Every finding on record at The Commons at Lisle Creek Estates

Based on interview and record review, the facility failed to obtain and implement wound care orders in a timely manner for a resident admitted with arterial and other non-pressure wounds.This applies to 1 of 3 residents (R1) reviewed for wound care in the sample of 7. Findings include:R1's admission record showed she was admitted to the facility on [DATE], with diagnoses that included emphysema, unspecified open wound to right foot, peripheral vascular disease, disorder of the skin and subcutaneous tissue, streptococcal sepsis, sepsis, acute kidney failure and altered mental status. R1 was discharged on August 3, 2026, according to R1's census.R1's hospital records showed on July 23, 2026, R1 had a right ankle full thinness venous ulcer being treated with alginate and gauze with the last dressing change being July 23, 2026, at 9:00 PM. R1's nursing progress note written by V10 (Registered Nurse/RN) showed resident was admitted to the facility on [DATE], at approximately 1:00 PM with two wounds to her right arm, two wounds on her sacrum, and one wound on her heel. R1's Weekly skin observation, dated July 24, 2026, showed R1 had a pressure wound to her coccyx, an unstageable wound to the right buttocks, two right arm wounds and one right heal wound. On August 13, 2026, at 9:52 AM, V11 (Hospital Care Manager) stated R1 was admitted to the hospital on [DATE], and was discharged [DATE]. V11 stated R1 was readmitted on [DATE], and she had three wound dressings that were dated July 24, 2026, showing the dressings had not been changed by the facility. R1's hospital registered nurse progress note, dated August 3, 2026, showed the following: upon performing a physical assessment of R1 with her charge nurse at the bedside, we noticed [the] patient's wound care had not been addressed at the [facility]. This was evidenced by the wound care dressings dated July 24, [2026]. Noting that the dressings had not been changed since her discharge from the hospital. R1 had the following physician orders for her non-pressure wounds:1.Right lateral Arm, above elbow, skin tear: cleanse with normal saline, pat dry, apple xeroform gauze, secure with gauze border dressing daily. Dated August 3, 2026. 2. Left Medial Ankle, Arterial: apply betadine once daily, everyday shift and dated July 30, 2026 and to start July 31, 2026.R1 did not have any orders prior to July 30, 2026, for wound care. Nor was there any documentation a dressing change was done to any of R1's wounds prior to July 29, 2026, or before July 31, 2026. On August 13, 2026 at 12:28 PM, V10 (Registered Nurse/RN) stated she admitted R1 to the facility on July 24, 2026, but was not the nurse who was caring for R1. V10 stated she did her part of the admission, which was to do an assessment, document what she saw, scan the orders to the pharmacy, and give the nurse caring for the resident report. V10 stated it is the responsibility of the nurse caring for the resident to obtain orders, the night shift to audit the chart and put in orders, and V9 (Assistant Director of Nursing/Wound Care Nurse) to reassess the wounds and put in orders for the wound care. V10 stated residents need wound orders to have continuity of care. V10 stated wound care should be addressed on admission. V10 stated she informed the Director of Nursing that the resident had wounds, plus that was known before the resident arrived to the facility because they received wound information in report from the hospital. On August 12, 2026, at 5:12 PM, V2 (Director of Nursing) stated resident wound treatments and care should be addressed on admission. V2 stated nurses should call the doctor to obtain wound care orders and review the after-visit summary for wound orders with the doctor on admission. On August 13, 2026, at 11:19 AM, V2 stated V9 (ADON/Wound Care Nurse) was supposed to monitor every admission and wound to ensure orders were in place and wounds were addressed and that wasn't done for R1. V2 stated the wound care orders are necessary to prevent worsening of wound, prevent infection, and help heal the wound. On August 13, 2026, at 11:41 AM, V12 (Wound Care Physician) stated she expect wounds identified on admission to be addressed on admission and treated to prevent infection, manage drainage, and prevent worsening of the wound. V12 stated the primary care provider could have put in orders to treat R1's wounds until R1 was seen by the wound care provider. R1's wound care note written V12 and dated July 29, 2026 identified the following wounds: an arterial wound of the right, medial ankle full thickness, and an arterial wound of the left, medial ankle with undetermined thickness. R1's hospital records for her August 3, 2026, admission showed she was referred to the wound care doctor on August 3, 2026, the wound note showed R1 had the following wounds:Right ankle medial venous ulcer.Right buttocks pressure injurySacrum pressure injuryRight elbow skin tearRight lateral breast wound, and Right anterior arm skin tear The facility's Wound Treatment Management policy and procedure, dated September 10, 2025, showed, 1. Wound treatments will be provided in accordance with physician orders, including the cleansing, method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on interview and record review, the facility failed to obtain and implement wound care orders in a timely manner for a resident admitted with pressure wound injuries.This applies to 1 of 3 residents (R1) reviewed for pressure wound care in the sample of 7. Findings include:R1's admission record showed she was admitted to the facility on [DATE], with diagnoses that included emphysema, unspecified open wound to right foot, peripheral vascular disease, disorder of the skin and subcutaneous tissue, streptococcal sepsis, sepsis, acute kidney failure and altered mental status. R1 was discharged on August 3, 2026 according to R1 census.R1's hospital records showed on July 24, 2026, R1 had the following pressure injury wounds with dressings that had been changed on July 24, 2026 at 6:00 AM:Sacrum pressure injury full thickness with skin protectant and foam border dressing applied. Right buttocks pressure full thickness pressure injury with collagenase foam boarder dressing applied. Right anterior hip/trochanter pressure injury skin protectant and foam border dressing applied.R1's nursing progress note written by V10 (Registered Nurse/RN) showed resident was admitted to the facility on [DATE], at approximately 1:00 PM with two wounds to her right arm, two wounds on her sacrum, and one wound on her heel. R1's Weekly skin observation, dated July 24, 2026, showed R1 had a pressure wound to her coccyx, an unstageable wound to the right buttocks, two right arm wounds and one right heal wound. On August 13, 2026, at 9:52 AM, V11 (Hospital Care Manager) stated tR1 was admitted to the hospital on [DATE], and was discharged [DATE]. V11 stated R1 was readmitted on [DATE], and she had three wound dressings that were dated July 24, 2026, showing the dressings had not been changed by the facility. R1's hospital registered nurse progress note, dated August 3, 2026, showed the following: upon performing a physical assessment of R1 with her charge nurse at the bedside, we noticed [the] patient's wound care had not been addressed at the [facility]. This was evidenced by the wound care dressings dated July 24, [2026]. Noting that the dressings had not been changed since her discharge from the hospital. R1 had the following physician order for her pressure wound: Sacrum, Pressure ulcer: Apply calcium alginate, secure with gauze border daily and as needed if saturated, soiled, or dislodged. every day shift dated July 30, 2026 and to be started July 31, 2026.R1 did not have any orders prior to July 30, 2026, for wound care. Nor was there any documentation a dressing change was done to any of R1's wounds prior to July 29, 2026, or before July 31, 2026. On August 13, 2026 at 12:28 PM, V10 (Registered Nurse/RN) stated she admitted R1 to the facility on July 24, 2026, but was not the nurse who was caring for R1. V10 stated she did her part of the admission, which was to do an assessment, document what she saw, scan the orders to the pharmacy, and give the nurse caring for the resident report. V10 stated it is the responsibility of the nurse caring for the resident to obtain orders, the night shift to audit the chart and put in orders, and V9 (Assistant Director of Nursing/Wound Care Nurse) to reassess the wounds and put in orders for the wound care. V10 stated residents need wound orders to have continuity of care. V10 stated wound care should be addressed on admission. V10 stated she informed the Director of Nursing the resident had wounds, plus that was known before the resident arrived to the facility because they received wound information in report from the hospital. On August 12, 2026, at 5:12 PM, V2 (Director of Nursing) stated resident wound treatments and care should be addressed on admission. V2 stated nurses should call the doctor to obtain wound care orders and review the after-visit summary for wound orders with the doctor on admission. On August 13, 2026 at 11:19 AM, V2 stated V9 (ADON/Wound Care Nurse) was supposed to monitor every admission and wound to ensure that orders were in place and wounds were addressed and that wasn't done for R1. V2 stated the wound care orders are necessary to prevent worsening of wound, prevent infection, and help heal the wound. On August 13, 2026 at 11:41 AM, V12 (Wound Care Doctor) stated she expects wounds identified on admission to be addressed on admission and treated to prevent infection, manage drainage, and prevent worsening of the wound. V12 stated the primary care provider could have put in orders to treat R1's wounds until R1 was seen by the wound care provider. R1's wound care note written V12 and dated July 29, 2026, identified the following pressure injuries: an unstageable (due to necrosis) sacrum full thickness pressure ulcer and a left heel unstageable deep tissue injury resolved on July 29, 2026.R1's hospital records for her August 3, 2026, admission showed she was referred to the wound care doctor on August 3, 2026, the wound note showed R1 had the following wounds:Right ankle medial venous ulcer.Right buttocks pressure injurySacrum pressure injuryRight elbow skin tearRight lateral breast wound, and Right anterior arm skin tear The facility's Wound Treatment Management policy and procedure, dated September 10, 2025, showed, 1. Wound treatments will be provided in accordance with physician orders, including the cleansing, method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on observation, interview, and record review, the facility failed to ensure residents central line insertions site were visible and the dressing were changed in a timely manner to prevent infection. This applies to 2 of 3 residents (R1 and R4) reviewed for intravenous catheters in the sample of 7.Findings include:1. R4's admission record showed R4 had a recent hospital stay from July 29, 2026 to August 8th 2026 and had diagnoses that included acute osteomyelitis of the left ankle and foot, type 2 diabetes mellitus with diabetic polyneuropathy, major depressive disorder, peripheral vascular disease, muscle weakness, anxiety, cognitive communication deficit, and non-st elevation myocardial infarction. R4's nursing progress note, dated August 8, 2026, showed R4 was readmitted to the facility on [DATE], with diagnoses of left heal wound infected with methicillin-resistant staphylococcus aureus (MRSA) and receiving antibiotics via a peripherally inserted central catheter (PICC) located on R4's right upper arm.On August 12, 2026 at 12:06 PM, V3 (Licensed Practical Nurse) and V2 (Director of Nursing) wheeled R4 to R4's room to remove a completed antibiotic tubing and flush R4's PICC line. R4 was observed to have a right upper arm PICC line with a round sponge like dressing covering the insertion site, and the transparent dressing covering the site was dated August 3, 2026. V2 verbally confirmed the dressing was dated August 3, 2026. On August 12, 2026 at 12:26 PM, V3 stated R4 was sent to the hospital on July 29, 2026, and returned to the facility on August 8, 2026, with a PICC line and that PICC line dressing was dated August 3, 2026. V3 stated when residents come to the facility with a PICC line, the nurse will assess the insertion site for signs of infection and infiltration daily. V3 stated the PICC line dressing on R4's right arm was dated August 3, 2026 and does not allow her to visualize the insertion site or the immediate area surrounding the insertion site. V3 stated usually there is just a transparent dressing covering the insertion site and the immediate surrounding area where they can visualize the area. V3 stated R4's dressing is due to be changed on Saturday August 15, 2026. R4 has the following physician order, dated August 10, 2026 and to start on August 15, 2026: PICC line dressing change: change transparent dressing-and measure arm circumference every evening shift every Saturday for PICC line care. R4's treatment administration record (TAR) showed a physician order for PICC dressing changed every evening shift that was initialed it was done by V8 (Registered Nurse/RN) on August 9, 2026. There was no other documentation presented that showed R4's PICC line dressing had been changed since her admission on [DATE]. On August 13, 2026 at 10:36 AM, V8 (Registered Nurse/RN) stated R4 was readmitted from the hospital on August 8, 2026, and R4's PICC line dressing should have been changed once a week starting on August 10, 2026. V8 stated she did not change R4's PICC line dressing on August 9, 2026, even though the TAR is marked that she had changed the PICC line dressing. V8 stated the TAR was marked in error that R4's PICC line dressing was changed on August 9, 2026 by her.On August 12, 2026 at 12:43 PM, V2 stated intravenous catheter insertion sites should be assessed daily for signs of infection and the dressing should be changed every seven days. V2 stated the nurses should be able to see the insertion site of the intravenous catheter and surrounding area to assess for complications. V2 stated the nurses should be looking at the date on the intravenous catheter dressing and the physician order to determine when the dressing should be changed. V2 stated PICC line dressing should be changed every seven days to prevent infection. On August 13, 2026 at 10:10 AM, V2 stated the nurse putting in the dressing change order for R4 made a mistake by not putting the correct date that R4's dressing should have been changed. 2) R1's admission record showed she was admitted to the facility on [DATE] with diagnoses that included emphysema, unspecified open wound to right foot, peripheral vascular disease, disorder of the skin and subcutaneous tissue, streptococcal sepsis, sepsis, acute kidney failure and altered mental status. R1's hospital records showed on July 23, 2026, a single lumen right jugular tunneled central venous catheter was placed in R1. R1's progress note written by V10 (Registered Nurse/RN) and dated July 24, 2026, showed R1 was admitted with an intravenous port to her right chest. On August 13, 2026 at 12:28 PM, V10 stated she assessed R1's central line and it is the night shift nurses who should audit the resident's chart and put in dressing changes for central lines. V10 stated she admitted R1 but was not assigned to R1. R1's physician orders and care plan were absent of any orders or interventions to address R1's central line. On August 13, 2026 at 9:52 AM, V11 (Hospital Care Manager) stated R1 was admitted to the hospital on [DATE] and was discharged [DATE] with a central line. V11 stated R1 was readmitted on [DATE] and the central dressing was dated July 23, 2026, showing it had not been changed by the facility. R1's hospital Registered Nurse (RN) progress note, dated August 3, 2026, showed the following: upon during a physical assessment of R1, my charge RN and I also noticed that [R1's] central line dressing was dated July 23, [2026] and had also not been changed since discharge from the hospital. The facility's Care and Maintenance of Central Venous Catheter policy and procedure, dated December 10, 2026 (actual date on policy), showed the following: Assess the site for signs of infection at the insertion site. Change sterile, transparent, and semipermeable dressings every 5-7 days.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 49 residents receiving dietary services.Findings include:The CMS 671, dated of 12/16/2025, shows a total of 49 residents residing in the facility.On 12/16/2025 at 9:36 AM, V17, Chef, confirmed all residents residing in the facility were receiving dietary service on the survey start date of 12/16/25.On 12/16/2025 9:36 AM, the kitchen tour began with V17, Chef. The following was observed:*Three red sanitization buckets were in use during food preparation. The sanitization strips that were utilized had the normal range listed as 272- 700 PPM (Parts Per Million). The third red sanitation bucket tested was 1130 PPM.*V17, Chef, stated the dishwashing machine disinfects by temperature. V19, Dishwasher, placed a digital disk-type thermometer through the dishwasher for a test run. The reading was 159.9 degrees Fahrenheit on the digital-disk thermometer.V19, Dishwasher, stated she documents the temperature from the dishwasher dial on the log. If the digital-disk thermometer that runs through the dishwasher and the dishwasher dial don't match, the supervisor should be notified. V19 stated the temperatures had not matched earlier and she did not notify her supervisor.*Dry Storage contained:Four 6lb (pound) 14oz (ounce) dented cans of black beansA 20lb bag of jasmine rice open to air.A 20lb bag of basmati rice open to air.A 20lb bag of lentils open to air.A 20lb bag of split peas open to air.Ten new and capped carbon dioxide cylinders were not in any restraint or holder.V17 stated there is no place for dented cans and dented cans are just thrown out. V17 stated the carbon dioxide cylinders were for the soda machine. V17 did not have any information on how to store the cylinders*Outside the dry storage was a washer / dryer unit. The wash tub was filled with dirty textiles. The dryer lint trap was filled with red lint, and the dryer contained a bag of textiles.*The floor of the walk-in cooler was dirty and had onion skins and blueberries scattered on the floor. The walk-in cooler contained:A silver facility pan, with contents identified by V17 as diced parsley with no label or date.A box of 16 cucumber that had mushy soft white spots.A silver facility pan that contained spaghetti noodles that was unlabeled and had no dates.An 11lb box of yellow peppers that were wilted and wrinkledA 5lb package of American cheese with a single date of 12/8/25.A 2lb 8oz accessed package of sliced mozzarella with no opened-on or use -by dates.A 2lb accessed package of sliced smoked ham that was open to air without opened-on or use-by dates.A 32 oz package of sliced turkey, open to air, with no opened-on or use-by date.A metal facility pan of boiled eggs with a preparation date of 12/11/25 and use-by 12/14/25.A metal pan of deviled egg filling with a single date of 12/15/25.A 1-gallon jar of pepperoncini peppers with a single date of 7/28/25.An opened 8oz can energy drink.*The walk-in freezer contained:A metal facility pan, with white disks identified by V17 as ravioli, unlabeled and undated. The plastic wrap was partially open, leaving item open to air.*The three-door reach in cooler contained:32 oz package of sliced ham, open to air, undated, and partially dried out.32 oz package of sliced turkey open to air and undated.24 oz of package of Swiss cheese slices open to air and undated.Chicken salad with single date of 12/9.*The ice cream cooler contained:A 3-gallon container of rum raisin ice cream that was open to air.A 3-gallon container of butter pecan ice cream that was open to air.A 3-gallon container of mint chocolate chip ice cream that was open to air.A 3-gallon container of strawberry ice cream that was open to air.A 3-gallon container of chocolate ice cream that was open to air.A 3-gallon container of vanilla ice cream that was open to air.*Two mixers not in use were dirty and uncovered.*The meat slicer not in use was dirty and uncovered.On 12/16/2025 at 12:45 PM, V17 stated dented cans should not be used because they can become tainted with botulism. The kitchen staff should check items at the time of delivery and not accept the items that are damaged or spoiled. Food items should be sealed to prevent contamination. V17 stated items should be labeled with contents, open / prepared on dates, and use-by dates, so they know what the items is when it was prepared and when they should discard so residents aren't getting sick from it. Staff should not have personal food / drink in the kitchen area as it can cause contamination. Spoiled food items should be thrown out because they create bacteria. V17 stated, We do not keep logs for the red sanitization buckets. We normally take the sanitizer ppm for the three compartments sink only. The correct ppm for the sanitizer should be 400 ppm to 700pm. The dish machine disinfects by temperature, and the final rinse should be a minimum of 180 degrees. The dial on the machine and the digital disk we run should match. If not, the Dishwasher should notify the Supervisor so the machine can be calibrated. The company that manages the dishwasher would have to come out. Technically, we can't be sure the dishes are sanitized and safe to use if the two numbers aren't matching.On 12/19/2025 8:46 AM, V18, Coordinator of Dining Services, stated she oversees the kitchen staff in part, and the Dishwashers report to her. V18 stated she collects the logs for the three-compartment sink, the coolers, freezers, storeroom, dishwasher, food temps, and red sanitization buckets. V18 stated, If the Chef is not there, they will notify me, and I call the maintenance to come repair it. The staff notify me if the dishwasher is malfunctioning. The sanitizer that goes in the three-compartment sink and red sanitization buckets is automated. The Dishwashers should use a temperature strip, as well as look at the dial on the dish machine. The temperature from the dish machine dial is what is documented on the log. The dishwasher disinfects by temperature not chemical. The rinse cycle should reach 180 degrees to disinfect the dishes. The wash cycle should be between 160 and 180 degrees, but the rinse cycle is what disinfects. V18 stated she reviews the logs for completion and accuracy. The facility provided the logs for the sanitizer pail testing for November, October, and September 2025. The logs that were provided logs were completed and included testing seven times per day. Every documented test showed a sanitizer level of 200 PPM. The December 2025 sanitizer log also showed 200 PPM for seven times per day, daily, through December 16th, 2025, at 7pm. The manufacturer instructions for the sanitizer utilized by the facility documents the desired sanitizer range of 272 PPM to 700 PPM, and the manufacturer's instructions on the test strips matched the desired sanitizer range of 272 PPM to 700PPM. (200 PPM is not listed on the test strips utilized by the facility.) The high temperature dish machine logs for November, October, and September 2025 showed a rinse temperature of 170 degrees Fahrenheit, three times per day, every day. The December high temperature dish machine log also had documentation of a rinse temperature of 170 degrees Fahrenheit three times per day through December 16th, 2025, after the breakfast meal.The documentation provided by the facility as their policy indicates 272-700 PPM as the desired sanitizer concentration range. The policy documentation showed to fill the sanitization buckets from the pot and pan sanitizing dispenser and test with the litmus strip. Record on the pot and pan test strip / sanitization bucket log.The facility policy Labeling, dated 2005, states, all prepared items must have a label with the name of the item, date and time prepared, by whom, and a discard / use-by date. Discard / use-by dates should be no more than 3 days for leftovers / hazardous foods, and 7 days for all other prepared food.The facility policy Food Storage, dated 2005, states dented cans must be marked with a large X and to set aside in separate area so they will not be used.The facility policy Washing and Sanitizing Dishes 2005 states, for high temperature dish machines, wash water temperature must be a minimum of 150-165 degrees Fahrenheit, and the rinse water must reach 180 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to safely store hazardous chemicals and carbon dioxide cylinders in the kitchen and failed to maintain a clothes dryer in a safe manner.This applies to all 49 residents receiving dietary services. Findings include:The CMS 671, dated 12/16/2025, shows a total of 49 residents residing in the facility.1.On 12/16/2025 at 9:36 AM, during the kitchen tour with V17, Chef, ten new and capped carbon dioxide cylinders were unsecured and not restrained in a holder.V17 stated the carbon dioxide cylinders were for the soda machine. V17 stated the facility did not have any information on how to store the cylinders.2.Outside the dry storage was a washer / dryer unit with the wash tub filled with dirty textiles. The lint trap in dryer was filled with red lint, and the dryer contained a bag of textiles.On 12/17/2025 at 12:08 PM, V20, Maintenance, stated the dryer should be cleared of lint and the unit should be kept clean. V20 stated the lint keeps items from drying well and lint build up is a fire hazard.On 12/17/2025 at 10:49 AM, V1, Administrator, stated he spoke with his corporate resource, and carbon dioxide canisters should be in a rack or secured because they are under pressure. V1 stated the restraint protects the valves so the tanks don't explode.On 12/19/2025 at 10:13 AM, a 32-ounce bottle of charcoal lighter fluid was noted in a storage cabinet outside of the kitchen dry storage.On 12/19/2025 at 9:43 AM, V21, Customer Service Representative, stated carbon dioxide cylinders need to be secured and kept at room temperature. V21 stated if the cylinders aren't secured and they fall, they act as a torpedo and someone could be injured. Carbon dioxide removes the oxygen from the area the people in the room could pass out and potentially die. V21 stated there should be a carbon dioxide detector in the area. It could possibly go into the ventilation system.On 12/19/2025 at 10:26 AM, V22, Director of Operations, stated there is no carbon dioxide detector in dry storage. V22 stated there was a concern the carbon dioxide cylinders weren't secured or chained. If they fall, they turn into a torpedo. If people are in there, they could be injured by the tank falling or contents leaking. V22 stated that lighter fluid is flammable and should not be stored in the kitchen area as it could cause a fire. The facility policy Storage of Chemicals and Toxic Materials, dated 2005, states all chemical and other toxic materials must be stored appropriately away from food preparation / food storage areas to maintain the health and safety of the residents and associates.The SDS (Safety Data Sheets) carbon dioxide is liquified gas under pressure. It may displace oxygen and cause rapid suffocation. May increase respiration and heart rate. Always keep container upright.

Based on observation, interview, and record review, the facility failed to renew an as needed hospice order prior to administering the medication, failed to apply compression treatments as ordered, and failed to ensure a resident with a fungal rash was kept dry and clean. This applies to 3 of 4 (R7, R1, R34) residents reviewed for quality of care in a sample of 18.The findings include:1. On 12/16/2025 at 3 PM, R7 was in her geriatric chair at the nurse's station. R7 was severely cognitively impaired. R7 was anxious and fidgeting in her chair despite staff attempting to redirect. On 12/16/2025 at 3:25 PM, V4 (RN/Registered Nurse) said R7's ABH Gel (Ativan 0.5mg/Benadryl 12.5mg/Haldol 0.25mg) as needed medication for agitation had been administered at 3 PM. V4 said R7 continued to show periods of anxiety despite of redirection. V4 said R7's EMR (Electronic Medical Record) did not have an active renewal order for her ABH Gel medication as ordered from hospice. V4 said as needed hospice orders should be renewed prior to the completion date so medications can be administered as ordered. On 12/17/2025 at 2:20 PM, V2, Director of Nursing/DON, said medications should only be administered with a physician's order. V2 said she expected nurses to contact R7's hospice team to ensure her as needed ABH Gel was re-activated in her EMR. V2 said hospice continued to recommend the ongoing use of ABH Gel for R7's agitation and anxious behaviors. V2 said it was important to ensure all administered medications were accurately recorded in the resident's EMR. R7's EMR reviewed on 12/16/2025 showed her order for ABH Gel (Ativan 0.5mg/Benadryl 12.5mg/Haldol 0.25mg) had to be renewed prior to 12/11/2025. R7's Individual Controlled Substance Record sheet for ABH Gel showed R7 also received the medication on 12/11/2025, 12/14/2025, and 12/16/2025. The facility policy titled General Dose Preparation and Medication Administration, dated 12/01/2007, said prior to administration of medication the facility staff should take all measures required by the facility policy and applicable law, including confirmation that the MAR (Medication Administration Record) reflects the most recent orders. The facility's Hospice Nursing Facility Services Agreement, dated 11/14/2022, said if there are physician orders that are inconsistent with the hospice plan of care or hospice protocols, a nurse with facility shall notify hospice. An authorized representative of hospice shall resolve differences directly with the physician and secure the necessary orders. 2. On 12/16/2025 at 9:55 AM, R1 was sitting in his wheelchair at the nurse's station. R1 had compression wraps to his lower extremities and they were loosely wrapped around his ankles. R1's lower extremities had chronic edema and vascular discoloration. On 12/16/2025 at 1 PM, V3 (Licensed Practical Nurse/LPN) changed R1's left medial leg venous wound dressing. V3 said R1 had chronic venous statis ulcers to his left lower extremity due to his lymphedema. After V3 completed R1's treatment, she only applied a compression wrap to his right lower extremity. V3 applied a regular white sock to R1's left foot. On 12/17/2025 at 9 AM and 11:30 AM, R1 was wheeling himself on the unit. R1 did not have any compression wraps to either leg. On 12/17/2025 at 12 PM, V2 (DON) said she expected nurses to follow physician treatment orders to ensure residents received proper skin management care. V2 said R1's compression wraps should be applied as ordered to ensure his chronic edema was controlled to prevent further skin breakdown. R1's Order Review Report had an order dated 11/25/2025 for (compression wrap) to bilateral extremities every morning and remove before bedtime for swelling. R1's Wound Evaluation and Management Summary, dated 12/10/2025, said R1's wound management recommendations included for him to continue with compression wraps to bilateral extremities daily. R1's skin impairment care plan said he was at risk for further skin alteration related to his venous insufficiency with venous ulcers to his bilateral lower extremities. The care plan's interventions included to provide treatment orders as ordered by the physician. The facility's policy titled Medication and Treatment Orders, dated 2001, said treatment orders will be interpretated and implemented consistent with the principles of safe and administration of treatments as ordered. 3. R34's face sheet documents she was admitted to the facility on [DATE]. Diagnoses include atrial fibrillation, congestive heart failure, hypertensive heart disease, hypothyroidism, hypertension, hypothyroidism, hyperlipidemia, gastro-esophageal reflux disease, neuralgia and neuritis, gastritis and osteoarthritis. MDS (Minimum Data Sheet), dated 11/6/25, documents she has intact cognitive functions. MDS showed R34 is dependent on staff for toileting hygiene and personal hygiene. MDS showed R34 is always incontinent for urine and bowel. On 12/16/25 at 9:46 AM, incontinence care was provided to R34 by V5 (CNA-Certified Nurse Assistant) and V6 (CNA). R34 was observed wearing two incontinent briefs. Both incontinence briefs were heavily soaked and had a strong scent of urine. Upon removal of the incontinent briefs, R34's left groin was red, and two fluid filled blisters were present. V5 said she will report the new skin issue to the nurse. V5 stepped out of the room and returned with V7 (RN- Registered Nurse). V7 assessed the skin and verified the blisters were a new skin issue and she will inform R34's physician. V7 stepped out of the room and V5 and V6 continued providing incontinence care. V5 said incontinence care on R34 was provided by the previous shift and she was not sure what time it was provided. On 12/16/25 at 10:00 AM, R34 said staff always applied two incontinent briefs on her throughout day and night because she was a heavy wetter. On 12/17/25 at 10:00 AM, review of R34's POS (Physician Order Sheet) showed a 12/16/25 order for Nystatin-Triamcinolone External Cream, to apply to groin and affected area topically twice a day for fungal rash for 10 days. On 12/17/25 at 10:00 AM, review of R34's Progress Notes showed V7 documented on 12/16/25 at 11:48 AM, V5 observed rash/redness in R34's groin area. On 12/17/25 at 2:00 PM, V2 (DON-Director of Nursing) said staff should only apply one incontinent brief. She said applying two incontinent briefs can lead to increased skin issues and increased infection risk. Facility's Policy and Procedure titled Perineal Care, dated 10/2016, documents the following: Purpose: The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. The Policy and Procedure on Perineal Care did not address the use of incontinent brief.

Based on observation, interview, and record review, the facility failed to reconcile controlled substances. This applies to 3 of 3 residents (R7, R47, and R59) reviewed for narcotics in a sample of 18.The findings include:1.On 12/16/2025 at 3:35 PM, the medication cart's narcotic drawer continued to be reviewed with V4. R7's had six ABH Gel droplet syringes available. R7's Individual Controlled Substance Record sheet showed seven droplet syringes should have been available. V4 said she administered a dose at 3 PM. V4 said she forgot to sign it off on the record sheet when she removed it for administration. R7's Individual Controlled Substance Record sheet showed the last administered dose was on 12/16/2025 at 12 AM. The sheet indicated there should still be seven syringes available. 2.On 12/16/2025 at 3:35 PM, a medication cart was reviewed with V4 (Registered Nurse/RN). R47's medication cards for Lacosamide 100 mg (milligrams) and Zolpidem Tartrate 5 mg were observed with the pink controlled substance proof-of-use forms wrapped with a rubber band inside the locked narcotic drawer, not in narcotic count binder. V4 said the controlled medications were not being counted during shift change medication reconciliation because he was discharged . R47's EMR (Electronic Medical Record) showed he discharged from the facility on 12/09/2025. 2. On 12/16/2025 at 3:35 PM, R59's medication card for Tramadol 50 mg was also observed with its pink controlled substance proof of use form wrapped with a rubber band inside the locked narcotic drawer in the same cart. V4 said R59's medication was not being accounted for during shift change because she was discharged . R59's EMR showed she was discharged from the facility on 12/13/2025. On 12/17/2025 at 2:25 PM, V2 said if a resident was discharged from the facility, the narcotic medication should be accounted for until removed for destruction. V2 said the nurses should count all controlled medications daily during shift hand off to prevent diversion. V2 said the medication should be logged when removed to ensure accuracy. The facility policy titled Routine Reconciliation of Controlled Substances, dated 08/01/2024, said the facility should routinely reconcile control substances stored in the medication carts and emergency supplies and should reconcile controlled substances waiting to be destroyed.

Based on observation, interview, and record review, the facility failed to ensure a resident was transferred safely with a mechanical lift.This applies to 1 resident (R1) reviewed for safety in a sample of 3. The past non-compliance occurred between 7/10/2025 and 7/18/2025.The findings include:R1's face-sheet showed R1 was a [AGE] years old female admitted with diagnoses to include congestive heart failure, dementia, anxiety, depression, hypertension, osteoporosis, intervertebral disc degeneration, urinary infection, sepsis and encephalopathy. R1's MDS (Minimum Data Set) on 7/11/25 showed severe cognitive impairment. R1's Progress notes, dated 7/11/25 at 8:15 AM, showed right sided bruising noted by CNA while giving bed bath. RN assessed R1 and found dark purple bruising on right side ribs, hip, knee and foot. The final Facility Reported Incident (FRI) received on 7/18/25 at 12:00 PM showed, On July 11, 2025, (R1) was observed by a Certified Nurse Assistant (CNA) with discoloration on the right ribs, right hip, right knee and right ankle area. The areas were evaluated and observed to be dark purple with a yellow hue, the skin was intact, warm, and dry to touch. Measurements of the discoloration include right ribs at 16 x 11.5cm, right hip at 12 x 8.5cm, right knee at 2 x 2cm, and right lateral ankle at 3.5 x 2cm. The FRI also showed, on 7/10/25 afternoon, V5 (CNA) reported that she transferred the resident by herself with the [mechanical lift brand name] in the afternoon. The FRI continued to show that upon interview, V5 stated she had forgotten to report a skin observation to the nurse, and denied there was any unusual occurrence during the transfer. The FRI report then showed V5 stated there was a possibility that the [mechanical lift brand name] lift arm that holds the sling, could have pressed up against the resident's rib area when she reached over to release the sling from the other side of the resident's body.On 7/29/25 at 9:30 AM, a skin check was done on R1. This writer observed mild greenish discoloration on the right hip area. On 7/29/25 at 11:00 AM, V3 (CNA) reported on 7/11/25 at around 9:30 AM, she noticed blackish purple bruises on R1 on her right flanks, right hip, right knee, and right ankle. V3 stated R1 had pain and tenderness at that time when V3 touched or turned her. On 7/29/25 at 11:50 AM, V3 (CNA), V4 (CNA), V7 (RN-Registered nurse) and V8 (RN) stated mechanical lift transfers must be done by two persons.On 7/29/25 at 12:35 PM, V6 (R1's Physician) stated, (R1) was on a blood thinning medicine, although the possibility of spontaneous bleed is mostly seen as an intra-cranial bleed or retro-peritoneal bleed. The CT (computed tomography) scan done for (R1) on 7/13/25 did not show any retroperitoneal or intracranial bleed, but it showed a sub-cutaneous bleed. (R1) probably has had an impact with a hard surface before 7/11/25, which led to the subcutaneous hematoma. Mechanical lift transfers must always be operated by two people for safe transfers.On 7/29/25 at 3:30 PM, V2 (DON-Director of Nursing) stated, (R1) probably hit a hard surface, though there are no witnesses to prove what happened. Otherwise (R1) would not have that pattern of bruises. It was something that could have been avoidable.On 7/29/25 at 1:10 PM V1 (Administrator) stated R1 definitely had some impact happened that should not have happened. V1 stated V5 (CNA) was terminated from the facility on 7/10/25. Facility's 'safe resident handling' competency showed mechanical lift should have two people during the transfer.Prior to the survey of 7/30/2025, the facility had taken the following actions to correct the noncompliance:*Beginning 7/11/2025, the facility educated licensed and unlicensed regular/agency nursing staff on safe resident handling/transfers, following resident care plans for transfers, observation/reporting skin issues such as bruising and redness, and the facility abuse policy*Beginning on 7/11/2025, the facility conducted safe resident handling competencies for the use of mechanical lift and gait belt transfers for licensed and unlicensed nursing staff, including the use of two persons for mechanical lifts, and conducted resident skin review competencies for licensed and unlicensed nursing staff*On 7/11/2025, and impromptu QAPI meeting was held*From 7/13/2025 to 7/18/2025, twelve mechanical lift transfers were audited. Audits continued throughout the survey

Based on observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and wear hair restraints in the facility kitchen. This applies to all resident that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated [DATE], documents the total census was 52 residents. On [DATE] at 11:10 AM, V25 (Associate Director of Dining Services) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On [DATE] starting and 10:10 AM, the facility kitchen was toured in the presence of V20 (Associate Director of Dining Services). For the entirety of the kitchen tour, V20 did not wear a hair restraint in the facility kitchen. During the kitchen tour, the following was found: In food prep area: 1. A tall uncovered rack of prepared plated salads located within 1 foot of the handwashing sink and 2 inches from the hand towel dispenser for drying hands after washing. 2. V21 (Ice Cream Parlor Clerk) prepping food without a hair restraint on. In the walk-in cooler: 3. An expired, opened 5 pound bag of feta cheese, with use by date of [DATE]. 4. ,d+[DATE] ounce undated bags of whipped topping. The bags say to use within 14 days of thawing, but there is no date anywhere on the bags. 5. ,d+[DATE] count packs of hot dogs, unlabeled and undated. 6. ,d+[DATE] ounce bags of expired guacamole with use by date of [DATE]. 7. 2- 5 pound containers of sliced mushrooms with a packed on date of [DATE] and no expiration date. 8. ,d+[DATE] count bags of yellow corn tortillas, undated. 9. ,d+[DATE].5 ounce bag of 6 inch flour tortillas with expiration date of [DATE]. In the dry storage: 10. ,d+[DATE] ounce opened package of hot cocoa mix not properly sealed with contents of package spilling out. 11. 2- 16 ounce packages of coconut flakes, opened and undated. 12. 1 large (estimated greater than 5 pounds) chocolate bar opened, and undated. 13. 1 expired opened bag of peanuts without ounce description, with use by date of [DATE]. 14. A medium silver bin of unlabeled and undated croutons. On [DATE] at 10:59 AM, two additional kitchen staff, V22 (Dining Room Supervisor) and V23 (Server) were observed working in the kitchen without wearing hair restraints. On [DATE] at 11:13 AM during a return to kitchen tour, V25 (Associate Director of Dining Services) was observed in the kitchen with hair restraint on, but only covering the top half and back of her head. V25's bangs on the front of her head were not restrained. V25 then traveled with surveyor to the 2nd floor food pantry where lunch service was observed. V25 assisted in food plating and delivery to residents, and her hair restraint remained in the same position, not properly containing all of her hair. On [DATE] at 12:46 PM, V25 (Associate Director of Dining Services) said all food items in the kitchen should be labeled and dated for food safety. V25 said food trays/carts in the food prep area should not be stored next to the handwashing sink because of the risk of cross contamination from splashing. V25 said all staff in the kitchen need to wear hair restraints so hair does not fall into the resident food and cause foodborne illness. V25 said all expired food items should be removed from food storage, so no outdated food items are accidentally served to the residents causing illness. V25 said all opened food items need to be tightly resealed to prevent contamination from insects and to maintain the freshness and quality of the food item. V25 said she would be more careful about making sure all of her hair is contained under her hair restraint. V25 said the facility did not have policies regarding: keeping food away from handwashing sink, removing expired foods, or resealing opened food items. The facility's policy titled, Hair Restraints, last revised ,d+[DATE], states, Policy Overview: All associates working in food preparation areas must wear hair restraints . Policy Detail: 1. All hair must be kept covered. The facility provided document titled, Refrigerator Storage Chart, last revised [DATE], shows mushrooms are okay to store unopened for ,d+[DATE] days. The facility policy titled, Food Storage, last revised ,d+[DATE], states, Policy Overview: All foods must be stored in a manner that maximizes nutrient retention, quality, and food safety The facility's policy titled, Labeling, last revised ,d+[DATE], states, Policy Overview: All food items must be labeled and dated before storing.

Based on observation, interview, and record review, facility failed to provide showers and nail care to residents who need assistance with ADLs (activities of daily living). This applies to 4 of 4 residents (R26, R151, R301 and R302) reviewed for ADLs in a sample of 23. Findings include: 1. R301's face-sheet showed R301 was admitted to the facility on [DATE], with diagnoses to include Covid-19, weakness, bilateral osteo-arthritis, mild cognitive impairment and cerebral infarction. R301's MDS (Minimum Data Set) showed R301 was cognitively intact. R301's Functional Abilities Assessment, dated 9/13/24, showed R301 needed substantial/maximum assist to shower/bathe and upper/lower body dressing up. R301's care plan, dated 9/11/24, did not address the need for ADLs care. On 9/17/24 at 12:36 PM, observed R301 sitting on her WC (wheelchair), in her room, unhappy. R301 stated she has not had a shower since she was admitted to the facility. R301 stated she had requested the staff multiple times for a shower and she did not get one. 2. R302's face-sheet showed R302 was admitted to the facility on [DATE], with diagnoses to include Covid-19, Diabetes Mellitus type 2, Depression, Morbid Obesity, and Pulmonary Embolism. R302's MDS (Minimum Data Set) showed R302 had moderate cognitive impairment. R302's Functional Abilities Assessment, dated 9/13/24, showed R302 needed partial/moderate assist to shower/bathe and supervision/touching assist for dressing up. R302's care plan, dated 9/12/24, revised on 9/18/24, addressed the problem of ADLs self-care performance deficit, interventions did not include showers. On 9/17/24 at 1:10 PM, observed R302 lying on her bed, with a grumpy face. R302 stated she has not had a shower since she was admitted to the facility. R302 stated she had requested the staff multiple times for a shower and she did not get one. On 9/18/24 at 1:08 PM, R302 stated she wanted to be showered, had made multiple requests, and did not receive a shower. R302 stated she had given up on that dream. On 9/18/24 at 12:21 PM, V12 (RN-Registered Nurse) stated, Every resident is usually given showers twice a week. (R301) is scheduled to get showers on Saturdays and Thursdays and (R302) is scheduled to get showers on Mondays and Fridays. V12 (RN) reviewed electronic documentation for showers and it showed, No records. V12 stated, (R301) and (R302) did not receive any showers since admission. On 9/18/24 at 1:30 PM, V19 (Licensed Practical Nurse/LPN) stated, (R301) and (R302) are scheduled to receive showers twice a week. V19 (LPN) reviewed electronic documentation for showers and it showed, No records. V19 stated, (R301) and (R302) did not receive any showers. On 9/19/24 at 11:05 AM, V2 (DON-Director of Nursing) stated, If (R301) and (R302) wanted showers, they should have been given one after all other residents are done for the shift, so that housekeeping can clean and sanitize the bathroom after they use it. They should have been given bath or shower twice in a week. Showers are documented electronically and not on paper. Facility policy on 'Supporting Activities of Daily Living, dated 02/2024, showed, Residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. 46380 3. On 9/17/2024 at 10:10 AM, R26 was observed to have long, dirty, and jagged nails. She said she asks staff to help her cut her nails, but nothing happens. R26's MDS (Minimum Data Sheet), dated 8/16/2024, documents BIMS (Brief Interview for Mental Status) of 15, which means her cognitive functions are intact. She requires set-up or clean up assistance with personal hygiene. 4. On 9/17/2024 at 10:15 AM, R151 was observed with long, dirty, and jagged fingernails. On 9/17/2024 at 2:06 PM, R151 said she does not like having her nails long and dirty, but nobody offered to cut her nails. R151's face sheet documents she was admitted to facility on 9/13/2024. R151's MDS has not been completed during the survey. R151's Functional Abilities and Goal Form, dated 9/16/2024, documents she is dependent on staff for personal hygiene. BIMS Form documents score is 11, which means she has moderately impaired cognitive functions. On 9/19/2024 at 10:54 AM, V2 (DON-Director of Nursing) said she expects staff to be checking nails when they are doing showers, hygiene care, and as needed. She said if nails are not kept clean and well-trimmed, it can be a source of infection, and resident can end up scratching themselves causing injury. Facility's Policy titled Supporting Activities of Daily Living, dated 4/2022 and revised on 2/2024, documents : 2. Appropriate care and services should be provided for residents who are unable to carry out ADLS (Activities of Daily Living) independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review, facility failed to follow infection control precautions. This applies to 6 residents (R2, R21, R33, R37, R46, and R301) reviewed for infection control in a sample of 23. Findings include: 1. On 9/17/24 at 10:45 AM, observed V9 (CNA-Certified Nursing Assistant) and V10 (CNA) give perineal care to R33, and transfer him to the recliner. V9 (CNA) and V10 (CNA) cleaned R33's perineal area with wet wipes. Both V9 and V10 did not remove soiled gloves or use hand sanitizer after wiping the perineal area. Using the same gloves, they turned R33 to left lateral position. V9 (CNA) cleaned R33's bottom. With the same gloves, V9 (CNA) took the tube of barrier cream from the night stand and applied some on his sacral area. V9 (CNA) changed gloves after applying the barrier cream, but did not wash hands or use hand sanitizer. V9 (CNA) and V10 (CNA) turned R33, applied the sling for the mechanical lift, (V10 using the same soiled gloves and no hand hygiene) and transferred R33 to the recliner. V9 (CNA) tied the garbage, removed her gloves. No hand sanitizer used or hand washing done. V9 (CNA) touched her face and rubbed her hands onto her uniform. V10 touched the curtains and parts of the bed with the same soiled gloves. Then V10 removed gloves, no hand hygiene was done, and wheeled R33 out of the room to the dining room for lunch. 2. On 09/17/24 at 12:34 PM, observed V18 (R301's Daughter) sitting in R301's room without any PPE (Personal Protective Equipment). Per V18, nobody told her =she had to wear the PPE. On 9/17/24 at 1:00 PM, V11 (CNA-Certified Nursing Assistant), came into R301's room with lunch tray, and no gloves on. Without gloves, V11 (CNA) set up her tray, moved R301's wheelchair to position her to eat lunch, touched the bedside table, and moved items to accommodate the tray on the table, touched R301's bed, and before she left room, she used hand sanitizer. On 9/17/24 at 1:10 PM, V11 (CNA-Certified Nursing Assistant), came into R302's room with lunch tray and no gloves on. Without gloves, V11 (CNA) set up her tray, touched the bed and bedside table, moved items on the bedside table to make space to keep the tray. On 09/18/24 at 1:30 PM, V19 (LPN-Licensed Practical Nurse) stated, Everyone entering the room of a resident with Covid + and on isolation must wear PPE. On 9/18/24 at 12:03 PM, V28 (RN-Registered Nurse) stated, Every person entering the room of a resident with Covid + and on isolation must wear PPE. V28 (RN) stated, During ADL care, when gloves are removed after use and before wearing new gloves on, hands must be washed or use hand sanitizer. On 9/19/24 at 11:10 AM, V2 (DON-Director of Nursing) stated, The CNAs should have either washed their hands or used hand sanitizer as they went from the soiled to clean area of the perineal care procedure. Every time they are done with cleaning a soiled part of the body, they should do hand hygiene and change gloves. Nursing staff have been educated on the isolation precautions for residents with Covid-19. Anyone entering the Covid-19 isolation room must wear PPE and do hand hygiene after care. The facility's polity titled Handwashing/Hand Hygiene IC-13, dated 10/2021, showed, Policy Detail: 7. CDC recommends using Alcohol Based Hand Sanitizer b) Before and after contact with residents h) Before moving from a contaminated body site to a clean body site during resident care 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 44387 3. R21's EMR (Electronic Medical Record) shows diagnoses urinary tract infection, retention of urine and obstructive and reflux uropathy. R21's Care plan (initiated 8/19/24) states resident has chronic use of indwelling catheter, is at risk of recurrent Extended-Spectrum Beta-Lactamases Urinary Tract Infection (ESBL UTI). On 9/17/24 at 10:08 AM, R21 was observed sitting up in bed eating his breakfast. R21's indwelling catheter drainage bag was on laying on the floor. The catheter drainage bag was in privacy bag. On 9/18/24 at 8:36 AM, during medication administration, R21 was in bed resting, R21's indwelling catheter was on laying on the floor. On 9/18/24 at 8:34 AM, V13 (Registered Nurse/RN) said R21's indwelling catheter drainage bag should not be on the floor for contamination reasons, and so the urine can flow better. On 8/18/24 at 10:50 AM, V2 (Director of Nursing/DON) said, Indwelling catheter bags should be always in privacy bags and the drainage bag should not be on the floor, and if the bed is too low, the drainage bag should be in a basin to avoid potential contamination and infection control reasons. The facility's Urinary Catheter Care policy (revised 08/2023) states drainage bags to be kept off of direct contact with the floor. 45906 4. R46's Face sheet shows an admission diagnosis of enterocolitis due to clostridium difficile (CDIFF), dated 9/12/24. R46's EMAR (Electronic Medical Administration Record) shows an order for Stool C-DIFF contact isolation precautions, dated 9/12/24 at 1400, and order dated 9/12/24 at 1600, for vancomycin HCl oral suspension 2.5 mL (milliliter) by mouth four times a day for CDIFF until 9/19/24 at 2359. R46's Care Plan, revised on 9/12/24, shows the resident has C.Difficile and is on oral antibiotics. Interventions include educate resident/family/staff regarding preventative measures to contain the infection and place in a private room with stool contact isolation precautions. On 9/17/24 at 11:35 AM, R46's door was observed with a contact isolation sign on it and a stocked cart with PPE (Personal Protective Equipment) outside the room. On 9/19/24 at 11:09 AM, R46 was observed lying in her bed with the door open, and the contact isolation sign was no longer on her door. V25 (CNA/Certified Nurse Assistant) walked into the resident's room to assist her to the bathroom without putting on a gown. V25 closed the door behind her. R46's nurse, V15 (RN/Registered Nurse), stated R46 was still receiving antibiotics to treat the CDIFF, and she was still on contact isolation precautions. V15 then opened R46's door and notified V25 that R46 was still on contact isolation, and V25 then came out of R46's room and put on a gown and reentered R46's room to continue assisting her with toileting. V12 (RN) then said V2 (DON/Director of Nursing) told her she took the contact isolation sign off the door, but R46 was still contact isolation, so V12 was going to put the sign back on R46's door. On 9/19/24 at 11:15 AM, V25 walked out of R46's room after finishing assisting her with toileting, and said she did not know R46 was isolation for CDIFF. V25 (CNA) said she took R46 to the bathroom this morning, changed her, and washed her, and she did not wear PPE, because she did not know the resident was isolation for CDIFF. V25 said she did not know until just now when V15 (RN) told her to put a gown on while providing care to R46. On 9/19/24 at 1:05 PM, V2 (DON) said R46 is still on isolation for CDIFF until her antibiotics (oral vancomycin) are completed and she is no longer symptomatic having loose stools. V2 said gown and gloves are required to be worn by all staff in a contact isolation CDIFF room at a minimum, because CDIFF is one of the most resistant bacteria and it is more easily spread by contact with the CDIFF spores. V2 said the isolation sign showing the type of isolation (contact, droplet, etc.) should be posted on isolation room doors at all times, so staff and visitors know what PPE to wear inside the resident's room. The facility's policy titled, Clostridium Difficile, last revised 10/2018, states, Policy Statement: Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. Policy Interpretation and Implementation . 3. The primary reservoirs for C. difficile are infected people and surfaces. Spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods .9. Residents with diarrhea associated with C. difficile are placed in contact isolation. 5. R2's Face sheet shows the following diagnoses: pressure ulcer, urinary tract infection, dementia, and retention of urine. R2's POS (Physician Order Sheet) shows order, dated 9/12/24, for enhanced barrier precautions related to wounds and urinary catheter. R2's Care Plan, initiated on 7/18/24, shows the resident has urinary catheter related to neurogenic bladder and pressure ulcer. Interventions include using enhanced barrier precautions to prevent infection. Care Plan, initiated on 9/16/24, shows R2 recently had a urinary tract infection. On 9/19/24 at 10:43 AM, V12 (RN/Registered Nurse) was observed providing wound care without following enhanced barrier precautions. Enhanced barrier precautions sign was on R2's door and PPE (Personal Protective Equipment) was located hanging off the door. V12 was wearing gloves, but not wearing a gown. V25 (CNA) was assisting V12 with wound care and was not wearing a gown. V12 then saw surveyor put a gown on before entering R2's room and she said, Oh yeah, I have to put a gown on. R2's urinary catheter drainage bag was observed hanging over the right side of her bed, sitting on the floor. V12 finished wound care and left R2's room while V25 (CNA) continued to assist R2 with dressing, without following enhanced barrier precautions and putting a gown on. While V25 assisted R2 with dressing, R2's urinary catheter drainage bag remained on the floor. V25 walked to the right side of R2's bed where the drainage bag was on the floor and she used her foot/shoe to move the drainage bag over. On 9/19/24 at 1:05 PM, V2 (DON) said, Staff gowns and gloves are required while providing care for residents on enhanced barrier precautions, including wound care and any contact with urinary catheter, including helping a resident get dressed. Enhanced barrier precautions are put in place to prevent the spread of potential infection to staff and residents. A urinary catheter drainage bag should never be sitting on the floor because of the risk of cross contamination and urinary tract infection. The facility's policy titled, Enhanced Barrier Precautions Policy, last revised 10/2023, states, Policy Overview: Enhanced barrier precautions (EBPs) should be utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Detail: .2. EBPs employ targeted gown and glove use during high contact resident care activities .3. Examples of high- contact resident care activities requiring the use of gown and gloves for EBPs include: Dressing .Wound Care .10. Signs are posted on the door or wall outside the resident room indicating EBP precautions and PPE are required. The facility's policy titled, Procedure: Urinary Catheter Care last revised 1/2016 states, The purpose of this procedure is to prevent infection of the resident's urinary tract .Procedure: A. General .7.Verify the catheter tubing and drainage bag are kept off direct contact with the floor . 46380 48944 6. R37's MDS (Minimum Data Set), dated 8/29/2024, showed R37 was dependent on staff for his toileting needs. On 9/17/2024 at 10:31 AM, R37 was in bed. V9 (Certified Nurse Assistant/CNA) and V10 (CNA) said they were going to change R37's incontinence brief. V9 did not wash her hands, and applied a pair of gloves she obtained from her uniform pocket. R37's incontinence brief was soiled with urine and had dry stool. V9 proceeded to provide R37 with incontinence care, and then applied a clean incontinence brief. V9 did not wash her hands or remove her gloves during the process. Then V9 said she was going to inform V15 (Registered Nurse/RN) that R37's sacral dressing needed to be changed. V9 removed her soiled gloves and left the room without washing her hands. Then V9 returned to the room, and again failed to perform hand hygiene. V9 applied a set of gloves she obtained from her uniform pocket again. On 9/19/2024 at 11:00 AM, V2 (Director of Nursing/DON) said she expects staff to properly perform hand hygiene before starting incontinence care. V2 said staff should remove their gloves and repeat hand hygiene when going from dirty to clean or changing to another task. V2 also said staff should never place or obtain gloves from their uniform pockets because it is considered unclean. V2 said proper hand hygiene and gloving practices are required to maintain appropriate infection control practices.

Based on interview and record review, the facility failed to implement an antimicrobial stewardship program, providing antibiotic use protocols, and monitoring to prevent antibiotic resistance. This applies to 8 of 8 residents (R1, R7, R32, R42, R46, R303, R353, R354) reviewed for antibiotics in a sample of 23. The findings include: On 9/18/2024 at 10:08 AM, surveyor reviewed facility's Infection Control Program with V3 (ADON-Assistant Director of Nursing/IC- Infection Preventionist). V3 said Antibiotic Stewardship is not being done in the facility. She said infections were logged, but antibiotic use was not monitored. She said she knows the facility need to start doing Antibiotic Stewardship. 1. R1's POS (Physician Order Sheet), dated 9/13/2024, shows an order for Ciprofloxacin HCL (Hydrochloride) tablet 500 mg (milligram), give 1 tablet by mouth every 12 hours for UTI (Urinary Tract Infection) for 7 days. Stop date is 9/20/2024. 2. R7's POS, dated 3/21/2024, shows an order for Methenamine Hippurate oral tablet, 1 gm (gram). Give one tablet by mouth two times a day related to personal history of UTI. The order has no stop date. 3. R32's POS, dated 8/26/2024, shows an order for Metronidazole oral tablet 500 mg. Give one tablet by mouth every morning and at bedtime related to diverticulitis of intestine. Stop date is 10/05/2024. 4. R42's POS, dated 9/12/2024, shows an order for Acyclovir External Ointment 5% (Acyclovir Topical). Apply to left upper thigh vesicle topically every six hours for shingles left upper thigh. Apply until vesicles scab or crust over. R42 also has an order for Valacyclovir HCL oral tablet, 1 gm. Give one tablet by mouth three times a day for shingles for seven days. Stop date for Valacyclovir HCL is 9/20/2024. 5. R46's POS, dated 9/12/2024, shows an order for Vancomycin HCL Oral Suspension 50 mg/ml, give 2.5 ml (milliliter) by mouth four times a day related to Enterocolitis due to Clostridium Difficile. Stop date is 9/19/2024. 6. R303's POS, dated 9/17/2024, shows an order for Cephalexin Oral Capsule 500 mg. Give one capsule by mouth two times a day for UTI (urinary tract infection) until 09/20/2024. 7. R353's POS, dated 9/17/2024, shows an order for Cefadroxil Oral Capsule 500 mg. Give one capsule by mouth every 48 hours related to UTI until 09/26/2024. 8. R354's POS, dated 9/10/2024, shows an order for Entecavir Oral Tablet 0.5 mg. Give one tablet by mouth one time a day for prophylaxis related to viral hepatitis B with no stop date. There is also an order on 9/10/2024 for Moxifloxacin HCL Ophthalmic Solution 0.5 %. Instill 1 drop in both eyes three times a day for eyelid infection for 10 days, with stop date of 9/20/2024. There is also an order for Metronidazole External Cream 0.75 %. Apply to face topically two times a day for antifungal, with no stop date. On 9/19/2024 at 10:54 AM, V2 (DON-Director of Nursing) said the importance of Antibiotic Stewardship is to minimize the use of antibiotics, make sure there is no unnecessary use of antibiotic, and to prevent system resistance from antibiotics. She said V3 (ADON-Assistant Director of Nursing) was trained to do Antibiotic Stewardship, and she is not aware V3 was not doing it. Facility's Community Antimicrobial Stewardship Mission Statement, dated 7/10/2024, stated the following: Our community embraces the importance of an infection prevention and control program. This includes an antimicrobial stewardship program, providing antibiotic use protocols and monitoring to prevent antibiotic resistance. We are committed to the prudent use of antimicrobials on behalf of all residents and are privileged to serve through a sustainable antimicrobial stewardship program.

Based on observation, interview, and record review, the facility failed to provide privacy for residents with a contagious gastrointestinal infection and Foley catheter. This applies to 2 of 2 residents (R46 and R2) reviewed for privacy in the sample 23. Findings include: 1. On 9/18/2024 at 9:45 AM, R46 was in her room with her door partically open. The outside of R46's room door had a sign that said, The Progression of a C. Diff (Clostridium difficile) Infection. R46's room was located across the nurses' station, which was in a very high-traffic area. There were multiple visitors, staff members, and other residents outside R46's room. R46's comprehensive care, plan dated 9/19/2024, had multiple interventions including Promote dignity by ensuring privacy, initiated on 9/12/2024. R46's posted sign titled, The Progression of a C. Diff Infection said, C. diff is a bacterium (germ) that causes diarrhea and colitis (an inflammation of the colon). R46's Order Summary Report, dated 9/19/2024, had an order for Stool C-DIFF contact isolation precautions, initiated on 9/12/2024. 2. On 9/18/2024 at 2:32 PM, R2 was sitting in her geriatric wheelchair at the nurses' station where there were multiple visitors, staff members, and other residents in the area. R2's urinary catheter bag was hanging from underneath her geriatric wheelchair. R2's urinary catheter drainage bag contained urine which was visible because it was not inside a privacy bag. R2's care plan, dated 9/19/2024, for her urinary catheter had multiple interventions including Privacy bags at all times, initiated on 7/18/2024. On 9/19/2024 at 11:02 AM, V2 (Director of Nursing/DON) said R46's identified infection sign should have not been posted outside her door because it was visible to all. V2 continued to say residents with urinary catheters required their drainage bags to always be placed inside their privacy bags. The facility's policy titled Quality of Life-Dignity, dated 10/2022, said, Residents should be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Detail 1. Residents should be treated with dignity and respect .10. Associates should protect confidential clinical information. Examples include the following .b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member .Please note: In the interest of public health, posting the resident's isolation status or transmission-based precautions is permissible as long as the type of infection remains confidential .12. Demeaning practices and standards of care that compromise dignity are prohibited. Associates should promote dignity and assist residents; for example: a. Helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record review, the facility failed to properly transfer resident and failed to properly dispose of a sharp disposable razor. This applies to 2 out of 2 residents (R42, R356) reviewed for accidents in a sample of 23. Findings include: 1. R42's MDS (Minimum Data Sheet), dated 8/23/2024, documents her BIMS (Brief Interview for Mental Status) score is 14, which means her cognitive functions are intact. On 9/18/2024 at 9:45 AM, R42 said she transfers with the use of a mechanical lift, with help from two staff. She said on 8/30/2024, V16 (CNA-Certified Nurse Assistant) attempted to transfer her by physically lifting her from her bed to wheelchair. She said before V16 lifted her, she reminded V16 she uses a mechanical lift for transfers and there must be two staff doing it, but V16 said she could transfer R42 without using the mechanical lift. R42 said her sling was on her wheelchair She said V16 was unable to safely transfer her and flung her to the floor. She said she was sore after the fall, but had no injury. On 9/19/2024 at 10:54 AM, V2 (DON-Director of Nursing) said V16 was employed by the facility and has worked with R42 multiple times. She said she is sure V16 was aware R42 was transferred using a mechanical lift with two people assist. V2 said V16 said she could not find the sling during that time and decided to transfer R42 without using the mechanical lift. She said she expects her staff to follow transfer status of all residents as documented in the Kardex of each resident's Plan of Care. She said nurses also remind staff, especially agency staff, of resident's transfer status. She said if resident is not transferred following the plan of care, there is a potential for serious injury that can happen to both resident and staff. V2's investigation of incident, dated 9/3/2024, documents V16 attempted a self-transfer of resident without using the proper equipment. V16 was aware of R42's transfer mode of mechanical lift, but attempted to transfer R42 by lifting her physically from her bed. R42 is physically unable to support self or assist in physical transfer. Facility's Policy titled Supporting Activities of Daily Living, dated 4/2022 and revised on 2/2024, documents : 2. Appropriate care and services should be provided for residents who are unable to carry out ADLS (Activities of Daily Living) independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: .b. mobility (transfer and ambulation, including walking). 44387 2. On 9/17/24 at 10:57 AM, there was used dirty disposable razor (3 blades) on R356's bedside dresser. At 12:15 PM, R356 said he shaves himself. On 9/18/24 at 10:02 AM, razor still noted on the bedside dresser. There was a sharps container in resident's bathroom. R356's MDS (Minimum Data Set) of 9/17/24 shows R356's cognition is intact and needs partial to moderate assistance with personal hygiene. On 9/18/24 at 10:14 AM, V12 (Registered Nurse/RN) said R356 is not able to shave himself, the staff does his grooming. V12 said the disposable razor should not be in the resident's room when not in use; it should either be discarded after use or stored in a clear plastic bag because it is a potential hazard, and the resident could hurt himself. On 9/19/24 at 10:46 AM, V2 (Director of Nursing/DON) said staff should dispose of disposable razor after use; each room has a sharps container to dispose of disposal razors/single use razors to eliminate cross contamination and for safety concerns. V2 said the facility does not have a policy for disposing of disposable razors. The facility's Sharps Container Disposal policy (revised 11/2019) states contaminated sharps shall be discarded immediately or as soon as feasible into designated containers.

Based on observation, interview, and record review, the facility failed to obtain physician orders for over the counter medications and to have medications stored in resident rooms. This applies to 2 of 2 residents (R29 and R354) reviewed for medications in the sample of 23. The findings include: 1. On 9/17/24 at 11:08 AM, there were 3 tubes of Clobetasol Propionate Gel 0.05% on R29's bedside table. R29 said she has irritation due to diarrhea, and staff applies on her buttocks after every brief change. On 9/18/24 at 10:01 AM, the tubes of Clobetasol were still noted on R29's bedside table. On 9/18/24 at 10:12 AM, V12 (Registered Nurse/RN) said staff uses the Clobetasol on R29 after incontinent care, and she has an order for it to be kept at bedside. On 9/18/24 at 3:05 PM, V2 (Director of Nursing/DON) said R29's previous order did not state she could store the Clobetasol cream in her room. Review of R29's order shows, Clobetasol Propionate External Gel 0.05% apply to perineum and rectal area topically every morning at bedtime for irritation. Order for it to be left at bedside was received during the survey. 2. On 9/17/24 at 11:19 AM, there was a tube of generic Ultra Strength Topical Analgesic Cream on R354's bedside dresser. AT 9/17/24 at 11:27 AM, R354 said she uses the cream when her back hurts. On 9/18/24 at 9:53 AM, the tube of generic topical analgesic cream was still on R354's bedside dresser. On 9/18/24 at 10:10 AM, V12 (RN) said R354 does not have a physician order for the topical analgesic cream. On 9/19/24 at 10:52 AM, V2 (DON) said there has to be a physician order for medications to be stored in the resident's room; also, to ensure that the medication is safe to use. Review of R354's records, R354 does not have an order for the ultra-strength topical analgesic cream. The facility's Medication Storage policy (last reviewed 12/2020) states medications are to be stored in designated locations such as lockbox, locked cabinet, or secured areas.

Based on observation, interview, and record review, the facility failed to provide assistance with ADLs (Activities of Daily Living) for residents assessed as needing staff assistance for ADL (Activities of Daily Living) care and grooming. This applies to 4 of 5 residents (R1, R4, R17, and R187) reviewed for ADL care. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that include Parkinson's disease, history of falls, muscle weakness, and unspecified lack of coordination. R1's MDS (Minimum Data Set), dated 8/1/2023, showed R1 required one staff physical assistance for personal hygiene. R1's care plan showed resident has an ADL self-care deficit related to pain and shoulders and knees. R1 has contractures, staff shall provide skin care to keep clean and prevent skin breakdown. R1 has a terminal prognosis and has been admitted under hospice. Adjust provisions of ADLs to compensate for resident's changing abilities. On 10/03/23 12:30 PM, R1 was sitting up in her wheelchair in her room; she has long white hair on her chin and has several dark and light hairs on her upper lip (Mustache). R1 said she needs help with removing the facial hair. R1 also has long jagged and uneven nails. R1 said she has asked to have those cut, and no one has helped her. On 10/04/23 11:54 AM, R1 still has the long chin hairs and mustache. Nails have not been cut. 2. R187's EMR showed R187 was admitted to the facility 9/26/23, with diagnoses that include cellulitis of buttock, pressure ulcer of left buttock , anxiety disorder, major depression, muscle weakness, abnormal posture, displaced bi-malleolar fracture of the left lower leg, subsequent encounter for closed fracture with routine healing. R187's MDS was not completed due to recent admission. R187's care plan showed R187 has ADL self-care performance deficit, requires moderate assistance with her ADLs including bed mobility, transfers, bathing/showering, and toileting. On 10/02/23, at 10:40 AM, R187 had thick eye make-up on her eyes, [NAME] was flaking and was smeared on her cheeks. R187 wears a wig; it was uncombed and was not sitting on her head correctly. R187 said no one has washed her up or even helped her wash her face. R187 had long, jagged nails, with a yellow- brown substance underneath them. On 10/04/23 at 12:58 PM, R187 had long uneven nails with a yellow-brown substance under her nails. R187 said she she used wear her nails long when she worked. R178 stated she likes her nails long, and when asked about cleaning them, she said someone could help her with that. On 10/4/23 at 1:05 PM, V14 (RN/Registered Nurse) said, Yes we do need to clean under a resident's fingernails, comb their hair, and brush their teeth everyday, not just shower days. On 10/4/23 at 1:10 PM, V2 (DON/Director of Nursing) stated she expects all ADLs to be done as needed on shower day and also on non-shower days. V2 said shaving is also an expectation when providing grooming/ADL care. Residents can have long nails if that is their preference, but V2 said if there is a brown substance under them, staff should be cleaning under the resident's nails. 35267 3. R17's Face sheet, dated 10/4/23, shows R17's diagnoses include pneumonia, COVID19, Diabetes 2, dementia, Alzheimer's disease, congestive heart failure, respiratory failure with hypoxia, and bronchospasm. MDS (Minimum Data Set), dated 7/4/23, shows R17 was cognitively intact and R17 required the extensive assistance from staff for bed mobility, dressing and was totally dependent on staff for transfers and toileting use, and and was always incontinent of bladder and frequently incontinent of bowel. Care plan, initiated 6/29/23, shows R17 had the potential for impairment of skin integrity related to incontinence of bowel and bladder and decreased mobility. The care plan shows facility staff were required to assist her with turning and repositioning as needed and provide incontinence care as needed. On 10/02/23 at 1:04 PM during resident council group interview, R17 stated staff normally take approximately thirty minutes to assist him with toileting. 4. R4's Face sheet, dated 10/4/23, shows R4's diagnoses include peripheral autonomic neuropathy, congestive heart failure, anxiety, dementia, depressive disorder, spinal stenosis, cellulitis, muscle weakness, and abnormalities of gait and mobility. R4's MDS, dated [DATE], shows R4 was cognitively intact and R4 required the extensive assistance of staff for bed mobility and was totally dependent on staff for dressing, toilet use, and R4 was always incontinent of bowel and bladder. Care plan, initiated 7/19/23, shows R4 was at risk for skin breakdown due to total incontinence of bowel and bladder and decreased mobility. The care plan shows R4 was to have staff assisting with incontinence care as needed On 10/02/23 at 1:04 PM during resident council group interview, R4 stated he waits over an hour approximately once a week during the night shift to receive assistance for toileting. Facility provided policy titled, Supporting Activities of Daily Living, dated 4/2022, showed, Residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene .2. Appropriate care and services should be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .c. Elimination (toileting).

Based on observation, interview, and record review, the facility failed to identify person-centered, non-pharmacological approaches for residents receiving psychotropic medications. The facility also failed to identify resident-specific behaviors to monitor the response/effectiveness of psychotropic medications. This applies to 4 of 5 residents (R1, R25, R29, and R187) reviewed for unnecessary medications in a sample of 15. The findings include: 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, atherosclerotic heart disease, and muscle weakness. R1 was admitted to hospice on 7/27/23 for end stage Parkinson's disease. R1's MDS (Minimum Data Set), dated 8/1/23, showed R1 was cognitively intact. R1's care plan, dated 8/30/23, showed R1 takes anti-anxiety medications- intervention initiated 4/26/2023 showed, 'administer medication as ordered, monitor and document side effects and effectiveness. (R1) has potential for impaired behavioral patterns. Behavioral services consult as needed and medications administered as ordered. Monitor/document for effectiveness and side effects. R1's POS (Physician Order Set) showed on 9/3/2023, R1's medications included Lorazepam 0.5 mg, give one tablet by mouth every 4 hours as need for anxiety. There was no end date for this medication order. Informed consent was signed for Lorazepam. There were no resident-specific behaviors to monitor for the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/2/2023 at 11:10 AM, R1 was down in activities. R1 said she enjoys coming down to participate in whatever activity is going on. On 10/3/2023, at 12:30 PM, R1 said she does not get anxious, but would say she is a little fearful when she is being transferred with the mechanical lift. 2. R25's EMR showed he was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, catatonic disorder due to known physiological condition, Covid-19, multiple sclerosis, major depression, encounter for palliative care, and unspecified psychosis not due to a substance or known physiological condition. R25's MDS, dated [DATE], showed R25 had severely impaired cognition. R25's care plan, 7/18/23, showed R25 had a communication problem (expressive aphasia) related to dementia with agitation. On 7/27/2023, care plan showed R25 uses an antidepressant medication related to depression. Interventions include: Give medication as ordered and monitor/document side effects and effectiveness, report to physician as needed any symptoms of depression unaltered by antidepressant medications, sad, irritable, anger, crying, shame, worthless, guilt, suicidal ideations, lethargy, changes in cognition, ect. (R25) is on a psychotropic medication, administer as ordered and monitor/ document effectiveness of medication. R25's POS showed R25's medications included, Citalopram 20 mg, give 1 tablet by mouth one time a day for Agitation. Risperidone 2 mg by mouth 2 times a day for agitation, and Depakote 125 mg, give 2 capsules by mouth three times a day for agitation (ordered12/26/22). Informed consents were signed for Citalopram and Risperidone, but there was no informed consent signed for Depakote. There were no resident-specific behaviors to monitor the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/02/23 at 10:10 AM, R25 was in bed with eyes closed, he appeared to be asleep and comfortable. R25 is in isolation for Covid-19 diagnosis. On 10/4/23, R25 was observed through out the day and no behaviors were noted. 3. R29's EMR showed R29 was admitted to the facility on [DATE], with diagnoses that included unspecified convulsions, dementia with behaviors, anxiety, and major depression. R29's MDS, dated [DATE], showed R29's cognition was severely impaired. R29's care plan showed R29 has impaired cognitive function/dementia; interventions include: providing medication as ordered, ask yes/no questions, explain care and procedures to resident prior to beginning, approach resident in calm, gentle manner. (R29) uses psychotropic medications interventions included administer medications as ordered, consult with pharmacy, physician to consider dose reduction when clinically appropriate, monitor/record/report to physician any side effects and adverse reactions of psychoactive medications. (R29) to MD (Medial Doctor) as needed any symptoms of depression unaltered by antidepressant medications, sad, irritable, anger, crying, shame, worthless, guilt, suicidal ideations, lethargy, changes in cognition, ect. Resident uses an anti-anxiety medication - give as ordered and monitor/document side effects and effectiveness. R29's POS showed R29's medications included Quetiapine 25 mg, one tablet by mouth in the evening for major depression, Sertraline 100 mg, one tablet by mouth in the morning for major depression, and Lorazepam oral concentrate 2 mg/ml, give 0.5 ml by mouth every 4 hours as needed for 14 days. Informed Consent for Antipsychotic, Antidepressant, and Anti-anxiety were signed, but there were no resident-specific behaviors to monitor for the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/02/23, R29 was sitting in his wheelchair in his room. He is in isolation for diagnosis of Covid-19. He is pleasant and has no concerns. 4. R187's EMR showed R187 was admitted to the facility 9/26/23, with diagnoses that included cellulitis of buttock, pressure ulcer of left buttock, anxiety disorder, major depression, muscle weakness, abnormal posture, and C-diff (Clostridium Difficile). R187's MDS was not completed due to her recent admission. R187's care plan showed she is on an anti-anxiety medication related to anxiety disorder, Interventions include: monitor/ document adverse reactions and effectiveness. (R187) uses antidepressant medication related to insomnia. Medication is to be given as ordered, monitor/document adverse reactions and effectiveness. R187's POS showed R187 has been prescribed Diazepam 10 mg, one tablet by mouth every 24 hours as needed for anxiety for 14 days. R187 is on Trazodone tablet 50 mg by mouth at bedtime for major depression. R187 Psychological progress note showed R187 was seen on 9/28/2023. Plan is to work on coping skills with the physical health changes and anxiety. Continue 1:1 psychotherapy 1 to 4 times a month to regulate mood, thoughts and behaviors. Informed Consent for an Anti-anxiety and sedative/hyptonic medication were signed, but there were no resident-specific behaviors to monitor for the response/effectiveness of psychotropic medications. There weren't any non-pharmological interventions documented. On 10/02/23 at 10:40 AM, R187 was hallucinating and saying there was high powered rifle up there (pointed to ceiling). V21 (Physician) came into the room, and R187 told him, Be careful where you walk, I'm not sure what traps they on the floor. I am trying to stay alive, and hoping everyone else in here stays alive too. V21 said he was going to check her urine to see if she has an UTI (Urinary Tract Infection). On 10/3/2023 at 8:45 AM, V5 (LPN/Licensed Practical Nurse) said R187 seems confused at times, and they are waiting to see what her Urinalysis and Culture show. She has not mentioned anything about rifles or has not seemed paranoid to her. On 10/04/23 at 8:31 AM, V2 (DON/Director of Nursing) said there has not been any behavior monitoring on R1, R25, R29, or R187. V2 said R25 did not have a consent for Depakote, somehow, they missed it. They called the family last night and now have a signed consent. V2 said the staff should be monitoring the resident for behaviors and document in the progress notes or on the MAR (Medication Administration Record). Facility provided their policy titled, Psychotropic Drug Management Policy, with the last revision date of 10/2022. The policy overview showed, Non-drug interventions should be implemented to the extent possible to assist the resident attain a satisfactory quality of life .An unnecessary drug is any drug when used .without adequate monitoring, without adequate indication for it's use .To avoid the use of unnecessary drugs .psychotropic medications will be used only after non-drug interventions alone have failed to manage behavioral symptoms .Policy Detail A. Health care Provider Responsibilities .The psychotropic medication order shall include the following information: b. manifestations of the disorder treated, d. monitoring parameters, as appropriate. 3. The health care provider shall write a progress note describing the behaviors and the reason for ordering the psychotropic drug and include a risk versus benefit statement .PRN(as needed) psychotropic .b. PRN orders for anti-anxiety, anti-depressant, and hypnotic drugs are limited to 14 days unless the Health Care Provider (HCP) believes it is appropriate for the PRN order to be extended beyond 14 days. The HCP shall document their rationale in the resident's medical record and indicate the duration of the PRN order .B. Nursing Responsibilities .2. The nurse shall implement non-drug interventions to help modify the resident's behavior 3. Nursing shall not administer the psychotropic medication until the informed consent has been obtained from the resident and/or legal representative .5. Document the following information about specific behaviors: a. number and frequency of behaviors, b. preceding or precipitating factors, c. interventions attempted (if psychotropic drug is used as an intervention, institute appropriate behavior monitoring and adverse consequences), d. side effect documentation of the side effects should occur each shift within the EMR (Electronic Medical Record) behavior monitoring, when applicable.

Based on interview and record review, the facility failed to plan and serve menus which provided variety and the minimum servings of grains as per facility policy. This applies to 4 of 4 residents (R4, R15, R18, and R25) reviewed for menu planning in a sample of 15. The findings include: 1. On 10/2/23 at 1:04 PM during resident council group interview, R4 stated the facility serves meatloaf too often on the menus, and sometimes he gets meatloaf twice in a row. R4 stated he often receives repetitive menu items served at meals. Review of facility regular diet menu food offerings to non-selecting residents, dated 9/1/23 to 10/7/23, show a total of 16 servings of planned meatloaf entrees, 14 versions of meatball entrees, and over 75 fish entrees planned and served on the menu during the timeframe. Ono 10/4/23 at 10:30 AM, V10 (Dietitian) stated there should not be as many servings of meatloaf, meatballs, or fish on the facility planned menus. 2. Menu Planning Criteria policy, revised 4/2013, shows the facility will provide regular diets no less than 6 servings of grains daily. Review of facility regular diet menu food offerings to non-selecting residents, dated 9/1/23 to 10/7/23, show on the following dates, residents who did not select their menus were served less than 6 grains each day: 9/1, 9/3, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/18, 9/20, 9/26, 9/28, 9/30, 10/3, 10/4, 10/5, and 10/7/23. The menus also showed a total of 16 servings of meatloaf, 14 servings of meatball entree versions, and over 75 servings of fish were served during the timeframe. The menus show breads and grains were planned to be served with all meals. On 10/03/23 at 2:00 PM, V11 (Skilled Dining Manager) stated R15, R18, and R25 received the standard general menus as planned because they did not individually select their menu items. V11 reviewed the non-selective general menu items, and stated the menus were often short on grain servings. V11 stated she was unsure why the facility was not serving the minimum servings of grains per the facility policy. At 12:32 PM, V11 stated the facility did not serve the daily bread servings at meals as indicated at the bottom of their menus, and those servings of breads were not served to residents not selecting menus their menus. On 10/02/23 at 2:49 PM, V11 the menus are planned by corporate, and then an onsite menu manager makes substitutions at the facility. V11 stated facility Dietitians also look over the menus and ensure all menu requirements are met. On 10/04/23 at 10:30 AM, V10 (Dietitian) stated she needed to review the menus because several of the days reviewed were short of grains per the facility policy. V10 stated the food service staff required further training to be able to make changes to the menus and still meet the minimum requirements of the menus.

Based on observation and interview, the facility failed to ensure R4's room entryway light was working properly and provided adequate lighting, and R9's special pressure reduction mattress was functioning correctly. This applies to 2 of 2 (R4, R9 ) reviewed for homelike environment in a sample of 15. Findings include: 1. R4's face sheet documents an [AGE] year old male admitted to the facility on [DATE], with diagnoses that include: Peripheral Neuropathy, spinal stenosis, muscle weakness, and unspecified abnormalities of gait and mobility. On 10/2/23 at 10:30 AM, R4's room entryway was noted to be dark and the room dimly lit. R4 stated the light in the entryway flickers and goes out, and there is only one light in the fixture behind him that works now. R4 stated he told V20 (Maintenance Supervisor) about it a couple weeks ago. The entry light was turned on and the light was noted to [NAME] and go on and off. On 10/3/23 at 9:54 AM, R4 stated the lights have not worked properly for 6 months. R4 stated he has told the staff several times. R4 stated he told V20 about his lights not working about 2 weeks ago. The entryway light was turned on and again it flickered and went off. On 10/3/23 at 10:51 AM, V17 (Director of Operations) stated if residents lights are not working, the staff that is going in and out of the room should be reporting to maintenance the issues with the lights. 2. R9's face sheet documents a [AGE] year old female admitted to the facility on [DATE], with diagnoses that include the following: Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with acute exacerbation, Atherosclerosis of aorta, Heart Failure, Legal blindness, and Muscle Weakness. R9's physician orders document the following: 8/3/2022 Pressure Redistribution/Reduction Mattress- Low Air Loss. 8/3/2022 Hospice On 10/2/23 at 10:07 AM, R9 was observed on 10/2/2023 at 10:07AM in bed lying on her back. The bed was noted to be concave and not properly inflated. The bed was noted to blinking 10lb and the orange service light was noted to be blinking, indicating the bed needs service. On 10/2/23 at 4:22 PM, R9 is lying on her back in her bed that still looks concave and improperly inflated. The bed is still beeping, blinking in white characters 10lb, and blinking orange light that indicates service. V19 (LPN) stated it does not look like R9's bed is correctly inflated. V19 stated, It is blinking 'service' so it probably needs someone to look at it. Work Order for R9, dated 10/2/2023 at 4:44 PM, documents the following: R9's air mattress is deflating unevenly. The air mattress pressure monitor is blinking signaling an issue and that it may be broken.

Based on observation, interview, and record review, the facility failed to follow proper technique when administering a nasal spray to a resident. This applies to 1 of 5 residents (R4) reviewed for medication administration. The finding included: R4's Face sheet showed R4 was admitted to the facility on [DATE], with diagnoses that included congestive heart failure, anxiety, dementia, major depression, muscle weakness, and idiopathic peripheral neuropathy. R4's MAR showed he gets Flonase Allergy Relief Nasal Suspension, one spray into each nostril two times a day for congestion. On 10/3/23 at 9:15 AM, V4 (RN/Registered Nurse) was administering R4's morning medications. R4 was placed in an upright position looking forward. R4 held the nasal spray tip at the entrance of the right nostril and did not insert the tip into the nasal cavity of the nose. V4 administered one spray into the right nasal. V4 placed the nasal spray tip at the entrance of the left nostril and administered one spray. V4 said she did not think she actually had to enter the tip of the nasal spray into the nasal cavity. On 10/03/23 at 4:03 PM, V2 (DON/Director of Nursing) said, When administering a nasal spray, the nurse needs to first explain to the resident what she is going to do. The nurse will need to hand the resident a tissue and have them blow their nose, dispose of that tissue and hand the resident a new tissue before administering the nasal spray. The nurse will take the nasal spray and insert into one nostril and up into the nasal cavity then administer one spray. The nurse then needs to repeat the same steps into the other nostril. If there is a second spray needed, the nurse needs to wait a few minutes and repeat again. Facility their Nasal Drops and Spray Medication Competency showed the steps to administer a nasal medication .5. Ask the resident to blow his nose, 6. Position resident correctly, 7. Administer the medication, 8. Keep the resident's head tilted back appropriately .

Based on observation, interview, and record review, the facility failed to follow safe transfer practices when utilizing a mechanical lift. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in a sample of 3. This failure resulted in R1 incurring 2 lacerations to her head requiring staples to both lacerations. Findings include: The Admission Record documents R1 with diagnoses to include Parkinson's Disease, History of Falling and Muscle Weakness. R1's Minimum Data Set, dated dated [DATE], documents R1 as cognitively intact and requiring the extensive assistance of 2 staff for transfers. R1's Care Plan for Activities of Daily Living assistance, dated 7/27/2023, documents R1 to be transferred by 2 staff using a mechanical lift. A Progress Note, dated 8/30/2023 at 7:47 AM, documents R1 being transferred to the emergency room after the mechanical lift tipped over onto R1 during a transfer, causing right arm pain and lacerations to her scalp. At 10:38 AM, these notes document R1 returning from the emergency room with staples to her scalp lacerations. A signed statement completed by V3 (Agency Nursing Assistant) on 8/30/2023, documents V3 was transferring R1 from the bed to the wheelchair without assistance. During the transfer, R1 was yelling and grabbing the arm of the lift during the transfer, and as she was lowering R1 into the wheelchair, she was not aligned properly over her wheelchair, and the lift tipped over onto R1. On 9/13/2023 at 10:00 AM, R1 had 2 healing lacerations to her scalp, one above her left ear, and the second near the top of her head. R1 stated she was being transferred with a mechanical lift by one nursing assistant, and the machine fell over and striking her on the head causing the lacerations. On 9/13/2023 at 9:30 AM, V2 (Director of Nursing) stated V11 (Nurse) notified her of the incident, and arrived to R1's room to assist. V2 stated when she entered the room, the lift was tilted over on its side and R1 was partially in the wheelchair sideways, with her legs across the armrest of the wheelchair. V2 stated R1 had 2 lacerations to her head where the arm of the lift hit her, requiring R1 to be sent to the emergency room ; she returned with staples to both of the lacerations. V2 stated facility policy is always to utilize 2 staff for all mechanical lift transfers and V3 was doing R1's transfer without another staff to assisting. V2 stated she concluded the base of the lift machine was not open wide enough, (R1) is tall and heavy, can be resistive at times, and grabs at the bars on the lift. V2 stated V3 lost control of the lift as she swung R1 to the side and it started to tip; if V3 had a second staff person assisting, that second person could have placed their foot on the base to balance the weight to prevent it from tipping, or prevented the loss of control or the tip, by guiding the machine. On 9/13/2023 at 11:15 AM, V4 (Medical Director) stated he was aware R1 was injured during a mechanical lift transfer. V4 stated, They are to operate the equipment safely to prevent falls. The whole reason for the (mechanical lift) is to safely transfer residents. I am not even sure how that could have happened.

Based on observation, interview, and record review, the facility failed to ensure two staff assisted a resident during a mechanical lift transfer, and failed to utilize the proper sized equipment. This failure resulted in R1 sustaining a leg laceration requiring 11 sutures. This applies to 1 of 5 residents (R1) reviewed for accidents and supervision in a sample of 5. The findings include: Face sheet, printed 6/12/23, shows R1's diagnoses include dementia without behavioral disturbance, anxiety, depression, syncope and collapse, urinary tract infection, and chronic kidney disease. MDS (Minimum Data Set), dated 5/23/23, shows R1 was severely cognitively impaired, was totally dependent on two staff for transfers, and required the extensive assistance from staff for bed mobility, toileting, dressing, and personal hygiene. On 6/12/23 at 1:00 PM with V5 (CNA - Certified Nursing Assistant) and V6 (CNA), R1 was transferred from her bed to her wheelchair, utilizing a mechanical lift and a large full body sling. R1 had a brown, dry wound that was long and linear on the back of her right calf. Initial and Final Report from the facility to IDPH (Illinois Department of Public Health), dated 5/23/23, shows R1 was unable to independently self-transfer or ambulate. The report shows R1 was transferred using a mechanical lift when she sustained a skin tear to the right calf area. The investigation report shows V4 (CNA) stated he identified blood on R1's leg after transferring R1 to her wheelchair, but was unsure what caused the injury. V4 stated V5 was assisting him at the time of the transfer, and he utilized the mechanical lift sling that was left on her chair in her room to transfer R1. The investigation shows V5 denied assisting V4 with R1's transfer at the time of the injury. The report shows R1 was transported to the hospital, where she received 11 sutures to help repair the skin tear. The report shows the facility determined during the transfer, the CNA utilized the wrong size sling, and there was only one staff present during the transfer, which was the root cause of the injury. On 6/13/23 at 5:04 PM, V7 (Physician) stated he had no reason to speculate otherwise that R1's laceration occurred during her mechanical lift transfer. V7 stated he had no reason to doubt the conclusion of the facility's injury evaluation that the wrong size sling and lack of two people assisting the mechanical lift transfer caused her laceration injury. V7 stated he examined R1 approximately two weeks prior, and had no concerns regarding lacerations. On 6/12/23 at 9:45 AM, V3 (LPN - Licensed Practical Nurse) stated on the 5/23/23, R1 was brought to the dining room in her wheelchair at approximately 8:00 AM by V4 (CNA). V3 stated she noticed a mix of fresh and older blood on R1's pants and wheelchair leg board. V3 stated she pulled up R1's pant leg, and identified a large amount of fresh blood coming from a deep, open wound on R1's lower leg. V3 stated the wound looked deep enough to require sutures, notified R1's physician, and R1 was sent to the hospital for evaluation. V3 stated R1 was very confused, but was grimacing in pain, so V3 provided R1 with Tylenol for pain management. V3 stated she cleaned the wound, covered it, and called for transport to the hospital. V3 stated she measured the wound prior to hospital transfer to be 9 cm (centimeters) in length, however, the hospital measurements showed 12 cm when she returned to the facility. V3 stated she asked V4 how the wound occurred and V4 stated he did not know. Bruise and Skin Tear Investigation, undated, shows R1's injury was reported on 5/23/23 at 8:45 AM, when V3 (LPN- Licensed Practical Nurse) observed blood on R1's clothing and a 9.5 cm (centimeter) skin tear was observed on her right calf. The report shows an inappropriate transfer occurred, and R1 was transferred using an extra large sling instead of a large sling. Nursing note, dated 5/23/23, shows R1 was administered Tylenol for pain, the laceration was covered and protected, and R1 received an order to be transferred to the emergency department for sutures. Emergency Department records, dated 5/23/23, show R1 had a laceration to her right back leg measuring 12 centimeters below the left posterior calf. On 6/12/23 12:20 AM, V4 (CNA) stated the mechanical lift sling cut into R1 when he transferred her the day she was injured. V4 stated the full sling, not the two legged sling, was used, the R1's legs rested on the rough part of the mechanical lift sling, and the sling it dug into her skin. V4 stated he did not notice the injury at the time of the transfer, but noticed something red when he took R1 to breakfast afterward. V4 notified the nurse who assessed the wound and also examined the sling. V4 stated the sling was very long, thick and rough and V4 stated that day the sling dug into her leg. V4 stated an agency CNA assisted him with the transfer at the time of the injury, but could not recall the CNA's name. On 6/12/23 at 9:38 AM, V5 (CNA) stated V4 asked her to agree to tell V1 (Administrator) she was in the room assisting with the transfer of R1, however, V5 declined to do so. V5 stated she was not present when V4 transferred R1 and R1 sustained her injury. V5 stated V3 (LPN - Licensed Practical Nurse) showed V5 R1's skin tear and V5 described it as deep. V2 (DON-Director of Nursing) stated it was her expectation all mechanical lift transfers were to be performed with two staff assisting. V2 stated she determined V4 transferred R1 by himself the morning of the injury. On 6/13/23 at 10:55 AM, V2 stated each CNA must use their judgement as to which sling should be used for each resident based on resident size. On 6/12/23 at 9:20 AM, V1 (Administrator) stated his investigation of R1's injury showed R1 received her skin tear which required sutures during her transfer using a mechanical lift performed by V4. V1 stated initially, V4 stated he was assisted with the mechanical lift transfer by V5, however, when V1 interviewed V5, V5 denied assisting with the transfer. V1 stated his investigation concluded V4 improperly transferred R1 without assistance from a second staff, and V4 also utilized the incorrect size sling - both of which resulted in R1's injury. On 6/12/23 at 10:33 AM, V2 (DON) stated V4 used a long and extra large sling to transfer R1 when she was injured and the sling was too long for the resident. V2 stated the CNA determines what size sling to use for a mechanical lift transfer resident based on resident size unless therapy makes a recommendation. V2 stated if staff use a sling that is too long, the sling rests lower on the resident's leg. V2 stated R1's injury was the back of the calf where an extra long sling would have rested and made contact with the leg. V2 stated V4 told V2 he noticed blood on R1's leg after he transferred her to the chair from her bed. V2 stated it was her expectation that all mechanical lift transfers are performed with two staff assisting and V2 stated she determined V4 transferred R1 by himself the morning of the injury. Mechanical Lift User Instruction Manual, dated 2015, shows, Always check the sling is suitable for he particular patient and is of the correct size and capacity. Facility Mechanical/Assistive Lifts Policy, revised 9/2017, shows, 2. Use of all mechanical/assistive lift equipment should be according to manufacturer's recommendations 4. Associates should be educated on proper use of the equipment. 5 A manufacturer approved sling should be used during mechanical assistive transfers 9. Education should be provided on the proper use of the assistive mechanical lifting equipment prior to its use

Based on observation, interview, and record review, the facility failed to prevent the verbal/mental abuse of a facility resident. This failure resulted in psychosocial harm to R1 as exhibited by crying, shaking, fear, feeling intimidated, vulnerable and threatened, and experiencing ongoing emotional anguish after the abusive event. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 4. The findings include: Face sheet, dated 4/12/23, shows R1's diagnoses includes closed fracture with routine healing, chronic migraine, anxiety disorder, muscle weakness, difficulty walking, mood disorder, major depressive disorder, and osteoarthritis. MDS (Minimum Data Set), dated 3/27/23, shows R1's cognition was intact. On 4/11/23 at 11:57 AM, R1 stated on 4/2/23, V2 (CNA - Certified Nursing Assistant) rudely flung her room door open, which slammed against her dresser drawers, and walked into her room. R1 stated V2 kept loudly saying, It's gonna be a good day! Yes it is! And I am going to do what I have to do. It's gonna be a good day! R1 stated she reminded V2 that R1 was to receive a shower that day, and V2 replied loudly, You're not getting a shower! You are not scheduled today! R1 stated she had not had a shower in five days. R1 stated she reminded V2 when V2 initially approached R1 to take a shower, R1 had a migraine headache and asked to postpone her shower until she felt better later. V2 yelled at R1 stating, I'm not going to give you a shower! V2 told R1 because she declined earlier due to her migraine, R1 refused and V2 was not giving R1 a shower. R1 stated V2 put her pointer finger within two feet of R1's face, shook it, and yelled, You aren't getting an extra shower! I have things to do and you aren't getting a shower! V2 yelled, I'm going to have a good day today and I'm not doing an extra shower! R1 stated, It was abusive! I was shaking! R1 stated she felt like she was being threatened, and was not going to continue to ask V2 for a shower because she was unsure what would happen next. R1 stated, She could have hit me. R1 stated she then asked V2 to provide her with clothes from her closet. V2 opened R1's closet swiftly and stated, Well everything is here is dull! R1 replied her sons were doing the best they could, and V2 responded, Well they aren't taking you home so I guess I understand! R1 began to cry during the interview, and stated V2 tried to make R1 feel like her sons did not care about her. R1 stated she cried when V2 told her that her family would not take her home. R1 stated V2 kept telling R1 she had seniority at the facility, and R1 felt like V2 was trying to intimidate her not to get out of line. R1 stated she was very upset, shocked, and felt disgusting, angry, emotional, sad, and vulnerable. R1 stated she shook the rest of the day, and began to cry again during the interview. R1 stated, I was afraid of her! It was trauma I will be honest. There are times I still cry because of what she said to me about my family not wanting me. It comes back to me. R1 stated she was unsure of what to do next and did not know who she could trust. R1 stated she believed V4 (Nurse) heard the yelling from the hallway and entered R1's room. R1 stated she told V4 everything that happened, and she told V4 she did not want V2 taking care of her again. R1 stated she was very angry, shocked, and crying at the time, and V4 held her hand. R1 stated V5 (Social Services Director) came and talked to her the next day, and R1 told her V2 had been abusive toward her. R1 stated, Someone in that line of work should not be working in any facility taking care of patients like that. On 4/11/23 at 10:25 AM, V4 (Nurse) stated on 4/2/23, she was working with V2 earlier in the morning, and V2 was talking back to V4 during the shift. V4 stated later she was in another resident's room when she heard V2 yelling in R1's room being disrespectful, rude, and loud, directed toward R1. V4 stated she heard V2 and R1 were arguing about showers. V4 stated she went to R1's room and asked V2 to leave the room. V4 stated R1 was shaking. V4 stated, It was abusive. V4 stated she had never seen anyone talk like that toward a resident. V4 stated R1 was crying when V4 was in the room. V4 stated she reassigned V6 (Certified Nursing Assistant/CNA) to R1's care, and told V2 she would no longer care for R1, and to not go into R1's room. V4 reassigned V2 to another resident. V4 stated V2 denied raising her voice and/or being rude to R1, and told V4 she was only acting that way toward V4. V4 responded she had just gone to R1's room because V2 was yelling at R1. V4 stated she texted V3 (Director of Nursing) immediately to tell her what had happened. V4 stated when she returned to R1, R1 told V4, I am afraid if she comes back. V4 stated R1 told her V2 pointed her finger in R1s face and stated, You don't have anywhere to go! Your family would not take you! V4 stated she left the room and reassigned V6 (CNA) to R1 and R1 was crying when V4 returned to R1 saying, I have a place to go . Nobody likes me here! V4 stated R1 was scared and upset. On 4/11/23 at 11:27 AM, V6 (CNA) stated on 4/2/23, V4 asked V6 to switch resident assignments and work with R1. V6 asked what happened, and V4 stated V2 yelled at R1. V6 stated V4 asked V6 to go check on R1 and talk to her so R1 could calm down. V6 stated when she introduced herself to R1, R1 began crying. R1 told V6, 'I am worthless! They treat me like trash!' V6 tried to calm R1 down, and told R1 she would give her a shower after she removed residents from the dining room from breakfast. V6 stated when she took R1 to the shower room, R1 began crying again and stated, (V2) abused me verbally! R1 told V6 that V2 told R1 that her family would not take R1 back, and they were going to dump R1 at the facility. R1 told V5 that R2 stated R1's clothes were like rags. V6 stated when she saw R1 later to give her lunch, R1 began crying again, and asked if V2 was still at the facility. V6 stated R1 told V6 that she was going to make sure she reported V2 to the Administrator, and V6 gave R1 the Administrator's name. Nursing progress note, date 4/3/23, shows R1 asked to speak to V5 (Director of Social Services.) On 4/11/23 at 12:54 PM, V5 (Director of Social Services) stated R1 asked V5 to see her on 4/3/23. V5 stated R1 wanted to document the episode, which occurred between R1 and V2 on 4/2/23. V5 stated R1 reported V2 stormed in her room, they argued about R1's shower, and V2 pointed her finger in R1's face and told her she did not deserve an extra shower. V5 stated R1 reported V2 told R1 her clothes were dull, it was no wonder her family did not visit R1, and R1 was not going home. V5 stated R1 reported she was sad and R1 was teary-eyed and shaking during the interview. Written statement, collected by V5 and signed by R1 on 4/3/23, shows, Patient had detailed notes [V2] came 'busting' into the room and the door hit the dresser. [V2] asked how [R1] was doing and the patient said she was excited to be getting her shower. [V2] replied, 'Well you're not getting one girl!' and was pointing in her face with her finger. Patient stated it is her shower day and her schedule is on her board. [V2] said you ain't getting one you refused. Patient stated 'I never refused I asked to wait a bit as I had a migraine.' [V2] said 'I marked you refused. If someone else wants to give you a shower then they can, but I'm not.' Patient asked for assistance in dressing and [V2] went to her closet and said, 'These clothes are all dull. No wonder your family doesn't visit and you're not going home. On 4/12/23 at 11:45 PM, V7 (Physician) stated his expectation at the facility was for the residents to be free of abuse. V7 stated R1 was reasonably upset, because her son told her she was not safe to return to home from the facility where she previously lived independently. V7 stated R1 was not happy abut the change, and this is a sore spot with her that she can not go home. V7 stated R1 had episodes of crying when she was first admitted to the facility because of pain and physical limitations, but R1's mood had improved since because she was making progress, and crying was not normal for her in recent weeks. On 4/11/23 at 1:43 PM, V3 (Director of Nursing/DON) stated on 4/2/23 at 10:40 AM, she received a call from V4, telling V3 that V2 walked off of her shift, after confrontations with V3 and R1. V3 stated during that call, V4 reported V2 and R1 had a loud verbal exchange. V4 went to R1's room to remove V2, and V2 was reassigned to another resident. V3 stated she was unsure if it was reported to her R1 experienced V2 pointing her finger in R1's face, R1 was told her family would not visit and would not take her home, or R1 was crying/shaking. On 4/11/23 at 2:43 PM, V1 (Administrator) stated he concluded the abuse of R1 was unsubstantiated in the facility investigation because V4 did not hear exactly what V2 yelled at R1, and V2's fingerpointing was not witnessed. R3's Minimum Data Set (MDS), dated [DATE], shows R3's cognition was intact. On 4/11/23 at 11:10 AM, R3 stated V2 Can be rough as hell. R3 stated he heard V2 be curt with residents on a regular basis. R4's MDS, dated [DATE], shows R4's cognition was intact. On 4/11/23 at 11:52 AM, R4 stated V2 could be a little bit rude/mean. Final Facility Investigation Report, dated 4/7/23, shows on 4/3/23 (R1) reported she was denied her scheduled shower, and had negative verbal statements and physical gestures (non-contact) directed toward her from the CNA assigned to provide her care. The investigation shows V5 (Social Services Director) interviewed R1 who stated V2 (CNA) busted into her room and asked how R1 was feeling. R1 responded she was excited to be receiving a shower and V2 responded, Well you're not getting one girl. R1 stated V2 was pointing her finger in R1's face. The report shows R1 told V2 it was her shower day, but V2 replied R1 had refused due to a migraine. R1 then stated she asked for assistance dressing, and V2 told R1 that her clothes were dull and it was no wonder why R1's family did not visit R1. R1 stated V2 stated R1 was not going to go home. Review of the final investigation documents showed V1 interviewed V2 and V2 denied the allegations. The documents show V3 (Director of Nursing) interviewed V4 (Nurse), who stated she overheard a loud verbal exchange between V2 and R1. V4 stated she was unable to determine if V2 pointed her finger at R1. V4 stated when she questioned V2 about the loud verbal exchanged, V2 refused to answer, and exited the facility. V4 stated she notified V3 of the incident. The final report shows the allegation of abuse was not substantiated. Facility time sheet, dated 4/2/23, shows V2 began work at 6:10 AM, and V1 punched her out of the facility at 11:00 AM. Facility Abuse, Neglect and Exploitation Policy, revised 10/2022, shows, Residents have the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation The policy shows the abuse definition includes, Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The policy shows mental abuse definition includes humiliation, harassment, and withholding of treatment or services. The definition of verbal abuse includes Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents

Based on observation, interview and record review failed to follow a physician's orders regarding skin care prevention order to prevent development of stage III pressure sore, failed to monitor and report skin changes and failed to update a care plan for redness on sacral area. These failures resulted in R16 developing a stage III pressure sore. This applies to 1 of 4 residents (R16) reviewed for pressure ulcers in the sample of 15. The findings include: R16 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. MDS (Minimum Data Set) assessment dated [DATE] showed that R16 is cognitively intact and needs extensive assistance with one person physical assist in bed mobility, personal hygiene, transfer, dressing and toilet use. On 8/28/18 at 11:15 AM, R16 was up in wheelchair and V12 (CNA-Certified Nursing Assistant) wheeled R16 to the bathroom. V12 put gloves on and assisted R16 to sit on the toilet. V12 removed R16's incontinent pad and it was saturated with urine. V12 assisted R16 to standing position and was asked to check R16's bottom. Resident was noted with an open sore on the sacral/coccyx area with no wound dressing. V12 said that around 9:30 AM V12 assisted R16 to the bathroom and V12 had noticed that R16's wound on the sacral area had no dressing. V12 was asked if V12 informed the nurse that the dressing came off. V12 said no, and V12 thinks that the nurse knows R16 has an open wound. On 8/28/2018 at 11:45 AM V13 (Nurse) and V6 (ADON-Assistant Director of Nursing) said they were not informed about R16's sacral/coccyx wound and were not aware a wound was present. On 8/28/18 at 1:05 PM, wound care was observed with V7 (NP-Nurse Practitioner) and V14 (Nurse) while R16 was standing in the bathroom. V7 measured the open wound on R16's coccyx/sacral pressure sore. The open wound measured 5.6 cm length x 1.4 width x 0.2 depth with small serosanguinous drainage, and V7 said the wound was a Stage III pressure ulcer, with 75 % slough and peri area red and wide spread rash. V7 said that V7 saw R16's buttocks during (MONTH) (YEAR) sometime, with V15 (nurse) and R16 had redness on R16's bottom and V7 ordered Duoderm ([MEDICATION NAME]) dressing for skin prevention. On 08/28/18 at 1:15 PM V14 was asked who provides wound treatment for [REDACTED]. V14 said that shower schedules showed that R16 had a shower yesterday (Monday 08/27/18) day shift and Thursday evening shift for skin check. On 8/28/18 at 1:45 PM V13 (nurse) said that V13 did not see the wound because it is scheduled for afternoon shift to do the treatment and charting. V13 said all V13 did was take the order on 7/25/18, and on 8/13/18 V13 changed the order to afternoon shift because it is afternoon charting and treatment. Physician order dated 8/13/18 showed that R16 had an order for [REDACTED]. On 8/28/18 at 1:50 PM, V6 confirmed that on 7/25/18 the treatment order Duoderm to sacrum was ordered for skin care prevention for R16's redness on the sacral area. On 8/30/18 at 9:30 AM, V7 stated that V7 saw R16 with V15 (Nurse) present, and that there was nothing on R16's bottom, it was just redness. Duoderm was ordered for skin protection. V7 said that on 8/28/18 was V7's first time to see the pressure sore on R16's sacral/coccyx area. V7 stated the wound could have been caught earlier than the Stage III. The aide should have reported any skin changes and been treated earlier or changed the treatment order. The wound could have been avoided if closer observation and reporting to the nurse was done. On 8/30/18 at 10:15 AM, V17 (Physician) stated that V17 was notified on 8/28/18 that R16 has a Stage III pressure ulcer with slough 75% on R16 sacral/coccyx area. V17 said V17 does not know when the wound happened. V17 said that R16 is not moving, has [DIAGNOSES REDACTED]. Daily skin checks, monitoring and reporting is important to prevent the development of a pressure sore and to prevent a pressure ulcer from becoming a Stage III wound. V17 was asked if R16's wound could have been prevented from becoming a Stage III pressure ulcer if the wound was monitored more closely, and daily skin checks were done since this resident is high risk and had redness on R16's bottom, and V17 agreed. The facility did not have any skin assessment information or any charting/documentation on R16's sacral redness or condition of the wound documented on the chart prior to 08/28/18. POS (Physician Order Sheet) dated 8/13/18 has an order to cover the area with Duoderm, change every 3 days and PRN (as needed). On 8/29/18, at 2:55 PM, V2 (DON-Director of Nursing) stated that skin checks are done weekly and if the CNA notices anything, the CNAs have to report skin changes to the nurse. Skin checks are done on shower days. The CNA and nurse check the skin together and the nurse documents on the skin integrity form. MDS (Minimum Data Set) dated 8/18/18 showed that R16 is cognitively intact, requires extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene and bathing. R16 is also coded as frequently incontinent with bowel and occasionally incontinent of urine. R16's current care plan did not show plan of care for redness on R16's sacral area. The facility's procedure with revision date of (MONTH) 2010 on wound care showed under documentation: The following information should be recorded in the resident's electronic medical record: - The type of wound care given, - The date and time the wound care was given, - The name and title of the associate performing the wound care, - Any change in resident's condition, - All data ( i.e. wound bed color, size, drainage etc.) collected when inspecting the wound. - The signature and title of the associate recording the data.

Based on record review, observation and interviews the facility failed to supervise residents at increased risk for falls, failed to avoid resident falls and failed to revise interventions to prevent further falls when necessary. As the result of these failure: R1 was transferred to the hospital after an unwitnessed fall, R1 returned from the hospital three hours later with a [DIAGNOSES REDACTED]. and R3 fell and was diagnosed with [REDACTED]. This applies to 3 of 3 residents (R1, R2 and R3) reviewed for falls in the sample of 12. the findings include: 1) R3 was admitted to the facility on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. R3's Nursing Fall Risk Admission Data Collection, dated (MONTH) 20, (YEAR) documented the resident didn't have a history of falls, scored R3 as at risk for falls and recommended initiation of fall risk interventions. R3's BIMS of (MONTH) 16, (YEAR) scored the resident at 3 indicating severe cognitive impairment. Bed mobility and toilet use scored the resident as in need of extensive assistance of two or more persons. R3 was also assessed as non ambulatory. Facility incident report of (MONTH) 6, (YEAR), documents that R3 was found at 3:00PM in R3's room on the floor with pain to the left hip. According to the facility incident report, R3 was admitted to the local hospital for surgical repair of the left hip after falling in R3 room. The radiology report dated (MONTH) 6, (YEAR) denotes an acute left [MEDICAL CONDITION]. On (MONTH) 20, (YEAR) a care plan for R3 was initiated that addressed the resident's impaired cognitive function/dementia or impaired thought processes due to dementia. The fall care plan for R3 wasn't initiated until (MONTH) 7, (YEAR) after the resident fell and fractured R3's femur. Fall prevention interventions listed included encouraging the resident to wear non skid footwear when ambulating or mobilizing in wheelchair, encourage resident to use call light. R3 is confused and unable to follow staff instructions on use of call lights, is unable to understand being encouraged to participate in activities. On (MONTH) 30, (YEAR) between 2:05 PM and 3:45 PM V3 stated before R3 broke R3's hip R3 didn't walk well, wasn't oriented and couldn't remember instructions. V3 said R3 required hands on help and lots of coaching to walk due to believing R3 is independent. On the day R3 fell physical therapy had brought R3 back to the room and didn't inform staff. On (MONTH) 3, (YEAR) at 3:50 PM V10 (nurse) described R3 as very confused and with difficulty processing information. R3's fall where R3 fractured R3's hip happened in R3's room at 2:30 PM. R3 was found laying face down and complained of leg pain, was sent to the hospital and determined to have a [MEDICAL CONDITION]. 2) R1's facility record showed R1 was admitted to the facility (MONTH) 19, (YEAR) with [DIAGNOSES REDACTED]. R1's 14 day Minimum Data Set (MDS) dated (MONTH) 1, (YEAR) , under the Brief Interview for Mental Status (BIMS) scored the resident as having some difficulty with cognition. The MDS also assessed the resident as in need of extensive assistance of two persons to transfer and as unable to balance (R1) when walking and transferring without staff help. R1's Admission Data for Fall Risk dated (MONTH) 19, (YEAR) scored the resident as a fall risk and instructed fall risk interventions to be initiated and documented on the interim care plan. R1 had a fall (MONTH) 24, (YEAR). Review of R1's Physical Therapy Evaluation of (MONTH) 20, (YEAR) assessed the resident as having deficits in gait, transfers and bed mobility skills, impairments in strength and also showed R1 had impaired cognition, visual and perceptual deficits and decreased proprioception that impacted his safety and independence .the patient is at risk for falls. R1's care plan, initiated (MONTH) 19, (YEAR) assessed the resident as a fall risk. The facility failed to implement interventions to prevent falls until R1's fall on (MONTH) 24, (YEAR) and didn't update and or revise the resident's care plan until after the fall on (MONTH) 11, (YEAR). The facility also failed to consider the resident's previously identified confusion when interventions such as encouraging R1 to use the call light for assistance and encouraging the resident to participate in activities and providing cues and supervision as indicated were put into place. The (MONTH) 24, (YEAR) Incident Report for R1 at 1:30 PM documented R1 fell in R1's room and was witnessed by R1's roommate but was not witnessed by staff. According to the Incident Report the resident was observed on the floor and said (R1) had been trying to go find help. No injury was noted. The only documentation of R1's fall on (MONTH) 24, (YEAR) was at 8:46 PM in the Progress Notes Note of (MONTH) 25, (YEAR) mentions a low bed and staff encouraging R1 to ask for help and to lock the wheel chair. The call light was placed within reach. On (MONTH) 7, (YEAR) R1 is documented as having told R1's family that R1 had fallen that morning and told staff R1 falls daily. Staff assessed the resident at that time, but found no injury. On (MONTH) 11, (YEAR) at 11:55 AM R1 had another unwitnessed fall in R1's room. The Incident Report for R1 stated (R1 had) fallen when R1 reached for the door handle and lost R1's balance and fell backwards. R1 was observed guarding R1's right arm, complaining of pain in the area and not being able to move R1's right arm. R1 also had a bruise on R1's left lower back . R1 was transferred to an area hospital. Progress Note of (MONTH) 11, (YEAR) at 12:52 PM documents R1's transfer to the hospital after an unwitnessed fall, but failed to give information on the resident's condition post fall that required R1's transfer to the hospital. R1 returned from the hospital three hours later with a [DIAGNOSES REDACTED]. On (MONTH) 3, (YEAR) at 11:40 AM V5(Certified Nurse Aide) was interviewed regarding R1. V5 stated R1 could walk with transfer help, R1's walking was unsteady. V5 stated on (MONTH) 11, (YEAR) V5 had just returned from lunch and and didn't find R1 on the floor and was unsure which staff did. V5 helped get R1 off the floor and the resident complained of shoulder pain, but didn't say how R1 fell . R1 couldn't remember to call staff even if call light was within reach. V5 was unable to remember which previous fall prevention measures were in place to prevent R1 falling. R1 knew how to unlock R1's own wheelchair and would try to get out of R1's wheelchair and bed. V5 stated V5 knew the fall prevention policy was to help prevent or decrease but wasn't able to remember anything else. 3) R2 was admitted to the facility on (MONTH) 15, (YEAR) with [DIAGNOSES REDACTED]. R2's Fall Risk Admission Data Collection coded the resident as high risk for falls as did the other seven Fall Risk Data Collection Forms completed post falls although the Fall Risk Form of (MONTH) 22, (YEAR) History of Falls is incorrect; by (MONTH) 22, (YEAR) R2 had many more than one to two falls. A PT evaluation on (MONTH) 19, (YEAR) indicated R2 had impairments in strength activity tolerance and balance that contributed to increased difficulty with bed mobility, transfers and gait and also assessed R2 as needing constant multiple cueing to complete tasks safely. PT staff assessed due to the documented physical impairments and associated functional deficits, the patient is at risk for: falls. R2's MDS of (MONTH) 17, (YEAR) and (MONTH) 17, (YEAR) assessed the resident as having BIMS scores of 14 and 13. Both MDSs assessed R2 as in need of extensive assistance of 2 persons in bed mobility and both assessed R2 as having unsteady balance without staff help. R2 has had eight falls (December 5, (YEAR), (MONTH) 19, (YEAR), (MONTH) 4, 25 and 27, (YEAR), (MONTH) 18, 22 and 24, (YEAR)) that occurred at various times of the day. Seven of the eight falls were unwitnessed, only the fall on (MONTH) 24, (YEAR) was witnessed when R2 fell in the hall. The incident report of the fall on (MONTH) 25, (YEAR) documented the fall resulted in R2 scraping R2's knee when R2 fell . R2's care plan addressing R2's risk for falls wasn't initiated until (MONTH) 5, (YEAR) and the last revision was (MONTH) 28, (YEAR). The facility failed to update and or revise the resident's care plan after each fall when it became evident the interventions in place at the time of the falls were ineffective and failed to consider the resident's previously identified confusion when interventions such as educating R2 about what to do in case of falls, encouraging the resident to participate in activities and providing cues and supervision as indicated was put into place. On (MONTH) 28, (YEAR) at 3:50 PM R2 was observed sitting in a wheelchair. While alert, R2 was very confused and would look at the surveyor, but wasn't able to answer questions. V9 (Visitor) was present and stated R2 falls because R2 can't remember to wait for help no matter how often R2's told to ask for help. R2 locks/unlocks R2's wheel chair R2's self. Staff instructs R2 multiple times to use the call light to ask for help. V9 stated V9 had put signs in R2's room reminding R2 to ask for help before walking. V3 (Certified Nursing Assistant/CNA) was identified as having cared for R2 on (MONTH) 5, (YEAR), (MONTH) 19, (YEAR) and (MONTH) 24, (YEAR) on the shifts the resident fell . On (MONTH) 30, (YEAR) between 2:05 PM and 3:45 PM V3 described R2 as forgetful and hard headed and needing extensive assistance to get out of the chair and R2 tries to walk without using R2's walker and will try to transfer on R2's own. V3 stated if a resident is assessed as a fall risk, he or she isn't to be left alone in their room and also said wheelchairs are to be locked when in use. V3 also denied having worked on the days R2 fell . On (MONTH) 28, (YEAR) at 1:00 PM R4 was observed sitting in a wheelchair at the elevator. The chair wasn't locked and R4 was able to propel R4's self. R4 was irritable and stated the staff makes (R4) stay on the floor and won't let (R4) leave. Further interview showed the resident was slightly confused. At 2:20 PM R3, R5, R7 and R9 were observed sitting in wheelchairs at the nursing station. R3, R5, R7 and R9's wheelchairs weren't locked. R3 was confused and not interviewable. On (MONTH) 28, (YEAR) at 9:00 AM V2 (Director of Nurses/DON) admitted having residents who had falls with fractures and later provided a list of residents with falls. R1 and R3's names were listed and identified as having fractures. At 1:55 PM V2 stated care plans are to be updated after each fall as are the fall risk assessments. At 4:45 PM V2 stated new interventions such as urine cultures and culture and sensitivity post fall were put into place to prevent R1 having further falls. The facility's policy on Fall Prevention states that a resident who scores 10 or higher as a fall risk is to have a care plan to reflect that higher risk for falls and approaches identified to limit those falls. Family and residents are to be educated on the fall prevention program and what they can do to prevent falls, residents are to be monitored frequently, residents instructed to use the call light and wait for assistance and the care plan is to be revised as needed.

Based on observation, record review and interview the facility failed to choose an appropriate medical positioning device (Orthotics) to relieve pressure to heal existing pressure injury and to prevent from developing new pressure injuries. The facility also failed to follow Orthoses manufacturer's recommendation for the use of the Orthotics. As a result R1 developed a new unstageable pressure injury on right lateral foot (5th metatarsal); and a deep tissue injury to right lateral heel. This applies to 1 of 3 residents (R1) in the sample of 10 residents evaluated for pressure injuries. The findings include: On October 24, 2017 at 9:50 AM R1 was lying in bed in supine position. R1 had a cushion boot to the left foot and a positioning device on the right foot. R1's right leg and foot was externally rotated and the Orthotics was pressing on right lateral foot. On all days of the survey, R1 was in bed in supine position with right leg and foot externally rotated and the Orthotics positioning device was pressing on the right lateral foot. There were no pillows under R1's legs to keep the legs elevated. On October 25, 2017 at 11:30 AM E15 (Nurse) said R1 has a pressure injury on the right malleolus process (lateral ankle), and when we attempt to keep R1's leg straight R1 complains of pain. The Orthotics are supposed to keep pressure off the heel and to prevent flexion contracture. R1's admission record showed R1 was admitted to the facility on [DATE]. R1's current physician orders [REDACTED]. R1's May 27, 2017 weekly skin review showed, R1 acquired pressure injury on the right heel and right outer ankle. R1's May 26, 2017 Braden Scale scored '16' meaning R1 is at high risk for acquiring pressure injury. The risk factors included in the Braden Scale were sensory perception, moisture, activity, mobility, nutrition, friction and shearing. The facility did not analyze these risk factors to determine if the risk factors could be modified. R1's August 15, 2017 significant change assessment Minimum Data Set trigger including pressure injury showing R1 has a stage 2 pressure injury. R1's August 29, 2017 Care Area Assessment (CAA) included pressure injury. The pressure injury CAA is not comprehensive to show why R1 acquired the pressure injury. On October 30, 2017 at 12:10 PM E13 (Treatment Nurse) over the phone stated the facility do not perform tissue tolerance test to determine turning and repositioning schedule. R1's May 30, 2017 pressure ulcer care plan interventions included on June 5, 2017 to use heel protector. There is no detail to include as how the heel protector to be applied and how long to keep it on and off. The care plan intervention for turning and repositioning is vague, it simply states turn and reposition as needed. On October 26, 2017 at 10:00 AM E13 performed pressure injury treatment. R1 was lying in the bed with right leg externally rotated and the Orthotics was pressing against the right lateral foot. R1's legs were not elevated. E13 said R1 has a pressure injury to the right malleolus area and E13 was going to change the dressing. R1's right malleolus area pressure injury measured 1.4 cm (centimeters) x 1.8 cm x 0.2 cm with undermining area of 0.2 cm at 4-5 O' clock. There was 5.2 cm redness around the pressure injury. When E13 removed R1's Orthotics (heel lifter), R1 had no socks on, there were two new areas of pressure injuries the facility was not aware. (1) right lateral foot (5th metatarsal) unstageable measuring 1.8 cm x 1.6 cm. The center of the sore was scabbed. (2) right lateral heel 0.4 cm x 2.8 cm deep tissue injury. E13 stated R1's leg is externally rotated even with Orthotics, it is pressing on the foot. When we keep the leg straight R1 complains of pain. I am not aware of the new sores, this is the first time I am seeing. I will contact the physician for the treatment and ask hospice to get an appropriate Orthotics, I don't know what other Orthotics are available. The Orthotics is supposed to protect heel and prevent foot drop. The Orthoses manufacturer's indication for the use of orthotic noted offloads vulnerable soft tissue, maintains foot and ankle position to offset joint contracture. Recommended wearing schedule with individuals having compromised sensation, at risk for skin breakdown or disruption of soft tissue surface -- check skin after one hour of wear -- if no concerns increase wearing time by two hour increments not to exceed six hours of wear without removal for 30 minutes to one hour, then reapply. In general -- care should be taken when the surface area of the superstructure of straps comes in contact with areas with compromised or open soft tissue. These areas should be bridged and or relieved in most all cases to eliminate further soft tissue compromise. and to seek further assistance from Orthotist to customize the system to meet the needs of the individual. There is no documentation to show if the facility contacted orthotist seeking their assistance. On October 27, 2017 at 9:00 AM Z3 (Physician, Medical Director and Oversees wounds) said R1 is an adult failing to thrive, has [MEDICAL CONDITION], with or without Orthotics the right foot boot the right leg externally rotating, with the cognition deficit we can't make R1 keep the right leg straight, the staff needs to keep close watch on this, R1's wounds are vascular and pressure related. R1's physician orders [REDACTED].

Based on observation, interview and record review, the facility failed to: Evaluate and identify the risk factors and clinical reasons for the development of R 2 ' s pressure ulcer on the left heel. Develop and implement a preventative plan of care for R 2 who was identified mild risk for developing pressure ulcer. Develop and implement a pressure ulcer plan of care for R 2 with specific and individualize interventions to help heal R 2 ' s current pressure ulcer and to prevent the progression of the existing area. These failures resulted in R 2 acquiring a facility Deep Tissue Injury on the left heel on 10-25-11 and this area progressed in size from 3.0 cm X 1.5 on 10-25-11 to 7.0 cm X 4.2 cm This is for one of two residents with pressure sores. Findings include: The facility monthly pressure ulcer tracking form showed R 2 acquired Deep Tissue Injury on the left heel on 10-25-11. This area was described as dark in color, intact measured at 3.0 cm X 1.5 cm. On 11-03-11 at 10:50 AM, skin assessment was conducted with the Treatment Nurse (E 3). E 3 identified a Deep Tissue Injury on R 2 ' s left heel, described as " buggy, dark in color-purplish " , and measured at 7.0 cm X 4.2 cm. There was no comprehensive assessment conducted for R 2, E 3 stated " we use the monthly pressure ulcer tracking form, the nurses notes and the treatment record sheet (TAR). " E 3 and E 2 confirmed there's no analysis whether this facility acquired pressure ulcer on R 2 was avoidable or unavoidable, risk factors were not identified and address, to prevent the development of pressure ulcer. Review of R2's plan of care presented by the Care Plan/ MDS Coordinator (E 6) and E 3 on 11-03-11 showed no specific pressure ulcer care plan was developed. The care plan reads: Frequently incontinent of bowel and bladder during the day and always incontinent at night. She has potential for skin breakdown & urinary tract infection related to cognitive impairments, loose bowel movement, generalize weakness & need for assistance with toileting secondary to dementia ...Noted to have deep tissue injury on her left heel + bluish black discoloration, non open. E 6 stated " we don ' t necessarily need to have (specific problem). " There was no preventative plan that was developed or implemented to R 2. Interview with the Nurse in Charge (E 7) on 11-03-11 at 11:30 AM, E 7 stated " I was the one that found the discoloration on her left heel on 10-25-11, I documented it in the nurses notes. I told the Treatment Nurse (E 3) and prescribed skin prep and the bumper pillow when in bed. I was off then when I came back on 10-27-11, base on my nurses here, the area has a blister on it, and we ordered air mattress and the boot, after that the Treatment Nurse took over with the pressure ulcer. " R 2 ' s Braden scale for predicting pressure ulcer risk from 10-14-11 through 11-04-11 showed a score of " 16 - mild risk for developing pressure ulcer. " On 11-04-11 at 11:45 AM, the facility Administrative staff, (Administrator/E 1, the Director of Nursing /E 2, and the Corporate Nurse Consultant) presented documentation that includes ultrasound report dated 10-24-11 reads: There was no evidence of [MEDICAL CONDITION] in bilateral lower extremities.