Every finding on record at The Pearl of Downers Grove

Based on observation, interview, and record review, the facility failed to provide supervision and implement identified fall prevention interventions for a newly admitted resident with a recent femur fracture and history of falls. This applies to 1 (R1) of 3 residents reviewed for accidents and supervision.The findings include:R1's face sheet showed that R1 was admitted to the facility on [DATE]. R1 had multiple diagnoses, including a fractured femur, difficulty walking, diabetes, anxiety, depression, hypertension, and a history of falls.R1's minimal data set (MDS) dated [DATE], showed that R1 had moderately impaired cognition and required maximal assistance from staff to complete activities of daily living.On July 07, 2026, at 2:45 PM, R1 was lying in bed with V6 (Family Member) present in her room. R1's floor mats were against the window in her room. R1 said she had recently fallen at the facility on the day she arrived. She said she turned and fell off the side of the bed. She said she yelled for help, but no one came to assist her. R1 said she eventually pulled her sheets from her bed onto the floor so she could reach her cell phone to call her daughter. R1 said she was on the floor for at least half an hour because an entire episode of Everybody Loves [NAME] came on and went off while she was there. R1 said the next thing she saw was the paramedics entering her room. A review of the TV Guide on tvguide.com showed that Everybody Loves [NAME] runs on channel 23.1 as a double episode daily from 8:00 PM to 8:30 PM and from 8:30 PM to 9:00 PM. On July 07, 2026, at 2:45 PM, V6 said she received a call from R1 on June 30, 2026, at 8:59 PM. V6 said R1 was crying and stated that she had been on the floor for an hour and that there were no staff were present to help. V6 said she immediately called 911 and headed to the facility to check on R1. V6 said the paramedics arrived around 9:14 PM, and she followed them in at 9:15 PM. V6 said that upon entry, she did not see any staff, and the paramedics assumed she was an employee and asked for paperwork. V6 said she eventually saw staff as the paramedics were lifting R1 onto the stretcher and taking her to the hospital. V6 said the CNA (Certified Nursing Assistant) and the nurse came around to V6's room at the same time, and both were unaware of the situation. On July 07, 2026, at 3:55 PM, V5 (CNA) said that on June 30, 2026, she was scheduled to work a double shift on the hallway where R1 was admitted . R1 said that another CNA was scheduled to work with her; however, that CNA called off. V5 said that V4 (Nursing Scheduler) informed her that V8 (CNA) could stay until 7:00 PM. V5 said that V4 told her that another CNA from a different unit would come over to help her when V8 left; however, the CNAs on the other units were unaware of this. V5 said that at the beginning of the shift, V8 had R1 on her assigned list, and when V8 left, V5 was responsible for the entire unit. V5 said that she looked around at 7:00 PM and did not see V8, so she assumed V8 had left at that time and that all her residents were fine and in bed. V5 said that she did rounds at 8:00 PM. V5 said that she knew R1 because R1 often came into the community to visit her grandson. V5 said that R1 was alert and oriented, so she knew that if she needed something, she would call. V5 said that R1's room door was closed, and her call light was off, so she assumed R1 was asleep and did not go to her room or enter to check on her. V5 said she was in a room with a resident when she heard footsteps in the hall. When she exited the room, she saw paramedics inside R1's room and asked them what was going on. The paramedics informed her that no one was at the nurses' station and that R1 had fallen. V5 said the paramedics asked her to give them space to work on R1, and as she walked to the nurses' station, V6 followed behind her, extremely upset.V6 was yelling expletives and saying that R1 had been on the floor for quite some time and that no one was around. V5 said that V6 was so angry that she flung a tray that was on the nurses' station onto the ground. R1 said she called V4 (Scheduler) yelling, to inform V4 of the situation. V5 said that there was no way for her to know that R1 needed help because R1's call light was not on. V5 said that if she had a resident who was a fall risk, she would check on them every 15 to 30 minutes, and residents who are not fall risks are checked every 30 minutes to an hour. V5 said that she was not informed that R1 was a fall risk. V5 said that she was aware that R1 was recovering from surgery due to a previous fall but did not believe R1 was a fall risk. V5 said she was unsure of how long R1 was on the floor and said that she had not seen R1 during the time in which she was responsible for R1's care. V5 said she did not see R1 before the paramedics transported her to the emergency room. On July 07, 2026, at 4:15 PM, V7 (LPN) stated she last saw R1 at 6:40 PM, when she administered R1's medications and informed V8 that R1 needed to be changed. V7 stated that between 9:00 PM and 10:00 PM, she was at the medicine cart at the front of the hallway when the paramedics arrived and informed her that R1 was on the floor and had been there for an hour. V7 stated she saw only the paramedics enter and did not see V6. V7 stated the paramedics took R1 to the hospital, and five minutes later she saw V6 coming down the hall. V7 stated she did not give the paramedics any paperwork on R1. V7 stated she did not hear R1 call out for help.On July 08, 2026, at 9:05 AM, V4 said she normally schedules only one CNA in the hall where R1 was. V4 said that on that day she scheduled two CNAs because there were two admissions. There was a call-off on June 30, 2026, and V4 said she asked V8 if she could stay, but V8 was only able to stay until 7:00 PM. When V8 left, she was to give a report to V5, and V5 was supposed to ask a CNA on another unit for assistance when needed. Once V8 left, V5 was responsible for all residents on the unit. V4 said that staff should round at least every two hours, that there are fall risks in the unit, and that staff should be vigilant and conduct frequent rounds. V4 said that staff should have ensured that the bed was in the lowest position, floor mats were in place, and call lights were working. On July 08, 2026, at 9:25 AM, V8 stated that she was responsible for R1's care between 2:00 PM and 7:00 PM. V8 stated that R1 was already in bed during her last rounds, so she changed R1's brief at 5:30 PM. V8 stated that R1 was alert and oriented, so if she needed anything after that, she would have used her call button. V8 stated that R1 did not have any side rails or grab bars on her bed but recalled R1 asking staff about side bars. V8 stated that R1's daughter had placed a chair on the side of R1's bed because she was concerned that R1 would fall. V8 stated she believed the nurse had informed maintenance of the request. V8 stated that she gave V5 and V7 reports before she left. V8 stated that she checked on R1 about four times during her shift. On July 08, 2026, at 10:40 PM, V9 (CNA) and V10 (CNA) said that R1 is a fall risk and should be checked every thirty minutes. V9 said that R1's fall interventions include floor mats and a low bed. On July 08, 2026, at 3:23 PM, V2 (Director of Nursing/DON) stated that staff should conduct purposeful rounding and that he does not believe there is a policy specifying how often staff should round on residents during a shift. V2 said that V5 was caring for another resident at the time of the incident, and that the paramedics entered the building, ignored V7, and went to the room to assess R1. V6 called V1 (Administrator) to express her frustration that R1 had fallen and had been on the ground for some time. V2 said that R1 was last seen by the CNA at 7:00 PM. V2 said that R1 was weight-bearing as tolerated and the floor mats would have caused an obstruction. V2 said that V2 now has grab bars and floor mats. V2 said that someone had to let the paramedics into the facility because the doors are locked at that hour. V2 said he asked staff who opened the door but still does not know who let the paramedics in. V2 confirmed that he created a fall care plan for R1 on July 07, 2026. R1's fall care plan dated June 30, 2026, included two interventions, pain management and keeping the call light within reach. An incident report dated June 30, 2026, created by V7, showed that at 9:10 PM, paramedics arrived at the facility while V7 was completing an assignment and stated that R1 was on the ground and needed assistance. The report showed that the immediate action taken was an assessment performed by V7, with a report given to paramedics. However, V2 stated that V7 was ignored by the paramedics, and V7 said that the paramedics left the facility without the paperwork for R1. The Downers Grove Fire Department Emergency Medical Services (EMS) report dated June 30, 2026, showed that the Downers Grove Fire Department ambulance and fire truck were dispatched to the nursing facility for a fall. Per notes, R1's daughter called R1 because she fell and couldn't reach the staff at the facility. The medics arrived to find R1 A&O(alert and oriented) x 4 on the ground by the bed. The report showed that R1's bed was about 2.5-3 feet off the ground, and her bed had no railings. R1 was screaming, saying that she had fallen an hour ago and had been screaming to try to reach the nursing staff to help her. R1 was recovering from surgery on her right femur. R1 was complaining of pain around her surgical site. R1 said she was repositioning for comfort when she shifted too far and fell to the ground. R1 was given fentanyl for pain, but pain was minimally relieved as R1 stated her pain was a 9.5/10 as she was placed on the stretcher for transport. R1 was transported to the hospital, and a verbal report was given to V15 (emergency room RN/Registered Nurse). Following the transfer of care for R1 to the ER staff, the paramedics discussed the events and condition that R1 was found in with the emergency room staff and confirmed that V15 would report the incident to the necessary authorities. On July 08, 2026, at 1:30 PM, V16 (Deputy Chief) stated that he spoke to the paramedics who were on the scene. V16 said that the medics reported that the skilled nursing facility staff were not present when they made patient contact but were outside the room (in the hallway) when they departed. On July 08, 2026, at 2:32 PM, V15 (RN) reported that R1 arrived at the emergency room by ambulance and they were told that there were no side rails on her bed. R1 was awake and alert upon arrival. R1 stated she was repositioning herself in bed and fell off the bed. R1 said V15 said she had been yelling for at least an hour, and no one came in, so she called V6 (Family Member). R1 was concerned about re-injuring her leg because she fell on the side of her body where she had surgery. A timeline review submitted by V2 does not align with responses provided by V5 and V7. The timeline shows that R1 was checked at 7:00 PM, and during that time R1's brief was changed. V5 said she did not check on R1 between 7:00 PM and 9:00 PM and had not seen R1 until the paramedics arrived. V8 said that R1 was checked and changed at 5:30 PM. A late progress note submitted by V7 on July 1, 2026, at 10:52 PM, with an effective date of June 30, 2026, at 6:40 PM, showed that a CNA checked and changed R1's brief at 6:40 PM. A fall assessment dated [DATE], at 4:14 PM showed that R1 was assessed as a new admit with a history of 1-2 falls. There were no concerns with memory and recall, and no concerns with vision. R1 was occasionally incontinent. R1 was confined to a chair, oriented, and unable to stand. The date of admission was triggered as over 3 months, when it should have been triggered as less than 3 months for a new admit. This would have marked R1 as a moderate risk resident instead of the low risk that is displayed. A fall assessment dated [DATE], at 7:17 PM, showed that R1 was readmitted less than 3 months ago and had a history of 12 falls within the last six months. There were no concerns with memory and recall or with vision. R1 was occasionally incontinent. R1 was confined to a chair, oriented, and unable to stand. R1 is a moderate fall risk.A side rail assessment dated [DATE], at 4:19PM, showed that R1 was a newly admitted resident in pain and unable to bear weight. R1 required side rails for a sense of security and to prevent rolling out of bed. R1 needed side rails to turn from side to side, to support self during transfers, and to aid in entering and exiting the bed. The assessment showed that R1 needed 1/2 side rails on the right and left upper sides of the bed. Consent was given by V6, who is her POA.On June 8, 2026, at 4:00 PM, V1 (Administrator) stated that the facility's beds lack side rails and that an assessment would be required before side rails or grab bars could be placed on a resident's bed. V1 said that R1's side rail assessment was completed after maintenance had left for the day.

Based on observation, interview, and record review, the facility failed to render appropriate catheter care for residents at risk for urinary infections. This applies to 4 of 4 (R1-R4) residents reviewed for urinary catheters. The findings include:1. R3's care plan states R1 required the use of an indwelling urinary catheter due to his diagnosis of urinary obstructive uropathy and that he was incontinent of bowel. The care plan also said he was at risk for urinary tract infections (UTIs) due to the use of the catheter and incontinence. The staff was to provide thorough perineal hygiene care to prevent infections. On 5/16/2026 at 1:20 PM, R3 was in bed, his urinary catheter was draining cloudy, dark-amber urine. V9 (Certified Nurse Assistant/CNA) said R3 was incontinent of bowel, and she had last rendered incontinence care at approximately 10 AM. Then V9 and V10 (Restorative Aide) assessed R3's incontinence brief and urinary catheter. R3's brief was dry, but the urinary catheter's tubing had thick-brown adherent residue stuck on it up to the insertion site. V9 proceeded to clean the catheter by cleaning the tube multiple times in both upward and downwards strokes using the same cleaning wipe. They then proceeded to change R3's incontinence brief without thoroughly removing the brown adherent substance still present on the tubing. R3's MDS (Minimum Data Set) dated 5/05/2026, said he was always incontinent of bowel and required substantial-maximal staff assistance with his toileting hygiene. R3's Order Summary Report dated 5/16/2026 said he was currently receiving Bactrim DS (oral antibiotic) for treatment of a UTI. 2. R2's care plan states he required the use of an indwelling urinary catheter due to his diagnosis of urinary obstructive uropathy and that he was incontinent of bowel. The care plan also said he was at risk for urinary tract infections due to the use of the catheter and incontinence. The staff was to provide thorough perineal hygiene care to prevent infections. On 5/16/2026 at 1:35 PM, V10 (Restorative Aide) and V3 (Infection Preventionist/IP Nurse) assisted R2 to bed. R2's urinary catheter was draining cloudy, pale-yellow urine. V10 said he had toileted R2 approximately 2 hours prior and had assisted him with his bowel care needs. They assessed R2's incontinence brief and urinary catheter. R2's brief was dry, but the urinary catheter's tubing had thick red-brown adherent residue on it, and the residue was present throughout his scrotum, penile area, and insertion site. V10 proceeded to clean R2's perineal area and the catheter, and then applied a new brief. R2's catheter still had the residue present. V3 observed and proceeded to educate V10 on proper catheter cleaning to ensure the prevention of infections. R2's MDS dated [DATE], said he was frequently incontinent of bowel and required substantial-maximal staff assistance with his toileting hygiene. 3. R4's care plan states he required the use of a suprapubic urinary catheter due to his diagnosis of neurogenic bladder. The care plan also said he was at risk for urinary tract infections due to the use of the catheter and was dependent on staff to provide proper catheter care to prevent infections. On 5/16/2026 at 2 PM, R4 was in bed, his suprapubic urinary catheter was draining light-amber urine with sediments. R4 said he had a history of recurrent UTIs (urinary tract infections) and was dependent on staff for the daily care of his catheter. R4 continued to say that, unfortunately, his daily catheter care was not consistently being provided. V7 (CNA) said she last changed R4's incontinence brief at approximately 9:30 AM. V7 assessed R4's incontinence brief and urinary catheter. R4's suprapubic catheter's tubing near the insertion site had brown adherent residue present. Then V3 (IP Nurse) came to assist V7 with R4's catheter care. V7 then proceeded to clean the catheter by cleaning the tube multiple times in both upward and downwards strokes using the same cleaning wipe. V3 observed and proceeded to educate V7 on proper catheter cleaning to ensure the prevention of infections. R4's MDS dated [DATE], said he was dependent on staff assistance with his toileting hygiene. 4. R1's care plan states he required the use of an indwelling urinary catheter due to his diagnosis of urinary obstructive uropathy and that he was incontinent of bowel. The care plan also said he was at risk for urinary tract infections due to the use of the catheter and incontinence. The staff was to provide thorough perineal hygiene care to prevent infections. On 5/16/2026 at 3 PM, R1 was sitting on the edge of the bed, he had a urinary catheter in place. V6 (Agency CNA) said that at approximately 11 AM, she had toileted and assisted R1 with his bowel care needs. V6 proceeded to remove R1's brief, which was soiled with a moderate amount of dried feces. R1's scrotal area, right upper inner thigh, catheter anchoring device, and tubing were also soiled with dried feces. V6 proceeded to render R1 with perineal care and said she was unsure if the soiled catheter anchoring device had to be changed. R1's urinary catheter's connection-port site was being held by the soiled anchoring device. R1's MDS dated [DATE], said he was frequently incontinent of bowel and required substantial-maximal staff assistance with his toileting hygiene. On 5/16/2026 at 3:40 PM, V3 (IP Nurse) said residents with urinary catheters were at risk for CAUTIs (catheter-associated urinary tract infections) and required proper perineal/catheter care for prevention. V3 said the nursing staff was expected to assess and render proper cleaning when assisting residents with their toileting care needs. V3 said infections were preventable by changing cleaning wipes when cleaning in a downward stroke only, which would prevent bacteria from entering the urethra and urinary bladder. The facility's policy titled Perineal Care/Indwelling Catheter, dated 03/02/2026, said residents' perineal care was provided to clean the perineum, prevent infection and odors, and provide comfort. Staff were to provide perineal care daily and as needed for all residents requiring assistance and those with Foley catheters. For male residents, the staff was to retract the foreskin if present, wash, dry, and replace the foreskin. Ensuring proper cleaning of the catheter by wiping down the tubing using a downward stroke with a clean cloth.

Based on interview and record review the facility failed to identify, assess, and initiate treatment orders for an acquired pressure injury upon identification. This failure resulted in R3 developing an unstageable left ischium pressure ulcer. This applies to 1 of 7 residents (R3) reviewed unstageable for pressure ulcers The findings include: R3's face sheet shows he was admitted to the facility on [DATE] with diagnoses including quadriplegia, personal history of traumatic brain injury, encounter for attention to gastrostomy, epilepsy and neuromuscular dysfunction of bladder. R3'S Braden Scale assessment dated [DATE] shows he was at moderate risk for developing pressure. R3's Braden Scale assessment shows on 10/24/25 he was a HIGH RISK for developing pressure. R3's EHR (Electronic Health Records) shows he had a facility acquired stage 2 ischium pressure ulcer identified on 9/10/25 and healed on 9/23/25. R3'S Physician Order Sheets dated through January 2026 shows orders dated 9/10/25 for wedge cushion and low air loss mattress. The P.O.S. shows he was admitted to hospice in June 2025. R3's Wound Notes by V4 (Wound Nurse) dated 12/18/25 shows left ischium deep tissue injury measuring 12 cm (centimeters) x 9.0 cm), deep [NAME] 70%, blood filled blister 30%, moderate amount of serosanguineous drainage. Peri wound criteria: erythema, maceration, bogginess. On 1/21/26 at 2:40 PM, V9 (Nurse Practitioner-Wound) said R3 had multiple risk factors for developing wounds. R3 was totally dependent on staff for all cares and had a history of wounds prior that healed. Sometimes the wounds can progressively get worse if the area is not off-loaded and not repositioned frequently. If they were assessing R3's skin it should have been non-blanchable prior to the skin being deep maroon. It's not unusual for a deep tissue injury to open because of the necrotic tissue in the wound. R3's deep tissue injury opened to an unstageable left ischium pressure wound. On 1/22/26 at 8:02 AM, V7 (Registered Nurse-RN) said R3 is non-verbal, totally dependent on staff for all cares including bed mobility. On 12/17/25 she was R3's night nurse. It was reported to her by the aide, R3 had a wound on his bottom. It was reported R3's ischium was red and bleeding. V7 said she did not assess the wound or document in the resident's medical record the wound. She notified V4 (Wound Nurse) in the morning about R3's wound. Usually, we report the wounds to the wound nurse, and she will assess the wound. On 1/21/26 at 10:28 AM, V4 (Wound Nurse) said any new wounds should be reported to me. She takes pictures of the wound, assesses the wound, notifies the physician and family, and obtains treatment orders. On 12/18/25, she was notified about R3's left ischium wound by the aide. R3 had a large deep tissue injury measuring 12cm x 9cm, it was bad when she assessed the wound. There was no dressing on his ischium. It seemed strange there was no wound on 12/16/25 when V8 (Wound Nurse) said she checked his skin. It seems like a very small amount of time for the wound to get that bad. The wound should have been identified prior to it being a large maroon area on his ischium. She confirmed nursing did not report the wound to her; and the aide notified her. R3 is totally dependent on staff, non-verbal resident, he is a quadriplegic from a motorcycle accident a year ago. R3 was at great risk for developing pressure to that area, he had a previous healed wound to the ischium, preferred to lay on his left side. He was dependent on staff for repositioning, he had a wedge and would wiggle off the wedge. R3 had a healed pressure ulcer to the same area and was followed by the wound care team. He should have had a protection dressing in place to that area. On 1/21/26 at 2:06 PM, V8 (Wound Nurse) said R3's wound re-opened to his left ischium, it started as a deep tissue injury then opened. R3 was being followed by wound care prior to the wound developing. R3 should have had a protective dressing in place prior to the wound re-developing. V8 said she was providing R3's wound treatments and did not see the wound prior to it being found at 12 cm x 9cm deep maroon pressure. V8 said she assessed R3's skin last on 12/13/25 and he did not have a wound to his ischium and confirmed she did not assess R3's skin on 12/16/25. V8 stated, wounds can appear overnight sometimes. On 1/21/26 at 1:30 PM, V6 (Certified Nursing Assistant-CNA) said she was R3's regular aide. R3 was non-verbal, transferred using the mechanical lift, he would wiggle maybe his arms, but was not able to scoot his lower body or legs. On 12/18/25, on day shift, R3 had a dark spot on his ischium and there was no dressing to that area. The previous shift reported the wound and there was never a dressing in place prior to that. If there is new wound, staff should report it to the nurse right away. On 1/23/26 at 9:48 AM, V15 (Wound CNA) said she rounds with the wound nurses. She last rounded with V8 on 12/13/25 and said R3 did not have a wound to his ischium. She was confused how the new wound was so big. She said V8 would apply a protective dressing to R3's lower left back, but not where the new wound was. After the new wound was found we were making sure R3 was repositioned more frequently. R3 favored his left side and could not roll from side to side on his own. On 1/21/26 at 11:26 AM, V2 (DON) said he was investigating how R3 re-developed the left ischium wound. It's hard to figure out. R3 is dependent on staff for all cares. He had a history of skin breakdown, and was high risk due to his co-morbidities. He tended to lay on his left side. V7 (RN) reported she was notified of R3's wound by the aide and documented the wound. V4 (Wound Nurse) said she did not notice any wounds to R3's ischium prior to when it was identified. Any new wounds should be assessed, reported to the physician/family, obtain treatment orders, and documented. On 1/23/26 at 1:30 PM, V2 said he did not know V7 did not document R3's wound in the electronic medical record and confirmed it should have been identified prior. R3's EHR shows there was no documentation of the left ischial pressure on 12/17/25. V3's Wound Progress Note dated 12/24/25 shows he was seen for initial wound evaluation. Left Ischial is a deep tissue injury persistent with non-blanchable deep red, maroon, or purple discoloration pressure ulcer. Wound measurements 14 cm x 9cm x 0.1cm. V3's Wound Progress Note dated 1/7/26 shows his Left Ischial is an unstageable pressure injury with full thickness skin and tissue loss. Wound measurements 9cm x 8.5cm x 1.1cm. R3's current care plan shows he has the potential for impairment to the skin and developed a pressure wound to his left ischium with interventions including assist with turning and repositioning frequently, barrier cream to areas exposed, identify/document potential causative factors, low air loss mattress, wedge pillow, notify nurse immediately of any new skin areas of skin breakdown, report changes in skin status to physician. The facility's Treatment/Services to prevent/Heal Pressure Injuries and other wounds policies dated 1/21 states, It is the policy of this facility to ensure it identifies and provides needed care and services that are resident centered.a resident receives care.to prevent pressure injuries and doe not develop pressure injuries unless the individual's clinical condition demonstrates unavoidable.interventions will be implemented in the resident's plan of care to prevent injury development.

Based on observation, interview, and record review the facility to provide care and services and failed to maintain the catheter below the level of the bladder for a resident with an indwelling urinary catheter. This applies to 1 of 3 residents (R1) reviewed for indwelling catheters in the sample of 7. The findings include: R1's face sheets shows he was admitted to the facility on [DATE], with diagnoses including obstructive and reflux uropathy, atrial fibrillation, congested heart failure, paralytic ileus, alcoholic cirrhosis liver, polyneuropathy, benign prostatic hyperplasia without urinary tract symptoms, anxiety, major depressive disorder, and COPD. On 01/16/26 at 10:30 AM, R1 was observed lying in his bed and his indwelling catheter bag hanging on the top drawer handle of his bedside table. The drainage tubing was positioned pulling back to the right side and not positioned below the level of the bladder. R1's anchored device was folded around the tubing not secured to his leg. R1 said he has tearing to his penis (from previous facility) because the staff were not using the anchored device, not emptying his drainage bag and the weight of the bag would pull on his penis. R1 said he reported to the staff he needed a new anchoring device yesterday but they did nothing. On 1/16/26 at 11:06 AM, V5 (Licensed Practical Nurse-LPN) said R1 has a catheter and is followed by a urologist and she is not sure who changes his catheter when needed. She confirmed R1 has a penile tear, due to poor hygiene. I don't think V4 (Wound Nurse) does anything for it. V5 said she has not observed the area this morning and his drainage bag was full 1600 cc of urine was emptied this morning. Staff should empty the drainage bag every shift and as needed. On 1/16/26 at 11:15 AM, V5 entered R1's room and questioned why the drainage bag was hooked on the top of drawer handle of the bedside table. She lifted the drainage bag in a upward position above the level of the bladder and handed the bag to the aide and placed it on the left side. R1 requested for the drainage bag to placed on the right side. V5 said the drainage bag should be positioned below the level of the bladder. V5 said R1 prefers it to be placed on the right side. R1 stated, I never told them to hang it on the drawer. R1's meatal tear was present at the catheter insertion site without the secured device in place. V5 confirmed the secured anchored device was not in place and there should be one in place to prevent pulling. On 1/16/26 at 12:33 PM, V3 (ADON) said catheter care should be done every shift and as needed. Catheter care includes emptying the bag at minimum every shift and as needed, privacy bag, and stat lock in working condition. If the catheter bag is full it can put pressure on the urethral causing pressure and urine back flow to potentially causing bacteria infections. Stat locks are in place for males to ensure pressure or pulling is prevented because it could cause trauma or tearing to the tip of the penis. R1 has told me he has this issue and he explained this is a risk due to chronic catheter use. R1's current care plan shows he has an indwelling catheter with interventions to secure tubing properly to prevent pulling or dislodgement, monitor insertion site and surrounding, keep drainage bag below the level of the bladder at all times. R1's care plan does not include his meatal tear. The facility's Indwelling Urinary Catheter Use Policy states, It is the policy of the facility to ensure appropriate use of indwelling catheters in accordance with State and Federal Regulations .consider a securement device or staff will ensure that catheter tubing is supported .to prevent inadvertent removal or tugging.

Based on observation, interview, and record review, the facility failed to ensure safe wheelchair transport for a cognitively impaired resident (R34) that required staff assistance. As a result, R34 sustained pain and significant bruising to the right side of the face, forehead and orbital area to the right eye. This applies to 1 of 1 resident (R34) reviewed for fall-related accidents in the sample of 18. The findings include: The EMR (Electronic Medical Record) shows that R34, is a [AGE] year-old with diagnoses of dementia, psychosis, anxiety disorder, major depressive disorder, age related physical debility, repeated falls, unsteadiness of feet, difficulty walking, need of assistance with care, hyperlipidemia, Vitamin D deficiency, hypothyroidism, and chronic kidney disease. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE], showed that R34's cognition was severely impaired with a BIMS (Brief Interview Mental Status) score of 0/15. The MDS documents that R34 required substantial to maximum assistance from staff during wheelchair transport in the corridor or similar places. On April 7, 2025, at 10:30 A.M., R34 was seated in her wheelchair in the corridor. R34 was observed with a dark blue bruise on the forehead, entire right side of her face and lower orbital area of the right eye. R34 was not interviewable and not able to verbalize how she acquired the bruise. R34 was noted to be anxious and was pacing back and forth from the outside and inside her room. V10 (LPN/Licensed Practical Nurse) was present during this time. V24 said that R34 sustained the bruise from a fall incident that occurred on March 15, 2025, while being transported by CNA using wheelchair without the use of wheelchair leg rests. V24 also said that R34 was anxious and must not be feeling comfortable from the facial bruise. The facility's incident report dated March 15, 2025, showed: CNA (Certified Nurse Assistant) was transporting (R34) to the dining room, for lunch when (R34's) foot got caught underneath the wheelchair, (R34) slid out of the wheelchair and landed on her side hitting her head .911 called . hematoma forehead. The nurse's progress notes March 15, 2025, at 1:19 P.M., showed CNA was transporting (R34) to the dining room for lunch when (R34) foot got caught underneath the wheelchair, (R34) slid out the wheelchair and landed on her right side hitting her head.BP 102/58 HR 103 R 18 T 96.9. NOD (Nurse on Duty) help CNA assist (R34) back to wheelchair and to her room. 911 called and .transport (R34) to .hospital for evaluation. On April 9, 2025, at 12:10 P.M., V17 (LPN/Nurse Supervisor on March 15,2025) said that R34 had fell forward while seated in her wheelchair and being transported and propelled by (V16/CNA). V17 said that R34's feet were caught underneath the wheelchair that caused the fall. V17 also said that the fall could have been prevented if leg rests were used. V17 added that during the fall incident on March 15, 2025, R34's leg rest were not used during transport and assisted by V16. On April 9,2025 at 12:17 P.M., V19 (CNA) said that R34 did not have the leg rests attached to the wheelchair when transported by V16 and R34 legs were caught and caused the fall. V19 said she saw V16 (CNA) propel R34 in a wheelchair and R34 fell forward. Multiple attempts made for an interview with V16 (CNA) during survey but to no avail. On April 9, 2025, at 12:19 P.M., V18 (LPN, on duty on March 15, 2025, Day shift) said that (V16) had propelled and assisted (R34) to dining room for lunch, (R34) fell forward, there were no leg rests used, (R34's legs/feet) were caught under the wheelchair. On April 9, 2025, at 11:42 AM, V2 (Acting Director of Nursing) said that V16 was supposed to use leg rests when assisting and transporting R34 to ensure safe transport. On April 9, 2025, at 12:06 P.M., V11 (Director of Skilled Rehabilitation/ Physical Therapist) stated that leg rests must be used to ensure safe transport using a wheelchair and being propelled by staff. V11 added this would prevent legs/feet being caught under the wheelchair during transport and would prevent fall accident. On April 9, 2025, at 12:40 P.M. V20 (CNA), said yes, (R34) has pain due to the bruise, she might not be able to say it but with the bruise that big, she must be in pain. On April 9,2025 at 12:42 P.M., V21 (RN) said that R34 has facial pain due to the large bruise. On April 9, 2025, at 11:00 A.M., V14 (Regional Nurse Consultant) said the facility must implement safe transport via wheelchair. V14 also said that facility has no policy for safe transport, but skilled therapy department practice was to be implemented to ensure safe transport for resident while being transported using a wheelchair.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and treat a pressure injury per facility policy. This failure resulted in the development of a DTI (Deep Tissue Injury) for a resident at moderate risk for the development of pressure injuries. This applies to 1 of 4 residents (R59) reviewed for pressure injuries in the sample of 18. The findings include: Face sheet, dated April 9, 2025, shows R59 was admitted to the facility on [DATE], and her diagnoses included pulmonary embolism, malignant neoplasm of bronchus or lung, weakness, diabetes, protein-calorie malnutrition, vascular dementia, congestive heart failure, chronic kidney disease, and need for assistance with personal care. MDS (Minimum Data Set), dated January 15, 2025, shows R59's cognition was severely compromised and R59 required substantial / maximal assistance from staff for rolling left and right. Skin Observation Weekly, dated October 10, 2024, shows R59's skin was normal with no open areas. Braden scale, dated October 9, 2024, shows R59 was at high risk for pressure injuries because she was completely immobile, was bedfast, and did not make even slight changes in body or extremity position without assistance. Braden scale, dated February 6, 2025, shows R59 was assessed to only be at moderate risk for pressure injuries, was chairfast, had very limited mobility and made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. The assessment also shows R59 had very limited sensory perception. On April 8, 2025, at 12:33 PM, V10 (Licensed Practical Nurse) stated she was unaware of any pressure ulcer related to R59. On April 8, 2025, at 12:37 PM V12 (Wound Nurse) stated R59 had a facility-acquired pressure injury that was assessed as an unstageable right plantar DTI. V12 stated R59 had the pressure injury for months which was caused by her sitting position in her chair. V12 stated R59 was being treated with betadine and a gauze island twice a week. On April 8, 2025, at 12:39 PM, V12 (Wound Nurse) walked into R59's room and pulled back the sheets to observe R59's feet. V12 stated, that's not quite offloaded. R59 had black socks on both feet, both feet were resting on a pillow and R59's lateral plantar side of right foot touching pillow. R59's green pressure-relieving boots were on the counter across from her bed and not on her feet. V12 stated R59's pillow under her lower extremities should be placed back under her calves to give her a boost and so her feet were not touching anything. V12 stated R59's pillow should not have been placed under her feet. On April 8, 2025, at 2:07 PM, R59 was lying in bed with offload boots and V13 (CNA/Certified Nursing Assistant) took off the sock on the right foot. There was a dressing present. At 2:10 PM, V12 took off the dressing and R59 had a blackened area with raised edges on her right sole. This area was approximately 2.5 cm (centimeters) in diameter with redness in the surrounding area. V12 was asked to describe the area, and she said it was a deep tissue injury, which was unstageable due to necrotic tissue. Initial Wound Evaluation & Management Summary, dated February 25, 2025, shows R59 was identified to have a wound on her right plantar foot. The assessment shows R59 had a pressure ulcer identified as an unstageable DTI with intact skin greater than 7 days in duration measuring 2 centimeters (cm) by 2.5 cm and the depth was not measurable. The skin was assessed as intact with purple/maroon discoloration. The evaluation's dressing recommendations included betadine and silicone foam with border twice a week and as needed. The evaluation's intervention recommendations include offloading the wound, use of a pressure off-loading boot, and repositioning R59 per facility protocol. Care plan, initiated October 11, 2024, and reviewed April 8, 2025, showed R59 had the potential for impairment to skin integrity related to incontinence, the diagnosis of diabetes, and impaired mobility. R59's intervention, dated October 11, 2024, included providing a pressure reducing mattress on bed. The care plan fails to show any pressure relieving interventions implemented to prevent the development of a pressure injury on her lower extremities while sitting in her chair. The care plan also failed to show interventions for her diagnosed pressure injury, or the implementation of enhanced barrier precautions related to her wound. POS (Physician Order Sheet), dated January 1, 2025, to April 30, 2025, shows R59's physician orders included: - Offload boots to be worn while in chair and during bedtime three times a day for DTI (ordered February 26, 2025) - Bottom lateral foot: Monitor and cleanse wound with NSS (Normal Saline Solution), apply betadine and cover with dry dressing two times a week one time a day every Tues, Fri for wound care (ordered February 18, 2025, and revised February 26, 2025) - Right plantar foot: Cleanse wound with NSS, apply betadine and cover with dry dressing two times a week. One time a day every Tuesday, Friday for wound care (ordered February 26, 2025, and revised April 5, 2025) - Infection precautions enhanced barrier secondary to wounds (ordered March 27, 2025) On April 9, 2025, at 1:08 PM, V22 (Physician) stated usually on admission at the facility the wound care team assesses and recommends pressure injury prevention interventions for residents at risk for pressure injuries. V22 stated usually the interventions including repositioning, floating heels and use of pressure relieving boots is part of the resident's care plan as preventative measures the facility should be doing if a resident was identified as someone that requires those measures. V22 stated it was certainly possible that the lack of interventions could have caused R59's DTI. V22 stated the facility either did not conduct a proper assessment or if they were providing the interventions they did not document them. On April 9, 2025, at 12:25 PM, V38 (Physician) stated R59 should have interventions in place based on the facility protocol. V38 stated R59's pillow should be behind her heel and R59 should have both offloading boots on when in bed. Wound Evaluation and Management Summary, dated April 1, 2025, shows R59 had a pressure injury that was described as an unstageable DTI for greater than 40 days measuring 1.8 cm by 2 cm with a depth unmeasurable. The assessment was no exudate, and the skin was intact with purple/maroon discoloration. The treatment plan shows apply betadine twice a week and as needed for 22 days in addition to a gauze island with boarder to be applied twice a week and as needed for 22 days. The plan of care (reviewed and addressed) shows R59's wounds were to be off-loaded and R59 was to be repositioned per facility protocol. Wound Evaluation & Management Summary, dated April 8, 2025, shows R59's pressure ulcer measured 1.8 cm by 2 cm and the depth was not measurable. The wound was described as an unstageable DTI with intact skin with no exudate. The plan of care recommendations show R59's wound was to be off-loaded. Pressure Injury Prevention and Management Policy, undated, shows, The intent of this organization is to develop and maintain systems and pr\processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PI) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcer/injury Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions or Revision of the interventions as appropriate Risk Assessments 4. Findings from the pressure ulcer/injury risk assessment will be incorporated into the resident's plan of care Preventive Measures 1. Preventive interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences. Such interventions may include: .c. Use of pressure reducing/relieving support surfaces or devices that assist with pressure redistribution and tissue load Care Plans: 1. A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury

Based on observation, interview, and record review, the facility failed to prepare and serve food to residents as per their planned and dietitian-approved facility menu and per facility policy. This applies to all 82 residents residing in the facility receiving oral diets. The findings include: Long Term Care Facility Application for Medicare and Medicaid, dated April 7, 2025, shows the facility census was 83 residents. Order Listing Report, dated April 8, 2025, shows there was one resident who did not receive an oral diet (R67) and there were 8 residents who received puree diets. Facility Menu Extension, dated April 8, 2025, show all residents on all diets received a hamburger patty (3 ounces) on a bun. The menu shows pureed diets were to receive pureed hamburger on a bun and mechanical diets were to be served a ground hamburger on a bun. Order Listing Report, dated April 8, 2025, shows 18 residents (R1, R4, R7, R16, R22, R23, R26, R33, F34, R35, R38, R39, R49, R53, R59, R60, R61, R70) had physician orders for Mechanical Soft Diets. On April 8, 2025, at 11:47 AM during lunch service, V6 (Dietary Aide) was plating ground meals onto lunch plates. V6 placed a scoop of ground beef, a scoop of ground green beans, and scoop of ground hash browned potatoes onto the Mechanical Soft plates. No bread was served on the mechanical soft lunch trays served to residents receiving Mechanical Soft diets. V6 served hamburger patties with cheese on a bun to regular and to all other diets other than those residents receiving pureed/mechanical soft diets at lunch. The hamburger patty appeared to weigh less than 3 ounces. On April 8, 2025, at 2:28 PM with V5 (Food Service Manager), one beef patty with one slice of cheese from lunch was weighed on a scale provided by V5. The beef patty and cheese weighed a total of 2.6 ounces. V5 stated the beef patty and cheese was expected to weigh 3 ounces total to provide the three ounces good quality protein per the planned/approved facility menu at lunch. V5 stated the egg omelet served in the morning was expected to provide two ounces of good quality protein. V5 stated the kitchen serves 5 raviolis in a serving at dinner which V5 thought would provide 2 ounces of good quality protein. V5 stated the residents served ground diets at lunch were formerly supposed to be served a bun with their ground hamburger patties but that the dietitian instructed the food service not to serve any bread to residents receiving mechanical soft diets. On April 8, 2025, at 10:44 AM, V5 stated she utilized a frozen, pre-made egg/cheese omelet product for breakfast instead of making the item by scratch. V5 provided the egg omelet manufacturing information which showed one omelet weighed 3.5 ounces but only each provided a total of 10 grams of protein per omelet. Review of facility cheese ravioli manufacturers product information showed a serving size of 9 ravioli only provided a total of 10 grams of protein per serving (including low quality protein from the pasta). Therefore 5 raviolis only provided an approximate total of 5.5 g high and low quality protein in the serving provide to residents. On April 9, 2025, at 10:09 AM, V40 (Dietitian) stated she discussed giving Mechanical Soft diets a soft piece of untoasted bread in replacement of any bread that was planned on the regular menu. V40 stated the residents receiving Mechanical Soft diets should have been served the equivalent of the regular menu bread servings from the hamburger bun which was two slices of bread. V40 stated she reviewed and approved all of the menus for all of the facility diets. V40 stated it was her expectation that a total of six ounces weight of good quality protein was served each day. V40 stated the hamburger patty was expected to provide 3 ounces of cooked good quality protein. V40 stated the manufacturer serving size of 9 ravioli did not appear to provide one total ounce of high quality protein in the serving. V40 stated if the facility only served 5 raviolis, the serving would not meet the equivalent of one ounce of high quality protein at dinner. V40 stated the menu as served on April 8, 2024, including the omelet, hamburger patty, and ravioli, did not provide a total of 6 ounces of high quality protein. Facility Menu policy, dated September 2, 2021, shows Menus are planned in advance and are followed as written to meet the nutritional needs of the residents The Director of Food and Nutrition Services and Registered Dietitian sign and approve the menus. Menus are served as written unless changed due to an unpopular item on the menu, and item could not be procured, or in the event of a special meal Facility Document Meal Pattern, dated September 2, 2021, shows Meat or Meat Alternatives should total to 5.5 ounces for the day. Facility Portion Control policy/procedure, dated May 15, 2020, shows Portion size is determined by the nutritional needs of the residents, federal and state regulations that specify the food groups, and portion sizes that must be served according to the facility menu `1. Use standardized recipes based on facility census and cycle menus. 2. Serve portions according to the menu spreadsheet 4. Weight or measure ingredients. Weighting is the most accurate 2. Facility Document Meal Pattern, dated September 2, 2021, shows the daily menu should contain 2 or more servings of fruit per day (1/2 cup per serving), 3 or more servings of vegetables per day (raw vegetables must be 1 cup serving), and 6 servings per day of grains/breads. Review of the facility Week 1 menu, approved February 7, 2025, shows the menu was short in food item servings on the following days: Sunday had only a total of 4 grain/bread servings and 2 vegetable servings Monday had only 1 vegetable serving Thursday had only 5 grain/bread servings and 1 vegetable serving Friday had only 3 grain/bread servings Saturday had only 5 grain/bread servings and 2 vegetable servings Review of facility Week 2 menu, approved February 6, 2025, shows the menu was short in food item servings on the following days: Monday had only a total of 5 grain/bread servings and 2 vegetable servings Tuesday day had only 1 fruit serving and 4 grain/bread servings Wednesday had only 2 vegetable servings Thursday had only 3 grain/bread servings and 2 vegetable servings Friday had only 2 grain/bread servings and 2 vegetable servings Saturday had only 4 grain bread servings Review of facility Week 3 menu, approved February 20, 2025, shows the menu was short in food item servings on the following days: Sunday had only 4 grain/bread servings and 2 vegetable servings Monday had only 4 grain/bread servings Tuesday had only 5 grain/bread servings Wednesday had only 4 grain/bread servings Thursday had only 4 grain/bread servings Friday had only 4 grain/bread servings Saturday had only 4 grain/bread servings. Review of facility Week 4 menu, approved March 26, 2024, shows the menu was short in food item servings on the following days: Sunday had only 5 grain/bread servings Monday had only 5 grain/bread servings Tuesday had only 2 vegetable servings Wednesday had only 1 fruit serving and 4 grain/bread servings Friday had only 1 fruit serving and 5 grain/bread servings Saturday had only 5 grain/bread servings

Based on observation, interview, and record review, the facility failed to perform hand hygiene after touching soiled dishes per facility policy and failed to utilize sanitizing solution at the proper concentration to sanitize food contact services per manufacturer instructions. This applies to all 83 residents living in the facility. The findings include: Long Term Care Facility Application for Medicare and Medicaid, dated April 7, 2025, shows the facility census was 83 residents. Order Listing Report, dated April 8, 2025, shows there was one resident who did not receive an oral diet (R67). On April 8, 2025, at 9:51 AM in the dish machine room, V15 (Dietary Aide) scraped and loaded dirty dishes into the mechanical dish machine. V15 then removed her gloves and without washing her hands or replacing gloves, V15 walked to the clean side of the dish machine and touched clean/sanitized bowls. V15 removed the bowls from the clean/sanitized dish rack and placed the bowls into storage. V15 then put on a new pair of gloves without washing her hands. V15 walked to the dirty side of the dish machine and began touching dirty bowls. Without changing her gloves and/or washing her hands, V15 walked to the clean side of the dish machine and began touching clean/sanitized plate lids, stacked them, and returned them to storage. Without changing her gloves and/or washing her hands, V15 then took clean/sanitized beverage pitchers to storage. Without changing her gloves and/or washing her hands, V15 then stacked clean/sanitized plate lids and placed them into storage. On April 10, 2025, at 3:57 PM, V5 (Food Service Director) stated she expected staff to wash their hands and change their gloves after touching soiled dishes and before touching clean dishes. Facility Policy Use of Disposable Gloves for Food Handling, dated February 27, 2020, shows disposable gloves were to be used appropriately by all employees and hands were to be washed between glove use. Facility policy Safe Food Handling Practices, dated September 23, 2019, shows All work surfaces and equipment are clean and sanitized after each use If the person washing is also going to pull and store the clean dishes, hands must be washed before pulling the clean dishes. Germs/bacteria can be spread to the clean dishes if clean dishes are not pulled with clean hands. Hands must be washed with soap and water Mechanical Ware Washing (Dish Machine) Policy/Procedure, dated September 27, 2018, shows Handwashing is imperative to prevent cross-contamination when the same person washes the dirty dishes and stores the clean dishes. 2. On April 7, 2025, at 9:40 AM in the kitchen during lunch meal preparation, V6 (Dietary Aide) used a wipe cloth out of red sanitizer bucket at the cook's station to wipe the counter of the cook's station. V7 (Cook) used a quaternary ammonium test strip and measured the sanitizing solution concentration in the red bucket which measured 100 ppm (parts per million). V6 stated the minimum sanitizing solution concentration should measure 155 ppm quaternary ammonium. On April 10, 2025, at 3:57 PM, V5 stated the quaternary ammonium chemical sanitizing solution in the sanitizing wipe buckets should measure 150-400 ppm. Facility chemical manufacturing product information, undated, shows the facility chemical sanitizing solution was to be utilized at 150-400 ppm of active quaternary ammonium.

Based on observation, interview, and record review, the facility failed to conduct infection surveillance for resident infections in the facility. The facility also failed to have a complete water management program for Legionella. The facility also failed to follow their policy for EBP (Enhanced Barrier Precautions) and hand hygiene. This applies to all 83 residents residing in the facility. The findings include: The facility's Long-Term Care Application for Medicare and Medicaid dated April 7, 2025, showed the facility's census was 83 residents. 1. On April 8, 2025, at 1:04 PM, V2 (DON/Director of Nursing) said she is the Infection Preventionist for the facility. V2 said when a resident shows signs of an infection, the facility staff will notify the physician for orders. V2 said the facility uses McGeer's Criteria when an infection is identified. V2 continued to say V2, or facility staff do not complete a McGeer's Criteria assessment for residents with infections. V2 said when an antibiotic is ordered, the facility completes an assessment titled Antibiotic Timeout. V2 said the assessment does not include the McGeer's Criteria. V2 said she compiles a monthly list of residents who received antibiotics and conducts her infection surveillance from that list. V2 said from the list, V2 tracks infection trends and transmission-based precautions in the facility. The facility's Order Listing Reports for January 2025, February 2025, and March 2025 showed the resident status as current. On April 9, 2025, at 12:40 PM, the Order Listing Reports were reviewed with V2. Upon review of the reports, V2 said the reports were only run for residents who were currently residing in the facility at the time the report was generated. V2 said she should have been reviewing the antibiotic use and infections for all residents residing in the facility for the month. V2 said since she did not review all residents in the facility for the month who received antibiotics, V2 did not have accurate surveillance of infections within the facility. The Order Listing Reports for antibiotic use for all residents in the facility for January 2025, February 2025, and March 2025, dated April 9, 2025, showed in January 2025, 11 anti-infectives were prescribed for infections and no surveillance was completed. The report continued to show in February 2025, 9 anti-infectives were prescribed for infections and no surveillance was completed. The report showed in March 2025, 9 anti-infectives were prescribed and no surveillance was completed. On April 9, 2025, at 3:45 PM, V1 (Administrator) said V2 should be conducting surveillance for all infections identified in the facility. The facility's undated policy titled Antibiotic Stewardship Program showed Policy: The organization is committed to providing sufficient resources to establish and maintain systems and processes for a facility-wide system to monitor the use of antibiotics through an interdisciplinary Antibiotic Stewardship Program . The Antibiotic Stewardship team will analyze infection data (including type of infection or symptoms being treated, antibiotic utilization, and adverse outcomes, etc.) monthly and feedback will be provided to the QAPI (Quality Assurance and Performance Improvement) Committee regarding antibiotic stewardship practices . Specific Procedures/Guidance: . 7. Infection and antibiotic therapy usage will be maintained for each unit/neighborhood of the facility monthly. a. A tracking tool will be utilized to capture the following information at a minimum: i. Resident identifier and room location at onset. ii. Type of infection/symptom and if infection met or did not meet established criteria. iii. Antibiotic use (name of antibiotic, dose, frequency, duration of use); if multiple antibiotics are prescribed for the condition, each antibiotic will be tracked. iv. Outcome- resolution of symptoms, presence of adverse outcomes, etc. v. Type of precautions used (including adjustments for person centered care) . 10. Information from each unit/neighborhood will be reported at least monthly to the Director of Nursing and/or infection control preventionist for tracking/trending and analysis in the facility . 2. On April 8, 2025, at 3:56 PM, V23 (Maintenance Director) said for the facility's water management plan for Legionella, V23 will run the water in vacant resident rooms while a visual inspection of the room is being conducted. V23 continued to say V23 will test water temperatures in a resident room in each unit, the shower room, the kitchen, and the laundry room. V23 said he does not document temperatures of the hot water heaters or tanks. V23 said he does not perform chlorine testing of the facility's water. V23 said he is not aware if any of the hot water tanks or heaters have a thermometer on them. On April 9, 2025, at 12:05 PM, V23 said he does not know what the control measures are for the facility's water management plan for Legionella. V23 said he does not know what to do if the control measures are not met. On April 9, 2025, at 1:18 PM, V23 said the facility does not maintain documentation of running the water in vacant resident rooms. As of April 9, 2025, at 3:44 PM, the facility did not have documentation to show a water management plan containing areas at risk for Legionella growth, control measures for at risk areas, ways to respond when control measures are not met, or routine safety logs for control measures. On April 9, 2025, at 3:45 PM, V1 (Administrator) said her expectations are the facility should have a water management plan for Legionella including control measures and the monitoring of control measures. V1 said V23 should be completing documentation of control measure monitoring. The facility's policy dated November 16, 2023, titled Legionella/Water Management Plan showed Policy: The facility is committed to established and maintaining an effective water management system to minimize the occurrence of Legionnaire's Disease. Definitions: 'Legionnaire's Disease': is a serious type of pneumonia caused by bacteria, called Legionella, that lives in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Specific Procedures/Guidance: 1. The facility will develop and maintain a water management program that includes the following elements: . c. Identify areas where Legionella could grow and spread. d. Decide where control measures should be applied, monitor and log compliance quarterly . e. Establish ways to respond when control measures are not met . g. Document all activities (i.e. monitoring, response to variances, etc.): i. Routine safety logs will be maintained . 2. The water management program will be reviewed at least annually and as needed, to include when: a. Data review shows control measures are persistently outside of control limits . 15845 3. On April 8, 2025, between 8:28 A.M. and 9:03 A.M., V28 (Licensed Practical Nurse/LPN) had administered multiple prescribed medications to R67 via the resident's gastric tube. A posted sign outside R67's room clearly instructed staff to wear appropriate Personal Protective Equipment (PPE), including gown and gloves, due to R67's Enhanced Barrier Precautions (EBP) status, which was ordered in response to the resident's gastric tube care. Despite this posted instruction and the documented order on the April 2025 Physician Order Sheet (POS) requiring EBP, V28 failed to don the required PPE gown while administering the medications. Additionally, during the medication administration process, V28 changed soiled gloves but failed to perform hand hygiene before donning a clean pair of gloves, as required by the facility's undated Hand Hygiene policy. This policy documents that glove use is not a substitute for hand hygiene and mandates hand hygiene before and after glove use and before and after direct resident contact. Later that same day, at 1:11 P.M., V28, flushed R67's gastric tube. During this procedure, V26 also failed to wear the required PPE gown, despite engaging in direct contact with R67's gastric tube. This was a procedure/task that explicitly listed under High-Contact Resident Care Activities Requiring EBP in the facility's EBP policy dated March 28, 2024. Additionally, V28 failed to perform hand hygiene both upon entering and leaving R67's room. 4. On April 8, 2025, at 9:15 A.M., the medication administration observation continued with V28, with gloves on V28 performed a blood glucose finger-stick test on R6. Following this procedure, V28 removed the soiled gloves but failed to perform hand hygiene before proceeding to prepare and administer 14 units of Humalog insulin via subcutaneous injection to R6. This was not following the facility's Insulin Administration policy dated October 1, 2021, which requires handwashing before and after insulin administration. Furthermore, while still failing to perform hand hygiene, V28 administered multiple oral medications to R6 and subsequently proceeded to prepare and administer oral medications to R55. During this process, V28 did not perform hand hygiene before donning a new pair of gloves, nor after glove removal, as required by the facility's Hand Hygiene policy. The facility Policies show: Enhanced Barrier Precautions Policy (March 28, 2024): Requires gown and gloves during high-contact resident care activities, including device care or use during gastric feeding/enteral tube management. Insulin Administration Policy (October 1, 2021): Requires handwashing before and after insulin administration. Hand Hygiene Policy (Undated): Specifies that glove use does not replace hand hygiene and mandates hand hygiene before and after glove use, and before and after direct contact with resident's intact skin. 35267 5. POS (Physician Order Sheet), dated April 9, 2025, shows R29's diagnoses included pressure ulcers, urinary tract status, major depressive disorder, bipolar disorder, paraplegia, epilepsy, osteomyelitis, and infection of intervertebral disc. On April 7, 2025, at 9:56 AM, R29 had no transmission or enhanced barrier precautions outside of his room indicating what type of precautions were required to enter his room or perform care. Inside of R29's room there were two red biohazard disposal bins. There was a PPE (Personal Protective Equipment) dispenser hanging on R29's door holding gloves, gowns and masks. R29 stated he was recently hospitalized for an infection in his blood. R29 had an indwelling urinary catheter hanging on the side of his bed. On April 7, 2025, at 10:03 AM V29 (Social Services) was unable to locate any barrier precautions signage outside R29's door of his room. Red biohazard bins were inside door of room. On April 7, 2025, at 10:06 AM, V10 (Licensed Practical Nurse) stated she just received labs that morning showing R29 had ESBL (Extended-spectrum beta-lactamase) infection in his urine and that R29 had MRSA (Methicillin-Resistant Staphylococcus aureus) infection in his wound. V10 stated she was waiting on two other cultures to come back from the laboratory. Nursing note, dated March 31, 2025, shows R29 had a MRSA infection and pneumonia and contact precautions were required. POS, dated April 9, 2025, shows the following active physician orders for R29: - April 7, 2025, Contact isolation for ESBL in urine - February 22, 2025, Infection precautions - enhanced barrier related to wounds, colostomy, urostomy, every shift for EBP (Enhanced Barrier Precautions) - January 12, 2025, Strict contact isolation for MRSA and C Striatum every shift for wound infection Physician Note, dated April 2, 2025, shows R29 was recently hospitalized at [hospital] January 2-January 12, 2025, for bacteremia, source likely sacral OM (Osteomyelitis), also treated for aspiration PNA (Pneumonia). The note shows R29 was stabilized and discharged back to facility on January 12, 2025, with IV ABT (Intravenous Antibiotic) Vancomycin and Meropenem EOT (End of Treatment) February 14, 2025. On April 9, 2025, at 3:47 PM, V2 (Director of Nursing) stated R29 should have had a contact precautions sign hanging on the door of his room. 6. POS, dated (January 1, 2025, to April 30, 2025, shows the following physician orders for R59: - Bottom Lateral foot: Monitor and cleanse wound with NSS, apply betadine and cover with dry dressing two times a week one time a day every Tuesday and Friday for wound care (ordered February 18, 2025, and revised February 26, 2025) - Right plantar foot: Cleanse wound with NSS apply betadine and cover with dry dressing two times a week. One time a day every Tuesday, Fri for wound care. And as needed for soilage and or saturation (ordered April 5, 2025) - Infection precautions enhanced barrier secondary to wounds (ordered March 27, 2025) On April 8, 2025, V10 (Licensed Practical Nurse) stated she was not aware of any pressure injuries regarding R59. On April 8, 2025, at 12:37 PM V12 (Wound Nurse) stated R59 had an unstageable right plantar DTI for months. At 12:39 PM, V12 walked into R59's room with no gown, no gloves, no mask and pulled back the sheets with bare hands to observe R59's feet. With bare hands, V12 pulled off R59's right sock and displayed R59's wound dressing on her foot. There was no isolation precaution sign at the entrance of R59's room and there were no PPE supplies at the entrance to R59's room. On April 8, 2025, at 1:30 PM, V12 (Wound Nurse) stated R59 should have EBP (Enhanced Barrier Precautions) in place for her wound. V12 stated she was unaware of R59's order for EBP. On April 9, 2025, at 12:25 PM V38 (Physician) stated she expected residents to be placed on enhanced barrier precautions for all wounds per Centers for Disease Control guidelines. R59's care plan, reviewed on April 8, 2025, shows no identification of R59's facility acquired pressure injury or need for Enhance Barrier Precautions related to R59's wound. Wound evaluation & Management Summary, dated April 8, 2025, shows R59's pressure ulcer measured 1.8 cm by 2 cm and the depth was not measurable. The wound was described as an unstageable DTI with intact skin with no exudate. The plan of care recommendations show R59's wound was to be off-loaded. Facility Enhanced Barrier Precautions (EBP) Policy, undated, shows EBP will be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities Enhanced Barrier Precautions refer to the infection control intervention aimed at reducing transmission of MDROs (Multi-Drug Resistant Organisms) through the targeted use of gown and gloves during high-contact resident care activities. 1. Criteria for Implementing EBP: EBP should be employed in the following scenarios: Residents with infection or colonization by a CDC (Centers for Disease Control) -targeted MDRO when contact Precautions are not otherwise applicable. Residents with wounds and/or indwelling medical devices, irrespective of MDRO infection or colonization status . High-Contact Resident Care Activities Requiring EBP: EBP should be utilized during the following activities: Dressing, bathing, showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care

Based on interview and record review, the facility failed to follow their policy for antibiotic stewardship. This applies to all 83 residents residing in the facility. The findings include: The facility's Long-Term Care Application for Medicare and Medicaid dated April 7, 2025, showed the facility's census was 83 residents. On April 8, 2025, at 1:04 PM, V2 (DON/Director of Nursing) said when a resident in the facility has an infection, McGeer's Criteria is supposed to be used. V2 continued to say she had not completed McGeer's Criteria since she started as the Infection Preventionist in November 2024. V2 reviewed antibiotic use for R79 in March 2025. V2 said she did not complete McGeer's criteria for R79 and reviewing McGeer's Criteria now, R79 did not meet criteria for an infection. V2 said R79 was prescribed antibiotics due to laboratory results and R79 did not have any symptoms. V2 said R79's urine culture results showed R79 had a growth of ESBL (Extended-Spectrum Beta-Lactamases) of 50,000 to 100,000 colonies. V2 said R79's laboratory results did not meet McGeer's Criteria. V2 said when an antibiotic is ordered, the facility completes an assessment titled Antibiotic Timeout. V2 said the assessment does not include the McGeer's Criteria. V2 said she compiles a monthly list of residents who received antibiotics. The facility's Order Listing Reports for January 2025, February 2025, and March 2025 showed the resident status as current. On April 9, 2025, at 12:40 PM, the Order Listing Reports were reviewed with V2. Upon review of the reports, V2 said the reports were only run for residents who were currently residing in the facility at the time the report was generated. V2 said she should have been reviewing the antibiotic use for all residents residing in the facility for the month. V2 said since she did not review all residents in the facility for the month who received antibiotics, V2 did not have accurate monitoring of antibiotic use within the facility. The Order Listing Reports for antibiotic use for all residents in the facility for January 2025, February 2025, and March 2025, dated April 9, 2025, showed in January 2025, 11 anti-infectives were prescribed for infections and no surveillance was completed. The report continued to show in February 2025, 9 anti-infectives were prescribed for infections and no surveillance was completed. The report showed in March 2025, 9 anti-infectives were prescribed and no surveillance was completed. On April 9, 2025, at 1:51 PM, V25 (Agency RN/Registered Nurse) said when she suspects a resident has an infection, she calls the provider. V25 said she does not complete a McGeer's criteria when she suspects a resident infection. V25 said she was not instructed by the facility to complete a McGeer's Criteria when assessing a resident for a possible infection. On April 9, 2025, at 1:55 PM, V21 (Agency RN) said she was not instructed by the facility to complete McGeer's Criteria when she suspects a resident has an infection. V21 said she does not know what McGeer's Criteria is or how to complete the assessment. On April 9, 2025, at 2:01 PM, V27 (RN) said she suspects a resident has a UTI (Urinary Tract Infection) if the resident has symptoms like fever, confusion, lethargy, or a change from their baseline. V27 said she has not been instructed to complete the McGeer's Criteria for a suspected resident infection. V27 said she was unaware what McGeer's Criteria was. The facility did not have documentation to show McGeer's Criteria was performed for suspected resident infections from November 2024, to present. On April 9, 2025, at 3:45 PM, V1 (Administrator) said V2 should be following the facility's policy for antibiotic stewardship and accurately compiling antibiotic use. V1 continued to say V2 should be utilizing McGeer's Criteria to ensure a resident requires antibiotics. The facility's undated policy titled Antibiotic Stewardship Program showed Policy: The organization is committed to providing sufficient resources to establish and maintain systems and processes for a facility-wide system to monitor the use of antibiotics through an interdisciplinary Antibiotic Stewardship Program. Improving the use of antibiotics in the nursing facility to protect residents and reduce the threat of antibiotic resistance is a priority. The goals of the program include: Ensuring that residents who require an antibiotic, are prescribed the appropriate antibiotic, reducing the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. The Antibiotic Stewardship team will analyze infection data (including type of infection or symptoms being treated, antibiotic utilization, and adverse outcomes, etc.) monthly and feedback will be provided to the QAPI (Quality Assurance and Performance Improvement) Committee regarding antibiotic stewardship practices . Specific Procedures/Guidance: . 2. The Antibiotic Stewardship team will meet monthly to review antimicrobial regimens for appropriate: a. Drug; b. Indication for use (i.e. type of infection, symptom, prophylactic use, etc.); c. Opportunities for elimination of lines or devices; d. Cultures and sensitivities obtained during review period; e. Person centered precautions/isolation status; f. Clinical assessments; g. Resident response to antimicrobial therapy including the development of a secondary infection, allergy, adverse outcomes such as diarrhea, rash, gastritis, etc. 3. The Antibiotic Stewardship Program will review all routes of antibiotics: oral, intramuscular, intravenous, ocular, PEG (Percutaneous Endoscopic Gastrostomy), topical, etc. 4. A standard of criteria for defining various infections, (i.e. McGeer's Criteria) will be adopted and utilized for classifying infections and/or related symptoms. These standards will be approved by the QAPI Committee with input from the Medical Director, consulting pharmacist, Director of Nursing and infection control preventionist. These standards will be communicated and accessible to prescribing physicians/non-physician practitioners, and licensed nursing staff. a. Antibiotic therapy should be based on the following guidelines: (if the infective pathogen is not known) or prophylactic therapy (given to prevent development of an infection), the therapy is prescribed using a narrow spectrum antimicrobial over the shortest duration possible to achieve therapeutic effectiveness. b. If the infective pathogen is known: according to the microbiology results and susceptibilities, when available. c. Consistent with the appropriate dosage, route, and frequency or prescribed antibiotics for the individual as well as the site and type of infection, for the shortest number of days. d. Based on appropriate duration of a specific antibiotic and reviewed routinely to determine clinical effectiveness. i. Single antibiotic therapy should be used in most instances, where clinically appropriate. 5. When symptoms of infection are identified, the clinical team (i.e. nursing, provider, etc.) will complete an evaluation of the resident and communicate findings to the resident's physician for orders related to diagnostic testing and/or treatment. Tracking and surveillance will be initiated for all symptoms and/or infections that require diagnostic testing (i.e. urinalysis, chest x-rays, etc.) and/or with orders for antibiotic therapy. 6. The initial tracking/surveillance tool will be initiated by the infection control preventionist or designated licensed nurse (i.e. unit manager/coordinator, DON/Assistant Director of Nursing, etc.) and will be completed for each resident as applicable. 7. Infection and antibiotic therapy usage will be maintained for each unit/neighborhood of the facility monthly. a. A tracking tool will be utilized to capture the following information at a minimum: i. Resident identifier and room location at onset. ii. Type of infection/symptom and if infection met or did not meet established criteria. iii. Antibiotic use (name of antibiotic, dose, frequency, duration of use); if multiple antibiotics are prescribed for the condition, each antibiotic will be tracked. iv. Outcome- resolution of symptoms, presence of adverse outcomes, etc. v. Type of precautions used (including adjustments for person centered care). 8. The clinical record will be reviewed to validate the presence of absence signs and symptoms of infection, implementation of orders for diagnostic testing or treatment, resident response to treatment, and related diagnostic reports . 12. A summary of the monthly tracking, analysis and actions taken will be communicated to the QAPI Committee for additional oversight and oversight .

Based on interview and record review, the facility failed to employ a qualified food service manager. This applies to all 83 residents residing in the facility. The findings include: Long Term Care Facility Application for Medicare and Medicaid, dated April 7, 2025, shows the facility census was 83 residents. On April 9, 2025, at 9:32 AM, V5 (Food Service Manager) stated she had not enrolled in the dietary manager course and did not take the course in the past. V5 stated she was sent the link for the class registration recently and needed to enroll in the class. V5 stated she had a Serve Safe Sanitation certification but no other certifications as the Food Service Manager. On April 8, 2025, at 9:30 AM, the facility provided a ServSafe certificate for V5 dated 11/22/24 and expiring November 22, 2029. As of April 10, 2025, at 4:20 PM, the facility failed to provide documentation regarding V5's qualification as the Food Service Manager.

Based on interview and record review the facility failed to provide sufficient number of Nursing staff to ensure call lights are answered timely and assistance with ADL care is given as needed. This has the potential to affect all 83 residents who reside in the facility. The findings include: During the resident meeting on April 8, 2025, at 10:00 AM, 4 of the 7 residents in attendance, R6, R13, R36 and R58, all stated they experienced extended wait time for call light response during the evening and overnight shift. R33's name was on the list to attend the resident meeting, but did not attend, there was a note on the list next to his name that showed CNA did not get him up. On April 7, 2025, at 10:53 AM, R487 said she gets anxious during the overnight shift and sometimes the evening shift because she has to wait for a response to her call light 2 or 3 hours. R487 said she puts her call light on when she needs incontinence care or when she gets chest pressure and needs her PRN (as needed) medication from the Nurse. On April 8, 2025, at 12:39 PM, R33 was in his bed eating his lunch and stated he wanted to go to the resident meeting, but the CNA did not get him up because it was not his scheduled day to get up. R33 stated he wants to get up at least 3 days a week and wants to attend BINGO on Tuesday and Saturdays and wants to be dressed in his own clothes when he goes out of his room. R33's request was made known to V28 (R33's LPN) On April 9, 2025, at 2:40 PM, R13, stated almost every overnight she waits an extended amount of time to receive care for incontinence and stated it was uncomfortable to wait in a wet brief for it to be changed. On April 9, 2025, at 2;35 PM, R 36 stated during the day she uses the bathroom but during the night she uses the incontinence brief because the wait for call light response doesn't give her enough time to get to the bathroom without soiling the brief. On April 9, 2025, at 2:35 PM, R58 stated he listens at night and hears the call lights activated and sounding for 30 minutes or more without being turned off. R58 stated this occurs every overnight shift. The Resident Council Meeting minutes dated December 27, 2024, showed the residents raised concerns regarding extended call light response times on the evening, overnight shifts and during the weekends. Residents also identified a concern with medications that are scheduled to be given in the morning are not given until the afternoon. The Resident Council meeting minutes dated January 29, 2025, showed the meeting was attended by V35 (Ombudsman) and two family members. The family members raised concern regarding residents not receiving care on the weekends as they observe residents in bed wearing gowns in the afternoon. shaving of facial hair not being done, and residents are consistently soiled. Residents again raised the concern that medications scheduled to be given in the morning are not administered until the afternoon. Resident also stated staff will turn off a call light, not respond to the need, stating they will return, and staff do not come back. The Resident Council meeting minutes dated February 26, 2025, showed the residents again raised the concern regarding extended call light response times, during the evening and overnight shift. The Residents also raised a concern of not being able to get up out of bed before breakfast due to staffing. The Resident Council Meeting Minutes dated March 26, 2025, showed residents raised the concern regarding extended call light response times especially on the evening and overnight shifts. The residents reported that staff are complaining to them that there is short staffing. On April 9, 2025, at 9:46 AM, V1(Administrator) stated an evaluation of resident care needs in relation to number of CNA staff was not reviewed in response to the Resident Council Meeting concerns. V1 also explained that the Facility Assessment, dated August 8, 2024, showed in a 24-hour period direct care Nurses would be 4 RNs and 5 LPNs, and 30 CNAs. On April 9, 2025, at 10:30 AM, V31 (Staffing Coordinator/CNA) provided daily assignments for April 7-10, 2025, and a list of residents who need 2 staff assists with ADL care. Based on the list of residents, who need 2 staff assists, Unit 1 had 5 of 14 residents who needed 2 staff assists with ADL care. The Daily Assignment sheet for April 7, 2025. showed there was 1 CNA staff on Unit 1 for both the evening and the night shift. The daily assignment sheet for April 8, 9, and 10 showed there was 1 CNA on the overnight shift each day. Unit 2 had 10 of 23 residents who needed 2 staff assists with ADL Care. The Daily Assignment sheet showed on April 7, 8, 9, and 10, there was 1 CNA scheduled for Unit 2 on the overnight shift each day. Unit 3 had 15 of 43 residents who required 2 staff assists with ADL care. The Daily Assignment sheet for April 7, 8, 9, and 10, showed 2 CNA on Unit 3 on the overnight shift each day. R6 and R33 reside on Unit 2. R13, R36, R58, and R487 reside on Unit 3. V31 stated when the residents need 2 staff assists and there is only 1 assigned CNA, the Nurse could help the CNAs provide care for a resident if the nurse was not busy. V31 stated a CNA could come from another Unit to help give care for those residents who need 2 assists for care, which could potentially leave no CNA on a Unit while the CNA assists on another Unit. The Facility assessment dated [DATE], showed 30 CNA staff were needed to provide care in a 24-hour period based on resident care profile. The Daily Assignment sheets dated April 8 through 10, showed there were 20 CNAs who worked in each 24-hour period.

Based on interview and record review the facility failed to ensure that bed hold notices were issued in writing to residents upon transfer to the hospital. This failure has the potential to affect all 83 residents who reside in the facility. The findings include: R12's Face Sheet showed R12 to be [AGE] years old and admitted to the facility on [DATE]. R12's Hospital Transfer Form showed resident was discharged to the hospital on April 5, 2025. On April 8, 2025, 11:17 AM, V2 (Director of Nursing) stated V36 (Registered Nurse) who discharged R12, did not issue a bed hold notice and one was not issued because she did not see anything documented in R12's electronic medical record. V2 stated she was not aware of the bed hold policy and who was responsible for issuing the bed hold policy. V2 stated she will follow up with the facility's nurse consultant and look for the bed hold policy. On April 8, 2025, at 3:30 PM, V2 stated she did not find that a bed hold policy was given to R12. V2 stated they will give a bed hold notice to the resident or representative. On April 9, 2025, at 9:44 AM, V24 (Social Services Director) stated that he does not handle any notifications dealing with resident bed holds. On April 9, 2025, at 9:57 AM, V2 stated they gave R12's daughter a bed hold notice. V2 also stated that V34 (Business Office Manager) was responsible for giving bed hold notifications. On April 9, 2025, at 10:07 AM, V34 stated she issued a bed hold to R12's daughter yesterday. V34 stated yesterday was the first time she had issued a bed hold notice to anyone. V34 stated issuing bed holds has not been a part of her job duties. On April 9, 2025, at 1:19 PM, V2 stated that bed hold notifications are not being done. V2 gave the surveyor a copy of the forms sent out with R12. There was no bed hold notice within the forms. On April 9, 2025, at 1:25 PM V27 (Registered Nurse/RN) stated that when a resident is transferred to the hospital, they send with them a face sheet, orders, and labs. Then she showed the surveyor in her computer what she was sending. On April 9, 2025, at 1:30 PM V21 (RN) stated when a resident is transferred to the hospital she sends with them a face sheet, physician orders, labs, and any diagnostic exams. The facility's bed hold policy dated October 21, 2021, showed the following: 1. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: a. The rights and limitations of the resident regarding bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer).

Based on interview and record review the facility failed to follow their policy and notify the Ombudsman in writing of resident transfers and discharges to the hospital. This failure has the potential to affect all 83 residents who reside in the facility. The findings include: R12's Face Sheet showed R12 to be [AGE] years old and admitted to the facility on [DATE]. R12's Hospital Transfer Form showed resident was discharged to the hospital on April 5, 2025. On April 9, 2025, at 2:05 PM, V24 (Social Services Director) stated he does not handle the notifying family's and Ombudsman of resident discharges. On April 9, 2025, at 2:08 PM, Surveyor asked V2 (Director of Nursing), Ombudsmen, why do we have to notify them? I'll have to check into that. I'll be honest with you, this is the first time I'm hearing about notifying the Ombudsman, in regard to resident transfers and discharges to the hospital. Later at 4:52PM, V2 verified that the facility has not been notifying the Ombudsman of resident transfers/discharges to the hospital. V2 stated she has been working at the facility for a year and she is not aware of the facility notifying the Ombudsman when a resident is transferred/discharged to the hospital. On April 9, 2025, at 3:38 PM V35 (Ombudsman) stated that she was not receiving discharge/transfer notification from the facility. V35 stated she checked her records as far back as December 2024 and she has not received any bed hold notifications from the facility. The facility's process for Reporting Resident Out of the facility to the Ombudsman policy showed the following: The facility will notify the Ombudsman of any resident who leaves the facility under the following circumstances: unplanned discharges, including hospitalization where return is uncertain. All communication with the Ombudsman must be documented in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure each resident had a comprehensive care plan that outlined each residents' care needs accurately. This applies to 4 of 18 residents (R26, R27, R29, and R59) reviewed for care plans in the sample of 18. The Findings include: 1. R27's admission record showed R27 was admitted to the facility on [DATE], with multiple diagnosis including chronic atrial fibrillation, morbid obesity, sepsis unspecified organism, and benign prostatic hyperplasia with lower urinary tract symptoms. R27's MDS (Minimum Data Set) dated February 5, 2025, showed R27 was moderately cognitively impaired, and was dependent on staff assistance for toileting, bathing, dressing, bed mobility and transfer and had an indwelling urinary catheter and always incontinent of bowel. On April 7, 2025, at 11:03 AM, R27 was observed with urinary catheter tubing draining into a drainage bag. On April 9, 2025, V31 (Staffing Coordinator) provided a list of residents who needed 2 staff assist for incontinence care. R27's name was on that list. R27's care plan initiated on November 8, 2024, and revised on December 7, 2024, showed that R27 focus continence showed the resident is occasionally incontinent of bladder and continent of bowels due to which was left blank. The continence care plan intervention dated November 24, 2024, showed empty urinal as needed. There was no care plan for the use of, care for, maintenance or prevention of infection for R27's indwelling urinary catheter. There was no care plan to address R27's dependence on staff assistance for ADL care for bathing, dressing, bed mobility and transfer. 35267 2. R59's Face sheet, dated April 9, 2025, shows R59 was admitted to the facility on [DATE], and her diagnoses included pulmonary embolism, malignant neoplasm of bronchus or lung, weakness, diabetes, protein-calorie malnutrition, vascular dementia, congestive heart failure, chronic kidney disease, and need for assistance with personal care. On April 8, 2025, at 12:37 PM, V12 (Wound Nurse) stated R59 had a facility-acquired pressure injury that was assessed as an unstageable right plantar DTI (Deep Tissue Injury). V12 stated R59 had the pressure injury for months which was caused by her sitting position in her chair. V12 stated R59 was being treated with betadine and a gauze island twice a week. On April 8, 2025, at 12:33 PM, V10 (Licensed Practical Nurse) stated she was unaware of any pressure ulcer related to R59. Initial Wound Evaluation & Management Summary, dated February 25, 2025, shows R59 was identified to have a wound on her right plantar foot. Wound Evaluation & Management Summary, dated April 8, 2025, shows R59's pressure ulcer measured 1.8 cm by 2 cm and the depth was not measurable. The wound was described as an unstageable DTI with intact skin with no exudates. The plan of care recommendations show R59's wound was to be off-loaded. POS (Physician Order Sheet), dated January 1, 2025, to April 30, 2025, shows R59's physician orders included: - Offload boots to be worn while in chair and during bedtime three times a day for DTI (ordered February 26, 2025) - Bottom lateral foot: Monitor and cleanse wound with NSS (Normal Saline Solution), apply betadine and cover with dry dressing two times a week one time a day every Tues, Fri for wound care (ordered February 18, 2025, and revised February 26, 2025) - Right plantar foot: Cleanse wound with NSS, apply betadine and cover with dry dressing two times a week. One time a day every Tuesday, Friday for wound care (ordered February 26, 2025, and revised April 5, 2025) - Infection precautions enhanced barrier secondary to wounds (ordered March 27, 2025) Care plan, initiated October 11, 2024, and reviewed April 8, 2025, showed R59 had the potential for impairment to skin integrity related to incontinence, the diagnosis of diabetes, and impaired mobility. R59's intervention, dated October 11, 2024, included providing a pressure reducing mattress on bed. The care plan fails to show any pressure relieving interventions implemented to prevent the development of a pressure injury on her lower extremities while sitting in her chair. The care plan also failed to show interventions for her diagnosed pressure injury, or the implementation of enhanced barrier precautions related to her wound. Pressure Injury Prevention and Management Policy, undated, shows, Care Plans: 1. A resident centered care plan will be developed and implemented to address the resident's risk for development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury 3. Face sheet, dated April 9, 2025, shows R29 was admitted on [DATE], and R29's diagnoses includes bipolar disorder and major depressive disorder. Psychiatric note, dated January 23, 2025, shows R29 had diagnoses include major depressive disorder, bipolar disorder, insomnia, and unspecified psychosis. The psychiatric plan showed R29 was to continue current management utilizing clonazepam, lurasidone, Seroquel, melatonin and quetiapine. POS, dated April 9, 2025, shows R29 was receiving Seroquel, Lyrica, Clonazepam, melatonin and Quetiapine daily. On April 9, 2025, at 11:32 AM, V41 (Psychiatric Nurse Practitioner) stated R29 was prescribed lurasidone for his bipolar disorder, Seroquel for his depression and bipolar, and clonazepam for seizures and anxiety. Care plan initiated/revised March 21, 2025, shows R29's no care plans addressing R29's diagnoses of bipolar disorder, depression, anxiety, or his use of psychotropic medications. 45303 4. The EMR (Electronic Medical Record) showed R26 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, ventricular tachycardia, and arthritis. R26's MDS (Minimum Data Set) dated March 7, 2025, showed R26 had moderate cognitive impairment. As of April 9, 2025, at 9:32 AM, R26's care plan did not include a care plan for Alzheimer's disease or dementia care including R26's dementia care needs or individualized interventions related to R26's symptomology. On April 9, 2025, at 9:36 AM, V24 (Social Services Director) said he conducts care plan meetings along with nursing and therapy. V24 said R26's comprehensive care plan was completed on March 14, 2025. V24 said R26's Alzheimer's disease diagnosis should have been discussed at the care plan meeting. V24 said R26's care plan should have included an Alzheimer's disease care plan. The facility's undated policy titled Care Planning- Comprehensive Person-Centered showed, Policy: A baseline care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission. A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process . Specific Procedures/Guidance: .2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument process . 13. The comprehensive care plan will: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Be culturally competent and trauma-informed as applicable; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Promote resident safety; i. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and j. Reflect currently recognized standards of practice for problem areas and conditions .

Based on observation, interview, and record review, the facility failed to timely revise the care plan with specific fall-prevention interventions for a cognitively impaired resident that required staff assistance. This applies to 1 of 1 resident (R34) reviewed for fall-related accidents in a sample of 18. The findings include: The EMR (Electronic Medical Record) shows that R34, a [AGE] year-old with diagnoses of dementia, psychosis, anxiety disorder, major depressive disorder, age related physical debility, repeated falls, unsteadiness of feet, difficulty walking, need of assistance with care, hyperlipidemia, Vitamin D deficiency, hypothyroidism, and chronic kidney disease. R1 was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] showed that R34's cognition was severely impaired with BIMS (Brief Interview Mental Status) score of 0/15. The MDS documents that R34 required substantial to maximum assistance from staff during wheelchair transport in the corridor or similar places. On April 7, 2025 at 10:30 A.M., R34 was seated in her wheelchair in the corridor. R34 was observed with a dark blue bruise on the forehead, entire right side of her face and lower orbital area of the right eye. R34 was not interviewable and not able to verbalize how she acquired the bruise. R34 noted to be anxious and was pacing back and forth from outside and inside her room. V10 (LPN/Licensed Practical Nurse) was present during this time. V24 said that R34 sustained the bruise from a fall incident that occurred on March 15, 2025, while being transported by CNA using a wheelchair without the use of wheelchair leg rests. V24 also said that R34 was anxious and must not be feeling comfortable from the facial bruise. The facility's incident report dated March 15, 2025 showed: CNA (Certified Nurse Assistant) was transporting (R34) to the dining room, for lunch when (R34) foot got caught underneath the wheelchair, (R34) slid out of the wheelchair and landed on her side hitting her head .911 called . hematoma forehead. The nurse's progress notes March 15 ,2025 at 1:19 P.M., showed CNA was transporting (R34) to the dining room for lunch when (R34) foot got caught underneath the wheelchair, (R34) slid out the wheelchair and landed on her right side hitting her head.BP 102/58 HR 103 R 18 T 96.9. NOD (Nurse on Duty) help CNA assist (R34) back to wheelchair and to her room. 911 called and .transport (R34) to .hospital for evaluation. Review of R34's EMR including the fall incidents and care plan-initiated February 23, 2023 showed prior falls on February 23, May 26, July 5, July 26, September 20, and September 27, 2024. Despite this history, the care plan lacked specific, updated interventions and no root cause analysis was conducted after each fall to address contributing factors. On April 9, 2025, the Acting Director of Nursing (V2) validated that the March 15, 2025, fall had not prompted a care plan revision and that no root cause analysis or targeted prevention measures had been implemented.

Based on interview and record review, the facility failed to refer a resident with a new mental health diagnosis for a level II PASRR (Preadmission Screening and Resident Review). This applies to 1 of 2 residents (R19) reviewed for PASRR in the sample of 18. The findings include: The EMR (Electronic Medical Record) showed R19 was admitted to the facility on [DATE], with admitting diagnoses including major depressive disorder, anxiety disorder, and seizures. The EMR continued to show R19 was diagnosed with unspecified psychosis not due to substance or known physiological condition on October 5, 2024. R19's Active Order Summary Report dated April 9, 2025, showed R19 had the following active medication orders: olanzapine (antipsychotic) oral tablet 10 mg (milligrams), give one tablet by mouth at bedtime related to major depressive disorder; and venlafaxine extended-release oral capsule 150 mg, give one capsule by mouth one time a day related to major depressive disorder. On April 9, 2025, at 8:50 AM, V26 (Admissions Coordinator) said she is responsible for submitting the level I PASRR for residents if it was not completed prior to admission to the facility. V26 said she has never submitted a re-screening for a resident's level I PASRR if the resident received a new mental health diagnosis. On April 9, 2025, at 9:42 AM, V24 (Social Services Director) said he has nothing to do with PASRRs for residents. V24 continued to say he is not able to log into the website to conduct PASRRs. V24 said the admissions department is responsible for PASRRs. On April 9, 2025, at 12:19 PM, V2 (DON/Director of Nursing) said R19 must have been diagnosed with psychosis because she had new behaviors at that time. V2 said V2 does not have anything to do with PASRRs. R19's Notice of PASRR Level I Screen Outcome dated October 23, 2023, completed by V26 (Admissions Coordinator) showed . Ascend Outcome: Level I Outcome: No Level II Required- No Serious Mental Illness/Intellectual Disabilities/Related Conditions. Rationale: The Level I screen indicates that a PASSR disability is not present because of the following reason: There is no evidence of a PASRR condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. The facility does not have documentation to show R19 had a rescreening completed when R19 was diagnosed with psychosis. The facility's undated policy titled Long-term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy, showed .Policy: The organization observes preadmission screening requirements to ensure that: Medicaid-eligible individuals meet required level of care criteria for Long-term Services and Supports; People with known or suspected mental illness, intellectual disabilities, and/pr related conditions are not appropriately institutionalized or marginalized; to make sure that every individual receives the services and supports that will optimize their success in the least restrictive setting; Residents with these specific types of disabilities are admitted or allowed to remain in the facility, only if the facility can provide them with the services they need . 5) Signification Change in Condition: a. Additional Resident Reviews will be performed whenever there is: i. Resident with a previously negative level I screen who demonstrates new symptoms or possible mental illness, intellectual disability, or related condition. b. The facility will respond to a significant change in condition, or onset of new symptoms indicated by doing the following within 14 days: i. Notifying the PASRR authority .

Based on interview and record review, the facility failed to provide restorative services to a resident per facility policy. This applies to 1 of 1 resident (R29) reviewed for restorative services in the sample of 18. The findings include: On April 7, 2025, R29 stated he did not receive restorative therapy and would like to be receiving it. On April 8, 2025, at 12:13 PM V10 (Licensed Practical Nurse) stated she had not seen R29 receiving any restorative therapy. On April 8, 2025, V11 (Rehabilitation Manager) stated R29 was not receiving skilled therapy services because during his initial assessment R29 was evaluated to be at his prior level of functioning. R11 stated the therapy department did recommend R29 receive restorative therapy to be provided by the facility. V11 stated a referral was provided to V2 (Director of Nursing) for R29 to receive restorative therapy. On April 8, 2025, at 3:16 PM, V2 (Director of Nursing) stated she was not aware R29 was provided a referral for restorative therapy and R29 was not receiving restorative therapy. V2 also stated when the facility did not have enough staff, the facility CNAs (Certified Nursing Assistants) did not provide restorative therapy. Rehabilitation and Restorative Nursing Program document shows It is the policy of this facility that all residents will be screened for restorative care: 1. As terminated off active therapy, 2. When there is a significant change in status, 3. Quarterly with assessment progress, 4. On referral from nursing on therapy.

Based on observation and interview, the facility failed to provide nail care to residents who are dependent on staff assistance with ADLs (Activities of Daily Living). This applies to 3 of 3 residents (R44, R47, R485) in the sample of 18. The findings include: 1. R485's admission record showed R485 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis of left dominant side following cerebral infarction, cardiomegaly and dysphagia. R485's MDS (Minimum Data Set) showed R485 was moderately cognitively impaired and needed assistance with ADL's including supervision/light touch assistance with eating and oral hygiene, substantial assistance with bed mobility and dependent on staff for personal hygiene, bathing, toileting, dressing and transfer. R485 had mobility impairment to her left arm and left hand. On April 8, 2025, at 12:05 PM, R485's right hand was observed with all fingernails long and black/brown/yellow colored debris underneath the nails. R485 stated she would like her nails to be cleaned and trimmed. V28 (LPN) made aware of R485 request for nail care. 15845 2. On April 4, 2024 at 10:30 A.M., R44 was seated in his wheelchair in the main dining room. R44 was in the group of activities that was ongoing. R44 was observed with long, jagged edge fingernails. The fingernails were embedded to R44's inner palm of his contracted left hand. The same observation was observed regarding R44' fingernails on April 8, 2025 at 1:07 P.M. During this time of observation, V3 (LPN/Licensed Practical Nurse) was present. The care plan that was initiated on December 31,2024 showed that R44 was identified with self-care deficit due to left hemiplegia, due to CVA (cerebral vascular accident) depression, ADHD (attention deficit hyperactivity disorder), anxiety, hypothyroidism, and hypertension. The care plan also showed that R44 required total assistance from staff for ADLs (Activities of daily Living) such as hygiene and personal care. 3. On April 4, 2024 at 11:00 A.M., R47 was seated in his wheelchair in his room. R47 was observed with long, jagged edge fingernails. The fingernails were embedded to R47's inner palm of his contracted left hand. During this observation, V4 (RN/Registered Nurse) was present. On April 8, 2025 at 11:30 A.M., R47 was sitting in his wheelchair in his room. R47's fingernails remained long, jagged edges with black substance under the nails. V3 was present during this observation. The care plan that was initiated on July 30, 2022 showed that R47 was identified with self-care deficit due to left hemiplegia, left hemiparesis due to CVA, diabetes mellitus, and anxiety disorder. The care plan also showed that R47 required total assistance from staff for ADLs (Activities of Daily Living) such as hygiene and personal care. Both residents had care plans identifying self-care deficits related to left hemiplegia from cerebrovascular accidents and other medical conditions. Each required total staff assistance with hygiene and personal care, yet their fingernails were untrimmed, compromising comfort and hygiene. The facility's undated policy regarding Fingernails/Toenails showed: The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Routine nail care must be performed by nursing staff and or qualified activity team members. 3. Nail care includes daily cleaning and regular trimming. 4. Proper nail care can aid in the prevention of skin problems around nail bed. 7. Trimmed and smooth nails to prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review, the facility failed to provide interventions, and failed to prevent further decrease in ROM (Range of Motion) and failed to provide positioning device for residents with hand contractures. This applies to 2 of 5 residents (R67 and R485) reviewed for limited range of motion in the sample of 18. The findings include: 1. R67 admission record showed R67 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following non traumatic intracerebral hemorrhage affecting the left non dominant side, dysphagia, unspecified mood disorder, neuralgia and neuritis, and gastrostomy status. R67's MDS (Minimum Data Set) dated January 7, 2025, showed that R67 was cognitively intact and was dependent on staff assistance for eating through a feeding tube, bathing, toileting, dressing, bed mobility and transfer. On April 8, 2025, at 1:27 PM, R67 was lying in bed and her left hand was contracted in flexion. R67 wrote on her paper with her right hand, I have a splint when asked about the positioning for her left hand. V28 (LPN) was present and looked for the splint in R67's room but did not find a splint for R67's left hand. R67 demonstrated using her right hand she could only partially extend her thumb, index and middle finger and the 4th and 5th digit were difficult to extend. V11 (Rehabilitation Director) provided R67's Physical Therapy discharge recommendations dated August 15, 2024, for date of service range from July 5, 2024, through August 15, 2024. V11 stated R67 did not receive any Occupational Therapy while in the facility. The Physical Therapy discharge recommendation showed only a restorative transfer program using a full mechanical lift was recommended. R67's care plan dated January 29, 2025, for functional maintenance identified R67 had limited range of motion on her left side however interventions did not specify which joints would need either PROM, (Passive Range of Motion), or AAROM (Active Assisted Range of Motion) or how many repetitions of exercise each joint should receive or what positioning device should be used for R67's left hand to prevent further contractures. 2. R485's admission record showed R485 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis of left dominant side following cerebral infarction, cardiomegaly and dysphagia. R485's MDS (Minimum Data Set) dated showed R485 was moderately cognitively impaired and needed assistance with ADL's including supervision/light touch assistance with eating and oral hygiene, substantial assistance with bed mobility and dependent on staff for personal hygiene, bathing, toileting, dressing and transfer. R485 had mobility impairment to her left arm and left hand. On April 7, 2025, R485 was lying in bed and her left hand was noted with a flexion contracture. R485 stated she was supposed to have a splint in her left hand, but she doesn't have one. R485's OT (Occupational Therapy) Evaluation and Plan of Treatment dated March 26, 2025, showed R485's LUE (Left Upper Extremity) had a contracture. The OT Evaluation showed No, OT will not treat to address contracture and showed Nursing is managing the contracture. R485's care plan initiated on March 20, 2025, did not address any intervention for decreased range of motion and need for positioning device for the left-hand contracture. On April 8, 2025, at 3:03 PM, V1 (Administrator) stated they have a functional maintenance program, instead of a restorative program and that V2 is responsible to oversee that program. On April 8, 2025, at 3:23 PM, V2 (DON) stated R67 and R485 should have positioning devices or splinst to prevent further contractures and would refer them to therapy for an evaluation. The facility's policy titled Resident Mobility and Range of Motion undated, showed Policy 1. Residents will not experience an avoidable reduction in range of motion ROM .2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM .3. Residents with limited range of motion will receive the appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .Specific Procedures .1. As part of the resident's comprehensive assessment the licensed nurse may identify the residents .c. limitations in movement or mobility .2. As part of the comprehensive assessment the licensed nurse may also identify conditions that may place the resident at risk for complications .including .e. contractures .4. The care plan will be developed by the interdisciplinary team based on comprehensive assessment .6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice .

Based on interview and record review, the facility failed to provide safe transfer assistance. This failure resulted in R1 sustaining left and right femoral fractures. This applies to 1 of 3 residents (R1) reviewed for safe transfers. Findings include: R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old with diagnoses to include a right and left periprosthetic fracture around both artificial knee joints, dementia and physical disability. On 05/02/2024 at 11:18 AM, V13 Hospital staff stated Before these fractures, (R1) could not bear weight, she was contracted and unable to stand up on her own. She was bedbound. On 04/30/2024 at 02:17 PM, V9 Certified Nursing Assistant (CNA) stated That morning I got (R1) up out of bed like I always do. I put my arms under her armpits and did the pivot transfer. I felt her become dead weight then. Her knee seemed like it was swelling. I told the nurse (V6 Licensed Practical Nurse [LPN]). Then I took her down to the shower room and gave her a shower. The other knee was starting to swell up then, so I made sure the nurse knew what was going on. On 04/30/2024 at 11:00 AM V6 LPN stated (R1) is a one person assist for transfer. She's a pivot transfer. We don't always use a gait belt; it seems to cause (R1) pain when we do. We just put our hands under her arm pits and transfer. The Final Report to Illinois Department of Public Health dated 04/22/2024 documents under Summary CNA stated 'When I got to the room to get the resident up to the shower room, the resident was transferred by placing both arms under the patient's armpits to pivot and transfer.' The CNA stated she felt patient dead weight and sat the resident down in wheelchair. The CNA noticed when putting the gown on the resident, there was swelling observed to the left knee and the resident stated that there was pain to the left knee also. Under Summary of the Investigation, it documents All the staff from the day before (04/21/2024) stated they did not notice any swelling to the left or right knee. Xray's bilateral legs were ordered. The results stated there were fractures to both legs. The Radiology Results Report for R1 dated 04/22/2024 at 01:00 and 01:13 PM document under Findings: Right knee- There is an acute versus subacute comminuted fracture of the distal femur, immediately proximal to the distal femoral prosthesis with angulation. Left knee- There is an acute distal femoral shaft fracture, located immediately adjacent to the prosthetic femoral component of total knee replacement, which remains in anatomic alignment. The care plan for R1 dated 09/02/2023 and reviewed 03/05/2024 documents Transfer : The resident requires (SPECIFY what assistance) by (X) staff to move between surfaces (SPECIFY FREQ) and as necessary. Date Initiated: 09/02/2023 Revision on: 10/07/2023; which was incomplete and did not specify R1's individualized transfer needs. On 05/02/2024 at 10:45 AM, V2 Director of Nursing stated Transfer status is determined by the physical therapist. We monitor the residents everyday. The staff will notify nursing if a resident has a change in ability so the resident's transfer status can be reassessed. That information is then used in the care plans. The care plan for (R1) isn't updated. That is why there is no direction for transfers. On 05/01/2024 at 02:30 PM, V5 Physical Therapist stated The gait belt should always be used for every transfer. Anything else is not a safe transfer. On 05/01/2024 at 11:25 AM, V4 Medical Director stated (R1) has a lot of medical issues and has declined recently. She is very contracted on both legs. The injury may be the result of a forceful transfer. The undated Activities of Daily Living policy documents under Mobility (transfer and ambulation, including walking) i. Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan

Based on observation, interview, and record review, the facility failed to ensure residents identified as being at risk for pressure ulcers were provided interventions to prevent the development of facility-acquired pressure ulcers. The facility also failed to follow their policy for documentation and assessment of the facility-acquired pressure ulcers and implement new interventions to promote healing and prevent the further development of additional pressure ulcers. This failure resulted in R2 developing a facility-acquired Stage 2 pressure ulcer to the left outer ankle. This applies to 2 of 3 residents (R1, R2) reviewed for pressure ulcers in the sample of 7. The findings include: 1. The EMR shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), hypertension, muscle weakness, weakness, protein-calorie malnutrition, heart failure, chronic kidney disease, and glaucoma. R2's MDS dated [DATE] shows R2 has moderate cognitive impairment, requires supervision with eating, extensive assistance with bed mobility, dressing, and personal hygiene, and is totally dependent on facility staff for toilet use and bathing. R2 is always incontinent of bowel and bladder. R2's MDS continues to show R2 is at risk of developing a pressure ulcer and did not have a pressure ulcer at the time of the MDS assessment. R2's care plan, initiated July 30, 2022 shows R2 has the potential for impaired skin integrity related to impaired mobility, incontinence, prefers to stay in bed. As of April 17, 2023, R2's care plan was not updated to show interventions for R2's left lateral foot pressure ulcer and buttocks pressure ulcer. The EMR shows a physician order dated December 7, 2022 for CNA (Certified Nursing Assistant) to assist resident up in the wheelchair between 0700 (7:00 AM) - 930 (9:30 AM) every day. Nurse to document if patient refuses. The order is not shown on the MAR (Medication Administration Record) or TAR (Treatment Administration Order) to ensure facility nursing staff have a place to document acknowledgement of the order or R2's refusal. The facility does not have documentation to show R2 was assisted to the wheelchair daily or that the resident refused to get up to the wheelchair. On April 17, 2023 at 9:45 AM, R2 was sitting up in bed. R2's bilateral feet were resting on the bed, with his bilateral heels and the left lateral side of his foot resting on the mattress. A pair of foam boots were noted to be on the wheelchair near R2's bed. On April 17, 2023, at 11:30 AM, R2 was sitting up in bed with his heels and lateral side of his left foot resting on the mattress. V11 (RN) said R2 prefers to stay in bed and always stays in the same position in his bed. R2's foam boots were noted to be on R2's wheelchair across the room. On April 17, 2023 at 2:45 PM, R2 was sitting up in bed with his bilateral heels and lateral side of his left foot resting on the mattress. On April 18, 2023 at 10:52 AM, R2 was sitting up in his bed. V16 (CNA-Certified Nursing Assistant) and V17 (CNA) provided incontinence care to R2. R2's incontinence brief was soaked with urine. V16 and V17 said the folded sheet under R2's buttocks and the bed sheet were soaked with urine, approximately 6 to 8 inches from R2's left side. A strong urine odor was present, and the sheets had a dark brown dried ring around the urine-soaked area. A dressing covered a wound on R2's buttocks. On March 10, 2023 at 3:59 PM, V11 (RN) documented, .Writer also noted a wound on his left mid, lateral foot. Wound nurse and MD made aware. The facility does not have documentation to show R2 was seen by the wound care physician for the left lateral wound until April 18, 2023. The EMR shows an order dated March 10, 2023 to paint betadine to left medial lateral heel daily and as needed. The facility does not have documentation to show the wound care was administered on March 14 and 19, 2023. The order was discontinued on March 22, 2023. The EMR shows an order dated March 22, 2023 to paint left medial lateral (no site specified) daily and as needed every day shift for wound. The facility does not have documentation to show the wound treatment was administered on March 23, 27, 28, 29, 2023 and April 1, 6, and 9, 2023. On April 18, 2023 at 11:03 AM, V18 (Agency RN) was asked if she provided wound care to R2's left lateral foot. V18 said, I am from agency. I didn't even look at the TAR. That's up to the wound nurse. On April 18, 2023 at 11:10 AM, V15 (Wound Care Physician) and V3 (Wound Care Nurse) provided wound care to R2. V3 lifted R2's left leg from the bed to visualize R2's left lateral foot (outer foot) pressure ulcer. A second wound was visible on R2's left outer ankle. V3 and V15 did not acknowledge the presence of the ankle wound and did not assess the ankle wound. V3 set R2's leg down on the bed. This surveyor asked V3 if she was aware of a wound on R2's left ankle and V3 said no. This surveyor asked V3 and V15 to re-examine R2's left lateral leg. V3 lifted R2's left leg from the bed a second time, and V15 identified a Stage 2 pressure ulcer on R2's left outer ankle. V15 said the wound on R2's ankle is a Stage 2 pressure ulcer. V3 (Wound Care Nurse) said the wound on R2's left ankle is a newly developed, facility-acquired pressure ulcer as of April 18, 2023 and she was not aware of the pressure ulcer. R2 was turned to his left side. A pressure ulcer was visualized on R2's buttocks. V3 (Wound Care Nurse) continued to say the pressure ulcers on R2's buttocks and left lateral foot are facility-acquired pressure ulcers. V15 said, The wound on R2's left ankle is a Stage 2 pressure ulcer. The wound on his buttocks is a DTI (Deep Tissue Injury). They need to get a low air loss mattress for this resident. Pressure is the cause of his wounds, and if he is not being moved from that position or wearing the foam boots, then floating his feet with a pillow is the best option for him, especially if he refuses the boots. They need to change his position. V15 continued to say R2 was not referred to him to be seen for the pressure ulcer identified on R2's left lateral foot on March 10, 2023, and this was his first assessment of R2's current pressure ulcers. V15 said, If they do not put the residents on a referral list for me to see, then I do not know about the wounds and I do not see the residents. V15's (Wound Care Physician) progress note dated April 18, 2023 shows the following wound documentation: Site #1: Unstageable DTI of the left buttock partial thickness, Etiology: Pressure. Wound size: 2 x 2 x not measureable cm. Recommendations: Off-load wound, turn side to side in bed every 1-2 hours if able; low air loss mattress. Site #2: Stage 2 pressure wound of the left, lateral ankle partial thickness. Etiology: Pressure. Wound size: 0.8 x 0.8 x not measurable cm. Recommendations: Off-load wound, pressure off-loading boot, float heels in bed. Site #3: Stage 2 pressure wound of the left lateral foot, partial thickness. Etiology: Pressure. Wound size: 1.0 x 0.8 x not measurable cm. Recommendations: Off-load wound, pressure off-loading boot, float heels in bed. On April 18, 2023 at 1:26 PM, R2 was sitting up in bed eating lunch. R2's bilateral heels and the lateral side of his left foot were resting on the mattress. R2's heels were not off-loaded and R2 was not wearing foam boots. 2. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting his right dominant side, dementia, paroxysmal tachycardia, polyneuropathy, seizures, major depressive disorder, anxiety, repeated falls, peripheral vascular disease, chronic atrial fibrillation, right eye blepharitis, anemia, right shoulder pain, insomnia, anxiety, spinal stenosis, and sciatica. R1's MDS (Minimum Data Set) dated March 17, 2023 shows R1 has severe cognitive impairment, is able to eat with supervision, requires limited assistance with bed mobility, and extensive assistance with all other ADLs (Activities of Daily Living). R1 is frequently incontinent of bowel and bladder. R1's MDS continues to show R1 is at risk of developing pressure ulcers and did not have pressure ulcers at the time of the MDS assessment. On April 14, 2023 at 10:02 AM, V11 (RN-Registered Nurse) documented R1 had a right toe open blister measuring 1 cm (centimeter) by 1 cm. The documentation does not show which of R1's right toes had the open blister, or the location of the blister on R1's toe, the stage of the wound, type of tissue, the surrounding tissue description and presence/absence of pain with the pressure ulcer. On April 17, 2023 at 9:45 AM, R1 was sitting up in a wheelchair in his room. R1's wheelchair did not have foot/leg rests in place and R1's bilateral feet were resting on the floor of his room. R1 had bilateral elastic wraps extending from below his knees to each foot. R1 was wearing non-skid socks over the tops of his feet. The non-skid socks did not cover R1's heels, and his bare heels were resting on the floor. R1's bilateral legs appeared swollen from above his knees to his feet. R1 said, I have a sore on my butt and on my toe and it really hurts. R1 continued to say he has felt panicky lately when lying in bed and has spent the last three weeks sitting up in his wheelchair at night. On April 17, 2023 at 9:58 AM, V11 (RN) said R1 should have his legs elevated off of the floor while sitting in the wheelchair. V11 continued to say R1 has preferred to sit up in his wheelchair over the last three weeks due to shortness of breath. V11 said R1 does not have foam boots to offload his feet while sitting in the wheelchair. On April 17, 2023 at 11:30 AM, R1 continued to sit up in his wheelchair with his feet resting on the floor. On April 17, 2023 at 12:17 PM, V2 (DON-Director of Nursing) said, We did not put in new care plan interventions to address [R1's] pressure ulcer. We were aware he was wanting to sit in the wheelchair and refusing to go to bed over the last three weeks. We did not put interventions in place to prevent a pressure ulcer while he continued to sit up in the wheelchair. On April 18, 2023 at 8:50 AM, R1 was sitting in a wheelchair in his room eating his breakfast. R1's bilateral feet were resting on the floor. A new recliner chair was present in R1's room. R1 said, I have not tried to the recliner yet. On April 18, 2023 at 11:28 AM, V3 (Wound Care Nurse) and V11 (RN) transferred R1 from the wheelchair to his bed to provide wound care. V3 removed the bilateral elastic wraps from R1's lower legs. R1's legs appeared swollen from above his knees to the tips of his toes. His bilateral lower legs were red, with the right lower leg appearing redder than the left lower leg. R1 complained of pain on his right heel. V15 (Wound Care Physician) provided wound care to R1's right great toe. V15 was able to obtain bilateral pulses in R1's feet using a doppler device. V15 said the wound on R1's toe is a Stage 3 pressure ulcer and the wound required debridement. V15 continued to say, The biggest issue for this resident is incontinence and pressure. Also, the fact that he wants to sit in his wheelchair. A recliner will definitely help him offload his feet, or if he would be able to lay in bed for a while and offload his feet. V3 (Wound Care Nurse) turned to V15 and asked if R1's wound treatment should be administered three times a week. V15 said, No. [R1's] pressure ulcer treatment to his right great toe should be administered daily. The EMR shows the following order entered by V3 (Wound Care Nurse) for R1, dated April 18, 2023 at 11:57 AM: Right big toe wound: Cleanse with NS (Normal Saline), pat dry and cover with leptospermum honey, calcium alginate and island dressing every day shift every Tuesday, Thursday, Saturday. On April 18, 2023, V15 documented the following regarding R1's pressure ulcer: Stage 3 pressure wound of the right, first toe, full thickness. Etiology: pressure. Wound size (Length x Width x Depth): 1 x 1.2 x 0.1 cm. Exudate: Moderate serous. Additional wound detail: Venous and arterial are cofactors. Dressing treatment plan: Leptospermum honey apply once daily for 30 days. Alginate calcium apply once daily for 30 days. Secondary dressing(s): Gauze island with border apply once daily for 30 days. Recommendations: Off-load wound, elevate leg(s). No shoes unless open-toed. Plan of care reviewed and addressed: The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 69 days. This estimate is made with an 80 percent degree of certainty. The facility's undated Pressure Injury Prevention and Management Policy shows: Policy: The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and prevent development of additional pressure ulcer/injury. Evaluation/Assessments: 1. Evaluation/assessment of pressure ulcer/injury will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner. 2. Documentation of the evaluations/assessment of the pressure ulcer/injury will be maintained in the resident's medical record. Documentation may include a. Location of ulcer/injury. b. Date that the ulcer/injury was acquired (when known). C. Description of the ulcer/injury to include stage, measurements (length, width, depth), presence/absence of any tunneling or undermining, type of tissue (epithelial, granulation, sough, necrosis, etc.), presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the ulcer/injury. d. Treatment and interventions to promote healing. Treatment Protocols: 1. Treatments will be ordered by the physician/practitioner.5. Treatments, including preventive interventions, will be documented in the resident's medical record. 6. The physician/practitioner will be notified of the resident's refusal of prescribed treatments and/or interventions for prevention and care. Investigations: 1. If the resident develops a facility-acquired or worsening pressure ulcer/injury, the facility will conduct an investigation to causative factors. 2. Interventions to promote healing the acquired or worsening pressure ulcer/injury and to minimize recurrence of development will be incorporated into the resident's care plan.

1. Based on interview, and record review, the facility failed to ensure a resident's treatment for her stage IV pressure ulcer was completed as ordered, failed to ensure ongoing assessment and monitoring was done for the pressure ulcer, and failed to ensure the Wound Physician referral was carried out. These failures resulted in R1 being discharged to the hospital on 3/24/23 with a change in condition and a subsequent diagnosis of osteomyelitis to her stage IV pressure ulcer on her right heel. This applies to one of three residents (R1) reviewed for pressure ulcers in the sample of six. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/8/23 when facility staff stopped providing treatments to the pressure ulcer on R1's right heel and stopped completing and documenting wound assessments for R1's right heel Stage IV pressure ulcer. V1 (Administrator) was notified of the Immediate Jeopardy on 4/7/23 at 8:55 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 4/7/23; however, the facility remains out of compliance at a Level Two due to additional time needed to evaluate the effectiveness of the training for the implementation of pressure ulcer assessment, monitoring, documentation, and completion of physician-ordered treatments. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE] and discharged on [DATE]. On 4/1/23 at 9:53 AM, V4 (R1's Son) stated R1 had a pressure ulcer to her right heel that started in August 2022 at another facility. R1 had a stroke, went to the hospital and then to another rehab facility. R1 received treatment for her right heel wound at that facility and it improved, and she eventually transferred to this facility. V4 stated he received a call from the facility that R1 was unresponsive and had to go to the hospital. V4 stated when he got to the hospital, the Doctor lifted the cover over R1's feet and there was an awful odor, and the Doctor said the odor was from R1's heel wound. V4 stated the Doctor also told him R1 came in without a dressing on her right heel. V4 stated the boot for R1's right heel had discharge and blood in it and the Doctor told him that R1's pressure ulcer wound looked as if it had not been taken care of. V4 stated an MRI (Magnetic Resonance Imaging) was done that showed the wound to her right heel was infected to the bone. V4 stated the Doctor told him the infection had left R1 with three options: the first option would be surgery, but due to being [AGE] years old it was not advised because she would probably not survive; the second option would be intravenous antibiotics for 6 weeks, but her kidneys would not take that; or the third option would be to put R1 on hospice to die. V4 stated R1 was on hospice and dying. R1's 3/1/23 Interdisciplinary Discharge Summary from her previous facility showed that on 2/22/23, R1 was seen by a physician for her right heel stage IV pressure ulcer with noted improvement. R1's treatment was changed to include silver alginate, and R1 was to follow up with the physician in one week (3/1/23, day of admission). R1's 3/1/23 Admission Skin Integrity form showed she had a stage 4 pressure injury to her right heel, and no assessment of the pressure injury was documented. R1's 3/1/23 pressure ulcer risk assessment showed she was at high risk for pressure ulcers. R1's 3/2/23 Physician's Progress Note showed the presence of a right heel wound and a left heel deep tissue injury, and the facility should elevate R1's heels in bed, obtain a wound care consult, and continue dressing changes as ordered. R1's Physician Order's for her right heel pressure ulcer (effective 3/1/23, printed 4/1/23) showed a treatment order for Dakin's solution to be applied to the right heel pressure ulcer topically on day shift on Monday, Wednesday, and Friday. The right heel was to be cleansed with the solution, rinsed with saline and patted dry, and then calcium alginate with silver applied and covered with a gauze island dressing. R1's orders showed the treatment could also be applied as needed. R1's March 2023 TAR (Treatment Administration Record) reflected entries for the same orders; one entry for a scheduled treatment every Monday, Wednesday, and Friday, and a separate entry for the same as needed order. R1's TAR showed the scheduled treatment order entry was never signed off as completed, and instead showed four entries of 9 (on 3/8, 3/10, 3/13, and 3/15). The legend on the TAR showed 9 = Other/See Progress Notes; however, R1's progress notes from those dates do not contain information regarding R1's stage IV pressure ulcer or her treatment. This same entry on the TAR also showed R1's scheduled order was discontinued on 3/15/23. The as needed treatment entry on R1's TAR showed the treatment was completed twice, and last completed on 3/7/23, the same day the entry showed that it was also discontinued. R1's March 2023 MAR (Medication Administration Record) again reflected the same order, and the entry was signed off as completed one time in March on 3/3/23. The MAR showed the treatment was also discontinued on 3/7/23. R1's March 2023 TAR and MAR showed no treatments were done for R1's right heel stage IV pressure ulcer after 3/7/23 (for 17 days), until she was hospitalized on [DATE]. R1's March 2023 Physician Orders showed orders were good for 30 days unless otherwise noted, did not show that her right heel pressure treatment orders were discontinued, nor did they include Wound Care consult referral. R1's 3/9/23 Weekly Wound Assessment (8 days after admission) showed the admitted stage IV pressure injury to her right heel with 100% granulation tissue present in the wound. The right heel pressure ulcer (in centimeters -cm) measured 2.5 x 3.4 x 0.1 cm. This was the last Weekly Wound Assessment documented for R1's stage IV pressure ulcer in her medical record; no other documented assessments were found for R1's right heel for the next 15 days prior to R1's hospitalization on [DATE]. On 4/5/23 at 1:40 PM, V2 DON (Director of Nursing) verified that R1's 3/9/23 Weekly Wound Assessment was the last assessment in R1's medical record for R1's right heel pressure ulcer. On 4/5/23 at 3:21 PM, V9 (Nurse Practitioner) stated she saw R1 on 3/2/23 and put in a progress note. V9 stated R1 had a dressing on a wound to her right heel. V9 stated the facility should have put in the order for the Wound Care consult because it was documented in her progress note to get a Wound Care consult and it was the facility's protocol. V9 stated if treatments were not being done for R1's right heel wound, it would lead to deterioration of the wound, foul odor, soiled dressings, and infection, including osteomyelitis. V9 stated R1's wound could have taken 2-3 weeks to deteriorate from the 100% granulation tissue to eschar. V9 stated she reviewed her progress note and treatment order in R1's medical record and stated R1 should have been receiving treatments to her right heel wound on Mondays, Wednesdays, and Fridays. V9 described the R1's pressure ulcer treatment order and stated the treatment order was not discontinued. R1's 3/25/23 hospital Podiatry consult showed .Patient moaning during dressing change . Integumentary: There is a 4 cm diameter pressure ulceration on the posterior aspect of the patient's right heel. Covered with loosened eschar [dead tissue] .mild cellulitis surrounding the wound site . The Findings section of R1's 3/25/23 right heel MRI result from the hospital (from the day after R1's facility discharge) showed .soft tissue defect, skin at the area of the calcaneus [heel]. There is edema in the calcaneus. This is consistent with osteomyelitis . Under Impression the result showed Cellulitis, soft tissue ulcer with osteomyelitis calcaneus . On 4/1/23 at 10:56 AM, V5 LPN (Licensed Practical Nurse/Wound Care Nurse) stated R1 was admitted with the stage IV pressure ulcer to her right heel. The orders were to clean the wound with Dakin's solution, rinse with normal saline, apply calcium alginate and gauze. The treatments were to be done Monday, Wednesday, and Friday. V5 stated R1 came to the facility with these orders, and the treatment orders were to be continued. V5 stated they would not change the treatment unless the wound was deteriorating or not getting better after 2-3 weeks. V5 stated then they would ask the family if the facility could get a consult with their wound care physician. R1's Care Plan initiated on 3/2/23 with revisions on 3/9/23 and 3/17/23 showed she had a stage IV pressure ulcer to her right heel that was present upon admission. Interventions include to administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of the wound perimeter, wound bed and healing progress, report improvements and declines to the Doctor, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor dressing to make sure it is intact and adhering, and report loose dressing to the treatment nurse. On 4/1/23 at 3:20 PM, V5 LPN (Licensed Practical Nurse/Wound Care Nurse) stated if she is not here, the wound treatments still need to be done. V5 stated staff are to follow the treatment orders in the chart and that is why they are there. V5 stated if a dressing is not changed as ordered, the wound could deteriorate and become infected. V5 stated if the provider requests a Wound Care consult, then an order for it should put in. V5's weekly wound round notes showed measurements were done one time for R1 during her stay at the facility. V5 stated the rest of the time, they were just monitoring the right heel. V5 stated she could have missed R1's treatments when she was off with Covid, and added the other nurses are able to do treatments and measurements as well. On 4/1/23 at 4:56 PM, V6 RN (Registered Nurse/Nurse Practitioner) stated when a resident is admitted , a head-to-toe assessment is done and documented. V6 stated any wounds are documented and the Physician is informed. V6 stated an order is obtained for Wound Care to see the resident. V6 stated nurses can measure and describe the wound, but they cannot stage a wound. V6 stated if wound treatments are not done as ordered, the wound can deteriorate, including to the point of infection in the bone and sepsis. R1's 3/24/23 Nurse's Note showed when the nurse went to give R1 a respiratory treatment at 6:00 AM, R1 was very lethargic and could not open both eyes but was responsive to tactile stimuli. The notes showed when the physician was notified, R1 was sent to the emergency room . R1 did not return to the facility. On 4/5/23 at 12:40 PM, V2 DON (Director of Nursing) stated the facility's process for residents with wounds is to get a wound assessment upon admission and document the assessments in the resident's medical record. V2 stated families are notified about the wound. V2 stated if the Wound Care Doctor has a resident on caseload, then their notes are reviewed for the current treatment plan and those are entered as orders. V2 stated if the resident is not being seen by the Wound Care Physician, then orders are obtained from the primary Physician or Nurse Practitioner for a wound care consult. V2 stated if it is documented in the Physician or Nurse Practitioner progress notes that a Wound Care Consult is needed, the nurse will put in an order. V2 stated assessments of wounds and pressure ulcers are to be done weekly and the results documented in the resident's medical record. R1's Face Sheet showed diagnoses of dementia, major depressive disorder, anxiety, congestive heart failure, chronic obstructive pulmonary disease, hypothyroidism, anemia, hypertension, chronic kidney disease, hyperlipidemia, atherosclerotic heart disease, hemiplegia and hemiparesis of the left side. R1's 3/7/23 MDS (Minimum Data Set) showed R1 has moderate cognitive impairment, and bed mobility, toilet use, and personal hygiene occurred only once or twice. This MDS also showed one stage 4 pressure ulcer was present upon admission. The facility's undated Pressure Injury and Management showed the intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries unless clinically unavoidable, and that the facility provides care and services consistent with professional standards of practice to promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible). The policy continued, showing that evaluation/assessment of pressure ulcers/injuries will be completed weekly and with significant change in condition of the ulcer/injury by a licensed nurse and/or practitioner. Regarding documentation, the policy showed documentation of the evaluations/assessment of the pressure ulcer/injury will be maintained in the resident's medical record and may include location of ulcer/injury, date acquired, description to include stage, measurements (length, width, depth), type of tissue (epithelial, granulation, slough, necrosis, etc.), presence/absence and type of drainage, surrounding tissue description, and presence/absence of pain with the ulcer/injury If a referral is made to a wound consultant, a physician's order will be obtained for the referral . Treatments will be ordered by the physician/practitioner . The effectiveness of the pressure ulcer/injury treatment will be evaluated weekly during the weekly evaluation/assessment of the wound . If improvement in the wound is not seen within two weeks, the physician/practitioner will be contacted with the assessment and alternative treatment measure obtained as indicated . The resident centered care plan will be developed and implemented to address the resident's risk for the development of a pressure ulcer/injury and to promote healing if the resident has a pressure ulcer/injury . The first Immediacy Removal Plan provided by the facility on 4/7/23 at 10:00 AM was not accepted and was returned to the facility. The second Immediacy Removal Plan was provided at 12:52 PM and accepted. The Immediate Jeopardy that began on March 8, 2023 was removed on April 7, 2023 when the facility took the following actions to remove the immediacy: The facility wound nurse was educated on 4/6/23 by the Regional Nurse Consultant on facility policies related to pressure injury prevention and management, completing an accurate assessment regarding pressure injuries, and completing weekly wound assessment. In the absence of the wound nurse or wound physician, the facility charge nurses will be responsible for treatments and assessments of wounds. On 4/7/23, the facility's Immediacy Removal Plan showed the Director of Nursing or her designee will ensure that the charge nurses are completing the treatments and assessments of wounds in the absence of the wound nurse or wound physician. On 4/7/23, the facility's Immediacy Removal Plan showed the Director of Nursing or designee will conduct audits of wound treatments and assessments to ensure the charge nurses are completing wound treatments and assessments in the absence of the wound nurse or wound physician. A skin sweep of all residents was completed on 4/6/23. Any resident identified with potential skin concerns have appropriate evaluation, assessment, treatment order, and care plan in place as applicable. All residents have an order in place for weekly skin evaluations for ongoing monitoring. Any resident identified through the skin evaluation triggering for pressure, arterial, surgical, stasis, and diabetic skin issues will have weekly wound assessment complete. Nursing staff were re-educated on facility wound protocol, including the process for ongoing care of existing pressure ulcers, including assessment, monitoring and wound treatment completion by the DON or designee. Remaining nursing staff will not be allowed to return to work after 4/7/23 until the wound education is completed. All new nursing employees will be provided this education upon hire. All agency nursing staff will also be provided this education prior to starting work at the facility. The Medical Director was notified of the alleged deficient practice on 4/6/23. The facility conducted an ad hoc QAPI meeting reviewing the abatement plan on 4/7/23. The QAPI meeting included educational material reviewed with staff, including policies related to pressure injury prevention and management and completing an accurate assessment regarding pressure injuries. The QAPI meeting included the new process of entering orders for weekly ongoing skin evaluations and the necessary weekly wound assessment, if applicable. 2. Based on observation, interview and record review the facility failed to ensure a resident's pressure ulcer treatment was being carried out as ordered. This applies to 1 of 4 residents (R6) reviewed for pressure ulcers in the sample of six. The findings include: On 4/5/23 at 10:26 AM, R6 was in an isolation room, wearing a hospital-type gown that did not cover her while up in her padded wheelchair. R6 was positioned with the right side of her body rubbing on the side of her wheelchair. At 10:31 AM, a skin check was done with V11 CNA (Certified Nursing Assistant) and R6 had a thin, self-adherent dressing to her right hip that was soiled with brown drainage. The dressing was partially rolled back to show an open wound. The dressing was not dated or initialed and no ABD (abdominal) gauze pad covered the self-adherent dressing. R6's April 2023 wound treatment orders showed to apply calcium alginate and collagen sheet to the wound daily, cover with an ABD gauze pad, secure with tape, and offload the wound. R6's April 2023 TAR (Treatment Administration Record) showed the treatment in place was clean R6's right hip pressure ulcer with normal saline, pat dry, apply calcium alginate, and cover with ABD pad. R6's TAR did not include the application of a collagen sheet. Additionally, R6's TAR showed treatments were not signed off daily as being completed on 4/1, 4/2, and 4/4/23. R6's March 2023 TAR R6 showed the treatment in place for March showed the application of calcium alginate, and the wound covered with ABD pad and tape. R6's listed wound treatments for the entire month of March 2023 also did not include the order for a collagen sheet to be applied to the R6's pressure wound. Additionally, R6's March 2023 TAR showed the treatments were not signed off as completed on 3/5, 3/10, 3/14, 3/23 and 3/29. The addition of the collagen sheet for R6's pressure injury treatment was noted in R6's 2/21/23 Wound Physician's Progress Note (43 days earlier). R6's 3/28/23 Wound Physician's Progress Note showed R6 had a stage 4, full thickness pressure ulcer to her right hip. The wound measured (in centimeters -cm) 2 x 3.8 x 1.4 cm depth, with moderate serous drainage, 95 % granulation tissue and 5 % slough present. On 4/5/23 at 12:40 PM, V2 DON (Director of Nursing) stated the facility's process for residents with wounds is to get a wound assessment upon admission and document the assessments in the resident's medical record. V2 stated families are notified about the wound. V2 stated if the Wound Care Doctor has a resident on caseload, then their notes are reviewed for the current treatment plan and those are entered as orders. R6's Face Sheet showed her diagnoses include dementia, hypertension, hyperlipidemia, hypothyroidism, dysphagia, psychosis, major depressive disorder, vitamin B12 deficiency anemia, chronic kidney disease, and spinal stenosis. R6's 3/11/23 Minimum Data Set (MDS) showed extensive assistance was needed for her activities of daily living and she has severe cognitive impairment. The facility's undated Pressure Injury and Management policy showed the intent of this organization is to develop and maintain systems and processes to ensure that the facility provides care and services consistent with professional standards of practice to . promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible). The policy continued and showed treatments will be ordered by the physician/practitioner evaluated weekly during the weekly evaluation/assessment of the wound .

Based on interview and record review, the facility failed to implement their policy to thoroughly investigate an allegation of employee to resident sexual abuse. This failure resulted in, facility staff identifying R1, R3, R4, and R5 as residents explicitly photographed by V3 (Former Housekeeping Staff) when V11 (Police Detective) came to the facility on [DATE] and reported a sexual abuse investigation into V3. The facility also had an anonymous letter sent to them, dated October 12, 2022, regarding V3 and his past history of sexual abuse in the facility. This failure resulted in V3 taking sexually explicit videos and photographs involving R1, R3, R4, and R5 that was reported to the facility by V11 (Police Detective) on February 15, 2023. The facility also has an anonymous letter sent to them dated October 12, 2022, regarding V3 and past history of sexual abuse in the facility. V3's date of hire was October 11, 2022, and was suspended on November 18, 2022, after V22 (Former Administrator) became aware of the letter, and V3 later resigned. The facility failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the event and report the abuse to the state health department. This applies to 4 of 7 residents (R1, R3, R4, and R5) reviewed for sexual abuse in a sample of 7. The Immediate Jeopardy began on February 15, 2023, when police informed V1 (Administrator) of alleged sexual abuse of facility residents by V3 (Former Housekeeping Staff), and when V1 failed to implement the facility's abuse policy and procedure and take measures to ensure residents were free from abuse and reported cases of abuse were fully investigated. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on March 8, 2023, at 3:46 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 10, 2023, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility submitted a preliminary abuse incident investigation report on February 15, 2023, in which the facility was notified by V11 (Police Detective) of an investigation of sexual abuse in the community. V11 informed the facility that during this investigation, V3 (Former Housekeeping Staff) was identified as the alleged offender and the police found multiple explicit pictures of male residents of the facility. The report continued to document that V3 was employed by the facility from October 11, 2022, until V3 was terminated on November 21, 2022. The facility documents in the initial report that all males that resided in the facility at the time of this incident that are cognitively able to be interviewed will be interviewed and assessed for injury and trauma. The facility continued to add that resident representatives, physicians and local law enforcement were also notified of the event and that the facility would conduct a complete and thorough investigation. The facility submitted the final report to the department on February 22, 2023. The undated report documents, FINAL: Unable to substantiate at this time. Police investigation is still ongoing with facility cooperation. All possible effected residents interviewed and no corroboration of alleged events. Trauma assessment and psychosocial counseling provided. Families notified about alleged incident in coordination with local law enforcement. On March 8, 2023, at 9:07 AM, V1 (Administrator) said V11 (Police Detective) came to the facility on [DATE] and told V1 he was investigating a case in the community involving V3. V1 said V11 said the police had V3's cellphone and there were photographs of sexual abuse on V3's cellphone, oral in nature. V1 said the facility identified five residents (R1, R2, R3, R4, and R5) from the photographs provided by V11 as being the residents explicitly photographed by V3. V11 stated on March 14, 2023 that R2 was not one of the victims on the video.V1 continued to say he did not interview any staff members during this investigation. V1 said none of the residents said they were photographed so abuse was unsubstantiated. V1 continued to say this would not be abuse because he did not know if the photographs were taken consensually. R1's MDS (Minimum Data Set) dated January 6, 2023, showed R1 had severe cognitive impairment. R3's MDS dated [DATE], showed R3's cognitive skills for daily decision making was severely impaired. R4's MDS dated [DATE], showed R4 had moderate cognitive impairment. R5's MDS dated [DATE], showed R5 had severe cognitive impairment. On March 8, 2023, at 10:55 AM, V1 said V3 was suspended on November 18, 2022, because V22 (Former Administrator) received a letter about sexual abuse allegations about V3. On March 7, 2023, at 3:07 PM, V15 (Former Human Resources) said she worked as human resources starting around November 2022, and prior to working in human resources, she worked at the front desk. V15 said she received an anonymous letter while V3 was employed at the facility in October 2022 or November 2022. V15 continued to say the letter alleged V3 committed sexual abuse to residents. V15 said she opened the letter and immediately brought it to V22 (Former Administrator). The facility does not have documentation to show an investigation was completed in November 2022 for the allegations against V3. On March 8, 2023, at 3:26 PM, V23 (LPN/Licensed Practical Nurse) said she remembered V3 working at the facility. V23 continued to say when V3 worked at the facility she remembered him spending a lot of time in R3's room. V23 said, It was like [V3] favored [R3]. V23 continued to say she had never been interviewed by anyone in the facility regarding V3. On March 8, 2023, at 10:08 AM, V6 (RN/Registered Nurse) said she has worked at the facility for six years. V6 said she worked with V3 in October 2022 and November 2022. V6 continued to say she was never interviewed by the facility about working with V3. On March 8, 2023, at 10:12 AM, V7 (RN) said she has worked at the facility for eight years. V7 said she worked with V3 in October 2022 and November 2022. V7 continued to say she was never interviewed by the facility about working with V3. On March 8, 2023, at 10:24 AM, V19 (RN) said she has worked at the facility for three years. V19 said she worked with V3 in October 2022 and November 2022. V19 continued to say she was never interviewed by the facility about working with V3. On March 7, 2023, at 3:22 PM, V14 (RN) said she has worked at the facility for [AGE] years. V14 continued to say no one has interviewed her about V3. On March 7, 2023, at 3:26 PM, V32 (LPN) said she has worked at the facility for [AGE] years. V32 continued to say no one has interviewed her about V3. The facility's undated policy titled Abuse, showed, POLICY: This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom. The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. DEFINITIONS: 'Abuse'- is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 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 . 'Sexual abuse'- is non-consensual sexual contact of any type with a resident. SPECIFIC PROCEDURES/GUIDANCE: .2. Training . d. At a minimum, education on abuse, neglect, exploitation will be provided to facility staff upon hire and annually. In addition to the freedom from abuse, neglect, mistreatment of residents, misappropriation of property and exploitation requirements in 483.12, the organization will also provide training to their staff on: i. activities that constitute abuse, neglect, exploitation, and misappropriation or resident property as set forth at 483.12. ii. Procedures for reporting incidents of abuse, neglect, mistreatment, exploitation, or the misappropriation of resident's property. iii. Dementia management and resident abuse prevention . 3. Prevention a. The facility will not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion . f. A comprehensive assessment and individualized care plan will be developed for each resident to assist staff in providing effective interventions to prevent abuse, meet the resident's needs and promote quality of life . 4. Identification a. During orientation and annually at a minimum, staff will be educated on observation and reporting important information about resident care, condition or behavior. Staff are encouraged and protocols will be maintained to promote timely identification and reporting of events such as suspicious bruising or residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. b. Staff are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administration or facility leadership member. c. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and that the environment is free of hazards. d. Administrative and facility leadership staff will supervise staff to identify inappropriate behaviors, action and response to resident needs. 5. Investigation Designated staff will immediately review and investigate all allegations or observations of abuse. a. the results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. b. The organization will conduct analysis for trends and patterns related to incidents [i.e., falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidents, etc.]. c. Outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee and in accordance with federal, state, and local law. d. The Quality Assurance/Performance Improvement Committee will monitor trends and patterns for needed changes in facility policy, practice or protocols. 6. Protection . b. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. c. Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety. .e. The facility Quality Assurance/ Performance Improvement Committee will review and provide recommendation for unusual occurrences. An unusual occurrence or incident may include, but not be limited to: elopement, self-inflicted injury that is life threatening, suicide, ingestion of poison, violent behavior that cannot be re-directed and/or results in injury requiring transfer to an emergency room or hospital [i.e., rape, fracture, death, etc.] and other unusual incidents that require reporting to regulatory, investigative, or legal entities . The undated facility policy title, Abuse Investigation and Reporting, showed, POLICY: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. SPECIFIC PROCEDURES/GUIDANCE Role of the Administrator- 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator/designee will assign the investigation to an appropriate individual. 2. The Administrator/designee will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator/designee will keep the resident and his/her representative informed of the progress of the investigation. 4. The Administrator/designee may suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator/designee will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. 6. The Administrator/designee will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the investigator- 1. The individual[s] conducting the investigation may, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician/Practitioner as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 2. The following guidelines may be used when conducting interviews: . d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it . Reporting- 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials (if applicable); f. The resident's Attending Physician; and g. The facility Medical Director. 2. An allegation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone, in accordance with state regulations/guidelines . The Immediate Jeopardy that began on February 15, 2023, was removed on March 10, 2023, when the facility took the following actions to remove the immediacy. 1. The facility administrator was suspended until abuse education and polices are provided to administrator and his understanding is validated through completion of abuse training posttest. The administrator will be reeducated on abuse and neglect and the facility policies by the VP of clinical services and the Regional director of operations. The administrator's acting license will remain of record and the regional director of operations will fulfill administrative job duties in his absence. The Director of nursing will fulfill the role of the abuse coordinator in the administrator's absence. The administrator will receive training on March 9, 2023 and will return upon successful completion of training. The regional director of operations will follow up on the administrator's compliance with the abuse policy and reporting requirements. The regional director of operations will be notified of any potential abuse allegations and will review conclusions for accuracy prior to submission to state agency. The regional director of operations has reviewed the last 30 days of abuse reportables for accuracy of conclusion. Any discrepancies identified through the review of reportables will be amended and state agency notified. No changes have been made to the current abuse policy. 2. Trauma Screens have been conducted with all residents identified in abuse incident. Any resident identified suffering psychological effects will be deferred to psych services and/or contract licensed social work for assessment and development of plan of care. The facility social workers will be responsible for psychological outcome monitoring and referral to contract licensed social worker if need is identified. 3. All residents of the facility have the potential to be affected by the alleged deficient practice. The facility will conduct interviews for all interviewable residents with a BIMS (Brief Interview for Mental Status) score of eight or greater screening for abuse and neglect. Non-interviewable residents will have skin assessments performed assessing for signs and symptoms of abuse. Any allegations of abuse and neglect that are identified in the audit for abuse will be immediately addressed in accordance with the facility abuse and neglect policy. 4. All staff of the facility will be reeducated on the facility abuse and neglect policy and use of personal cellphone and taking photographs of residents by the DON (Director of Nursing) or designee. No staff will be allowed to return to work after March 10, 2023, until the abuse and neglect education is completed. All new employees will be provided this education upon hire and before providing care in resident care areas. All agency staff will also be provided this education during the facility orientation prior to starting work at the facility. All staff who received abuse training will be provided an abuse post quiz to validate understanding of abuse policy education. The VP (Vice President) of clinical education will audit to ensure all required staff have received education in accordance with removal of immediate jeopardy plan. Any staff identified through posttest of not receiving 100% accuracy will be provided one on one education with the director of nursing. 5. The medical director was notified of the immediate jeopardy on March 8, 2023. 6. The facility will conduct an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting reviewing the abatement plan by March 10, 2023. The QAPI meeting will include educational material reviewed with staff including abuse policy, cell phone policy and photographing of residents. The QAPI meeting will include the additional post abuse quiz with 100 percent expectant threshold rate and any employee not meeting threshold will receive 1:1 education by the director of nursing. The QAPI meeting will include the new process of regional director of operations to review all final abuse reportable to ensure conclusion of investigation is accurate prior to submission to state agency. The attendees of the ad hoc QAPI meeting will consist of the director of nursing services, the medical director, the facility infection preventionist, the regional director of operations, the VP of clinical operations, Human Resources, and a certified nursing assistant. The DON or designee will conduct daily observation audits across all shifts in resident care areas to identify staff utilizing cell phones daily for two weeks, then three times a week for two weeks, then monthly for two months. Any issues identified will be addressed immediately by DON/Designee and appropriate actions will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly. The DON or designee will conduct daily staff interviews to validate understanding of reporting guidelines and investigating allegations of abuse daily for two weeks, then three times a week for two weeks, then monthly for two months. Any issues identified will be addressed immediately by DON/Designee and appropriate actions will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly.

Based on interview and record review, in response to allegations of abuse, the facility failed to thoroughly investigate the alleged abuse and prevent further abuse or mistreatment from occurring. The facility failed to validate sexual abuse and implement training after an allegation of sexual abuse. This failure resulted in, facility staff identifying R1, R3, R4, and R5 as residents explicitly photographed by V3 (Former Housekeeping Staff) when V11 (Police Detective) came to the facility on [DATE], and reported a sexual abuse investigation into V3. The facility also had an anonymous letter sent to them, dated October 12, 2022, regarding V3 and his past history of sexual abuse in the facility. This failure resulted in V3 taking sexually explicit videos and photographs involving R1, R3, R4, and R5 that was reported to the facility by V11 (Police Detective) on February 15, 2023. The facility also has an anonymous letter sent to them dated October 12, 2022, regarding V3 and past history of sexual abuse in the facility. V3's date of hire was October 11, 2022, and was suspended on November 18, 2022, after V22 (Former Administrator) became aware of the letter, and V3 later resigned. The facility failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the event and report the abuse to the state health department. This applies to 4 of 7 residents (R1, R3, R4, and R5) reviewed for sexual abuse in a sample of 7. The Immediate Jeopardy began on February 15, 2023, when police informed V1 (Administrator) of alleged sexual abuse of facility residents by V3 (Former Housekeeping Staff), and when V1 failed to implement the facility's abuse policy and procedure and take measures to ensure residents were free from abuse and reported cases of abuse were fully investigated. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on March 8, 2023, at 3:46 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 10, 2023, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility submitted a preliminary abuse incident investigation report on February 15, 2023, in which the facility was notified by V11 (Police Detective) of an investigation of sexual abuse in the community. V11 informed the facility that during this investigation, V3 (Former Housekeeping Staff) was identified as the alleged offender and the police found multiple explicit pictures of male residents of the facility. The report continued to document that V3 was employed by the facility from October 11, 2022, until V3 was terminated on November 21, 2022. The facility documents in the initial report that all males that resided in the facility at the time of this incident that are cognitively able to be interviewed will be interviewed and assessed for injury and trauma. The facility continued to add that resident representatives, physicians and local law enforcement were also notified of the event and that the facility would conduct a complete and thorough investigation. The facility submitted the final report to the department on February 22, 2023. The undated report documents, FINAL: Unable to substantiate at this time. Police investigation is still ongoing with facility cooperation. All possible effected residents interviewed and no corroboration of alleged events. Trauma assessment and psychosocial counseling provided. Families notified about alleged incident in coordination with local law enforcement. On March 8, 2023, at 9:07 AM, V1 (Administrator) said V11 (Police Detective) came to the facility on [DATE], and told V1 he was investigating a case in the community involving V3. V1 said V11 said the police had V3's cellphone and there were photographs of sexual abuse on V3's cellphone, oral in nature. V1 said the facility identified four residents (R1, R3, R4, and R5) from the photographs provided by V11 as being the residents explicitly photographed by V3. V11 stated on March 14, 2023 that R2 was not one of the victims on the video. V1 continued to say he did not interview any staff members during this investigation. V1 said none of the residents said they were photographed so abuse was unsubstantiated. V1 continued to say this would not be abuse because he did not know if the photographs were consensually. R1's MDS (Minimum Data Set) dated January 6, 2023, showed R1 had severe cognitive impairment. As of March 6, 2023, at 1:01 PM, R1's care plan did not show a care plan for abuse. As of March 6, 2023, at 1:26 PM, R2's care plans did not show a care plan for abuse. R3's MDS dated [DATE], showed R3's cognitive skills for daily decision making was severely impaired. As of March 6, 2023, at 1:47 PM, R3's care plans did not show a care plan for abuse. R4's MDS dated [DATE], showed R4 had moderate cognitive impairment. R4's care plan did not show an abuse care plan. R5's MDS dated [DATE], showed R5 had severe cognitive impairment. R5's care plan did not show an abuse care plan. On March 8, 2023, at 10:55 AM, V1 said V3 was suspended on November 18, 2022, because V22 (Former Administrator) received a letter about sexual abuse allegations about V3. On March 14, 2023, at 3:51 PM, V11 said I did not tell the facility what to do, I told them they had their own protocol to follow, and ultimately it is their situation to investigate. I would not tell them what to do because it is their facility to run. On March 7, 2023, at 3:07 PM, V15 (Former Human Resources) said she worked as human resources starting around November 2022, and prior to working in human resources, she worked at the front desk. V15 said she received an anonymous letter while V3 was employed at the facility in October 2022 or November 2022. V15 continued to say the letter alleged V3 committed sexual abuse to residents. V15 said she opened the letter and immediately brought it to V22 (Former Administrator). On March 8, 2023, at 3:26 PM, V23 (LPN/Licensed Practical Nurse) said she remembered V3 working at the facility. V23 continued to say when V3 worked at the facility she remembered him spending a lot of time in R3's room. V23 said, It was like [V3] favored [R3]. V23 continued to say she had never been interviewed by anyone in the facility regarding V3. On March 8, 2023, at 10:08 AM, V6 (RN/Registered Nurse) said she has worked at the facility for six years. V6 said she worked with V3 in October 2022 and November 2022. V6 continued to say she was never interviewed by the facility about working with V3. V6 said she had not received abuse training since August 2022, and had not received any training regarding taking pictures of residents. On March 8, 2023, at 10:12 AM, V7 (RN) said she has worked at the facility for eight years. V7 said she worked with V3 in October 2022 and November 2022. V7 continued to say she was never interviewed by the facility about working with V3. V7 said she had not received any training on taking pictures of residents. On March 8, 2023, at 10:14 AM, V17 (Housekeeper) was interviewed with V18 (Agency CNA/Certified Nursing Assistant) translating. V17 said she has worked at the facility for three years. V17 continued to say she worked with V3 in October and November 2022 but was never interviewed by the facility about him. V17 said she received abuse training when she started three years ago but has not had any training since. On March 8, 2023, at 10:24 AM, V19 (RN) said she has worked at the facility for three years. V19 said she worked with V3 in October 2022 and November 2022. V19 continued to say she was never interviewed by the facility about working with V3. V19 said she could not remember the last time she received abuse training, but it was at least two years ago. V10 continued to say she did not receive training about taking pictures of residents. On March 8, 2023, at 10:27 AM, V20 (Agency CNA) said he has worked regularly at the facility for the past two to three months. V20 continued to say the facility has not provided him abuse training or training about taking pictures of residents. On March 7, 2023, at 3:22 PM, V14 (RN) said she has worked at the facility for [AGE] years. V14 continued to say no one has interviewed her about V3. On March 7, 2023, at 3:26 PM, V32 (LPN) said she has worked at the facility for [AGE] years. V32 continued to say no one has interviewed her about V3. The facility's undated policy titled Abuse, showed, POLICY: This organization recognizes and respects that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptom. The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. DEFINITIONS: 'Abuse'- is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 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 . 'Sexual abuse'- is non-consensual sexual contact of any type with a resident. SPECIFIC PROCEDURES/GUIDANCE: .2. Training . d. At a minimum, education on abuse, neglect, exploitation will be provided to facility staff upon hire and annually. In addition to the freedom from abuse, neglect, mistreatment of residents, misappropriation of property and exploitation requirements in 483.12, the organization will also provide training to their staff on: i. activities that constitute abuse, neglect, exploitation, and misappropriation or resident property as set forth at 483.12. ii. Procedures for reporting incidents of abuse, neglect, mistreatment, exploitation, or the misappropriation of resident's property. iii. Dementia management and resident abuse prevention . 3. Prevention a. The facility will not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion . f. A comprehensive assessment and individualized care plan will be developed for each resident to assist staff in providing effective interventions to prevent abuse, meet the resident's needs and promote quality of life . 4. Identification a. During orientation and annually at a minimum, staff will be educated on observation and reporting important information about resident care, condition or behavior. Staff are encouraged and protocols will be maintained to promote timely identification and reporting of events such as suspicious bruising or residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. b. Staff are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing, administration or facility leadership member. c. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and that the environment is free of hazards. d. Administrative and facility leadership staff will supervise staff to identify inappropriate behaviors, action and response to resident needs. 5. Investigation Designated staff will immediately review and investigate all allegations or observations of abuse. a. the results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. b. The organization will conduct analysis for trends and patterns related to incidents [i.e., falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidents, etc.]. c. Outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee and in accordance with federal, state, and local law. d. The Quality Assurance/Performance Improvement Committee will monitor trends and patterns for needed changes in facility policy, practice or protocols. 6. Protection . b. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. c. Other residents who may have potentially been affected or at risk will be identified and a plan of care will be developed or revised as appropriate to ensure their safety. .e. The facility Quality Assurance/ Performance Improvement Committee will review and provide recommendation for unusual occurrences. An unusual occurrence or incident may include, but not be limited to: elopement, self-inflicted injury that is life threatening, suicide, ingestion of poison, violent behavior that cannot be re-directed and/or results in injury requiring transfer to an emergency room or hospital [i.e., rape, fracture, death, etc.] and other unusual incidents that require reporting to regulatory, investigative, or legal entities . The undated facility policy title, Abuse Investigation and Reporting, showed, POLICY: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. SPECIFIC PROCEDURES/GUIDANCE Role of the Administrator- 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator/designee will assign the investigation to an appropriate individual. 2. The Administrator/designee will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator/designee will keep the resident and his/her representative informed of the progress of the investigation. 4. The Administrator/designee may suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator/designee will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented. 6. The Administrator/designee will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the investigator- 1. The individual[s] conducting the investigation may, at a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician/Practitioner as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. 2. The following guidelines may be used when conducting interviews: . d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it . Reporting- 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials (if applicable); f. The resident's Attending Physician; and g. The facility Medical Director. 2. An allegation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 3. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone, in accordance with state regulations/guidelines . The Immediate Jeopardy that began on February 15, 2023, was removed on March 10, 2023 when the facility took the following actions to remove the immediacy. 1. The facility administrator was suspended until abuse education and polices are provided to administrator and his understanding is validated through completion of abuse training posttest. The administrator will be reeducated on abuse and neglect and the facility policies by the VP of clinical services and the Regional director of operations. The administrator's acting license will remain of record and the regional director of operations will fulfill administrative job duties in his absence. The Director of nursing will fulfill the role of the abuse coordinator in the administrator's absence. The administrator will receive training on March 9, 2023, and will return upon successful completion of training. The regional director of operations will follow up on the administrator's compliance with the abuse policy and reporting requirements. The regional director of operations will be notified of any potential abuse allegations and will review conclusions for accuracy prior to submission to state agency. The regional director of operations has reviewed the last 30 days of abuse reportables for accuracy of conclusion. Any discrepancies identified through the review of reportables will be amended and state agency notified. No changes have been made to the current abuse policy. 2. Trauma Screens have been conducted with all residents identified in abuse incident. Any resident identified suffering psychological effects will be deferred to psych services and/or contract licensed social work for assessment and development of plan of care. The facility social workers will be responsible for psychological outcome monitoring and referral to contract licensed social worker if need is identified. 3. All residents of the facility have the potential to be affected by the alleged deficient practice. The facility will conduct interviews for all interviewable residents with a BIMS (Brief Interview for Mental Status) score of eight or greater screening for abuse and neglect. Non-interviewable residents will have skin assessments performed assessing for signs and symptoms of abuse. Any allegations of abuse and neglect that are identified in the audit for abuse will be immediately addressed in accordance with the facility abuse and neglect policy. 4. All staff of the facility will be reeducated on the facility abuse and neglect policy and use of personal cellphone and taking photographs of residents by the DON (Director of Nursing) or designee. No staff will be allowed to return to work after March 10, 2023, until the abuse and neglect education is completed. All new employees will be provided this education upon hire and before providing care in resident care areas. All agency staff will also be provided this education during the facility orientation prior to starting work at the facility. All staff who received abuse training will be provided an abuse post quiz to validate understanding of abuse policy education. The VP (Vice President) of clinical education will audit to ensure all required staff have received education in accordance with removal of immediate jeopardy plan. Any staff identified through posttest of not receiving 100% accuracy will be provided one on one education with the director of nursing. 5. The medical director was notified of the immediate jeopardy on March 8, 2023. 6. The facility will conduct an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting reviewing the abatement plan by March 10, 2023. The QAPI meeting will include educational material reviewed with staff including abuse policy, cell phone policy and photographing of residents. The QAPI meeting will include the additional post abuse quiz with 100 percent expectant threshold rate and any employee not meeting threshold will receive 1:1 education by the director of nursing. The QAPI meeting will include the new process of regional director of operations to review all final abuse reportable to ensure conclusion of investigation is accurate prior to submission to state agency. The attendees of the ad hoc QAPI meeting will consist of the director of nursing services, the medical director, the facility infection preventionist, the regional director of operations, the VP of clinical operations, Human Resources, and a certified nursing assistant. The DON or designee will conduct daily observation audits across all shifts in resident care areas to identify staff utilizing cell phones daily for two weeks, then three times a week for two weeks, then monthly for two months. Any issues identified will be addressed immediately by DON/Designee and appropriate actions will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly. The DON or designee will conduct daily staff interviews to validate understanding of reporting guidelines and investigating allegations of abuse daily for two weeks, then three times a week for two weeks, then monthly for two months. Any issues identified will be addressed immediately by DON/Designee and appropriate actions will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly.

Based on interview and record review the facility failed to keep residents free from sexual abuse and exploitation by V3 (Former Housekeeping Staff). R1, R3, R4 and R5 had sexually explicit videos and photographs taken of them by V3 in October 2022 and November of 2022. The facility failed to conduct a comprehensive investigation of these incidents and report these to the local police. The facility failed to ensure that residents exposed to abuse were kept safe for any additional abuse and take measures to ensure that additional residents were not exposed to abuse. This failure resulted in V3 taking sexually explicit videos and photographs involving R1, R3, R4, and R5 that was reported to the facility by V11 (Police Detective) on February 15, 2023. The facility also had an anonymous letter sent to them, dated October 12, 2022, regarding V3 and his past history of sexual abuse in the facility. V3's date of hire was October 11, 2022, and was suspended on November 18, 2022, after V22 (Former Administrator) became aware of the letter, and V3 later resigned. The facility failed to implement their Abuse policy and procedure and conduct a comprehensive investigation of the event and report the abuse to the state health department. This applies to 4 of 7 residents (R1, R3, R4, and R5) reviewed for sexual abuse in a sample of 7. The Immediate Jeopardy began on February 15, 2023, when police informed V1 (Administrator) of alleged sexual abuse of facility residents by V3 (Former Housekeeping Staff) and when V1 failed to implement the facility's abuse policy and procedure and take measures to ensure residents were free from abuse and reported cases of abuse were fully investigated. V1 (Administrator) and V2 (DON/Director of Nursing) were notified of the Immediate Jeopardy on March 8, 2023, at 3:46 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on March 10, 2023, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include the following: The facility submitted a preliminary abuse incident investigation report on February 15, 2023, in which the facility was notified by V11 (Police Detective) of an investigation of sexual abuse in the community. V11 informed the facility that during this investigation, V3 (Former Housekeeping Staff) was identified as the alleged offender and the police found multiple explicit pictures of male residents of the facility. The report continued to document that V3 was employed by the facility from October 11, 2022, until V3 was terminated on November 21, 2022. The facility documents in the initial report that all males that resided in the facility at the time of this incident that are cognitively able to be interviewed will be interviewed and assessed for injury and trauma. The facility continued to add that resident representatives, physicians and local law enforcement were also notified of the event and that the facility would conduct a complete and thorough investigation. The facility submitted the final report to the department on February 22, 2023. The undated report documents, FINAL: Unable to substantiate at this time. Police investigation is still ongoing with facility cooperation. All possible effected residents interviewed and no corroboration of alleged events. Trauma assessment and psychosocial counseling provided. Families notified about alleged incident in coordination with local law enforcement. On March 8, 2023, at 9:07 AM, V1 (Administrator) said V11 (Police Detective) came to the facility on [DATE] and told V1 he was investigating a case in the community involving V3. V1 said V11 said the police had V3's cellphone and there were photographs of sexual abuse on V3's cellphone, oral in nature. V1 said the facility identified five residents (R1, R2, R3, R4, and R5) from the photographs provided by V11 as being the residents explicitly photographed by V3. V11 stated on March 14, 2023 that R2 was not one of the victims on the video. V1 continued to say he did not interview any staff members during this investigation. V1 said none of the residents said they were photographed so abuse was unsubstantiated. V1 continued to say this would not be abuse because he did not know if the photographs were taken consensually. On March 8, 2023, at 12:44 PM, V1 said he did not notify the local police department. V1 continued to say V11 did not tell V1 not to call the local police department. On March 14, 2023, at 3:51 PM, V11 said I did not tell the facility what to do, I told them they had their own protocol to follow, and ultimately it is their situation to investigate. I would not tell them what to do because it is their facility to run. On March 8, 2023, at 10:55 AM, V2 (DON) said she reviewed the male residents who resided in the facility while V3 was employed, and she found 14 to 15 residents that could have been affected. V2 continued to say social services interviewed residents with straight forward questions. V2 confirmed the interview questions asked were Have you ever had a male attendant in your room? i.e., CNA (Certified Nursing Assistant), nurse, housekeeper, maintenance, dietary worker? Was he White, African American, Hispanic, or Asian? Did he behave inappropriately towards you? On March 8, 2023, at 11:40 AM, V21 (Social Services Director) said, I have been working at the facility since January 14, 2023. All I was told was there was an incident with a former employee and was only told they may have had inappropriate behavior with residents. [V1] asked me to do trauma screenings and well-being checks daily for the first three days and then weekly for a month. I started around February 22, 2023, with the well-being checks. I used the trauma screening [the Electronic Medical Record system]. I took the residents' statements which was the three questions, and I wrote down their responses. I am newer at the facility and do not really know behavior patterns of the residents. I looked through medical records for behaviors and talked to staff. We have a lot of new staff here and agency staff that may not know the residents and their baseline behaviors. For a trauma screen for someone with a low BIMS (Brief Interview for Mental Status), you can't really do a trauma screening, I try to redirect them to keep them on topic. When I ask a yes or no questions, I need a yes or no answer, so I keep asking the question. If they cannot answer the questions, then I inform someone I cannot do the screening. I knew the residents understood what I was asking because I asked the residents if they understood what I was asking, and they would say yes. There were not any residents I could not complete the screenings on. I cannot gauge whether these residents could recall the event from a few months ago. 1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including stroke affecting the left side, epilepsy, vascular dementia, depression, and aphasia. R1's MDS (Minimum Data Set) dated January 6, 2023, showed R1 had severe cognitive impairment. The MDS continued to show R1 required extensive assistance of facility staff for toilet use, personal hygiene, eating, dressing, and bed mobility. As of March 6, 2023, at 1:01 PM, R1's care plan did not show a care plan for abuse. On March 7, 2023, at 1:49 PM, V11 (Police Detective) said he was conducting an investigation of a sexual abuse allegation in the community and V3 was the perpetrator. V11 continued to say V3's cellphone was searched by police, and V3 had multiple nude photographs and nude video recordings of males. V11 said the photographs and videos had data to show they were taken at the facility. V11 said V3 took three videos of R1, which included two videos on November 5, 2022, at 6:11 PM and 6:15 PM of V3 washing R1, and one video on November 15, 2022, at 6:52 AM of R1's genitals. V11 continued to say V3 admitted to taking the nude photographs and videos of the residents. On March 6, 2023, at 2:47 PM, R1 was not interviewable. R1 would shrug his shoulders when asked questions. 2. R3's EMR showed R3 was admitted to the facility on [DATE], with multiple diagnoses including stroke affecting the right side, depression, dementia, and aphasia. R3's MDS dated [DATE], showed R3's cognitive skills for daily decision making was severely impaired. The MDS continued to show R3 required extensive assistance from facility staff for bed mobility, dressing, toilet use, and personal hygiene. As of March 6, 2023, at 1:47 PM, R3's care plans did not show a care plan for abuse. On March 7, 2023, at 1:49 PM, V11 said V3 took multiple three second videos of R3's genitalia on November 5, 2022. V11 continued to say on November 13, 2022, at 7:48 PM, V3 took a photograph of R3's genitals and then took a video of V3 performing oral sex on R3. On March 6, 2023, at 2:55 PM, due to R3's cognitive impairment, R3 could not be interviewed. On March 8, 2023, at 3:26 PM, V23 (LPN/Licensed Practical Nurse) said she remembered V3 working at the facility. V23 continued to say when V3 worked at the facility she remembered him spending a lot of time in R3's room. V23 said, It was like [V3] favored [R3]. 3. R4's EMR showed R4 was admitted to the facility on [DATE], with multiple diagnoses including: chronic obstructive pulmonary disease, dementia, dysphagia, legal blindness, and heart failure. R4's MDS dated [DATE], showed R4 had moderate cognitive impairment. The MDS continued to show R4 was totally dependent on facility staff for transferring, toilet use, personal hygiene, and locomotion on and off the unit. R4's care plan did not show an abuse care plan. On March 7, 2023, at 1:49 PM, V11 said on November 1, 2022, at 9:45 AM, V3 took a video of V3 touching R4's genitals. V11 continued to say V3 took a video on November 13, 2022, at 5:15 PM of V3 performing oral sex on R4. V11 said V3 took a video on November 16, 2022, at 7:52 PM, of V3 washing R4 and R4's genitals were exposed. 4. R5's EMR showed R5 was admitted to the facility on [DATE], with multiple diagnoses including: hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left side, dementia, and pneumonia. R5's MDS dated [DATE], showed R5 had severe cognitive impairment. The MDS continued to show R5 required extensive assistance from facility staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. R5's care plan did not show an abuse care plan. On March 7, 2023, at 1:49 PM, V11 said V3 took a video on October 22, 2022, at 6:23 PM of V3 touching R5's genitals. V11 continued to say V3 took another video at 6:36 PM of V3 touching R5's genitals. V11 said V3 took a video on October 30, 2022, at 4:59 PM, of V3 performing oral sex on R5. The Immediate Jeopardy that began on February 15, 2023, was removed on March 10, 2023, when the facility took the following actions to remove the immediacy. 1. The facility administrator was suspended until abuse education and polices are provided to administrator and his understanding is validated through completion of abuse training posttest. The administrator will be reeducated on abuse and neglect and the facility policies by the VP of clinical services and the Regional director of operations. The administrator's acting license will remain of record and the regional director of operations will fulfill administrative job duties in his absence. The Director of nursing will fulfill the role of the abuse coordinator in the administrator's absence. The administrator will receive training on March 9, 2023 and will return upon successful completion of training. The regional director of operations will follow up on the administrator's compliance with the abuse policy and reporting requirements. The regional director of operations will be notified of any potential abuse allegations and will review conclusions for accuracy prior to submission to state agency. The regional director of operations has reviewed the last 30 days of abuse reportables for accuracy of conclusion. Any discrepancies identified through the review of reportables will be amended and state agency notified. No changes have been made to the current abuse policy. 2. Trauma Screens have been conducted with all residents identified in the abuse incident. Any resident identified suffering psychological effects will be deferred to psych services and/or contract licensed social work for assessment and development of plan of care. The facility social workers will be responsible for psychological outcome monitoring and referral to contract licensed social worker if need is identified. 3. All residents of the facility have the potential to be affected by the alleged deficient practice. The facility will conduct interviews for all interviewable residents with a BIMS (Brief Interview for Mental Status) score of eight or greater screening for abuse and neglect. Non-interviewable residents will have skin assessments performed assessing for signs and symptoms of abuse. Any allegations of abuse and neglect that are identified in the audit for abuse will be immediately addressed in accordance with the facility abuse and neglect policy. 4. All staff of the facility will be reeducated on the facility abuse and neglect policy and use of personal cellphone and taking photographs of residents by the DON (Director of Nursing) or designee. No staff will be allowed to return to work after March 10, 2023, until the abuse and neglect education is completed. All new employees will be provided this education upon hire and before providing care in resident care areas. All agency staff will also be provided this education during the facility orientation prior to starting work at the facility. All staff who received abuse training will be provided an abuse post quiz to validate understanding of abuse policy education. The VP (Vice President) of clinical education will audit to ensure all required staff have received education in accordance with removal of immediate jeopardy plan. Any staff identified through posttest of not receiving 100% accuracy will be provided one on one education with the director of nursing. 5. The medical director was notified of the immediate jeopardy on March 8, 2023. 6. The facility will conduct an ad hoc QAPI (Quality Assurance and Performance Improvement) meeting reviewing the abatement plan by March 10, 2023. The QAPI meeting will include educational material reviewed with staff including abuse policy, cell phone policy and photographing of residents. The QAPI meeting will include the additional post abuse quiz with 100 percent expectant threshold rate and any employee not meeting threshold will receive 1:1 education by the director of nursing. The QAPI meeting will include the new process of regional director of operations to review all final abuse reportable to ensure conclusion of investigation is accurate prior to submission to state agency. The attendees of the ad hoc QAPI meeting will consist of the director of nursing services, the medical director, the facility infection preventionist, the regional director of operations, the VP of clinical operations, Human Resources, and a certified nursing assistant. The DON or designee will conduct daily observation audits across all shifts in resident care areas to identify staff utilizing cell phones daily for two weeks, then three times a week for two weeks, then monthly for two months. Any issues identified will be addressed immediately by DON/Designee and appropriate actions will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly. The DON or designee will conduct daily staff interviews to validate understanding of reporting guidelines and investigating allegations of abuse daily for two weeks, then three times a week for two weeks, then monthly for two months. Any issues identified will be addressed immediately by DON/Designee and appropriate actions will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly.

Based on observation, interview, and record review the facility failed to provide toilet assistance to prevent an unwitnessed fall; failed to follow the facility's fall protocol; and failed to assess a resident following an unwitnessed fall. These failures resulted in R1 sustaining multiple rib fractures, swelling to his right eye, and bilateral knee contusions. The facility failed to ensure fall interventions were in place for a resident with multiple falls (R3). This applies to 2 of 3 residents (R1, R3) reviewed for falls in the sample of 6. The findings include: 1. On 1/22/23 at 12:23 PM, V12 (R1's family member) said she arrived at the facility at 8:30 AM on 1/3/23. V12 stated, When I walked in, he was sleeping, but his room looked like a murder scene. I noticed both his knees were red and appeared bruised. There was a thick mattress on the floor beside his bed. His walker was broken and there was blood all over the room. There was drops of blood from the bed to the bathroom and a larger area of blood in the bathroom, by the toilet. It was so awful, I took pictures. Everything on his overbed table had been knocked off and was on the floor. I asked him what happened, and he told me that he turned on his call light around 3:50 AM to go to the bathroom. He said that the CNA (Certified Nursing Assistant) told him 'no, just go in your diaper.' He told me that he decided to go by himself, but lost his footing on the mattress and fell on to his walker. He had to hit that walker hard because it was broken, and he ended up with several fractured ribs. I was in tears when he told me what happened to him. I asked the CNA and nurses what happened, but no one knew anything. I waited in the room for a long time. Finally, an agency nurse came in to give him his morning medication, but she wanted no part of it. She said she didn't know anything, and she didn't want to be involved. By then, more of our family members had arrived and we went to the DON's (Director of Nursing's) office, but she wasn't there. Eventually, V2 (DON) came to his (R1's) room, but she said she didn't know anything about him falling. V2 told me that she had been on vacation and hadn't read her emails yet. R1's Face Sheet dated 1/22/23 showed diagnoses to include, but no limited to: spinal stenosis, depression, generalized muscle weakness, repeated falls, osteoarthritis, overactive bladder, hypertension, dementia, prostate cancer, abdominal aortic aneurysm, difficulty walking, and unsteadiness on feet. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment; required limited assistance of one person for bed mobility, transfers, and toilet use; and was always continent of bowel and bladder. R1's Admit-Readmit Screener dated 12/27/22 showed R1 was admitted from an acute care hospital for rehab. This document showed that he had dementia/cognitive impairment and a recent fractured hip. This document showed R1 was alert and oriented to person, time, and situation. R1's Morse Fall Scale dated 12/27/22 showed R1 was at High Risk for Falling, with a score of 95. R1's Care Plan initiated 12/27/22 showed, R1 is at risk for falls r/t (related to) dementia and recent fall at home . fell on [DATE] and was sent to the hospital for an evaluation. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . Follow facility fall protocol. R1's Progress Notes were reviewed from 12/27/22 (admission) to 1/3/23 (transfer to the emergency room ). There was no documentation of R1's unwitnessed fall by the nursing staff before 1:23 PM. At 1:23 PM, V19 (Agency LPN - Licensed Practical Nurse) charted, Resident was picked up by local ambulance, went out to local hospital accompanied by family per MD orders for further evaluation due to unwitnessed fall. R1's MD Progress Note dated 1/3/23 at 9:17 PM, showed, . Patient see in follow-up today for a fall that was unwitnessed earlier this a.m. (morning). Patient with dementia cannot give history. Discussed with family had significant blood in the room as well as some swelling in the right periorbital (eye) area, has some right chest pain, and bilateral knee pain . General: chronically ill appearing, does not appear stated age . Pain to right rib area . Redness to bilateral knees . Alert, cooperative, confused, cognition deficits noted. Assessments & Plan: .Status post fall: Potential rib injury; patient with trauma unwitnessed to orbital area; bilateral knee contusion; Because patient unable to give history and unwitnessed fall with significant mechanism evidenced by multiple injuries and blood sent here for evaluation. Further recommendation to follow. Discussed with family. Questions answered . The surveyor requested the facility's fall investigation and/or documentation of R1's unwitnessed fall. The facility was unable to provide the requested documentation. On 1/22/23 at 1:58 PM, V2 (DON) said after an unwitnessed fall the nurse should assess the resident and provide first aid. Then the nurse should call the MD for further orders; the family/POA should be notified; and the clinical person on call should be notified. The resident assessment and the information about the fall should be documented in the EMR (Electronic Medical Record). The nurse should complete an Incident Report; initiated Post-Fall Assessments; and enter a progress note. The documentation lets everyone know what happened. I don't know why there isn't any documentation of R1's fall. V2 stated, I went to talk to R1, and his family was very upset. The daughter told me there was blood on the floor and on his pillow. R1 told me that he got up, un-assisted, and went to the bathroom. He said he lost his footing on the fall mat and landed on his walker. He complained about pain in both his knees and his knees were red. He told me that he had bilateral knee replacements, so I started palpating areas. He complained of tenderness to his right rib area. I think he had a skin tear on his arm too. R1 denied hitting his head, but just to be safe I called V24 (MD), to get X-ray orders. On 1/22/23 at 8:25 PM, V17 (CNA - Certified Nursing Assistant) said he works the overnight shift (10P-6A), and he was assigned to R1 that night. V17 stated, He didn't fall for me. I haven't had a fall on my watch for months. I think R1 fell right before I came in. I have the same routine. I come in, get report, and collect my supplies for rounds. When I walked past R1's room, he was in bed, so I didn't think anything of it. I was in R1's room around 10:30 PM and noticed all the blood. There were drops of blood on the floor from R1's bed to the bathroom. I turned on the bathroom light and there was a pool of blood near the bathroom. I was like, WTH (what the hell)! I told the nurses right away and they said he'd been falling all day. I took a towel a tried to sop up the blood. The nurses from the previous shift was still there and stated, Oh, he fell . I basically was sitter with him that night. That's how I know he didn't fall on my shift. We use a lot of agency staff, so I don't know most of their names. I told the nurse that she needed to check his elbow because it was cut, and he had a few scratches on his face. I'm not sure what she did when she went in the room. On 1/23/23 at 9:05 AM, V15 (RN) said she worked the night shift on 1/2/23 but was not assigned to R1's room. V15 said if there is an unwitnessed fall, then the nurse must do a head-to-toe assessment, initiate neuro checks according to facility protocol, and notify the MD right away. There should be documentation in the progress notes and an Incident Report completed. The nurse should describe what happened, how the resident looked, where the resident was found, and who was notified. V15 stated, It is very important for resident safety to treat the residents appropriately 24/7. The progress notes let the care team know what is happening with the resident, so we can follow-up and/or continue care. If a resident had an unwitnessed fall, increased pain with breathing or laughing, and soreness to the right ribs, then that would be alarming. V15 said she was not assigned to R1's room; V21 (RN) was R1's nurse that night shift. On 1/23/23 at 12:07 PM, V21 (RN) said she remembers R1, and he was a very nice man. R1 was in bed and slept most of the night. R1 did not tell me about the fall, but I know he didn't fall on my shift. V21 stated, If R1 had an unwitnessed fall, then the previous nurse should have done a head-to-toe assessment. I did not receive report of any inquiries. If I had known, then R1 would have been on neuro checks and more frequent assessments. I don't know the nurses name, she was agency. She should have been the one to complete the Incident Report and document R1's fall. On 1/23/23 at 3:44 PM, V22 (RN) said she was familiar with R1. V22 stated, I think he fell twice that same night. One of the agency nurses had R1 and she didn't do anything. V17 (CNA) came to me and said that there was blood on R1's floor and his elbow was bleeding. R1 wasn't assigned to me, but I went in to check on him. There was blood all over the room. There was blood over by the window, which was 15 - 20 feet across his room. I told the agency nurse about it, and she said that he was found on the floor mat, next to his bed earlier in the shift. I was in his room around 10:30 PM with V17 (CNA). The agency nurse came down but was overwhelmed. R1 had a skin tear to his elbow. I don't know if the agency nurse did anything. When I told her about the blood in R1's room, the agency nurse replied, 'I didn't know he fell again. I can't do 2 falls in 1 shift!' I asked her if he could get out of bed, and she said she didn't know. The agency staff doesn't know anything about these residents, and they don't seem to know how to use the EMR (Electronic Medical Record). I'm not surprised there isn't any documentation. The communication is poor, and care can be disconnected because we have so much agency staff right now. V17 (CNA) was the one that asked if we could put a dressing on R1's skin tear, but the agency nurse didn't want anything to do with it. They don't want to be responsible for anything. I placed the dressing on R1's arm and left. I had my own assignment to take care of. I wouldn't be surprised if the agency CNA told him to go in his diaper, either. On 1/23/23 at 2:23 PM, V20 (Agency CNA) said she had been taking an assignment regularly at the facility since September. V20 stated, I remember R1, he was big sweetie. He used a walker and had a wheelchair. R1 could go to the bathroom with a 1 person assist. Basically, we were just there to keep him steady. He did really well. R1 would turn on his call light when he needed to go to the bathroom. He was continent but needed help to get to the bathroom. He would only try to get up by himself if someone wouldn't help him. I came in at 6 AM that day (1/3/23). I get report then start my rounds. He usually likes to sleep in a little bit, so his daughter made it to the room before I did. She expressed that he had a skin tear on his arm, and it was bleeding. She said she wasn't too sure what happened. I told the nurse and went back to check on him. He told me that he turned on his call light, to go to the bathroom, around 4 AM. He said that the CNA wouldn't take him to the toilet and told him to go in his diaper. R1 said that he tried to go to the bathroom himself but fell . he said he broke his walker. I could see the broken walker and a sharp part that had blood on it, where he probably cut his arm. He said he crawled to the bathroom. R1 said he yelled for help in the bathroom, but no one came, so he crawled back to bed. I did notice that his knees were really red. He was complaining of some pain to his right abdominal area when he laughed, talked, and sat up. That was a new pain for him. I told the nurse. I believe V6 (RN) did an assessment and said R1's knees were really red. R1 told her that's because I was crawling on the floor. There were little droplets of blood on the floor and in the bathroom, probably from his arm. The blood had dried up, so I had to call housekeeping to come clean it up. The walker was up against the wall, and I could see that it was broken. There was a thick mattress next to his bed. I'm sure that was hard for him to walk on. He was able to tell me what happened, but he wasn't sure who the CNA was that told him to go in his diaper. The CNA probably knew he had a diaper on and that's why they just told him to go in it. I was so surprised because he is one of the easiest residents to transfer. On 1/27/23 at 11:17 AM, V16 (CNA) said she was working the day shift on 1/3/23. V16 stated, I remember R1 telling me that he fell . He said that someone refused to take him to the bathroom, so he went by himself. He looked frustrated and irritated. This was around 6:30 - 7 AM. R1 had a scratch on his elbow. I told the nurse about it, she was an agency nurse, I don't know her name. I believe she did go and check on him. I remember he was very upset and so was his family. The whole situation with R1 was just not okay. He is an easy transfer, that's why I'm so confused that this happened. No one should refuse to take a resident to the bathroom and tell them to go in their diaper. That's just awful. R1 was able to tell us when he needed to go to the bathroom and was rarely incontinent. On 1/27/23 at 12:07 PM, V19 (Agency LPN) said she only worked one day at the facility and that was enough. V19 stated, I don't remember R1 by name, but I remember the incident. Nobody told me anything about a fall in report. But the family said that R1 turned on his call light overnight and staff refused to take him to the toilet, so he took himself. He crawled to the bathroom and back to bed. His knees were red, and his elbow had a skin tear. I had no part of the fall, and I didn't want any part of it. R1 was part of my assignment that day (1/3/23), but I didn't want to get involved in that mess. The family was very upset, so I excused myself from that too. They were getting pretty loud. I gave R1 his medications and got out of there. I apologized to them because of the negligence of the previous shift. I won't ever go back there. On 1/27/23 at 11:28 AM, V2 (DON) said R1 reported that he fell during the night, but was unsure of the time. V2 stated, I spoke with the night shift staff and they said he didn't fall during their shift. They said he fell on the previous shift (2P-10P). The evening staff said they had no recollections of any falls and they had been in his room. I have no idea if V24 (MD) was notified of the fall before I called him. I'm not sure the exact time, just that it was before noon on 1/3/23. I should have been notified of R1's fall. They call or text me all hours of the day and night, but I didn't receive anything about this. The nurse should have called R1's POA and MD too. They did not follow the fall protocol and procedure. I didn't see anything charted about the fall or notifications that were made. On 1/27/23 at 3:13 PM, V24 (MD - medical doctor) said R1 was a recent admission. V24 stated, I don't remember all the specifics, but I think it was an unwitnessed fall. It was pretty bloody. Clinically I thought he was at his baseline. Because of the unknown mechanism of injury and the multiple injuries, I sent him out to the hospital to be evaluated. He had rib pain. I wasn't sure if he hit his head. He was cleaned up by the time I got to the facility. I sent him to the emergency room , but he did not return to the facility. I'm not sure what time I was notified of R1's fall. It was in the morning of 1/3/23, but I would have to check my archives and I'm not sure if they go back that far. The surveyor requested V24 his phone/text archives and report the time he was notified. V24 did not call to provide the information. The facility's undated Assessing Falls and Their Causes Policy showed, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . General Guidelines - 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . 4. Residents will be assessment upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly . After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Notify a licensed nurse to evaluate the resident for potential injury. 3. Obtain and record vital signs as soon as it is safe to do so. 4. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. If an evaluation rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and document relevant details. 6. Notify the resident's attending physician/practitioner and family in a appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately. b. Provide first aid/treatment as appropriate, notify EMS and/or arrange transport to the Emergency Department for further evaluation/treatment as needed and/or ordered . 8. Document the presence/absence of observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 9. If the resident hit their head or the fall was unwitnessed, complete and documented neurological checks per facility protocol and/or physician order. 10. Complete an incident report for resident after the fall occurs. The incident report form should be completed by the licensed nurse with input from other staff as appropriate and submitted to the Director of Nursing Services. Defining Details of Falls: 1. After an observed or probably fall, clarify the details of the fall, such as when or where the fall occurred and what the individual was trying to do at the time the fall occurred. 2. After an unwitnessed fall, document observations of the resident's location, position, and possible environmental factors. 3. Observe to see if care plan interventions were in place at the time of the fall . Identifying Causes of a Fall or Fall Risk: 1. Immediately begin to try to identify possible or likely causes of the incident . 2. Evaluate possible chains of events (trends/patters) or circumstances preceding a recent fall, including: a. Time of day of the fall; b. Time of last meal; c. What the resident was doing; d. Whether the resident was standing, walking, reaching, or transferring from one position to another; e. Whether the resident was among other persons or alone; f. Whether the resident was trying to get to the toilet; g. Whether any environmental risk factors were involved . g. Whether there is a pattern of falls for this resident. 3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found. 4. As indicated, the attending physician/practitioner may examine the resident or may initiate testing to try to identify causes. 5. Consult with the attending physician/practitioner or medical director to confirm specific causes from multiple possibilities. When possible, document the basis for identifying specific factors as the causes. 6. If the cause is unknown but no additional evaluation is done, the physician/practitioner or nursing staff should note why . Documentation - When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found . 2. assessment dated , including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, as indicated. 5. Completion of a falls risk assessment per facility protocol. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person reporting the data. Reporting - 1. Notify the following individuals when a resident falls: a. The resident's family; b. The Attending Physician/Practitioner (timing of notification may vary, depending on whether injury was involved); c. The Director of Nursing Services and/or licensed nurse. 2. Report other information in accordance with facility policy and professional standards of practice. 2. On 1/22/23 at 9:59 AM, the door to R3's room was open. The surveyor was standing next to V8 (LPN), at the medication cart, facing R3's room. R3 was lying on her right side in bed. R3 was fully clothed, lying on top of her bed linens. R3's was laying in a side-lying position with her knees and ankles bent. R3's legs were off the bed from her mid-thigh down. R3's knees were hanging down and her ankles were resting in the seat of her wheelchair. R3's wheelchair was parked parallel to her bed. There was a thick fall matt leaning against the wall, on the opposite side of R3's room. V8 did not intervene. R3's roommate had family visiting and they left the room, speaking to V8. R3 was sleeping on an air mattress. R3's Facesheet dated 1/22/23 showed diagnoses to include, but not limited to: diabetes, dementia, osteoarthritis, depression, peripheral vascular disease, polyarthritis, kyphosis, repeated falls, and abnormalities of gait and mobility. R3's facility assessment dated [DATE] showed R3 had severe cognitive impairment; required extensive assistance of one staff member for bed mobility, transfers, and toilet use; was not steady and required staff assistance to stabilize; was always incontinent of bowel and bladder. R3's Morse Fall Scale dated 1/6/23 showed she was a High Fall Risk, with a score of 75. R3's Care Plan revised 1/12/23 showed, R3 has impaired cognitive function/dementia or impaired thought processes AEB (as evidenced by) BIMS = 5 . Interventions: .Cue, reorient, and supervise as needed . R3's Care Plan revised 1/12/23 showed, R3 has a communication problem r/t (related to) dementia, impaired hearing and vision . Interventions: Ensure/provide a safe environment: Call light in reach. Adequate low glare light. Bed in lowest position and wheels locked . R3's Care Plan revised 1/17/23 showed, R3 has had an actual fall with no injury, at risk for falls d/t (due to) impaired cognition and safety awareness, impaired mobility, and dx (diagnosis of) dementia. Self reported fall on 11/2/22, claimed she rolled out of bed with no injury . Interventions: . When resident is in bed, fold up her w/c (wheelchair) and put it across the room (post fall 1/1/23). Provide assist with transfer and bed mobility, as necessary . The facility's Incident Report dated 10/22/22 to 1/22/23 showed R3 had 1 witnessed fall and 4 unwitnessed falls (in 3 months). On 1/22/23 at 1:49 PM, V8 (LPN) said R3 has dementia and is alert to self only. V8 stated, She had a history of falls at home. We try to keep her busy in activities during the day, but sometimes she wheels herself back to her room. If we see R3 in her room, we try to bring her back out unless the CNA has time to take her to the bathroom. R3 is only supposed to be in bed in the low position with the fall matt in place. She can transfer herself back to bed, but she's not supposed to. The fall mat should be next to the bed, whenever she's in bed. The surveyor described how R3 had her legs hanging off the bed, with her feet in the seat of the wheelchair. V8 stated, She shouldn't have been positioned like that. She could have slipped right off the bed. R3 has an increase of falling and a higher risk of injury (with the fall mat not in place). I'm not sure how that happened. On 1/23/22 at 1:58 PM, V2 (DON) said fall interventions should be in place. The interventions were put in place to prevent falls and/or prevent serious injury if the resident falls.

Based on interview and record review the facility failed to ensure a resident who experienced an unwitnessed fall was assessed and provided treatment in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 6. This failure resulted in R1 remaining in the facility with multiple rib fractures, a swollen eye, and contusions to both his knees. The findings include: On 1/22/23 at 12:23 PM, V12 (R1's family member) said she arrived at the facility at 8:30 AM on 1/3/23. V12 stated, When I walked in, he was sleeping, but his room looked like a murder scene. I noticed both his knees were red and appeared bruised. There was a thick mattress on the floor beside his bed. His walker was broken and there was blood all over the room. There was drops of blood from the bed to the bathroom and a larger area of blood in the bathroom, by the toilet. It was so awful, I took pictures. Everything on his overbed table had been knocked off and was on the floor. I asked him what happened, and he told me that he turned on his call light around 3:50 AM to go to the bathroom. He said that the CNA (Certified Nursing Assistant) told him no, 'just go in your diaper.' He told me that he decided to go by himself but lost his footing on the mattress and fell on to his walker. He had to hit that walker hard because it was broken, and he ended up with several fractured ribs. I was in tears when he told me what happened to him. I asked the CNA and nurses what happened, but no one knew anything. I waited in the room for a long time. Finally, an agency nurse came in to give him his morning medication, but she wanted no part of it. She said she didn't know anything, and she didn't want to be involved. By then, more of our family members had arrived and we went to the DON's (Director of Nursing's) office, but she wasn't there. Eventually, V2 (DON) came to his (R1's) room, but she said she didn't know anything about him falling. V2 told me that she had been on vacation and hadn't read her emails yet. R1's Face Sheet dated 1/22/23 showed diagnoses to include, but no limited to: spinal stenosis, depression, generalized muscle weakness, repeated falls, osteoarthritis, overactive bladder, hypertension, dementia, prostate cancer, abdominal aortic aneurysm, difficulty walking, and unsteadiness on feet. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment; required limited assistance of one person for bed mobility, transfers, and toilet use; and was always continent of bowel and bladder. R1's Admit-Readmit Screener dated 12/27/22 showed R1 was admitted from an acute care hospital for rehab. This document showed that he had dementia/cognitive impairment and a recent fractured hip. This document showed R1 was alert and oriented to person, time, and situation. R1's Progress Notes were reviewed from 12/27/22 (admission) to 1/3/23 (transfer to the emergency room ). There was no documentation of R1's unwitnessed fall by the nursing staff before 1:23 PM. At 1:23 PM, V19 (Agency LPN - Licensed Practical Nurse) charted, Resident was picked up by local ambulance, went out to local hospital accompanied by family per MD orders for further evaluation due to unwitnessed fall. R1's MD Progress Note dated 1/3/23 at 9:17 PM, showed, . Patient see in follow-up today for a fall that was unwitnessed earlier this a.m. (morning). Patient with dementia cannot give history. Discussed with family had significant blood in the room as well as some swelling in the right periorbital (eye) area, has some right chest pain, and bilateral knee pain . General: chronically ill appearing, does not appear stated age . Pain to right rib area . Redness to bilateral knees . Alert, cooperative, confused, cognition deficits noted. Assessments & Plan: .Status post fall: Potential rib injury; patient with trauma unwitnessed to orbital area; bilateral knee contusion; Because patient unable to give history and unwitnessed fall with significant mechanism evidenced by multiple injuries and blood sent here for evaluation. Further recommendation to follow. Discussed with family. Questions answered . The surveyor requested the facility's fall investigation and/or documentation of R1's unwitnessed fall. The facility was unable to provide the requested documentation. On 1/22/23 at 1:42 PM, V6 (RN - Registered Nurse) said after an unwitnessed fall, the nurse should perform a thorough assessment and observe for injuries. The nurse should provide first aid as needed. Then call the MD (Medical Doctor), family representative or POA, and the DON. V6 stated, If there was a lot of blood, a swollen eye, right rib pain, and bilateral knee contusions, then I would call 911. Those injuries would need immediate action. Especially if I didn't know what happened. V6 said the nurse should complete an Incident Report; document the resident assessment and interventions; and document any first aid provided. On 1/22/23 at 1:58 PM, V2 (DON) said after an unwitnessed fall the nurse should assess the resident and provide first aid. Then the nurse should call the MD for further orders; the family/POA should be notified; and the clinical person on call should be notified. The resident assessment and the information about the fall should be documented in the EMR (Electronic Medical Record). The nurse should complete an Incident Report; initiated Post-Fall Assessments; and enter a progress note. The documentation lets everyone know what happened. I don't know why there isn't any documentation of R1's fall. V2 stated, I went to talk to R1, and his family was very upset. The daughter told me there was blood on the floor and on his pillow. R1 told me that he got up, un-assisted, and went to the bathroom. He said he lost his footing on the fall mat and landed on his walker. He complained about pain in both his knees and his knees were red. He told me that he had bilateral knee replacements, so I started palpating areas. He complained of tenderness to his right rib area. I think he had a skin tear on his arm too. R1 denied hitting his head, but just to be safe I called V24 (MD), to get X-ray orders. V24 said he was on his way to the facility, and he would see R1 first. On 1/23/23 at 9:05 AM, V15 (RN) said she worked the night shift on 1/2/23 but was not assigned to R1's room. V15 said if there is an unwitnessed fall, then the nurse must do a head-to-toe assessment, initiate neuro checks according to facility protocol, and notify the MD right away. There should be documentation in the progress notes and an Incident Report completed. The nurse should describe what happened, how the resident looked, where the resident was found, and who was notified. V15 stated, It is very important for resident safety to treat the residents appropriately 24/7. The progress notes let the care team know what is happening with the resident, so we can follow-up and/or continue care. If a resident had an unwitnessed fall, increased pain with breathing or laughing, and soreness to the right ribs, then that would be alarming. The MD should have been notified immediately and the resident sent out for CT, X-rays, etc. I may give the resident pain medication while they wait for EMS to arrive, but they should be sent out for proper evaluation. On 1/27/23 at 11:28 AM, V2 (DON) said R1 reported that he fell during the night, but was unsure of the time. V2 stated, I spoke with the night shift staff and they said he didn't fall during their shift. They said he fell on the previous shift (2P-10P). The evening staff said they had no recollections of any falls and they had been in his room. I have no idea if V24 (MD) was notified of the fall before I called him. I'm not sure the exact time, just that it was before noon on 1/3/23. I should have been notified of R1's fall. They call or text me all hours of the day and night, but I didn't receive anything about this. The nurse should have called R1's POA and MD too. They did not follow the fall protocol and procedure. I didn't see anything charted about the fall or notifications that were made. V2 was asked what complications could arise from multiple rib fractures. V2 said R1 could have become short of breath and/or had a punctured lung. V2 said a thorough assessment showed that R1 needed to be sent to the hospital. On 1/27/23 at 3:13 PM, V24 (MD - medical doctor) said R1 was a recent admission. V24 stated, I don't remember all the specifics, but I think it was an unwitnessed fall. It was pretty bloody. Clinically I thought he was at his baseline. Because of the unknown mechanism of injury and the multiple injuries, I sent him out to the hospital to evaluated. He had rib pain. I wasn't sure if he hit his head. He was cleaned up by the time I got to the facility. I sent him to the emergency room , but he did not return to the facility. I'm not sure what time I was notified of R1's fall. It was in the morning of 1/3/23, but I would have to check my archives and I'm not sure if they go back that far. The surveyor requested V24 his phone/text archives and report the time he was notified. V24 did not call to provide the information. The facility's undated Assessing Falls and Their Causes Policy showed, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Notify a licensed nurse to evaluate the resident for potential injury. 3. Obtain and record vital signs as soon as it is safe to do so. 4. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. If an evaluation rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and document relevant details. 6. Notify the resident's attending physician/practitioner and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately. b. Provide first aid/treatment as appropriate, notify EMS and/or arrange transport to the Emergency Department for further evaluation/treatment as needed and/or ordered . 8. Document the presence/absence of observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 9. If the resident hit their head or the fall was unwitnessed, complete and documented neurological checks per facility protocol and/or physician order. 10. Complete an incident report for resident after the fall occurs. The incident report form should be completed by the licensed nurse with input from other staff as appropriate and submitted to the Director of Nursing Services . The facility's undated Change in a Resident's Condition Policy showed, The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status . Specific Procedures/Guidance: 1. The nurse will notify the resident's Attending Physician/practitioner or physician on call when there has been a (an): a. accident or incident involving the resident . g. need to transfer the resident to a hospital . 2. Prior to notifying the physician/practitioner, a nurse will notify the resident's representative when: a. The resident is involved in any accident that results in an injury including injuries of an unknown source . 7. The nurse/designee will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Based on interview and record review, the facility failed to monitor lab results and failed to provide physician treatments to a resident with an arterial wound. This applies to 1 of 3 residents (R1) reviewed for lab monitoring and wounds in a sample of 15. This failure resulted in a delay of treating R1 for a low hemoglobin level causing him to experience symptoms which would have improved with treatment. Findings include: 1. Admission record dated 12/15/2022 documents R1 admitted to the facility 11/10/2022 with diagnoses to include post amputation, anemia, and kidney transplants. On 12/9/2022 at 11:20 AM V10 (R1's Daughter) stated the facility is not doing labs frequently enough and R1 was eventually sent for a blood transfusion but she feels the blood transfusion should have been done sooner. R1 confirmed he was more tired and didn't feel good prior to receiving the blood transfusion. R1's Laboratory Report dated 12/1/2022 documents a Complete Blood Count (CBC) dated 11/14/2022 with results showing a hemoglobin level of 8.2 grams/deciliter (gm/dL) and a normal range of 14-18 gm/dL. R1's Order Listing Report dated 11/10-12/13/2022 documents physician orders to complete a CBC on 11/25/2022. R1's Laboratory Report dated 12/1/2022 documents a CBC dated 11/25/2022 with results showing a hemoglobin level of 7.1 gm/dL (normal range of 14-18 gm/dL). R1's Order Listing Report dated 11/10-12/13/2022 documents physician orders to complete a Complete Blood Count (CBC) on 11/28/2022. R1's Laboratory Report dated 12/1/2022 does not show a CBC was completed 11/28/2022 and documents the next CBC on 12/1/2022 which shows R1's hemoglobin level as 6.2 gm/dL (normal range of 14-18 gm/dL). V5's (Physician Assistant) Progress Note dated 12/1/2022 documents R1 with a low hemoglobin and V10 reporting R1 being fatigued. V5 ordered to repeat a stat CBC and a plan to send R1 to the emergency room if the repeat hemoglobin is below 7 gm/dL. R1's Progress Notes dated 12/1/2022 at 10:11 PM documents R1's repeat CBC result with a hemoglobin of 6.2 and R1 complaining of being tired the entire shift. V5 was contacted and ordered R1 sent to the emergency room for evaluation. This note further documents R1 transferred at approximately 8:05 PM. On 12/13/2022 at 1:30 PM V5 stated R1's hemoglobin that was low on 11/25/2022 should have been repeated in 2-3 days. V5 stated once she became aware of R1's hemoglobin of 6.2 gm/dL on 12/1/2022 when a stat CBC was completed and R1 was sent out for a blood transfusion. V5 stated there was a glitch and the order was not relayed in the system correctly. V5 confirmed R1's low hemoglobin was likely the cause of his symptoms (tired and not feeling well) and if the lab was completed timely as ordered on 11/28/2022, R1 would likely have been sent for blood transfusion or an emergency room evaluation sooner. V5 stated R1's care was delayed causing him to suffer from symptoms which would be improved with treatment. 2. On 12/9/2022 at 11:20 AM R1 had a wrapped gauze dressing to his left hand. R1's 11/10-12/13/2022 Order Listing Report documents an order dated 11/19/2022 to cleanse R1's left second finger with normal saline and paint with betadine every 3 days and as needed. R1's Wound Report, completed by V14 (Wound Physician) dated 11/18/2022, documents an initial evaluation of R1's wounds which include an arterial wound to the left second and fourth fingers. V14 documents a treatment order for the left second finger to include leptospermum Honey three times per week and apply a dressing. R1's 11/10-12/13/2022 Order Listing Report and November-December 2022 Treatment Administration Record does not document R1's order being changed from betadine to leptospermum Honey and R1's left second finger wound was treated with betadine during this period. On 12/15/2022 at 2:50 PM V14 stated R1 was admitted with multiple different wounds and the betadine was supposed to be applied to the wound on the left fourth finger, not the second finger. V14 stated he expects the facility to follow and implement his orders. V14 further stated that the left second finger has a significant vascular issue and a vascular surgeon evaluation was recently ordered and pending. V14 stated that particular arm has a fistula that has issues and has obstructed blood flow. V14 confirmed R1's treatment should have been changed but stated he doubts any treatments will be effective until the vascular issue is addressed. The Brief Interview of Mental status date 11/16/2022 documents R1 as cognitively intact.

Based on interview and record review, the facility failed to utilize a gait belt during a transfer and failed to provide assistance to one resident with ADLs (activities of daily living). These failures resulted in R66 sustaining a fall while in the washroom and sustaining a femur fracture. These failures affect 1 out of 4 residents (R66) reviewed for falls out of a sample of 19. The findings include: R66's incident report dated November 8, 2017 documents that R66 fell in the washroom with the CNA (certified nurse's aid) present Upon assessment, other than an elbow abrasion, R66 did not complain of pain and appeared to have no injury. Nursing notes timed at 8:20 AM on November 8, 2017 indicate that R66 fell at approximately 2:20 AM and by 6:00 AM, R66 did complain of pain to her right thigh, and swelling was noted, as well as shortening of her right leg. R66's physician was notified and she was transferred to the hospital for evaluation. R66 was diagnosed with [REDACTED]. On January 11, 2018, V6 (LPN) stated that when she arrived to work on the morning of November 8. 2017, she was advised of R66's fall by night shift staff. She was advised that V5 (former CNA-certified nurse's assistant). had been caring for R66 that night. V6 went to assess R66 and notified the physician that R66 now had pain and swelling. She then began to investigate the incident and how it had occurred and spoke to V5 over the telephone. V6 asked V5 about the circumstances of the fall. V5 admitted to V6 that she had not used a gait belt when she transferred R66 in to the washroom.V5 told her that the resident had been holding on to the grab bar but let go to pull her pants up and lost her balance. She was not able to completely stop the fall but helped to ease R66 to the floor. V6 stated that the facility policy is that gait belts are to be used for all resident transfers. V6 also stated that V5 no longer works at the facility and was terminated as a result of this incident, due to not using the gait belt and because it was felt that V5 could have provided more assistance to R66 by helping pull up R66's pants. V6 stated that if V5 had used the gait belt or even had assisted R66 with pulling up her pants, she would have had her hands on R66 and might have been able to stop R66 from losing her balance and falling. . Handwritten statement completed on November 11, 2017 by V5 indicates that R66 was finished using the washroom and was pulling up her pajama pants and lost her balance. V5 stated she caught R66 before she fell completely to the floor so she could land on her bottom. V5's personnel file reflects that V5 was terminated on November 15, 2017. R66's MDS (Minimum Data Set) of September 30, 2017 scores R66 as a 2/2 for most ADLs, including transfers, dressing and toilet use. This indicates that R66 was a one person physical assist for these tasks. Facility policy on gait belts states tht gait belts are mandatory for all residents who need assistance with ambulation or transfers R66's face sheet documents that she was admitted to the facility July 1, 2017 and is [AGE] years old. R66 was identified as being at risk for falls with an initial fall care plan developed. R66 was noted to have several falls (10/16/17, 10/23/17, 10/11/17) prior to the November 8, 2017 fall, making R66 at high risk for falls. R66's [DIAGNOSES REDACTED].

Based on record review and interview the facility failed to ensure that techniques used to transfer residents from one position to another is completed safely. This is for one resident in a sample of 19. This failure resulted in the fracture of one resident's arm.(R14) Findings include; R14's record contains an occurrence log dated 3/8/11 that denotes the following; "Daughter came to nurse and stated that mother was complaining of right arm pain after she had been transferred from the bed to the wheelchair..." R14's occurrence report contains an interview with a certified nurse assistant (CNA) that denotes, "She used the sit-to stand lift to transfer the client (R14) from the bed to the wheelchair...states that while the client was lifted she heard a snap." R14's record contains a an X-Ray report dated 3/8/11 that denoted, "A diagonal displace fracture through the distal shaft of the right humerus is identified. There is significant proximal dislocation of the distal fracture fragment this resulted in for shortening of the humerus." This X-ray report describes a serious twisting fracture. R14's occurrence report lacks a conclusion as to how this serious fracture occurred. R14's record lacks a plan of care for transfers prior to the fractured arm. R14's record contains a family practioner note dated 3/8/11 that denoted ,"...transferring from bed to wheelchair in lift, complained of acute pain...revealed right humerus fracture." R14's record contains a care plan after the broken arm that states she is a two person transfer. In an interview with the E1 administrator she stated that an abuse investigation was not done on this resident. E1 states that inservice education was provided to the CNA who transferred R14. E1 states that the CNA is no longer employed at the facility. B. Based on observation, record review, and staff interview, the facility failed to ensure staff provide supervision to 1 of 10 sampled residents(R17) in a sample of 19, and 1 resident(R26) in the supplemental sample assessed as high risk for falls 2)R17 was admitted to facility on 1/4/12 with [DIAGNOSES REDACTED]. R17's admission Minimum Data Set assessed as alert and orientated and requires extensive assist with activities of daily living. R17 wears a sling on the right arm due to recent humerus fracture. R17 was also assessed as not steady, only able to stabilize with human assistance for balance during transition and walking. walking down the hallway. On 1/25/12 at 1:35 a request to do a skin check on R17 was made. E10 (CNA)who was assigned to R17 stated "R17 is on the bedside commode and will use the call light when she's done." R17's ,who is in isolation for[DIAGNOSES REDACTED], door was closed. E10 was observed going in and out of other residents rooms. At 1:40PM asked if she was done. R17 stated "yes, you can come in." E10 was then informed R17 was done, responded "she is, she was suppose to use the call light." R17's current care plan identifies R17 " at risk for falls, history of recent fall, gait unsteady and exhibits tremors of her hands at times. Care plan interventions include: Keep areas free of obstruction to reduce the risk of falls, place call light within easy reach, remind R17 to call for assistance, use alarm to monitor attempts to rise. 3.R26 was admitted to facility on 1/20/12 with [DIAGNOSES REDACTED]. R26's initial fall risk assessment dated [DATE] identified R26 as at risk for falls and to initiate precautions. R26 's nursing admission assessment denotes R26 is alert and orientated to person. R26 's care plan dated 1/20/12 for fall /safety risk included assess for contributors: sitting, pain, gait: encourage to use call light,physical therapy referral, bed /chair alarm, matts on floor. On 1/25/12 at 11:30 AM, R26's wheel chair was observed outside R26's closed bathroom door. E10 was overheard telling R26's wife outside the room, R26 was in the bathroom. E10 was observed standing outside R26's room, talking with staff, with back facing R26's room. At 11:35 AM, E10 then walked into R26's room to remove R26 from the bathroom. During family interview on 1/26/12 at 10:AM, family stated R26 is often put in the bathroom by staff, and then staff leave the room. E1(administrator) and E3(consultant) stated on 1/26/12 during the daily status meeting, staff are not to leave the room of residents on fall precautions after placing residents in the bathroom. Staff are to stand outside the residents bathroom door.

Based on interview & record review the facility failed to: (1 )Provide treatment & services to change R 2 ' s abdominal wound dressing ( post left nephrectomy) daily (2) Evaluate & assess R 2 ' s abdominal wound, to obtain base line measurement & description for comparison.(3) Document the progress or decline of R 2 ' s surgical wound. (4) Develop a plan of care to address R2 ' s surgical wound to promote healing & prevent possible complications. These failures resulted in R 2 ' s abdominal wound being infected on 3-25-11. Findings include: Review of R 2 ' s Physician order [REDACTED]. R 2 ' s nursing Admission assessment dated [DATE] at 12:50 PM under Integumentary page showed that R 2 has surgical wounds in the abdominal region. The nursing admission note reads: Patient has abdominal incision & redness in peri area, wears diaper ...There was no base line assessment & evaluation that was done, no measurement, or documentation whether R 2 has staples or suture on her abdominal area & how many. The skilled daily nurse ' s notes check list dated 03-19-11 & 03-20-11, under skin " surgical wound " was checked but no description, other assessment or evaluation regarding the wound was found. On 03-21, 03-22 & 03-24 -11 (skilled daily nurse ' s notes) the surgical wound in R 2 ' s abdomen was not mentioned at all. This finding was confirmed by the Treatment Nurse (E 4) on 05-19-11 at 1:30 PM. E4 stated " the nurses suppose to document it on the nurse ' s notes. " Review of the Treatment Administration Record showed an order to change R 2 ' s abdominal dressing daily. For 3 days (March 20, 21 & 22, 2011) this order was not followed, R 2 ' s Treatment Administration Record was not signed. On 05-19-11 at 12:10 PM the Administrative Staff/ MDS Coordinator/Unit Manager (E6) claimed " if it ' s not sign usually that means it ' s not done. " There was no specific care plan developed for R 2 ' s abdominal surgical wound. E 6 presented a check list sheet that reads: Skin condition- dressing changes (no site indicated). Infection alert- monitor wound, there were no interventions listed. E 6 claimed " this form is what the facility been using for a long time. " Review of skilled daily nurses note dated 03-25-11 at 11:00AM reads: patient ' s son insisted to call Medical Doctor regarding drainage from abdominal wound. He had concern re wound separation ...Doctor was called & ordered to transfer R 2 in the hospital for evaluation. Review of the hospital history & physical dated 03-25-11 showed that R 2 was admitted with [DIAGNOSES REDACTED]. When the facility discharging nurse (E8) was asked on 05-19-11 at 3:30 PM, why she discharged R 2 to the hospital, E 8 claimed " the son insisted, he show his mom (R2) with blood in her clothing I can ' t remember where, he showed me, I didn ' t know she was bleeding. He ' s scared his mom ' s (R2 ' s) wounds opening up. The night nurse usually changes the dressing on her abdominal dressing. "