish like maybe it was starting to bruise but nothing major. Over the last ,d+[DATE] weeks she has been better transferring with 2 assist than one. Some days she could stand really well and some days she was more unsteady. At one point she was ambulatory with restorative, so yes she could stand and bear weight. The fall happened about 10 minutes before I arrived and the nurse told me in report that there had been a fall- well kind of a fall because (R4) was lowered to the ground. (V11) had a lot of things going on that night and she was happy she got them all done and then this happened. (V11) asked me if I could call the POA- she had done all the paperwork, so I did. On [DATE] at 1:00 PM V11 (RN) stated, I was at the nurse's station and the call light was going off so the other CNA went to answer it. He came back and told me the resident was on the floor. I told the other nurse and then we went down there and when I walked in the room the resident was on the floor, on her butt with her knees bent and kind of to the side and she was leaning against the (V9's) legs. (V9) told me (R4's) legs gave out when she was trying to transfer her and (V9) lowered (R4) to the floor. I assessed (R4) and did her vital signs and then told her we were going to stand her up and put her in the chair and (R4) said ok. When she got in the chair I asked (R4) to raise her arms and then to move her legs. She was able to move both legs but her kicks were very weak and she was not able to move her legs very far. I asked her if she has pain and she said her right leg hurt but I didn't see any discoloration or deformity in the leg. She was not grimacing and did not show any other outward signs of pain. I went back to the nurse's station and the day shift nurse (V12-RN) was there. I told him what happened and asked him to call the POA. Then I faxed the NP with what had happened. (R4) does not get any medications through the night so I don't interact with her much other than to give (R4) her incentive spirometer. I have cared for her before and never had any problems with her. R4's EMR (Electronic Medical Record) shows that R4 expired in the facility under hospice care on [DATE] at 3:34 AM.

Based on observation, interview, and record review the facility failed to notify the physician of a new pressure wound, failed to initiate a treatment upon identification of a new pressure area, and failed to complete weekly assessments after identification of a new pressure wound. This failure resulted in R31's pressure wound deteriorating to a stage 3 before a wound treatment was initiated. The findings include: R31's face sheet showed she was admitted to the facility on [DATE]. R31's facility assessment dated [DATE] showed her diagnoses to include non-traumatic brain dysfunction, coronary artery disease, hypertension, peripheral vascular disease, and dementia. The same assessment showed R31 has severe cognitive deficits. R31's care plan initiated 7/20/23 showed, [R31] is at risk for impaired skin integrity due to cognitive deficits, impaired mobility, incontinence, PVD (peripheral vascular disease) and advanced age Daily skin inspection; report any charges in skin or signs of possible skin breakdown or redness . R31's 10/28/23 Nursing Note showed, Found very small 1.2 cm x 1.3 cm x 0.2 cm to resident coccyx, resident stated her buttocks was hurting and examined, did wash with NS (normal saline) and allied foam dressing. Resident spends a lot of time in her recliner and will need to reposition more often. Will ask MD (physician) for TX (treatment) and plan. R31's 10/29/23 Shower Sheet showed a dressing was present to R31's sacral region. R31's October 2023 eTAR (electronic Treatment Administration Record) showed no treatment orders for the wound identified on 10/28/23 to her coccyx. R31's 11/17/23 Nursing Note showed, . Resident has an open area between buttock, seen by wound care nurse and will see wound care nurse practitioner on Tuesday 11/21/23 . R31's 11/17/23 Wound Assessment Report showed a Stage 3 pressure ulcer was identified to R31's coccyx measuring 1.3 cm x 1.20 cm x 0.4 cm. This assessment showed the wound to be 50% granulation tissue and 50% slough. R31's 11/21/23 Wound Nurse Practitioner visit note showed, . Pressure ulcer of sacral region, stage 3 . On 2/6/24 at 2:10 PM, R31 said, I have a dressing change either every day or every other day. Sometimes it is more often than they hope because the dressing will come off. On 2/7/24 at 12:59, R31's dressing to her sacral region was being changed by V30 (Wound Care Nurse) and V16 LPN (Licensed Practical Nurse). R31 stated she does not sleep in her bed. V30 replied to R31 and said, I know, that's probably why you have this wound. On 2/08/24 at 11:47 AM, V30 (Wound Care Nurse) said she was not aware that R31's pressure area had been identified originally on 10/28/24. V30 said she was not notified. V30 said the facility does weekly skin checks on everyone which is documented on the residents eTAR as completed. V30 said the CNAs (Certified Nursing Assistant) complete shower sheets with every shower and turn them into her. V30 said the nurses notify her immediately of any skin changes and a treatment is started right away when a wound is found. V30 said the facility has a protocol for new wounds that the nurses follow. V30 confirmed there were no wound assessments found between 10/28/24 and 11/17/24. On 2/08/24 at 12:54 PM, V2 DON (Director of Nursing) said she expects treatment to be started immediately when a wound is first identified. V2 said this is important for wound healing so they can get a treatment started and get the nurse practitioner seeing the resident to follow the wound. The facility's policy and procedure revised 11/2022 showed, Skin Identification, Evaluation and Monitoring, Purpose: The purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion of findings A. Complete a general skin check to evaluate for changes in skin integrity. B. Document in medical record the finding of general skin check . 2. If new wound is identified: a. Initiate protective dressing b. Notify health care provider of findings and for further treatment orders. 3. Notification/Education of resident and resident representative of finding and physician orders . Skin Integrity Treatment Program. The treatment program will focus on the following strategies: A. Eliminate or reduce 1. the source of pressure using positioning techniques 2. other sources of skin injury by evaluating the cause and providing interventions B. Pain Control C. Preventative measures to reduce the risk of further tissue loss.

Based on observation, interview and record review the facility failed to provide necessary supervision to 1 of 3 residents (R1) reviewed for safety and supervision. This failure resulted in R1 falling off the stairs sustaining a laceration requiring sutures and an emergency visit. The findings include: R1's Physician Order Sheet dated 7/2023 shows R1 has diagnoses that include generalized muscle weakness, diabetes and acute pyelonephritis. R1's facility assessment dated [DATE] shows R1 has moderately impaired cognition, decisions are poor, and cues/supervision are required. The same assessment shows R1 needs 1 staff assist for locomotion off unit with his wheelchair. The Facility Reported Incident Final dated 6/21/23 with date of incident of 6/15/23 shows at, approximately 10:20 am (R1) was witnessed in his wheelchair on the front porch of the facility. The door alarm began ringing. Staff were assisting residents outside which triggered the alarm to sound. Staff were addressing the alarm when R1 was noted to be going to the steps and fell out of his wheelchair, face forward down the steps. 911 was called and R1 was sent to the hospital. R1 returned the same day with diagnosis of head injury due to trauma and facial lacerations with seven sutures . In conclusion, education was completed with staff on the safety and supervision of residents. 1:1 coaching was provided to the activity assistant involved. The Facility Resident Incident Report dated 6/15/23 shows R1 was being assisted outside for an activity. He (R1) got through the door rolled down towards steps and fell out of wheelchair when he hit the steps. A progress note dated 6/15/23 timed at 10:33 AM shows, a staff member came to the unit yelling out for a nurse for an emergency outside. Nurse immediately ran outside and observed resident (R1) laying supine on the ground with his wheelchair on top of him. Nurse alerted staff to call 911 and removed wheelchair off of resident. Resident was alert and awake. Resident had a large gash above the resident left eyebrow. Nurse applied gauze to control bleeding. Nurse called POA and spoke with (POA) EMS arrived within minutes and transported resident to the hospital. R1's Hospital discharged Records dated 6/15/23 timed at 14:33 (2:33 PM) shows, Head injury due to trauma, facial laceration, (and) arm abrasion. A document titled Interdisciplinary Resident Screen dated 6/21/23 shows resident demonstrates limited cognitive and safety awareness. Pt (patient) requires cues prompting for proper wheelchair use including wheelchair placement or break use. On 7/6/23 at 8:40 AM, R1 was alert sitting in his wheelchair in the dining room finishing breakfast. A scabbed over area was noted above his left eyebrow. When asked what happened, R1 said he fell outside but cannot remember how it happened. On 7/6/23 at 8:50 AM, V4 (Certified Nursing Assistant-CNA) said he was working on 6/15/23 when the incident happened. V4 (CNA) said R1 was being escorted outside the front porch. R1 was left unattended and R1 fell down the stairs. On 7/6/23 at 9:00 AM (V5 Receptionist) said she was working on 6/15/23 when the incident happened. V5 said the front door alarm was going off while residents were being brought outside for an activity at the front porch. V5 said she helped V7 (Activity Aide) wheel residents out. V5 said the concrete at the front area was not even, it's a downhill slope so she made sure residents in wheelchairs had their brakes on to prevent them from rolling down. V5 said she went back inside the facility and put the code in the alarm panels. V5 said a Laundry Staff (V6) also came to look at the alarm. V5 said then she saw V7 (Activity Aide) screaming and running after R1. V5 said she ran too and followed V7 and found R1 at the bottom of the stairs bleeding. V5 said nursing staff called 911 and R1 was sent to the hospital. On 7/6/23 at 9:20 AM, V7 (Activity Aide) said on 6/15/23 residents were being brought outside the front porch for a group activity. The alarm at the front door was going off. V5 (Receptionist) and another staff (V6) were taking care of the alarm. V7 (Activity Aide) said she was wheeling R1 and was in between the two doors (sliding door and front door) when she decided to stop, went back inside the facility to check what was going on with the alarm. V7 said she left R1 unsupervised in between the sliding door and the main front door. V7 said when she went back, R1 was already cruising down the front concrete that has the slope down going towards the stairs! V7 said she ran to catch R1, but R1 had already fallen at the bottom of the stairs hitting the pavement face first with his wheelchair on top of him. V7 said she yelled for help. V7 said she should not have left R1 unsupervised while transporting him outside. On 7/6/23 at 9:40 AM, V6 (Laundry Staff) said on 6/15/23, she was coming in to work and was at the front lobby hearing the alarm going off. V6 said she noticed V5 (Receptionist) and V7 (Activity Aide) were bringing residents out for an Activity. V6 said she saw V7 wheeling R1 in his wheelchair. V7 and R1 were in between the 2 doors, (the sliding door and the main front door). V7 left R1 there, stepped back inside to check the alarm. Later on, V6 said she heard V7 yelled Oh crap! V6 looked out and saw R1 in midair falling forward with his wheelchair down the steps. V6 said she ran to get the Nurse. R1 was sent to the hospital via 911. On 7/6/23 at 10:00 AM, V10 (Activity Director) said she had given strict instructions to all her staff including V7 that when residents on wheelchairs were being brought out to the front porch to ensure that the wheelchair was locked or else the wheelchair will roll downhill. The front concrete entry way is not even, it's a slope that leads to stairs and a large concrete statue. V10 said when R1 was left unsupervised, R1's wheelchair rolled down that downhill entryway that had caused the fall. On 7/6/23 at 12:00 PM, V9 (R1's physician) said R1's fall with injury was not related to a medical issue but a transportation issue. R1 was not supervised for his safety while being transported outside that had caused his fall. On 7/6/23 at 2:00 PM, V8 (Registered Nurse) said V6 (Laundry Staff) told her to go to the front porch quick, R1 fell . V8 (RN) said she saw R1 at the bottom of the stairs lying on the floor with his wheelchair on top of him. R1 was bleeding. 911 was called and R1 was sent to the hospital. V8 said R1 received sutures and was sent back to the facility. V8 said R1 was being transported via his wheelchair outside. The Activity Staff who was transporting R1 left R1 unattended. On 7/6/23 at 2:14 PM, V3 (Assistant Director of Nursing) said there was a lot of errors of judgement committed on 6/15/23. V3 said when a resident is being transported to the front porch, the staff should supervise the residents for safety. V3 said V7 (Activity Aide) should have not left R1 in between the 2 sets of doors. When a staff starts a task finish the task to ensure resident's safety. The front entryway has a slope going down that residents cannot left unsupervised. V3 said a resident on a wheelchair can roll down that uneven ramp. On 7/6/23 at 2:30 PM, V1 (Administrator) said staff should not leave any resident unattended/unsupervised. Staff should pay attention to the resident being transported. Since this incident happened, residents should have a staff or a family member with them when they go to the front porch. V1 also said, no Activity is allowed at the front porch at this time. V1 pointed out to this surveyor a signage by the front door that states, All residents MUST (in bold letters) have a family member or staff with them to be out on the front porch! THANK YOU! R1's care plan dated 1/25/23 shows R1 is at risk for falls with goal for R1 to not have fall with major injury. With intervention to include resident to be assisted outside with one on one.

I. Based on observation, interview, and record review, the facility failed to document wound assessments for a resident (R1), failed to notify a physician of a resident's worsening pressure wound (R1), failed to obtain new treatment orders for a resident's pressure wound (R1), failed to identify signs of infection for a resident's pressure wound (R1), failed to provide wound care in a manner to prevent infection for a resident (R1), failed to identify three pressure wounds for a resident caused by a medical device (R4). These failures contributed to R1's pressure wound advancing from a Stage 2 to an unstageable wound that became infected and required hospitalization , surgical debridement, and placement of a wound vac (negative pressure wound therapy). These failures also resulted in R4 obtaining two stage 3 pressure wounds and one unstageable pressure wound. These failures apply to 2 of 7 residents reviewed for pressure ulcer prevention and treatment in the sample of 19. The findings include: The Immediate Jeopardy began on 10/21/22 when R4 obtained two Stage 3 pressure ulcers and one unstageable pressure ulcer as the result of a medical device. V1 (Administrator) was notified of the Immediate Jeopardy on 1/12/23 at 1:27PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/16/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. 1) R4's electronic face sheet printed on 1/12/23 showed R4 has diagnosis including but not limited to displaced fracture of right lower leg, fall, malignant neoplasm of prostate, weakness, and history of pulmonary embolism. R4's facility assessment dated [DATE] showed R4 has no cognitive impairment, 2 unstageable pressure ulcers, and 1 unstageable deep tissue injury. R4's nursing care plan dated 9/20/22 showed, Risk for impaired skin integrity due to decreased mobility and incontinence. R4's care plan update on 10/21/22 showed, (R4) has 3 pressure injuries caused by CAM (Controlled Ankle Motion) boot. Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness. R4's Orthopedic visit note dated 10/4/22 showed, CAM boot-skin checks. R4's daily skilled nursing notes showed, 10/8/22 staples removed, right ankle healing, dressing dry and intact. 10/10/22 excoriation to right foot related to CAM boot. 10/18/22 no new skin issues. (At this time, no wound assessments had been completed for R4.) R4's physician's orders for October 2022 showed, 10/10/22 apply gauze to right medial ankle, apply foam dressing to top of right foot, change daily. R4's nursing progress note dated 10/8/22 showed, Skin warm & dry with bruising to right lateral ankle, covered with (support bandage) under CAM boot, did not tolerate assessment of area well . R4's weekly skin checks for October 2022 showed, 10/13/22 treatment ordered for right foot. R4's weekly skin checks for the month of October were completed with no identification of 3 pressure wounds until 10/21/22. R4's wound assessment report for 10/21/22 showed, Pressure wound to right heel identified 10/21/22. Unstageable due to suspected deep tissue injury. 4.0x2.5cm. Injury caused by CAM boot. Area of injury is very firm. Cover with absorbent pad and gauze. Pressure wound to right medial malleolus identified 10/21/22. Unstageable due to slough and eschar. 2.0x1cm. 10/21/22 Pressure wound to right top of foot identified 10/21/22. Unstageable due to slough and eschar. 1.0x3.0cm. (All wounds received the same treatment as the right heel). R4's wound assessment notes from the local wound center showed, 11/7/22 Right proximal dorsal foot Stage 3 pressure ulcer acquired 10/18/22 and measures 0.9x2.2x0.1cm with scant serosanguineous (pale red or pink) drainage. Right ankle stage 3 pressure injury acquired 10/18/22 and measures 1x1.1x0.1cm after surgical debridement. Right heel unstageable pressure injury obscured full-thickness skin and tissue loss acquired 10/18/22 and measures 2.1x2.5x0.1cm. R4 continues to receive treatment at the local wound center for his pressure injuries. On 1/12/23 at 2:16PM, V12 (R4's Nurse Practitioner) stated, (R4's) CAM boot caused his pressure ulcers. When a resident is wearing a CAM boot, skin should be assessed at least daily, ideally twice a day with application and removal of the CAM boot. All new skin concerns should be identified immediately and reported to the physician immediately. I know therapy will sometimes help do application and removal of the device, but they don't do skin checks. That is the nurse's responsibility to make sure the skin checks are completed. A Deep tissue injury is a discoloration (purple, dark purple coloring) and should be easy to identify. If the nurses were doing daily dressing changes, then they should have identified these 3 areas well before they started. I'm guessing they did not do skin assessments with application and removal of the CAM boot. On 1/12/23 at 3:44PM, V13 (Wound Care Nurse) stated, (R4) obtained 3 pressure ulcers from his CAM boot. Those things are notorious for causing pressure sores, so you have to be careful and diligent with them and monitor skin closely. I went through his skin checks and saw they were doing them weekly for him. If I was working as a floor nurse, I would be checking his skin daily at a minimum. I don't see any orders or documentation of his skin being checked more than weekly. I agree they should have caught it earlier but there are a lot of agency nurse's working the floor right now. The facility's policy titled, Prevention of Pressure Injuries Protocol revised on 01/2018 showed, C. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linens. If pressure injuries are not treated when discovered, they quickly get larger, become very painful for the resident, and often times becomes infected. 2) R1's electronic face sheet printed on 1/12/23 showed R1 has diagnoses including but not limited to pressure ulcer of sacral region, unstageable, Alzheimer's disease, Dementia without behaviors, and type 2 diabetes. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and has no current pressure ulcers. R1's nursing care plan dated 9/20/21 showed, Risk for impaired skin integrity due to decreased mobility, urinary incontinence, and moisture under body folds. I also lean in my wheelchair, and this could cause skin breakdown. (R1) has a pressure injury. Daily skin inspection, pressure reducing pad in my recliner if needed. 12/29/22 air mattress applied. A review of R1's pressure ulcer wound assessments showed: 11/30/22 coccyx wound resolved. Left medial buttock resolved with skin intact. 2.4x2cm (centimeter) dark red/light purple area where wound used to be. Discontinue collagen dressing and use foam dressing daily for protection. 12/7/22 left medial buttock no changes. Apply allevyn dressing for protection and change daily. 12/14/22 left medial buttock resolved. 12/16/22 sacral pressure ulcer 5.5x4.0cm unstageable pressure injury obscured full-thickness skin and tissue loss. Moderate amount of purulent (white, yellow) drainage, 51-75% slough. On 1/11/23 at 2:33PM, V2 (Director of Nursing) and V10 (Clinical Specialist) stated, Skin assessments should be documented on the resident's shower sheet and entered into the skin inspection report in the resident's electronic medical record. We typically do these weekly and as needed. V13 (Wound Care Nurse) assessed (R1's) wounds on 12/16/22 but we cannot find any other assessments after that one. We have been trying to create our own timeline to determine what happened with (R1's) wound but haven't been able to determine anything yet. After 12/16/22 the only other documentation about (R1's) wound is for her to be a direct admission to the local hospital for an infected decubitus ulcer. We would expect (V13) or floor staff to complete weekly assessments on all wounds. If (V13) is not here, then the floor nurses should be doing it. When staff are performing wound care, they should never put their hand inside the wound and should be cleaning from the center of the wound and wipe to the outer edges to prevent infection. You wouldn't want the bacteria being pushed back to the center of the wound. That is standard practice in wound care and our nurses know that. R1's wound assessment documentation entered on 1/12/23 showed, Late entry for 12/16/22 new wound to left buttock, 3.0x1.5cm, purple discoloration, possible deep tissue injury and coccyx, 1.25x0.75cm Stage 2 with epithelial tissue in the bed. (Wound care) representative contacted, and treatment orders received. Resident educated on the importance of relieving pressure to the buttocks and encouraged to lay in bed between meals. However, she does choose to participate in activities in the afternoon. (This wound assessment contradicts prior wound assessment documented on 12/16/22). Late entry for 12/20/22 Wound has deteriorated. Left buttocks is 5.5x2.5cm and is unstageable due to slough. Coccyx is 2.5x1.5cm, Stage 3, slough and granulation. Resident continues to be encouraged to lay down in between meals. Late entry for 12/27/22 Two wounds have now merged into one, measuring 5.5x5.5cm and unstageable to slough. Surrounding tissue has a purple discoloration and appears somewhat blistered. No documentation was present in R1's electronic medical record showing notification to a physician of R1's worsening pressure wound. R1's local hospital records showed, 12/29/22 showed, Yesterday I was contacted about the ulcer and today I saw a picture of the ulcer. It is necrotic and has a gangrenous smell. Unstageable at this time but obviously there is dead tissue on top that needs to be debrided .sacral area has a 7cm ulcer with satellite smaller ulcers of less than a cm . Wound culture shows gram negative bacteria .will continue ceftriaxone and doxycycline as well just in case the MRSA (Methicillin-resistant Staphylococcus aureus) from her nares is present in her wound and did not appear in her wound culture. 12/30/22 Ulcer consists of necrotic tissue with possible involvement of sacral bone. Polymicrobial cultures growing Escherichia coli and proteus mirabilis. 1/3/23 Post-operative day 4- ulcer measures 7x11x3.5cm. 1/5/23 infected decubitus ulcer with necrosis secondary to debridement and application of wound vac. On 1/11/23 at 11:06AM, V5 (Licensed Practical Nurse) was providing wound care for R1. V5 removed R1's wound vac dressing, changed her gloves, and then stuck her gloved finger around the inner side of R1's sacral wound wiping drainage from one area to another along the inside of the wound. V5 then measured R1's wound and obtained a measurement of 10.5x11.75cm. V5 stated she was unable to determine the depth of the wound as she did not have the appropriate supplies with her. V5 then poured saline into R1's wound and wiped from the outer edges of the wound towards the center of the wound. V5 made repetitive statements throughout the wound care that she has not changed a wound vac dressing in at least 3-4 years. V5 stated the staff had not been trained on the care of R1's wound vac and that the wound care nurse has been off on leave. V5 stated, I just watched a video on my phone before we came in to try and refresh my memory. On 1/11/23 at 1:52PM, V5 stated, When cleansing wounds, you should always clean from the center of the wound and continue to the outside of the wound to prevent infection. I guess I didn't do it that way because her wound is so big, and I felt like I was just throwing saline in there and wiping it up with gauze. I definitely should have done a better job. On 1/12/23 at 2:16PM, V12 (R1's Nurse Practitioner) stated, The wound care nurse should be assessing weekly and if she's not there I would think the floor nurses would do it. New orders should be obtained at the time that they see the wound is worsening. There's not an exact timeline but I would say if a wound isn't improving after a week then new orders should be obtained. (R1's) wound initially started in September with a small open area, we followed her closely through October. Her wound was improving, and we talked to the family about her going to the wound center and they did not want to do that due to it being too hard on her because she would have to go out weekly and be lifted. We talked to (R1) about a catheter, and she wasn't completely on board and then the wound improved so we didn't talk about it again. The wound continued to improve, and I was told at the end of November that it had improved and that it had healed in December. I looked at her wound on 12/19/22 with (V13-Wound Care Nurse) and the wound care consultant. The wound at that time was a dry, yellow slough with dark areas. It was an unstageable wound. When you touched it on top it felt like a scab. I typically call and have a conversation with the family but on that day, I did ask the nurse to contact the daughter to notify her. That is the last time I saw the wound before she went to the hospital. (R1's Physician) went to the facility twice the week I was off, and he did not have a chance to look at the wound and then called (V5-LPN) and based on what she said he had (R1) sent to the emergency room . It would not be my expectation that there would be 10 days between a change in wound care orders if the wound was worsening. I don't know what the staffing was like during that time or if it was consistent or not that they would notice a difference in her wound. Someone should have seen that it was different with the daily dressing changes and notified me or (R1's Physician). Her wound got very bad, very fast so it should have been closely monitored. On 1/12/23 at 3:44PM, V13 (Wound Care Nurse) stated, (R1's) pressure ulcer prevention measures were repositioning, dietary consult, liquid protein, encouraging her to lay down in bed to offload pressure as much as possible. At one time she was a safety concern, so she didn't have an air mattress applied. She had a wide bed, and we couldn't give her an air mattress. The staff were concerned when they rolled her for repositioning and incontinence care she would roll out of bed. She finally got her air mattress on 12/29/22. She is now in a regular bed with the air mattress and is doing fine with it. (R1) had a few wounds and she actually healed out on 12/12/22 but I kept her in wound assessment manager just to track her. On 11/30/22 her wounds measured 0x0, but I wanted to keep tracking her due to her high risk for pressure ulcers. Then on 12/16/22 it looked like she had a 3x1.5cm purple area that I thought possibly could be a deep tissue injury on the left buttock and what looked like a stage 2 on her coccyx. I called the wound care rep and told her what was going on and she gave me recommendations. (V12-Nurse Practitioner) signed off on 12/16/22 for the orders. On 12/19/22, (V12) and the wound care representative came in to look at the wound with me. I did not document that assessment. I did go into (R1's) chart and put in late entries today for the wound assessments I did in December. I was lax in doing my documentation in a timely manner. I usually wait 2 weeks at least before I change the treatment orders. (V5-LPN) contacted (R1's physician) on the 29th or 30th I'm not sure which date. I didn't talk to (V12) or (R1's physician) from 12/19-12/29. I don't feel like anything could have been done differently with (R1). On 1/13/22 at 8:39AM, V13 (Wound Care Nurse) stated, On 12/29/22 we noticed purulent drainage coming from (R1's) wound. Up until then it wasn't anything unusual. I don't know why the documentation was different on the wound assessment for 12/16/22. As far as I know the physician was not contacted from the 19th to the 29th. When I do my assessments and the wound is worsening, I would notify the provider. It was getting bigger, but we were using the silver and covering with the antimicrobial. I wanted to give the new treatment a chance to work before I contacted the provider and obviously it didn't work. When you go from a stage 2 to a stage 3 there is a presence of granulation tissue and slough. It doesn't necessarily mean the wound is getting deeper. I haven't seen a wound go from a stage 3 to an unstageable because usually when the wound is a stage 3 the resident will go for a debridement and then there's slough and eschar. I did document that (R1's) wound had deteriorated because it did. I really wanted the treatment to work for her but in this case it did not. I know I should have documented (R1's) wound assessments when I did them and there's no excuse for why I didn't, I was just lax about it. I was keeping an eye on her wounds, so I knew when it was worsening, the floor staff didn't really need to see that documentation because I was there. The facility's policy titled, Wound care/dressing change revised on 12/2017 showed, The purpose of this procedure is to provide guidelines for dressing changes of wounds in a sterile and non-sterile technique to promote healing .M. Cleanse wound with damped gauze using the one swipe method. One circular motion with each gauze 4x4 starting at the center and working to outer edge of wound .The following information should be recorded in the resident's medical record: .E. Any change in the resident's condition. F. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Complications related to the wound. The facility's policy titled, Prevention of Pressure Injuries Protocol revised on 01/2018 showed, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .General Guidelines .E. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious condition for the resident. F. The community should have system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family .J. Routinely assess and document the condition of the resident's skin per community wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury to the supervisor .Interventions and Preventive Measures: SKIN. A. Surface selection .1. Select surface based on resident/clinical assessment .b. Preventable surface/foam mattress for all residents, including Stage 1 and Stage 2 wounds. The Immediate Jeopardy that began on 10/21/22 was removed on 1/16/23 when the facility took the following actions to remove the immediacy. Immediate Jeopardy Removal Plan: 1.R1 and R4 were assessed by the wound nurse for new pressure areas on 1/13/23. 2. Current residents with pressure injuries and/or medical devices will be assessed by wound care nurse, licensed nursing staff and Quality director (LPN). This will be completed on or before 1/16/23. 3. Current licensed and direct care nursing staff were re-educated by the Director of Nursing or designee on identification of wounds, notification to physician for worsening wounds, pressure injury prevention, medical device application and removal, skin evaluations for residents with medical devices, signs/symptoms of worsening wounds and process for reporting new or worsened wounds. Completed on or before 1/16/23 or prior to working their next scheduled shift. 4. The Wound Care Nurse was re-educated by the Director of Clinical Operations on skin/wound champion training including, wound champion role/responsibilities, skin care & pressure injury prevention, wound assessments, wound treatments, and skin/wound documentation. Completed 1/16/23. 5.Interdisciplinary Team (IDT) reviewed the (facility) Skin Identification, Evaluation and Monitoring policy and procedure and it is in compliance with the CMS (Centers for Medicare & Medicaid) regulation F686. Completed 1/16/23. 6. Residents with new or changed pressure injuries or medical devices will be reviewed by the IDT during the daily clinical meeting for completion of skin evaluation, physician notification, and wound treatment orders. 7. During weekly Resident-at-Risk meetings, IDT will review the clinical record of residents with new or changed pressure injuries or medical devices. The review will be documented in the Resident's clinical record. 8.The Director of Nursing or designee will review weekly wound assessments for completion and complete random weekly observations of medical device application and removal, skin evaluations for residents with medical devices and pressure injury treatments. Results will be part of the plan of correction audit binder and will be reviewed weekly or as needed during IDT clinical meetings. 9. Quality Assurance plans to monitor facility compliance to make sure that correction is achieved and permanent. Monthly review of completed observation and skin/wound evaluation results and trends will be completed by the Director of Nursing or designee and reported to the facility's QAPI (Quality Assurance Performance Improvement) committee for the next three months and then re-evaluated to determine if further monitoring is indicated. Completion Date: 1/16/23 On 1/17/23, a review of the facility's in-service documentation showed 72% of the facility's core staff and 21 agency staff members had been educated regarding the new wound identification, reporting, and monitoring process. The remainder of staff and any new agency staff will be educated prior to the start of their next shift. Interviews with staff working on 1/17/23 showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan. II. Based on observation, interview, and record review, the facility failed to notify a physician of a resident's worsening pressure wound (R16), failed to obtain new treatment orders for a resident's pressure wound (R16), failed to identify pressure wounds for 3 residents (R17,R18,R19) prior to a stage 2, failed to obtain treatment orders for a residents pressure wound (R14,R16) and failed to identify a resident's pressure wound prior to a stage 3 (R16). This applies to 5 of 7 residents (R14, R16, R17, R18 and R19) reviewed for pressure ulcer prevention and treatment in the sample of 19. The findings include: 1) R16's electronic face sheet printed on 1/17/23 showed R16 has diagnoses including but not limited to dementia, peripheral vascular disease, major depressive disorder, and anxiety disorder. R16's facility assessment dated [DATE] showed R16 has two unstageable pressure ulcers. R16's nursing care plan initiated 7/15/13 showed, (R16) is at risk for pressure injury onset and delayed wound healing due to impaired mobility related to left above the knee amputation, and history of pressure ulcers. R16's undated nursing care plan showed, Unstageable pressure ulcer to right buttock/ischium, stage 3 pressure ulcer to left buttock/ischium. R16's wound assessment reports showed, 12/2/22 Right buttock/ischium Stage 3 pressure ulcer identified on 11/25/22 and measures 5.0x4.0x0.3cm with scant serous drainage. Padded foam dressing applied. 12/9/22 Right buttock/ischium deteriorated and is now an unstageable pressure ulcer measuring 5.0x4.0x0.3cm with scant serous drainage. R16's treatment administration record for December 2022 showed, 12/9/22 Right ischial wound: cleanse, cover with 2x2 hydrogel gauze and then silicone cover dressing, change daily. (14 days after R16's pressure ulcer was identified). No previous orders were identified on R16's treatment administration records for November 2022 for her right buttock/ischial pressure wound. R16's wound assessment reports for her right buttock/ischium pressure ulcer showed, 12/16/22 wound unchanged measuring 5.0x4.0x0.3cm with scant, serous drainage. Continue current treatment. 12/23/22 wound deteriorated measuring 5.0x5.0cm with wound bed 100% covered with slough and larger. 12/30/22 wound deteriorated measuring 5.0x6.0cm. 1/3/23 wound deteriorated measuring 5.0x6.0cm with 20% eschar. Wound drainage has become purulent. New order for wound treatment received. R16's wound assessment reports for her coccyx wound showed, 12/8/22 irritation/excoriation to coccyx identified 4/18/22 now measuring 4.0x5.0x2.0cm with small serosanguinous drainage. New treatment orders received. 12/15/22 wound unchanged measuring 4.0x5.0x2.0cm. No new orders. 12/22/22 wound unchanged measuring 4.0x5.0x2.0cm. No new orders. 12/29/22 wound deteriorated and measures 4.5x7.5x3.0cm with moderate serosanguineous drainage, wound is larger and deeper and undermining continues all the way around edges. R16's physician's orders and treatment administration records for December 2022 and January 2023 showed R16's wound care orders had not been adjusted despite R16's wounds deteriorating from 12/9/22 to 1/3/23 (24 days). No documentation was present in R16's electronic medical record showing that R16's physician had been notified of R16's wounds deteriorating. R16's wound assessment report for 1/16/23 showed, Stage 3 pressure ulcer to left buttock/ischium identified on 1/16/23 measuring 2.0x2.0x0.3cm with scant, serous drainage. R16's wound assessment reports for January 2023 showed no documentation of any previous wound to R16's left buttock/ischium. On 1/17/23 at 2:32PM, V13 (Wound Care Nurse) stated, (R16's) right buttock/ischium pressure wound started on 11/25/22. I'm sure I initiated a treatment for her but if it's not documented on the treatment administration record, it would be considered not done and that's a problem because her wound did get worse. Her coccyx wound is a pressure ulcer, but I didn't change it to a pressure ulcer in the wound management system. I am able to change the staging of a wound, but I didn't change it because it will be too confusing. If a wound is not documented correctly then someone looking at it may not see that she has a pressure ulcer, just excoriation. (R16) now has a stage 3 pressure ulcer to her left buttock/ischium that was found yesterday. It's a good question if it should have been found before a stage 3, probably should have but in her case, she is falling apart rapidly. She still eats a little bit; we just really don't know how she is getting so many wounds. It's hard to keep up with her skin. I would think the staff would be really paying attention to her skin at least daily, if not every shift because her condition is declining. I did not change wound care orders for (R16's) right buttock/ischial wound between 12/9/22-1/3/23 nor do I recall notifying the physician that her wound was deteriorating. I would have documented that on the wound assessment or in progress notes. The ideal time frame to see if a treatment is working is 2 weeks. I see now that is a problem because I waited too long. The wounds did not show any signs of improvement and actually deteriorated a little bit. 2.) R14's electronic face sheet printed on 1/17/23 showed R14 has diagnoses including but not limited to urinary tract infection, acute kidney failure, end stage renal disease, and morbid obesity. R14's facility assessment dated [DATE] showed R14 has no cognitive impairment and has two stage 2 pressure injuries. R14's nursing care plan dated 12/16/22 showed, Risk for impaired skin integrity due to decreased mobility. (R14) has a pressure injury that was present upon admission. R14's nursing care plan dated 1/16/23 showed, Pressure Ulcer: Sacrum stage 2 on admission. Administer treatment per physician's orders. R14's wound assessment report showed, 12/16/22 Stage 2 pressure ulcer to sacrum measuring 3.0x0.5cm. Stage 2 pressure ulcer to right buttock measuring 1.0x1.0cm. Wounds assessed, measured and allevyn dressing applied. R14's treatment administration record for December 2022 showed, 12/24/22 Apply allevyn to coccyx/buttock area-change daily and as needed. (8 days after R14's two Stage 2 pressure ulcers were identified.) On 1/17/23 at 2:32PM, V13 (Wound Care Nurse) stated, It looks like (R14's) wounds were identified upon her admission to the facility on [DATE]. I know I called the physician for treatment orders on 12/16/22 but I guess the order never made it to the treatment administration record for the floor nurses to complete the treatment on a daily basis. I think we initiated standing wound care orders for her wound care. I can see how it would look like they weren't done but I'm sure they were, the nurses just didn't have anywhere to document it being done. 3.) R17's electronic face sheet printed on 1/17/23 showed R17 has diagnoses including but not limited to Alzheimer's Disease, Dementia, chronic obstructive pulmonary disease, and major depressive disorder. R17's facility assessment dated [DATE] showed R17 has mild cognitive impairment and has no pressure ulcers. R17's nursing care plan dated 1/6/22 showed, Risk for impaired skin integrity due to incontinence and limited mobility. Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness. The facility was unable to provide evidence of daily skin inspections being performed. R17's weekly skin assessments showed R17's skin was intact from 12/3/22-1/7/22. R17's wound assessment report dated 1/12/23 showed, Stage 2 pressure ulcer right buttock/right of the intragluteal cleft measuring 1.5x3.0x0.01cm identified on 1/12/23. On 1/17/23 at 2:32PM, V13 stated, (R17) has a stage 2 pressure ulcer to her right buttock that was identified on 1/12/23. She should have had her wound identified prior to stage 2. There's no excuse as to why it wasn't identified prior to the skin breaking open. She was not getting daily skin assessments that I am aware of, or we would have caught this earlier. 4.) R18's electronic face sheet printed on 1/17/23 showed R18 has diagnoses including but not limited to systolic congestive heart failure, chronic obstructive pulmonary disease, hypertension and chronic kidney disease. R18's facility assessment dated [DATE] showed R18 has no current pressure ulcers. R18's nursing care plan dated 8/15/18 showed, Risk for impaired skin integrity due to decreased mobility, incontinence, peripheral vascular disease, and colitis with diarrhea. On 1/17/23 at 12:18PM, R18 stated, Someone that works here checked my skin the other day and they found a sore on my bottom. I don't know how bad it is, but it hurts. R18's wound assessment report dated 1/12/23 showed, Stage 2 pressure ulcer left buttock/left gluteal cleft measuring 1.30x1.30x0.01cm identified on 1/12/23. On 1/17/23 at 2:32PM, V13 stated, (R18) has a stage 2 pressure ulcer to her left buttock that was identified on 1/12/23. Her wound should have been found prior to this, especially since she is hospice and gets more visits and opportunities for additional staff to see her skin. 5.) R19's electronic face sheet printed on 1/17/23 showed R19 has diagnoses including but not limited to heart failure, prostate cancer, atherosclerotic heart disease, and anemia. R19's facility assessment dated [DATE] showed R19 has moderate cognitive impairment and has no current pressure injuries. R19's nursing care plan dated 12/21/21 showed, Risk for impaired skin integrity due to limited mobility and incontinence. On 1/17/23 at 2:06PM, R19 stated, I got a sore on my butt from sitting too much. They don't give me a cushion or anything when I sit in my recliner and when I sit up in my wheelchair, they leave me sit in it so long it hurts. My sore still hurts a bit but I hope it'll go away soon. My bottom has been sore for a while now, but they told me they were checking everyone's skin last week and that's when they found it. R19's wound assessment report dated 1/11/23 showed, Stage 2 pressure ulcer to right buttock measuring 0.50x0.50x0.01cm identified on 1/11/23. On 1/[TRUNCATED]

Based on observation, interview, and record review, the facility failed to supervise a resident with a history of [CONDITION(S)] ([CONDITION(S)], or a sudden temporary loss of consciousness) for one of four residents (R2) reviewed for safety and supervision in the sample of six. This failure resulted in R2 fracturing her left leg. The findings include: R2's Physician Orders Sheet dated 9/2022 shows R2 was readmitted to the facility on [DATE] with diagnoses including [CONDITION(S)] and collapse, weakness, and displaced fracture of lateral malleolus of left fibula. R2's Fall Risk assessment dated [DATE] shows R2 is a high risk for falls. R2's risk factors include altered elimination and dizziness/[CONDITION(S)]. R2's Care Plan dated 3/3/22 shows R2 is at risk for falls due to new surroundings. Assist [R2] with one staff member for all ambulation, monitor for changes in [R2's] condition that may warrant increased supervision/assistance and notify the physician. 7/25/22 staff to remain in bathroom with resident due to periods of [CONDITION(S)]. [R2] requires limited/extensive assistance of one for ADL (Activities of Daily Living) tasks due to weakness from recent hospitalization for pneumonia, shingles, and generalized weakness. R2's Departmental Notes dated 7/14/2022 at 4:44 AM shows, [R2] had an episode of feeling weak when up to use the bathroom this shift. Blood pressure 90/62. No other complaints since. Will continue to monitor. Dated 7/14/22 at 10:46 AM shows, Resident was unable to attend active range of motion exercise today due to her feeling weak and dizzy, per her nurse. Dated 7/15/22 at 10:28 AM shows, This nurse was called to shower room for aide who stated that [R2] became unresponsive in the shower chair. When this nurse arrived [R2] had come to and myself, a second nurse and two aides lowered her to the floor and elevated her feet. She was awake and speaking to me. Nurse practitioner in the building and assessed the resident and gave orders to send to the emergency room for evaluation .this nurse called and followed up with [local hospital] and found that [R2] was admitted with diagnosis of [CONDITION(S)]. On 9/6/22 at 9:35 AM, R2 said she recently had gotten her therapeutic boot off of her left leg. R2 said staff brought her to the bathroom about six weeks ago and left her there. R2 said she believes she passed out in the bathroom. R2 said she woke up on the floor. R2 said she didn't know how long she was on the bathroom floor. R2 said her left leg is still sore at times. On 9/6/22 at 1:34 PM, V6 CNA said she heard that there was a time when R2's blood pressure had been dropping but V6 had never been told to monitor R2 closer. V6 said she placed R2 on the toilet prior to her fall. V6 said R2 has issues with having bowel movements, so V6 said R2 takes longer on the toilet. V6 said she would've peeked in on R2 more frequently if she knew that R2 was having blood pressure issues. On 9/7/22 at 10:44 AM, V7 CNA said she went to go answer a resident's call light when she heard R2 calling out for help. V7 said she went into R2's bathroom and she found R2's walker was pushed up against the sink and R2's head was on the floor and R2 was on her knees. V7 said that R2 was awake but did not know what happened. V7 said that R2 was by herself in the bathroom. R2's Departmental Notes dated 7/19/22 at 9:24 AM shows, At 7:00 AM this nurse was called down to [R2's] room. [R2] was found in a front fetal position on her knees with face down towards the floor in front of the toilet. [R2] stated she doesn't remember falling and thinks she passed out. This nurse and CNA helped patient into sitting position. She complained of bilateral knee pain and left ankle pain .Complained of her nose hurting. Small bruise noted to bridge of her nose and bilateral knee bruises. 9:00 AM-Attempted to give morning medications to resident and she became nauseated and had a small yellow bile like emesis. Nurse Practitioner came to assess. Resident still not feeling well, shaky, weak, slightly lethargic, and complains of chills. Nurse practitioner suggested to be sent to emergency room . Dated 7/19/22 at 2:38 PM shows, This nurse called to follow up in regards to resident being sent out to the emergency room . [R2] admitted to [local hospital] with Covid, pneumonia, and left fibula fracture. The facility's Safety and Supervision policy revised on 12/2017 shows, The purpose of this policy is to provide a safe environment for residents, visitors and associates while promoting optimal work conditions. Residents should be visualized for safety during routine rounds and per care plan for individual needs.

Based on observation, interview, and record review the facility failed to safely transfer a resident using a mechanical lift for one of three residents (R1) reviewed for falls in the sample of 5. This failure resulted in R1 sustaining a [MEDICAL CONDITION] that required two staples and being admitted to the hospital for pain control for hip and back. The findings include: The facility assessment dated [DATE] shows R1 to have severe cognitive impairment, no behaviors, requires extensive assist with all care including bed mobility and transfers. The assessment also shows R1 has impaired range of motion to both upper and lower extremities and weighs 270 pounds. On 8/27/2019 at 8:45 AM, R1 was observed being transferred using the mechanical lift by 2 CNA's (Certified Nursing Assistant). R1 remained completely still during the transfer and was unable to move R1's legs while in the sling when this surveyor asked R1 to move R1's legs. R1 had a large old bruise behind her left knee and brusing to R1's right arm. The facility incident report dated 8/18/2019 shows R1 was being transferred by mechanical lift with two CNA's. The report shows R1 slipped out of the mechanical lift and was lying on the floor on R1's back in a pool of blood surrounding R1's head. The report also shows as the 2 CNA's were lifting R1 out of R1's wheelchair, one CNA moved the wheelchair from under R1 and then was moving back next to the resident when the attachment to the lift came undone to R1's right leg and R1 slid to the floor. The report shows R1's head was the first to hit the floor before the rest of her body slid to the ground. On 8/27/2019 at 9:35AM, V6 CNA said she was the staff assisting R1 to bed when (R1) fell from the mechanical lift. V6 said she attached R1's sling to the lift on the right side while the other CNA did the left. V6 said the other CNA began to lift R1 up and V6 pulled the wheelchair out from under R1 as R1's bottom came up off the wheelchair. V6 said R1 was not moving while being lifted and remained still. V6 had moved the wheelchair away from R1 and when she turned to go back to R1, R1 's right leg attachment to the lift came off and R1 slid to the floor. V6 said R1's head hit the floor first and the rest of R1's body just followed along. V6 said R1 was bleeding from R1's head and crying out in pain. On 8/27/2019 at 10:00AM, V7 CNA said she was assisting R1 from R1's wheelchair using the mechanical lift when R1 fell to the floor. V7 said she hooked up the left side of the sling and was in charge of raising the mechanical lift. V7 said as R1 was being lifted R1 remained still in the sling, the other CNA moved the wheelchair from under R1 and the right side leg attachment came off and R1 slid to the floor hitting R1's head first. V7 said R1 was bleeding from R1's head and crying out in pain. On 8/27/2019 at 12:15 PM, V4 LPN (Licensed Practical Nurse) said she was in another room that day when she heard a loud commotion in the hall followed by a resident screaming. V4 said V7 came to get her saying R1 had fallen out of the mechanical lift. V4 said when she entered the room she saw R1 on R1's back on the floor with a pool of blood under R1's head. V4 said R1 was awake and crying because of the pain. V4 said R1 was sent to the hospital by ambulance. On 8/27/2019 at 9:40 AM, V1 Administrator, V2 DON (Director of Nursing), and V3 Restorative Nurse said the conclusion of their investigation into the fall was that R1 must have lifted R1's leg up and the attachment came undone on the right leg. R1 was lying on the floor and the only attachment undone on the mechanical lift was the right leg. During the investigation it was determined that R1 hit R1's head first and the rest of the body just slid out to the floor. On 8/27/2019 V5 LPN, V8 and V9 CNA's said they do not believe that R1 could lift R1's legs while in the mechanical lift sling. R1 can barely lift R1's legs while lying in bed. V8 said one time she did not have the sling attached all the way to the lift and as she raised the lift she noticed the resident coming out of the sling. V8 said she has never seen the clips come off the lift unless they are not attached properly. On 8/27/2019 at 2:55PM, V2 DON said she expects her staff to transfer the residents in the safest way possible to avoid any injury. The facility nursing notes shows R1 was experiencing pain to R1's head and body after returning from the hospital. Bruising was identified to R1's right wrist, right elbow and and open skin to back of the left knee. The hospital records dated 8/18/2019 shows R1 was dropped from the mechanical lift approximately four feet. The [MEDICAL CONDITION] required two staples and initial x-ray showed possible fracture to her right hip. The follow-up cat scan did not show a fracture. R1 was admitted to the hospital for pain control to her right hip and upper back after the fall. The operating and product care instructions for the mechanical lift shows: caution: always check that all the sling attachment clips are fully in position before and during the lifting cycle, and in tension as the patients weight is gradually taken up. The facility policy for mechanical lifts with a revision date of 11/2018 shows the use of the mechanical equipment should be according to manufactures recommendations.

Based on observation, interview and record review the facility failed to ensure the safety of a resident with increased confusion and dementia by leaving resident unattended in the bathroom. This failure resulted in a fall that resulted in a fractured pelvis and a fractured right 10th rib for one resident and skin tear to left hand for another resident. This applies to 2 of 20 residents (R79, R28) reviewed for safety and supervision in the sample of 20. The findings include: On (MONTH) 30, (YEAR), at 2:36 PM, V18 (R79's Daughter) was in R79's room sitting with her. R79 was in a wheelchair and was trying to converse with V18; however, R79 appeared to be confused and having difficulty focusing on the conversation and comprehending what V18 was saying. V18 said she has been concerned about R79's safety because she has been having a lot of falls. V18 said R79 had just fallen within the last few weeks and hit her head and then she fell again yesterday when she was left alone in the bathroom and tried to get up on her own. V18 said she was told that a CNA (Certified Nursing Assistant) had put R79 on the toilet and had told her to ring the bell (pull the call light) when she was done. V18 stated she had requested that staff do not leave R79 alone in the bathroom because she has dementia. V18 said, (R79) will most certainly get up without assistance. V18 said she was told they would pass on her request to not leave R79 alone in the bathroom. V18 said the majority of R79's falls have happened in her room or in the bathroom and have been unwitnessed. V18 said R79 will just get up and start walking across the room. V18 said she has not been notified of any changes to R79's cares in response to the falls other than reminding her to use the call light which she is unable to do. R79's electronic nursing and progress notes showed on (MONTH) 29, (YEAR), CNA took resident to the bathroom and told her to put the call light on when she is done. CNA demonstrated the call light in the bathroom for her. Nurse heard resident yelling for help at 2:55 PM less than 5 minutes later and found resident on the floor. Resident was sitting on buttocks with back against the wall and feet outstretched, left arm grabbing the bar and right arm supporting herself on the floor. Resident complains of pain in her right hip. Neuro check and ROM (range of motion) WNL (within normal limits) except for right leg which she was unable to move without pain R79's electronic nursing and progress notes also showed several notes entered regarding R79's mental status as follows: On (MONTH) 1, (YEAR), at 1:32 PM, V11 CRA (Certified Rehabilitation Aid) documented R79 was unsteady with the walker, losing her balance often, leaning back, she sits with poor posture in her wheelchair often and is re-educated and corrected . On (MONTH) 3, (YEAR), at 4:29 PM, V14 LPN (Licensed Practical Nurse) documented R79's short term memory appears to be impaired She does display more signs of confusion . On (MONTH) 5, (YEAR), at 1:18 PM, V19 Activity Assistant documented R79 has become noticeable more confused . On (MONTH) 9, (YEAR), at 10:41 PM, V14 LPN, documented (R79) transferred herself to wheelchair tonight. When staff asked her why she transferred herself she replied because my roommate does it. Resident reminded again to not transfer herself and educated her on call light usage. On (MONTH) 12, (YEAR), at 9:32 PM, V22 LPN documented, At 2PM resident observed on her bedroom floor, Wheelchair was to her right and door to her left . On (MONTH) 14, (YEAR), at 3:03 AM, V20 documented, .resident does not use call light . On (MONTH) 17, (YEAR), at 9:15 PM, V14 documented, Resident was anxious and confused tonight . On (MONTH) 18, (YEAR), at 10:02 PM, V14 documented, Resident was anxious and confused tonight Daughter here and updated on resident's confusion. On (MONTH) 21, (YEAR), at 5: 56 AM, V21 documented, .Alert with a lot of confusion. She knows her first name but not her middle name . On (MONTH) 22, (YEAR), at 7:11 PM, V15 LPN, documented .patient is pleasantly confused. On (MONTH) 27, (YEAR), at 3:14 PM, V15 documented, .intermittent confusion . On (MONTH) 31, (YEAR), at 3:58 PM, V15 LPN (Licensed Practical Nurse) said R79 had been sent to the emergency roiagnom on (MONTH) 29, (YEAR) at 2:55 PM after a fall. V15 said R79 had returned to the facility at 9:55 PM that same night and was sent back to the hospital on (MONTH) 30, (YEAR) at around 6:00PM because of uncontrolled pain and difficulty transferring. V15 said R79 was now admitted to the hospital with [REDACTED]. R79's MDS (Minimum Data Set) dated (MONTH) 1, (YEAR), showed R79 was severely cognitively impaired and required assistance of one staff member to transfer from surface to surface. The same MDS showed R79 was not steady when moving on and off the toilet and could only stabilize with staff assistance, and R79 had a history of [REDACTED]. R79's fall assessments completed (MONTH) 16, (YEAR), (MONTH) 14, (YEAR), and (MONTH) 29, (YEAR) all showed R79 at a high risk for falls due to confusion, disorientation and impulsivity. R79's resident status sheet last reviewed (MONTH) (YEAR) showed R79 to be confused, alert and forgetful and require assistance of one staff member for transfers. R79's current care plan with problem onset date of (MONTH) 29, (YEAR) showed R79 to have a history of falling and poor standing balance. The same care plan showed intervention to monitor for changes in R79's condition that may warrant increased supervision/assistance and notify the physician. On (MONTH) 1, (YEAR), at 10:42 AM, V10 CNA (Certified Nursing Assistant) said she works full time on R79's hall. V10 said R79 has been terribly confused lately. V10 said when R79 is taken to the bathroom staff have to stay with her because she will try and get up on her own. V10 said R79 would not be able to remember to use her call light even if it was explained to her because she could never remember to do that. V10 said, If you put her there you better stay there. On (MONTH) 1, (YEAR), at 10:55 AM, V11 CRA (Certified Rehabilitation Assistant) said R79 is not steady during transfers and ambulation and needs a walker, gait belt, and at least one assist and at times a second staff member to follow with a wheelchair. V11 said R79 was confused and forgetful and it takes several verbal cues and reminding to get her to understand what staff are asking to do. V11 said, I would not leave her in the bathroom, she has to have someone with her for safety. On (MONTH) 1, (YEAR), at 11:53 AM, V2 DON (Director of Nursing) said they have a process that they use during clinical huddle and meeting to try and figure out why a fall happened and to put updated interventions in the care plan. We try to do an immediate intervention. V2 said when R79 was sent back to the emergency roiagnom on (MONTH) 30, (YEAR) and was found to have a fractured pelvis and a fractured right 10th rib. V2 said she received report that they are going to do pain management. V2 said these fractures are very painful and sometimes they send back with no physical therapy and just to do pain management and activity as tolerated. V2 said R79 is impulsive and does not retain information. V2 said we have to always be on the lookout for her because she is quick and we have to maintain a visual of her. V2 then said, R79 has dementia and we have to remind her to use her call light because she forgets. She has dementia. On (MONTH) 1, (YEAR), at 4:14 PM, R79 was observed back in the facility. R79 was lying in bed and calling out that she needed to use the bathroom. R79 was restless and was unable to follow the conversation when asked if she was experiencing pain. The hospital discharge instructions from R79's readmission to the facility on (MONTH) 1, (YEAR) showed R79 is to be toe touch weight bearing on right extremity (unable to put full weight on right side). The assessment and plan history and physical from the hospital printed (MONTH) 31, (YEAR) showed R79 to have an acute pelvic fracture, an acute compression [MEDICAL CONDITION] spine, an acute thigh and hip contusion, and an acute right rib fracture. The same discharge paperwork from the hospital showed R79's functional status at discharge as bed bound and a new narcotic pain control patch for pain control. 2. On (MONTH) 30, (YEAR) at 1:14PM, R28 was sitting in an overstuffed recliner in the television lounge. R28 had a dressing to his left hand and a gait belt around his chest. On (MONTH) 31, (YEAR) at 8:10AM, V3 LPN-Licensed Practical Nurse said, R28 wears the gait belt when sitting up, he tries to get up by himself. He has a history of falls. On (MONTH) 1, (YEAR) at 8:10AM, V3 LPN-Licensed Practical Nurse said, R28 has a skin tear to his left hand. The hospice CNA-Certified Nursing Assistant left R28 sitting alone in his wheel chair while preparing him for a bath. He fell forward. I educated the CNA; R28 is never to be left alone when in the wheel chair. R28's MDS-Minimum Data Set, dated dated dated (MONTH) 13, (YEAR) shows, Brief interview for Mental Status 3-Serverly Impaired. R28's has multiple [DIAGNOSES REDACTED]. The MDS: Functional status shows, Bathing Support: Total dependence Two persons physical assist. The facility's Incident list dated (MONTH) 1, (YEAR) to (MONTH) 30, (YEAR) shows, R28 has fallen 13 times. (MONTH) 16, (YEAR), (MONTH) 28, (YEAR), (MONTH) 15, (YEAR), (MONTH) 28, (YEAR), (MONTH) 27, (YEAR), (MONTH) 14, (YEAR), (MONTH) 17, (YEAR), (MONTH) 1, (YEAR), (MONTH) 18, (YEAR), (MONTH) 14 (YEAR), (MONTH) 24, (YEAR). (MONTH) 20, (YEAR), and (MONTH) 7, (YEAR).

Based on interview and record review the facility failed to ensure pain management was provided to a resident. This failure resulted in R11 experiencing medication withdrawl including restlessness and diaphoresis, and experiencing generalized pain throughout her body. This applies to 1 of 4 residents (R11) reviewed for controlled medications in the sample of 4. The findings include: On (MONTH) 18, (YEAR), R11 was resting in her bed with oxygen in place and her caretaker at the bedside. R11's current [DIAGNOSES REDACTED]. On (MONTH) 18, (YEAR), at 2:01 PM, V14 Registered Nurse (RN) said she arrived for her shift starting at 10 PM on (MONTH) 16th. V14 said she received report from the previous nurse that R11's pain patch would be in the pharmacy delivery tonight (October 16) and that the old patch was left on until the new ones arrive. V14 said the pain patch was supposed to be changed on (MONTH) 15 but was not changed until after 12:00 AM on (MONTH) 17th (approximately 28 hours late). V14 said she assessed R11 early in her shift (around 10PM) and noticed she was a little clammy, she said when she went back in a little later to check and make sure that the old patch had actually been left on, (R11)'s back was sweaty and she seemed restless. V14 said R11 usually does not move around very much but she was moving her legs around. V14 said R11 does not never complain of pain but on this night she described generalized pain all over. R11's eMAR (electronic medication administration record) for (MONTH) (YEAR) showed V14 changed R11's pain patch on (MONTH) 15, (YEAR). On (MONTH) 18, (YEAR), at 2:01 PM, V14 stated she was not in the facility on (MONTH) 15, (YEAR) but was working on (MONTH) 17, (YEAR). V14 said when she made the nursing note on (MONTH) 17, (YEAR) regarding the application of R11's pain patch, R11's signs and symptoms of pain, sweating and restlessness and signed out the pain patch. V14 said the documentation showing the (MONTH) 15th pain patch change must have been an error in the documentation system due to the medication showing overdue at the time of administration on (MONTH) 17, (YEAR). R11's narcotic sign out sheet for the pain patches showed V14 signed a patch out on (MONTH) 17, (YEAR). The pharmacy delivery sheet signed by V14 showed the delivery of R11's pain patch to the facility at 11:30 PM on (MONTH) 16, (YEAR). On (MONTH) 18, (YEAR), at 2:30 PM, V2 DON (Director of Nursing).V2 said if there is a missing pain medication she would expect the nursing staff to check the emergency supply of medications. If the missing medication is not stocked in the emergency medication supply she would expect the nurse to contact the on call physician and obtain the medication for the resident. V2 said there is no reason to delay. V2 said that R11 had an order for [REDACTED]. On (MONTH) 18, (YEAR), at 3:00 PM, V1 Administrator said she would expect the supply of medication to be available. If the medications were not available for the resident she would expect the nurse to contact the pharmacy and get it from the emergency supply if it is in the emergency box of medications. On (MONTH) 19, (YEAR), at 9:30 AM, V15 Pharmacy Manager V15 said the pain patch releases 12mcg of the medication per hour for 72 hours. V15 said after the first 72 hours passes even if the patch is left on the resident the amount of medication being released would be at a lesser rate. V15 said typical withdrawal symptoms from the pain patch would include reports of pain, diaphoresis (sweating), and anxiety or restlessness. R11's care plan with onset date of (MONTH) 8, (YEAR) showed R11 has the potential for pain as reported by her/family or as observed by changes in ADLs (activities of daily living) or behavior. The interventions on R11's care plan showed to initiate intervention as ordered by physician. R11's hospice care plan with problem onset date of (MONTH) 12, (YEAR) showed the goal as: will be made as comfortable as possible by alleviating or controlling pain. The interventions for the hospice care plan include: observe and assess for any signs of distress, increased pain, and initiate appropriate interventions, administer medications as ordered by physician, assess for signs and symptoms of increased pain: i.e. increased anxiety, irritability, moaning, yelling out, increased restlessness and/or thrashing around in bed and notify physician of such. R11's electronic MDS (Minimum Data Set) dated (MONTH) 6, (YEAR) showed R11 has moderately impaired cognitive function. R11's physician order [REDACTED]. The facility's policy for Emergency Pharmacy Services and Emergency Medication Supplies reviewed (MONTH) 11, (YEAR) showed emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances or products for infusion in limited quantities in compliance with applicable state regulations.

Based on interview and record review the facility failed to ensure an ordered pain patch was available to a resident on hospice services. This failure resulted in R11 experiencing medication withdrawl including restlessness and diaphoresis, and experiencing generalized pain throughout her body. This applies to 1 of 4 residents (R11) reviewed for controlled medications in the sample of 4. The findings include: On (MONTH) 18, (YEAR), R11 was resting in bed with oxygen in place with her caretaker at the bedside. R11's current [DIAGNOSES REDACTED]. R11's nursing note dated (MONTH) 17, (YEAR) at 3:21AM by V14 RN (Registered Nurse) showed, Residents [MEDICATION NAME] did come in tonight when pharmacy came at 11:30 PM. Author went in to change this residents patch, while I was changing her patch resident did complain of pain and she was notably sweating, and restless. Her [MEDICATION NAME] was supposed to be changed on Sunday 10/12/18. I placed the new patch in the middle of her back. I will report off to oncoming staff and administration per charge nurse. Resident did state late in the shift that she was feeling a little better. I will continue to monitor this resident . On (MONTH) 18, (YEAR), at 2:30 PM, V2 DON (Director of Nursing) said she was not aware that the pain patches were not sent from the pharmacy. V2 said if there is a missing pain medication she would expect the nursing staff to check the emergency supply of medications. If the missing medication is not stocked in the emergency medication supply, she would expect the nurse to contact the on call physician and obtain the medication for the resident. V2 said there is no reason to delay. V2 stated the nurse should order the refill for the patches as soon as the last patch in the current supply is applied. V2 said she does not know why there was a delay in getting the new supply of pain patches for R11. V2 said that R11 had an order for [REDACTED]. On (MONTH) 18, (YEAR), at 3:00 PM, V1 Administrator said she would expect the supply of medication to be available. If the medications were not available for the resident she would expect the nurse to contact the pharmacy and get it from the emergency supply if it is in the emergency box of medications. On (MONTH) 19, (YEAR), at 9:30 AM, V15 Pharmacy Manager stated R11 has been on [MEDICATION NAME] for quite a while and the pharmacy usually sends out a partial fill for 5 patches at a time. V15 said the patches that were sent to the facility on (MONTH) 16, (YEAR) were the second fill for the prescription. To get those patches the nurses would usually fax them a reorder sticker to let them know they needed to send the next refill. At 9:50 AM, V15 called the surveyor back and stated he searched through all of the refill requests faxed to the pharmacy from (MONTH) 9 through (MONTH) 16, (YEAR) and could not find one from the facility for the [MEDICATION NAME]es for R11. V15 stated he could find no documentation of phone calls from the facility verbally requesting the refill. V15 said the pain patch releases 12mcg of the medication per hour for 72 hours. V15 said after the first 72 hours passes even if the patch is left on the resident the amount of medication being released would be at a lesser rate. V15 said typical withdrawal symptoms from the pain patch would include reports of pain, diaphoresis (sweating), and anxiety or restlessness. R11's electronic MDS (Minimum Data Set) dated (MONTH) 6, (YEAR) showed R11 has moderately impaired cognitive function. R11's physician order [REDACTED]. The facility's policy for Emergency Pharmacy Services and Emergency Medication Supplies reviewed (MONTH) 11, (YEAR) showed emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medications including emergency drugs, antibiotics, controlled substances or products for infusion in limited quantities in compliance with applicable state regulations.

Based on interview and record review the facility failed to transfer a resident (R1) in a safe manner. The facility failed to assess and provide safety measures for a resident at risk for falling. These failures resulted in R1 sustaining fractures to both hips on 1/09/15. This applies to 1 of 6 residents (R1) reviewed for transfers in the sample of 6. The findings include: On 1/09/15 at 3:45 PM, the nursing notes states, an alert and oriented R1 arrived at the facility after a seven day hospital stay. On 1/09/15 at 9:00 PM, R1 sustained bilateral hip fractures from a fall during a transfer within the facility. On 1/10/15 at 10:41 PM the local hospital weighed R1 at 299 pounds with [DIAGNOSES REDACTED]. On 1/17/15 at 3:30 PM, E3 said because R1 was admitted at 4:00 PM and was sent to the local hospital at 9:00 PM she was not assessed by rehabilitation services, and did not have a Minimum Data Set (MDS) assessment. On 1/17/15 at 7:00 PM, E1 (Administrator) said that R1 was admitted to the facility after rehabilitation services (Rehab) left for the day. The rehab people do the assessment of the resident ' s ability to stand, transfer, and walk. E1 ' s expectation of the medical staff in a late hour admission is to look at the hospital record, ask the family, and if the resident is alert and oriented, ask them what their abilities are. On 1/17/15 at 4:44 PM E6 & E10 Certified nursing assistants (CNA) said "we transfered R1 two times." E6 said R1 was a little shaky, so we transfered R1 together (two person assist). On 1/23/15 at 3:05 PM, E10 said that on 01/09/15 at 8:55 PM, after placing R1 on the bed side commode (BSC), E4 Licensed Practical Nurse (LPN), asked E6 and I (E10) when we (E6, E10) get her (R1) up that she (E4) would like to check her bottom for any skin issues. E6 and E10 went on to other rooms while R1 used the BSC. E6 and E10 both stated that they returned to R1 ' s room when they heard E4 yelling for help. On 1/17/15 at 4:06 PM, E4 said, information about R1 ' s ability to transfer came from the hospital, family, and resident. E4 said, on 1/09/15 at 9:00 PM, when R1 was finished urinating E4 asked R1 to get into the bed so E4 could do a skin assessment. R1 said she would rather stand, and that she (R1) could lean against the back of the recliner for support. E4, without the aid of the 2 CNA ' s, said she cleaned R1 ' s perineal area and R1 leaned against the back of the recliner while E4 attempted to assess R1 ' s labia and bottom. R1 then said, " I have to sit, I have to sit! " E4 said R1 started to lean forward. R1 ' s legs spread to the point where she could not sit back down on the bed side commode. E4 said she eased R1 to her knees and ran to the doorway and yelled for help. At this point R1 ' s knees started to spread further appearing to do the " splits " with both her legs to each side and behind her. On 1/23/15 at 2:00 PM, E4 stated that R1 was standing less than 1 minute, maybe 45 seconds. E4 said when help came, we used a mechanical lift to put her on the bed. E4 said that R1 rated her pain at a 10 (0= No Pain and 10= worst pain ever). On 1/23/15 at 3:00 PM, Z3 said she did tell the facility that R1 can stand, pivot, sit, but that takes only 10 seconds and R1 was standing for longer than that. She spent the last 7 days in the hospital and she is weak. Z3 said, " R1 has arthritis and a bad back, and hasn ' t walked in years. I told the facility all that. Why didn ' t that nurse have help if she was going to do an assessment? " On 1/17/15 at 4:00, PM E5 Registered nurse (RN) said, to assess the abilities of a resident when rehab is not here to do it, the staff looks at what the hospital documented, the nurse and the CNA should do a quick assessment, and ask the resident what their abilities are if they are alert and oriented. I expect the staff to use a gait belt and proper body mechanics. On 1/23/15 at 12:15 PM, E2 Director of Nursing (DON) said, she expects that if a resident is admitted after rehab is gone, the nursing staff will look at the hospital assessment and discharge summary to assess the abilities of that resident to transfer, stand, and walk. E2 also said the resident is a good source of information if they are alert and oriented. In this case E2 stated, " I think she (R1) had a bad hospital stay and thought she (R1) could do something, but her (R1) body was tired and she couldn ' t do it. " On 1/27/15 at 10:35 AM, Z1 Medical Director/Medical Doctor, said that the nursing staff would be responsible for accurately assessing a resident that arrives after rehab leaves for the day. Z1 said to err on the side of caution, and use more help than you think you need until you know what the abilities of that resident is, especially one of that size, age and medical history. On 1/12/15 at 3:45 PM, E4 made a late nursing note entry for 1/09/15 at 9:00 PM. " Patient was sitting on commode in her room. Reported to this nurse (E4) that she (R1) could stand for assessment of her skin on her bottom ...She (R1) said I can hang on to the recliner ...She (R1) stood in front of the commode after some trouble removing from its sides ...She (R1) began to say I have to sit, I have to sit. Her (R1) feet had slid slightly apart and were now on the outside of the commode chair legs so the commode would not slide up behind her. She (R1) began leaning her head into the recliner seat and was lowered onto her knees by this nurse(E4) ...She (R1) was very frantic at this time calling for 911 ...This nurse (E4) stepped into the doorway and called for " help now. " Several CNA ' s and the PM supervisor (E5) came to assist. While assessing R1 ' s position and getting the mechanical lift device, the patient slid her knees apart appearing to do the splits with both legs now out to the sides of her (R1) and was no longer on her knees. She was mechanically lifted on to the bed. Complaining of pain all over after in bed. " The hospital physical therapy notes for R1 dated 1/8/15 at 3:11 PM list R1 ' s prior ambulation as " Non-ambulatory " . Under the heading, Social/Home Environment Comments, shows, " Hasn ' t ambulated in 4-5 years. Under the category of Activity Tolerance Comments, it states R1 has poor activity tolerance, and is " very shaky " . The 3 categories of, Sit to Stand, Stand to Sit, and Chair Transfer Ability list R1 as a " Contact Guard " (Have hands on the body in case there is a need for assistance). This document listed R1 ' s limiting factors as " Decreased Balance, and Decreased Strength. On 1/22/15 at 3:30 PM, E2 DON states, we received this document after the incident occurred. The 1/11/15 local hospital ' s Discharge Summary shows R1 injuries as bilateral hip fracture. The facility ' s Fall Prevention Program policy dated 6/18/13 under the heading, Policy Statement states, " The corporate ministry guiding principle is that all patients/residents are at risk for falls. All Presence life Connections Nursing Home employees have a role in fall prevention.