Every finding on record at The Sapphire at Maple Crest

Based on interview and record review the facility failed to ensure call lights were answered in a timely manner for 7 of 7 residents (R1-R7) who require assistance from staff reviewed for activities of daily living in the sample of 7. The findings include:On 7/16/26 at 1:06 PM, R1 stated staff take forever to change my incontinent brief. I wait up to three hours at night usually. Staff don't get me dressed and out of bed in time for my physical therapy some days. Sometimes I am still naked when therapy comes in to get me, then it gets pushed back to later in the day. V8 (family member) stated I visit often, and she is waiting for staff help many days when I arrive. They are fast on some shifts, but super slow on others. On 7/16/26 at 10:50 AM, R2 and R3 (roommates) said the call lights take a long time to be answered. R2 said second shift is the worst. It is up to 45 minutes to get someone in here. I have waited 3.5 hours with bowel movement in my pants in the past. R3 said I have to wait over an hour to be transferred back into bed. That is why I don't like to get up very often. Staff just do it whenever they want to do it. I hate it and have had UTIs from sitting in a wet brief so long. On 7/16/26 at 10:45 AM, R4 said sometimes it takes over an hour to get someone in here to answer my call light. The nights are the worst. The response time should be quicker. On 7/16/26 at 11:00 AM, R5 said call lights take so long to be answered that I don't' even bother to use it. On 7/16/26 at 12:30 PM, R6 said I wait a long time for the call light to be answered. I guess it's because I am way down here at the end of the hall. On 7/16/26 at 12:55 PM, V9 and V10 (R7's family members) stated they visit R7 several times a week. They need more help around here. We are okay with R7's care because we come in a lot and that helps things. It is the other residents that look like they need more one-on-one care some days. On 7/16/26 at 1:49 PM, V2 (Director of Nurses) stated call lights should be answered as quickly as possible. The expectation is to be answered in 10 to 15 minutes. Waiting over an hour is not acceptable. Incontinent residents should be changed right away. There is the potential for skin breakdown, infection, and a lack of dignity. V2 confirmed R1-R7 all need staff assistance with toileting and incontinence cares. The facility's Supporting Activities of Daily Living (ADL) policy last review dated 12/4/25 states: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and record review the facility failed to ensure medications were administered as ordered for 1 of 3 residents (R1) reviewed for medication administration in the sample of 7. The findings include: R1's face sheet dated 7/16/26 showed diagnoses including but not limited to difficulty walking, diabetes mellitus, asthma, hypertension, hyperlipidemia, and bilateral osteoarthritis of knees. R1's facility assessment dated [DATE] showed no cognitive impairment and no memory problems. R1's July 2026 physician order summary report showed orders for metformin to be given every morning and bedtime for diabetes mellitus. The report showed montelukast to be given at bedtime for asthma. The report showed acetaminophen (Tylenol) to be given every eight hours as needed for pain. The report showed hydrocodone-acetaminophen (Norco) to be given every six hours as needed for pain. On 7/16/26 at 1:06 PM, R1 stated she had a problem with her medication administration last week. R1 said it was all documented on her cell phone. R1 opened her phone and reviewed her notes. R1 said it was on July 9, and the nurse gave the wrong medicine. R1 said she had to wait over an hour for pain medication. R1 said she asked for Tylenol at 4 PM and did not get anything until after 5:30 PM. R1 stated when the nurse finally came in with the Tylenol, there were other tablets in the cup too. R1 clarified that the pills were the ones prescribed to her, but the nurse was trying to give them too soon. R1 said she knew the extra pills were her montelukast, metformin, and Norco which she does not take until bedtime. R1 said she refused to take anything but the Tylenol. R1 said she had to tell the nurse what to do. R1 said she was also concerned with her medications because for the last two days she has missed getting the montelukast. R1 said she did not know why the nurses had not been getting it to her as ordered. R1's July 2026 MAR (Medication Administration Report) was reviewed for 7/9/26. The report showed montelukast scheduled to be given at bedtime and metformin scheduled for 8 AM and 8 PM. The same report showed both were administered at 8 PM and with the 8 PM Norco. There was no documentation of the Tylenol ever having been given in the afternoon on 7/9. Progress notes showed Norco declined by R1 on 7/9 at 5:41 PM. R1's July 2026 MAR showed the montelukast documented with a number 9 for 7/14 and 7/15. The number 9 corresponded to Other/see progress notes. The progress notes for both dates showed the medication was on order. On 7/16/26 at 1:49 PM, V2 (Director of Nurses) stated any resident reporting pain should be addressed immediately to ensure comfort and reduce pain. Ongoing pain can start other health issues. Addressing pain sooner keeps it easier to control. R1 should have received the Tylenol within 15 minutes. The nurse should have responded quicker or tried something else until the medication was administered. V2 said scheduled medications can be given one hour before and one hour after. It is considered an error if it is given outside that parameter. If the time in between is too close or too far apart, it can affect the therapeutic levels. Missing medication can affect resident health. It is important nurses give medication as ordered and at the scheduled times. The facility's Medication Administration policy last review dated 4/5/26 states: All medications are administered safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms and help in diagnosis.

Based on interview and record review the facility failed to ensure a resident was provided a shower or bed bath. This applies to 1 of 3 residents (R1) reviewed for showers in the sample of 3. The findings include:On 6/8/26 at 9:22 AM, V3 (R1's Family Member) said he visited R1 on the weekend of 5/23/26 to 5/25/26. V3 said R1's hair was dirty and matted, R1's fingernails were dirty, and R1 appeared unkempt. R1's shower task for the past 30 days shows R1 was not provided a shower, bath, or bed bath from 5/16/26 to 6/1/26. On 6/8/26 at 12:08 PM, V1 (Administrator) said staff should be providing or offering baths or showers at least twice weekly to residents. V1 said staff document that showers or baths are provided or offered under the tasks part of the electronic medical records system. V1 said that is the only place staff document providing showers or baths. The task also shows if the resident refused the bath or shower. Facility Shower; Bathing policy dated 7/2025 states, All residents will be offered a shower and/or a bed bath at least weekly unless a physician order to the contrary is present in the medical record.

Based on interview and record review the facility failed to ensure residents were protected from potential abuse when a non-staff individual, who was not screened, trained or authorized by the facility, was permitted to provide resident care including incontinence care, transfers and assisting residents to change clothes for 4 of 4 residents (R4, R5, R6, and R7) reviewed for abuse in the sample of 8.The Immediate Jeopardy began on 5/10/2026 when V5 (Non-Staff Individual) entered the building and began providing resident care.V1 (Administrator) was notified of Immediate Jeopardy on 5/26/2026 at 8:23 AM. This surveyor confirmed by interview and record review that Immediate Jeopardy was removed on 5/26/2026 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:1. On 5/21/26 at 12:55 PM, R4 said that the other day, V4 (Certified Nursing Assistant- CNA) and another man that she had never seen before (V5-Non-Staff Individual) came into her room. R4 said that V4 said that it was his friend. R4 said that she asked V5 if he was going to start working at that facility and he shook his head yes. R4 said that she thinks that he said his name, but she does not remember. R4 said that V5 stood there and watched V4 get her to bed using the mechanical lift, took off her clothes to put her night gown on and changed her incontinence brief. R4 said that V5 did not do much, he just watched. R4 said, He (V5) saw everything but I figured if he was going to work here, he was going to see it all anyways.On 5/21/26 at 1:10 PM, R8 (R4's roommate) said that V4 and V5 entered her room around 8:00 PM. R8 said that V4 introduced V5 as his friend. R8 said that he was standing at a distance from her but he was about 5'8, black and had dreadlocks. R8 said that he had black clothes on and she did not see a name badge. R8 said that they did not provide any care to her but they did to R4, her roommate. R8 said that it bothered her that V4 had brought a friend in to help him and he saw her roommate exposed. R8 said that she tried to ask V4 about it but he kept avoiding the questions. R8 said that she heard V4 say to V5, We only have 3 left to do. R8 said that it made her feel uneasy so the next day, she informed V1 (Administrator) about the situation.2. On 5/20/26 at 1:10 PM, R5 said that she remembers V4 coming into her room and introducing her to V5 and said that he was going to start working at the facility. R5 said that she does not remember his name. R5 said that she had not seen him in the past and has not seen him since. R5 said that they provided incontinence care to her while she was in bed.3. On 5/21/26 at 9:30 AM, R6 said that he does remember a day when V4 brought in his friend to help him work. R6 said that V5 helped V4 change his brief and reposition him in bed. R6 said that V5 was a black guy that looked like V4. R6 said that he only saw him one time and has not seen him since. 4. On 5/20/26 at 1:14 PM, R7 said that she did have an interaction with V4 and V5. R7 said that V4 entered her room and introduced V5 as his friend. R7 said that V4 and V5 boosted her up in bed but did not provide any incontinence care. R7 said that she told them that they looked like the Boppsey twins because they looked alike. R7 said that they both were African American and they both had dreads. R7 said that she only saw V5 on that day and has not seen him since.On 5/21/26 at 11:39 AM, V4, (CNA) said that on 5/10/26 he had his friend (V5-Non-Staff Individual) come to the facility to meet one of the nurses. V4 said that V5 usually brings him to work and picks him up from work. V4 said that he had V5 enter through the back employee entrance. V4 said that he introduced V5 to V6 (Charge Nurse) and then V5 helped him boost a resident up in bed. V4 said that V5 was only in the facility for about 5-10 minutes and he does not recall what time of day it was. V4 said that he has known V5 for about a year but he is unsure if V5 is a CNA or not.On 5/20/26 at 1:49 PM, V8 (CNA) said V4 and V5 came up to her sometime after dinner, maybe around 7:00 PM, and V4 introduced V5 as his boyfriend and said that he was going to be working at the facility. V8 said that she immediately went to V6 (Charge Registered Nurse-RN) and she did not know anything about him working. V8 said that V5 was wearing blue or black scrubs, was African American and had dread locks. V8 said that she had never seen V5 at the facility prior to that day and has not seen him since. On 5/20/26 at 4:10 PM, V6 (Charge RN) said that on 5/10/26, there were three CNAs scheduled to work the PM shift. V6 said that around 6 or 7 PM, V4 came up to her and introduced her to V5. V6 said that V4 introduced him as his boyfriend and said that he was going to work the unit with him. V6 said that she asked V4 if he got that approved first and he said, yes. V6 said that she didn't know that V4 was not telling her the truth so she did not check with V2 (Director of Nursing-DON). V6 said, Looking back, I should have checked with [V2]. V6 said that V5 was a tall, thin, African American with dread locks.On 5/20/25 at 2:07 PM, V7 (Receptionist) said that around 6:00 PM, V4 came up to her at the front desk and said that one of his friends were coming in to help him and it was approved by V2. V7 said that V4 never said who was coming in to help but she figured it was a work friend that he was talking about. V7 said that around 7:40 PM, she looked down the hall way and she saw V4 and V5 going in and out of resident rooms. V7 said that she had never seen V5 at the facility in the past. V7 said that V5 was African American, had dreads and was wearing black scrubs.On 5/20/26 at 2:44 PM, V1 (Administrator) said that on 5/10/26 around 11:00 PM, she heard from V2 (DON) that V4 had had his boyfriend (V5) work with him that night. V1 said that she immediately had staff make sure he was no longer there and then started an investigation that next morning. V1 said that through her investigation, V4 did admit to having a friend that came to the facility but would not provide a name. V1 said that non-staff members should never be allowed in the facility to provide resident care. V1 said that V5 was not and is not an employee of the facility and should have never been at the facility in resident care areas or providing resident care. V1 said that it would be very unsafe for the residents and expose them to potential abuse if an untrained, non-staff member provided care to them. On 5/20/26 at 2:25 PM, V2 (Director of Nursing) said that on 5/10/26, V4 had called her and asked if he could have another CNA that works at the facility come in to help him. V2 said that she informed V4 that if he could get anyone to come in, she would give them a bonus. V2 said that when she said that, she meant anyone who is employed by the facility. V2 said that around 11:00 PM, she received a call from V9 (Night Shift Licensed Practical Nurse) stating she had heard that V4 had brought his boyfriend in to help get residents ready for bed. V2 said that at that time, V4's shift had already ended. V2 said that she immediately notified V1 and they started an investigation on 5/11/26. V2 said that there are many reasons why a staff member should not have random people come help with resident care. V2 said that it is not safe for the residents because the person has not had a background check, they have not gone through appropriate training and orientation and it would be strange for a resident to get care from a random stranger. V2 said that the thought of having a random person come in to provide cares to residents is insane. V2 said, Imagine having a strange male coming in and taking care of you.The facility's Incident Investigation shows that on 5/10/26 at approximately 11:00 PM, DON (Director of Nursing) became aware that an individual who was not employed by the facility was observed assisting the CNA on the 200 hall. It shows that facility CNAs reported that the individual was present on the unit and assumed he was there to help on 200 hall. Facility nurses observed the individual on the unit following the facility CNA and assumed he was called in. The statement received from V4 showed, [V4] reports that his friend came to see him on Sunday at work. He is unsure what time he arrived. He said that his friend is an aide and he did help him boost some residents in bed. He stated that the nurse was busy, so he had his friend help. He denies any malicious intent but stated that the other aides are so far up each other's butts that he didn't ask them for help.The facility's Abuse Prevention Program-Policy shows, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.The purpose of this policy and the Abuse Prevention Program is to describe the process for identification, assessment, and protection of residents from abuse, neglect, misappropriation of property and exploitation. This will be accomplished by: conducting pre-employment screening of employees.orienting and training employees on how to deal with stress and difficult situations.establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment.The Immediate Jeopardy that began on 5/10/2026 was removed on 5/26/2026 when the facility took the following actions to remove the immediacy:- The facility's Abuse Prevention Policy was reviewed on 5/26/26 with no updates at this time.- A Facility wide in-servicing on Abuse Prevention Program-Policy was initiated on 5/26/26 for all staff members on duty and will continue until all staff have been educated.- A Facility wide in-servicing on mandatory and immediate notification of unauthorized persons in the building providing resident care was initiated on 5/26/26 for all staff members on duty and will continue until all staff have been educated.- A facility wide in-servicing on verifying staff identity was initiated on 5/26/26 for all staff members on duty and will continue until all staff have been educated.- An emergency QAPI meeting was held with the Medical Director on 5/26/26.- The front and back door codes were changed on 5/26/26 and staff must use assigned badge to enter the facility.- All residents Abuse and Neglect assessments and care plans were reviewed and updated if appropriate on 5/26/26.- Residents and staff will be audited five times weekly, including evening and night shifts and weekends for 4 weeks and audits will be reviewed at QAPI with IDT and Medical Director.

Based on observation, interview and record review, the facility failed to prevent cross-contamination of soiled linens for 3 of 7 residents (R4, R5, and R7) reviewed for infection control in the sample of 7. The findings include:On 3/26/26 at 12:38 PM, V14 (a friend of R7) exited room [ROOM NUMBER] and informed this surveyor and V12 (Laundry and Housekeeping Manager) that there was stool on R7's bedding. V12 said she would inform staff that the bedding needed to be changed. At 12:51 PM, the soiled bedding from R7's bed was sitting directly on the floor with nothing under the soiled bedding.On 3/26/26 at 12:54 PM, during an interview with R5 (R7's roommate), R5 said staff usually put the dirty linen on the floor (pointing to the soiled bedding on the floor) and when they are done, they put them in a bag. V3 (CNA) entered the room. When asked if she put the bedding there, V3 said she had to go get a bag. She said she took the bedding off and realized there was not a bag to put them in, so she put them there and went to get a bag.At 1:16 PM, the soiled bedding was still on the floor in room [ROOM NUMBER]. When V3 entered the room, she stepped on the soiled bedding as she was walking past it to grab something. V5 (CNA/Ward Clerk) was standing by the room and was asked if it was okay for the staff to place soiled linens on the floor. V5 said soiled linens should either be in a bag or in the linen room. V3 said I told you I took the bedding off and then realized I did not have a bag.On 3/26/26 at 3:00 PM, V1 (Administrator) and V2 (Director of Nursing) were informed about the soiled linens being on the floor. V2 said the CNA should have put the soiled linens in a bag, tied it up and took it to the soiled utility room. V2 said the CNA should not put soiled linens on the floor.On 3/26/26 at 3:00 PM, another surveyor observed soiled washcloths in R4's room, on the floor next to a trash can. No staff were present in the room at the time.The facility's policy and procedure titled Laundry and Linen Handling & Storage, with a revision date of July 2017, showed the purpose of the procedure was to provide a process for the safe and aseptic handling, washing, and storage of linen. The procedure showed.In resident rooms 1. Do not allow linen, clean or soiled, to touch clothing or uniform. 2. Handle all soiled linen as though it is potentially infectious. 3. Deposit soiled briefs or underpads in a plastic bag or waste containers. 4. Place soiled linens in plastic bag to transport to soiled linen hampers.

Based on observation, interview and record review, the facility failed to ensure a resident was transferred out of bed in a timely manner and failed to provide incontinence care for a resident in a timely manner for 2 of 2 residents (R23, R57) reviewed for activities of daily living in the sample of 35.This failure resulted in R23 crying and voicing feelings of depression.The findings include:1. R23's admission Record, printed on 9/24/20245, showed she had diagnoses including, but not limited to major depressive disorder, mild cognitive impairment, dysphagia, and congestive heart failure. R23's recreational support care plan showed she is at the facility for long-term care and will attend meaningful activities that she chooses. The care plan showed R23 enjoys visiting with family and friends, enjoys reading books, listening to music, and is interested in participating in group activities. R23's care plans showed she has an ADL self-care deficit related to limited mobility, debility, and impaired balance. The care plan showed R23 uses a mechanical lift with 2 staff assist for all transfers. R23's 8/7/2025 facility assessment showed she was cognitively intact and was dependent on staff for transfers. On 9/23/2025 at 9:50 AM, staff informed V5 (Registered Nurse-RN) that R23 was waiting to get up but there was not a sling ready or available so she would have to wait. On 9/23/2025 at 11:17 AM, R23 was in her room lying in bed. R23 said she is dressed and is waiting to be gotten out of bed. R23 said the staff never get her up until close to noon. R23 said yesterday (Monday) and Sunday, they did not get her out of bed all day. R23 said staff told her they did not have a sling to get her up. R23 started to cry and said it is depressing. I want to get up. I don't want to sit in bed like this. I never did this at home. At 11:20 AM, R9 (R23's roommate) said she heard the aides tell R23 they did not have a sling. R9 said R23 is left in bed quite a bit. On 9/23/2025 at 11:36 AM, V6 and V22 (Certified Nursing Assistants-CNAs) entered R23's room with the mechanical sling lift. R23 was still upset when V6 and V22 entered the room. V6 was asked about the facility's supply of slings. V6 said the facility has a lot of slings, it just depends on what you get. When asked to explain, V6 said the 100 wing has more residents that use the mechanical lifts. V6 said we just have to wait sometimes too. Sometimes we have to use the mesh sling that is for showers. On 9/24/2025 10:17 am, R23 in hall sitting in her wheelchair, combing her hair in the doorway to her room. CNA said she just got R23 up. R23 was observed multiple times on 9/24/2025 sitting in the dining room at a table with other females, reading a book. On 9/25/2025 at 9:33 AM, V2 Director of Nursing (DON) said I told staff that a lot of our residents are early birds; they do not want to be left in bed. We have a lot of slings. The slings are taken down when they are soiled and when the residents are laid down for the night. Laundry stays until after 10:00 PM. We are looking at getting more slings, a different style for the residents that are continent but not able to stand. On 9/25/2025 at 10:38 AM, V3 (Assistant Director of Nursing-ADON) said R23 came from another facility. She wanted to work on her strength. V3 said R23 is on an active range of motion program to all of her extremities, to strengthen her mobility function. V3 said R23 is dependent on staff for transfers. Her lower extremities are not strong enough for her to stand and transfer currently. On 9/25/2025 at 12:45 PM, V6 (CNA) said on 9/23/2025 R23 was not gotten up until after 11:00 AM (observed by surveyor at 11:36 AM) because we had to wait for a sling. V6 said having to wait for a sling to transfer a resident is not a new thing. We have slings, it is just first come first served. 100 hall CNAs grab the slings first, so we have to wait until more are available. V6 said she worked on Monday; however, she was on the 100 hall and is not sure if R23 was gotten up on Monday. On 9/25/2025 at 12:55 PM, V17 (Nurse Practitioner) said not getting a resident out of bed repeatedly can affect the resident's mental health. V17 said no one has said anything to me about not getting R23 up. On 9/25/2025, R23 was again observed multiple times throughout the day, sitting in the dining room at the same table with other females, reading her book. R9's 6/20/2025 Brief Interview of Mental Status assessment showed she was cognitively intact. (R9 is R23's roommate). The facility's policy and procedure titled Activities of Daily Living, with a review date of August 2025, showed activities of daily living is encouraged to prevent disability and return or maintain residents at their maximal level of functioning based on their diagnosis. C. Feeding: a. Residents are encouraged to eat in the group dining room when possible, for socialization. E. Transfer: a. Privacy is provided to each resident. b. Resident is encouraged, if able, to assist with transfers. c. Adaptive equipment, assistance and instruction are given as required. 2. On 9/23/25 at 12:02 PM, V4 (Dietary Manager) stated to V13 Certified Nursing Assistant (CNA), R57 said she needs to use the bathroom. V13 replied, She doesn't go to the bathroom, she's just a check and change. V13 did not ask R57 if she needed to use the restroom or attend to R57's requests to use the bathroom. On 9/23/2025 at 12:10 PM, R57 was sitting in her wheelchair in the dining room at a table, waiting for her noon meal. R57 smelled like a bowel movement (BM). On 9/23/2025 at 12:19 PM, R57 was sitting in her wheelchair at the dining room table eating her lunch. R57 smelled like BM. On 9/23/25 at 12:43 PM, R57 was sitting in her wheelchair in the dining room at a table. Her wheelchair was pushed back a little and the front of her pants were wet. There were no spilled items on the table or the floor next to R57. There was a strong odor of BM present. On 9/23/2025 at 1:01 PM, R57 was wheeled down hall by V10 CNA and left in the hall. On 09/23/2025 at 1:09 PM, V11 CNA and V10 CNA took R57 into her room and transferred R57 from her wheelchair to her bed using a mechanical lift. The groin area and front of R57's pants were saturated. V11 lifted R57's shirt and there was mushy and loose stool above the waistband of her pants on her abdomen. V11 and V10 pulled down R57's pants and opened her incontinence brief and the resident's brief was full of mushy and liquid stool. When V10 and V11 turned R57 to remove the sling, it was wet and there was BM on the sling. On 9/24/2025 at 9:54 AM, V2 Director of Nursing (DON) stated, incontinence care should be provided in a timely manner; residents should be toileted frequently. When residents are turned, they are checked and changed. Staff do not have set times when they are to toilet and/or change residents. When someone says they must go to the bathroom, they are toileted. We do not train our staff to have residents wait or not toilet when requested. Even if the resident is confused or can't use a toilet, they should be taken to their room for care, offer a bedpan etc. We don't let the resident sit in the dining room incontinent during their meal. Staff are to change resident when they need to be changed. The Face Sheet dated 9/24/25 for R57 showed diagnoses including dementia, anxiety, protein-calorie malnutrition, chronic kidney disease, asthma, chronic obstructive pulmonary disease, traumatic subdural hemorrhage, hydronephrosis, anemia, depression, hypertension, and type 2 diabetes mellitus. The Care Plan dated 7/9/25 for R57 showed she has an activity of daily living self-care performance deficit related to a subdural hematoma. Toilet use: R57 requires total assist for toileting. The Minimum Data Set (MDS) dated [DATE] for R57 showed severe cognitive impairment; dependent on staff for toileting hygiene; always incontinent of bowel and bladder. The facility's Activities of Daily Living Policy (8/25) showed, A program of assistance and instructions in activity of daily living skills is care planned and implemented. Elimination: a. Privacy is provided to each resident. b. Adaptive equipment, assistance and instruction are given as required.

Based on interview and record review, the facility failed to properly cool a pork roast after cooking. This has the potential to affect all residents in the building.The findings include:The facility's roster provided to surveyor on 9/23/25 showed 66 residents residing in the building.On 9/23/25 at 10:42AM, V4 (Dietary Manager) sliced the pork roast for the noon meal. V4 stated, We don't normally do cooling logs because we don't normally cook food ahead of time. I did not do a cooling log for this roast but I'm sure we did the correct process. I just took it out of the cooler to slice it and then I'll place it in the oven. If the correct process is not followed and documented, then residents could be at risk for foodborne illness.The facility's recipe for Tender Pork Roast showed, Potentially hazardous foods shall be cooled: a) from 135 degrees F to 70 degrees F within 2 hours. B) From 70 degrees F to 41 degrees F within 4 hours.

Based on observation, interview, and record review, the facility failed to maintain a system for tracking infections, failed to wear personal protective equipment (PPE) into a contact isolation room for 1 resident (R68), failed to wear appropriate PPE for 3 residents (R11,R29,R58) on Enhanced Barrier Precautions, failed to perform hand hygiene and glove changes to prevent cross contamination during incontinence care for 1 resident (R57). These failures have the potential to affect all residents in the building. The findings include:1) The facility roster provided to surveyors on 9/23/25 showed 66 residents residing in the building. On 9/24/25 at 1:56PM, V2 (Director of Nursing/Infection Preventionist) stated, I only have some infection tracking from March 2025 that the previous IP (Infection Preventionist) did. I started in April of this year with my position, but I haven't tracked any infections. I'm going to be creating our infection control tracking but haven't had a chance to start it yet. I think there is a report I can pull from our system to show who is on antibiotics but haven't gotten into that yet. We should be tracking infections so that we can prevent new ones if possible and keep like infections co-horted together if needed. There's just been so much going on I don't even know where to start right now. On 9/24/25 at 2:23PM, V1 (Administrator) stated, We are going to get the infection control program back in order. (V2) is still pretty new so she is trying to get all of the kinks worked out with everything and she just has a lot going on. I know it's important to have the program up to date, but it just hasn't been the priority right now. The facility's policy titled, Infection Prevention and Control Program dated 6/2025 showed, Facility is responsible for protecting and promoting quality of life and health for all their patients and residents by developing and implementing Infection Prevention and Control Programs and systems that provide information and education, effective regulation and oversight, quality services, and surveillance of disease and conditions.4. Surveillance: the facility has a system in place for early detection and management of potentially infectious symptomatic residents, including implementation of precautions as appropriate. 2) R68's electronic face sheet printed on 9/25/25 showed R68 has diagnoses including but not limited to osteoarthritis, hypertension, cerebral infarction, depression, and atherosclerotic heart disease. R68's physician's orders dated 9/19/25 showed, Maintain enhanced barrier precautions to prevent infections related to history of ESBL (extended-spectrum beta-lactamase). R68's local hospital records dated 9/17/25 showed, (R68) presented from (facility) for bloody stools. Facility reported observing stringy bloody diarrhea which started yesterday.ADDENDUM - C diff returned back positive - oral vancomycin ordered> R68's physician's orders dated 9/21/25 showed, Fidaxomicin 200mg BID for 10 days for C-DIFF (Clostridium Difficile). On 9/23/25 at 9:51AM, V6 (Certified Nursing Assistant) entered R68's room with no PPE on. Surveyor entered room and observed V6 providing R68 with repositioning assistance with no PPE on. R68's door had a sign on it that stated, Contact Precautions: All staff must apply gown and gloves prior to entering room . On 9/23/25 at 10:08AM, V6 stated, (R68) is on isolation for CDIFF. As long as his stool is contained you don't need to wear PPE as long as you don't touch surfaces or anything. On 9/24/25 at 1:56PM, V2 stated, Contact precautions are required for anyone infected with C. Diff. It is a highly contagious organism and any staff entering that resident's room should be wearing a gown and gloves at all times. I'm not sure why (V6) thought she didn't need PPE on because C. Diff is transmittable by touching infected surfaces. It has never been our guidance to staff that they don't need PPE on when entering (R68's) room. The facility's policy titled, Transmission Based/Contact Precautions dated 8/2025 showed, Contact Precautions: Wear a gown and gloves for all interactions with the patient or potentially contaminated areas in the patient's or resident's environment. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the patient room.use contact precautions for the following: residents with C. difficile infection. 3. R58's admission Record (Face Sheet) showed diagnoses to include chronic venous ulcer of the left leg, stage 4 pressure ulcer of the buttock, and diabetes. On 9/23/25 at 10:31 AM, R58 was in his room. The door to his room had no signage indicating he was in any type of infection control isolation. There was no isolation bin outside or near R58's room. R58's cotton gauze dressing to his left leg extended from just below his knee to his foot. The dressing had a 4-inch circle of bloody drainage visible on the exterior of the dressing. On 9/23/2025 at 11:18 AM, V7 Licensed Practical Nurse (LPN) changed R58's soiled left leg dressing; V7 did not wear an isolation gown during this process. On 9/24/2025 at 11:12 AM, V2 Director of Nursing (DON) stated the floor nurses are trained on which residents require EBP (Enhanced Barrier Precautions), and the floor nurses should be posting EBP signage for those residents. V2 stated R58 should be in EBP. V2 stated V7 should have worn a gown during R58's dressing change on 9/23/25. V2 stated she was not aware the facility's policy stated PPE (Personal Protective Equipment) bins should be placed outside EBP rooms. V2 stated the purpose of EBP and PPE during wound care is to prevent wound infection and also to prevent taking organisms out of the isolation room. R58's Care Plan Focus area (created 10/28/24) showed he required EBP related to wounds. The facility's Enhanced Barrier Precaution policy (reviewed 2/2025) showed EBP is .an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of [organisms]. The policy showed EBP is required for residents with wounds and PPE is required during wound care. The policy showed, Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE.Make PPE, including gowns and gloves, available immediately outside the resident room. 4. On 9/23/25 at 1:57 PM the door of R29's room had an enhanced barrier precaution sign on it. V12 Registered Nurse (RN) put gloves on and went into R29's room to provide wound care to the resident's pressure injury. V12 did not put on a gown, removed R29's soiled dressing, cleaned the pressure injury, applied a new treatment, and dressing to the wound. R29 had an indwelling urinary catheter. V12 stated R29 should be on enhanced barrier precautions. V12 stated she should wear a gown and gloves when providing care and she forgot to put the gown on. On 9/24/25 at 9:54 AM, V2 Director of Nursing (DON) stated enhanced barrier precautions are for anyone that is colonized with a multidrug resistant organism (MDRO), has an indwelling device like a catheter, feeding tube, lines, and wounds that are not draining. If the resident has draining wounds they are on contact precautions. V2 stated anytime a resident has a device and/or is colonized an EBP sign is posted on their door. Staff should wear gowns and gloves with any close contact care for someone on EBP. They should wear gowns when emptying foley catheter, doing g-tube site care, wound care, peri care etc. The Face Sheet dated 9/24/25 for R29 showed diagnoses including anxiety disorder, hypertension, depression, mild protein calorie malnutrition, postherpetic polyneuropathy, chronic obstructive pulmonary disease, neuromuscular dysfunction, edema, and multiple sclerosis. The Wound Care Progress Note dated 9/19/25 for R29 showed she has a stage 4 pressure wound to her sacrum that is full thickness. The dressing treatment plan showed, Primary dressing - alginate calcium with silver once daily and as needed: if saturated, soiled, or dislodged. Secondary dressing - gauze island with border, apply once daily and as needed: if saturated, soiled, or dislodged. Peri wound treatment - skin prep apply once daily and as needed: if saturated, soiled, or dislodged. The facility's Enhanced Barrier Precaution policy (2/25) showed, enhanced barrier precautions apply to all residents with any of the following: wounds, and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy) regardless of MDRO status. When a resident is placed in enhanced barrier precautions, gown and gloves will be used during high-contact resident care activities. (Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing). Make PPE (personal protective equipment) including gowns and gloves, available immediately outside the resident room. 5. On 9/23/2025 at 1:09 PM, V11 Certified Nursing Assistant (CNA) and V10 CNA were at R57's bedside to provide incontinence care. V10 and V11 had gloves on. V11 lifted R57's shirt and she had a bowel movement. The BM was up over the top of her pants to her abdomen. V11 unfasted R57's incontinence brief and it was full of mushy BM. V11 used disposable wipes to clean the BM of the front of the resident. V11 removed her gloves, left the room to get washcloths and incontinence pad for the bed. V11 came back with the linen, applied gloves, and washed R57's groin. V11 cleaned R57's residents' buttocks and anus. V11 discarded the soiled washcloth. The mechanical lift sling under the resident had BM on it. V11 rolled up the linen and sling and tucked it under R57. V11 grabbed a clean incontinence pad and brief and placed that under the resident. R57 was then turned on her other side. V11 put her hands on R57 to keep her on her side. V10 cleaned R57's buttocks. V11 grabbed a clean dry towel to pat dry R57's groin area. V11 grabbed a clean washcloth and put it on the handle of the wheelchair. V11 asked V10 to wet the washcloth for her. V10 did not do it. V11 finished putting the incontinence brief on the resident and fastened it closed. V11 grabbed the washcloth from the handle of the chair, wet it and put some soap on it. V11 washed the BM off R57's abdomen and removed her soiled top. V11 put clean pants on R57. V11 straightened R57's pillow under her head and pillow and pulled her sheets and blanket up. V11 tied bags of garbage and linen closed. V11 stated she changes her gloves after she throws this away. V10 stated she changes her gloves after she wipes a person and before she gets a clean/new incontinence brief. V10 stated she changes her gloves when going from dirty to clean. V10 stated it is for infection control. V11 stated it's important for cross contamination. On 9/24/25 at 9:54 AM, V2 Director of Nursing (DON) stated staff should perform hand hygiene, they should wash their hands and put on gloves before the start of care. Gloves should be changed anytime they are soiled. Gloves are changed when going from dirty to clean. This is done because we don't want to contaminate the clean area. This is done to prevent cross contamination and transmission of bacteria especially during peri care. The Face Sheet dated 9/24/25 for R57 showed diagnoses including dementia, anxiety, protein-calorie malnutrition, chronic kidney disease, asthma, chronic obstructive pulmonary disease, traumatic subdural hemorrhage, hydronephrosis, anemia, depression, hypertension, and type 2 diabetes mellitus. The Care Plan dated 7/9/25 for R57 she has an activity of daily living self-care performance deficit related to a subdural hematoma. Toilet use: R57 requires total assist for toileting. The Minimum Data Set (MDS) dated [DATE] for R57 showed severe cognitive impairment; dependent on staff for toileting hygiene; always incontinent of bowel and bladder. The facility's Hand Washing Policy (4/21) showed, Goal: To prevent the spread of infection. Procedure: hand washing will occur b) When obviously soiled. h) After handling used dressings, used sputum containers, urine, bedpans, catheters, or soiled linen, or assisting the guest in the bathroom. The facility's Perineal Care policy (1/2025) showed, wash hands thoroughly and explain procedure to residents. Put on disposable gloves. Using clean washcloth/peri wipe, rinse thoroughly from front to back, pat dry. Remove your gloves, wash your hands (your gloves are dirty try not to touch anything). Reposition guest and make comfortable. 6. R11's Order Summary Report, printed on 9/24/2025, showed an order for an indwelling catheter related to a diagnosis of neurogenic bladder (a condition in which a person lacks bladder control due to brain, spinal cord or nerve problems). The Order Summary Report showed an order to maintain enhanced barrier precautions to prevent infections related to indwelling catheter. R11's care plans, provided by the facility on 9/24/2025, showed she was on Enhanced Barrier Precautions (EBP) related to an indwelling catheter and history of MRSA (methicillin-resistant Staphylococcus aureus). The care plan showed staff should wear gowns and gloves when having high-contact resident care activities. On 9/24/2025 at 1:14 PM, V6 (Certified Nursing Assistant-CNA) went with R11 to her room to empty her urinary drainage bag. Signage on R11's door showed Enhanced Barrier Precautions (EBP). The signed showed staff should wear a gown and gloves when providing direct patient care. Catheter care was one of the care tasks listed on the signage as needing a gown and gloves for. V6 only had gloves on. While emptying bag. At 1:17 PM, V6 was asked if emptying the catheter required a gown. V6 said no. V6 said a gown is needed if the resident has an active infection. On 9/24/2025 at 1:23 PM, V3 (Assistant Director of Nursing-ADON) said a gown and gloves are needed when emptying a catheter bag, to prevent infection. V3 said even if the resident does not have an active infection. On 9/25/2025 at 9:27 AM, V2 (Director of Nursing-DON) said when a resident is on EBP precautions, staff should be wearing a gown and gloves when providing direct care. The sign shows any resident with an indwelling device. That includes urinary catheters. For infection control. The facility's policy and procedure titled Enhanced Barrier Precautions, with a revision date of September 2025, showed Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multidrug Resistant Organisms (MDRO).EBP may be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO status, Infection or colonization with a CDC-targeted or other epidemiologically important MDRO. Examples of indwelling medical devices included central lines, urinary catheter, feeding tube, and tracheostomies. The policy showed examples of high-contact resident care activities included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care.

Based on observation, interview, and record review, the facility failed to offer activities. This applies to 6 of 6 residents (R10,R15,R28,R44,R48,R66) reviewed for activities in the sample of 35.The findings include: On 9/23/2025 at 10:46 AM, R66 stated There are no activities on the weekend. R66 stated she enjoys some of the activities the facility provides, and she would enjoy activities on the weekend. R66 said she would like weekend activities because they give us something to do. It helps us to pass the time.On 9/25/2025 at 9:06 AM, V18 Activities stated R66 does enjoy attending some of the activities the facility provides.R66's 7/18/25 Minimum Data Set (MDS) showed she was cognitively intact.R66's 1/16/25 Activity Assessment showed, [R66] is a LTC (Long-term care) resident. She has expressed the desire to remain in her room for most of her day. Activities of [R66] choice include, watching her favorite tv shows, visiting with family, reading, doing word searches, arts and crafts, and food related activities. She sometimes comes to bingo, music programs, and the dine in club. Activity staff will continue to encourage [R66] to participate in activities and provide her with monthly activity calendars. The assessment showed it was very important for R66 to do her favorite activities and to do things with groups of people.On 9/24/25 at 10:00AM, R28, R44, and R48 were present during the Resident Council Meeting. All residents stated there is only one activity staff member and she is off every other Monday, Friday, and weekend. Residents stated when the activity aide is not at the facility, no activities get done. Residents verbalized frustration with the weekends as they are just given a movie to watch and have to find something to do. All residents agreed that they are bored on the weekends, and the weekends seem very long until they have to wait until Monday when the activity aide comes back. On 9/24/25 at 2:33PM, V1 (Administrator) stated, I am the activity director right now because we don't have anyone else. We only have 1 activity aide and I am trying to hire another one for the days our aide is off. We do have movies on the weekends and either a physical church service or a video of a church service but that's all we have right now. Residents can always find something to do if they get bored. I don't currently have an activity calendar that is posted for the residents but we have a handwritten one that we go off of. We try to announce the activities as they come up but it doesn't always work that way. Observations of resident rooms on all hallways showed no activity calendar posted in common areas, resident rooms, or activity area. The facility's policy titled, Life Enrichment dated 8/25 showed, Guests will be offered Life Enrichment that enhance their sense of well-being and promote their physical, cognitive, spiritual, social and emotional health.

Based on observation, interview, and record review the facility failed to ensure a resident's pressure injury dressing was intact for 1 of 1 resident (R29) reviewed for pressure in the sample of 35. The findings include:On 9/23/25 at 1:57 PM, V12 Registered Nurse (RN) went into R29's room to change the dressing on the pressure injury to the resident's sacral area. V12 pulled R29's covers back and turned her on her side. R29's open sacral wound was not covered, and the dressing was barely attached at the bottom of the dressing. R29's dressing was soiled with drainage and an odor present. On 9/24/25 at 9:54 AM, V2 Director of Nursing (DON) stated staff should be monitoring the wound dressing to make sure it is intact. The Certified Nursing Assistant (CNA) should let the nurse know anytime a dressing becomes loose or is off so it can be reapplied. The CNA should let the nurse know if the dressing is soiled and needs to be changed. It is important for the dressing to remain in place to help with healing. The treatment is in place for a reason. Open wounds can get infected, so the dressing helps prevent infection and promote healing.The Face Sheet dated 9/24/25 for R29 showed diagnoses including anxiety disorder, hypertension, depression, mild protein calorie malnutrition, postherpetic polyneuropathy, chronic obstructive pulmonary disease, neuromuscular dysfunction, edema, and multiple sclerosis.The Wound Care Progress Note dated 9/19/25 for R29 showed she has a stage 4 pressure wound to her sacrum that is full thickness. The dressing treatment plan showed, Primary dressing - alginate calcium with silver once daily and as needed: if saturated, soiled, or dislodged. Secondary dressing - gauze island with border, apply once daily and as needed: if saturated, soiled, or dislodged. Peri wound treatment - skin prep apply once daily and as needed: if saturated, soiled, or dislodged. The Care plan dated 7/28/25 for R29 showed she is at risk for impaired skin integrity: multiple sclerosis, chronic obstructive pulmonary disease, and mild protein-calorie malnutrition, history of sacral pressure ulcer, bowel incontinence. Check skin daily The care plan did not show the resident currently has a stage 4 pressure ulcer and treatments.The Minimum Data Set (MDS) dated [DATE] for R29 showed she is dependent for toileting; needs substantial/maximal assistance for bed mobility, transfers, and dressing.The facility's Skin Management policy (9/24) showed, residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. The clinician will document preventative measures on the care plan. The licensed nurse will monitor, evaluate, and document changes regarding skin condition (to include dressing, surrounding skin, complications, and pain) in the medical record.

Based on observation, interview and record review, the facility failed to ensure dignity was maintained for 2 of 2 residents (R50, R47) reviewed for dignity in the sample of 35.The findings include:R50's admission Record, printed on 9/24/2025, showed she had diagnoses including, but not limited to, anxiety disorder, depression, memory deficit following cerebrovascular disease (stroke), protein-calorie malnutrition, chronic kidney disease stage 3, and Parkinson's disease. R50's facility assessment dated [DATE], showed she had severe cognitive impairment, range of motion impairment one-sided upper and lower extremities, and required substantial/maximal assist from staff for transfers. R50's care plans showed she was on hospice care due to a terminal condition. The care plan showed the goal was that R50 would receive emotional, physical, and spiritual support during the terminal phase of illness. Interventions in place were to approach in a calm manner and ensure a quiet environment for resident while offering activities of interest.R47's admission Record, printed on 9/25/2025, showed she had diagnoses including, but not limited to, dementia, depression, anxiety disorder, heart failure, protein-calorie malnutrition, and encounter for palliative care. R47's care plans, provided by the facility on 9/25/2025 showed she is receiving hospice services. R47's care plan showed R47 will be enabled to live to the limit of potential in physical, mental, emotional, and spiritual health and will be kept as comfortable and as pain free as possible.On 9/23/2025, between 9:30 AM-10:00 AM, R5 was heard yelling two times. V5 (Registered Nurse-RN) identified the resident that was yelling as R5. V5 said it is a behavior and she does it frequently. At 10:23 AM, R5 was heard yelling out again. At 10:25 AM, R5 was lying in her room, in the middle bed of a three-bed room. R50 and R47 were the residents that occupied the other beds. R50 was in a low bed with mattresses on both sides of the bed. V23 (R50's Daughter/POA) was sitting next to R50 holding her hand. This surveyor asked V23 if she could speak to her in private for a moment, V23 agreed. V23 said R50 was placed on hospice care a little over a week ago. V23 said R50 communicates very little and she (V23) struggles with R5 being in the same room as R50 because R5 swears and yells out frequently. V23 said R5 tells her (V23) to get out when she is in the room. She (R5) has said she is going to kill me and call the FBI. V23 said it is not peaceful. V23 said R50 was placed on hospice care for comfortable, peaceful, end-of-life care. V23 said she does not think it is peaceful with R5 yelling. At 10:43 AM, R5 was yelling again. V19 (Certified Nursing Assistant-CNA) said R5 yells out a lot. It is a behavior. At 3:00 PM, R5 yelled out Hello, where is she. Can you help just for a minute? R50 was lying in bed with her eyes closed. This surveyor knocked and asked R5 if she needed something. R5 was still yelling when she said Yes, I want that curtain pulled back. I can't see anyone and how am I supposed to call the nurse or anyone for help. When asked if she put the call light on, if staff would come see what she wanted. R5 said what call light. This surveyor pointed out the call light next to her and R5 said Why don't you push it and see what the hell happens. This surveyor put a glove on and pushed the call light. The call light lit up in the hallway. R5 said Yeah, don't leave any fingerprints. This surveyor informed R5 that it was for her protection surveyor did not touch her call light. R5 said Yeah right. Pull the curtain back. (she was saying all this very loud). This surveyor informed R5 I would get someone to help her. She said, Oh another one of them huh? As surveyor went out to get someone to assist R5, she started yelling again. At 3:06 PM, R9 was propelling herself down the hall. R9 stopped in front of this surveyor as she was walking out of R50's, R47's and R5's room. R9 asked if this surveyor was having fun with their screamer. R9 said, If I didn't know a lot of words, I could learn some from her. R5 yelled out Can someone help. I want that curtain pulled back. At 3:07 PM, V20 (Registered Nurse-RN/Charge Nurse) was informed of R5's yelling and agitation regarding the curtain being pulled. V20 said We left it like that because (R50) is dying, and her family was here. V20 went into the room and pulled the curtain back.On 9/24/2025 at 10:10 am, R50 was observed in a different room, down the hall. V23 (R50's daughter/Power of Attorney) was sitting next to R50, holding her hand. V23 thanked this surveyor for helping to get R50 moved to another room. V23 stated, (R5) was getting out of control with her yelling. V23 said one of the nurses working the previous night said she spoke to someone in management and told them they need to get R50 out of that room because R5's yelling is too much.On 9/24/2025 at 10:13 AM, R5 was sitting in her geriatric chair in the hall. R5 was yelling out. When R5 saw this surveyor, she said very loud Did you go to New York to get the pills. This surveyor was in the process of clarifying that was what she asked. R5 yelled Get over here. Quit dragging your feet. Did you go to New York to get the medicine? This surveyor informed R5 she does not work at the facility. R5 started yelling again, telling this surveyor her pants were dragging to pull up her pants. R47, (R5's other roommate) was in the hall near R5 while she was yelling. R47 was also on hospice care. R47's head was back, and her eyes were closed. At 1:08 PM, R5 was in her room screaming and swearing. Telling staff to get in there. R5 hit the side of the chair and yelled, Somebody get in here now. This surveyor went to the doorway and asked if she needed help. R5 yelled, I need out of this chair and into bed now. This surveyor informed R5 that she would get someone to help her. R5 said of course you are. As soon as this surveyor walked out of the room, R5 started yelling again. V5 (RN) was in the hall, just outside of the room, assisting another resident. R5 started calling V5 names. One of the CNAs went in to help R5.On 9/24/2025 at 1:26 PM, V21 (Hospice RN) said the goal of hospice care is to provide comfort and symptom management for the resident until their end-of-life transition. A calming, comfortable environment. V21 said a roommate yelling and swearing is not conducive to a calm environment.On 9/25/2025 at 8:43 AM, V2 (Director of Nursing-DON) said R50 was moved to that room to be close to the nurses' station due to falls. At 9:19 AM, V2 (DON) said R50 was already in that room. We put R5 in the room later. R5 was in another room. V2 said it is not fair to (R47 and R50) to have R5 in with them. In hindsight, I was looking at it from a fall risk. We moved R5 in there because she is also a fall risk. V2 said R47 has been on hospice a very long time. V2 said, Now, thinking about it and knowing that R50 was imminent, I would have moved R5. V2 said R5 is always like that.On 9/25/2025 at 10:28 AM, V3 (Assistant Director of Nursing-ADON) said R5 does have behaviors. We have staff reapproach; a different staff may work better. V3 said R5 has medications for her delusional disorders and depression, however, half of the time R5 refuses the medications.On 9/25/2025 at 1:39 PM, V20 (RN-Charge Nurse) said on 9/23/2025, sometime on second shift, she tried notifying V1 (Administrator) and V2 (DON), then got in touch with V3 (ADON). V20 said R5 was being extra vocal. I let them know we need to move her to another room because it was not the proper environment for hospice residents. V20 said R5 has behaviors. This is not something new. Everyone can hear R5.The facility's Dignity policy, with a reviewed date of August 2025, showed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Based on observation, interview, and record review the facility failed to ensure wound care was provided in a manner to prevent cross contamination and failed to apply tubular compression stockings for a resident with swelling. This applies to 2 of 2 residents (R58, R61) reviewed for quality of care in the sample of 35.The findings include: 1. R58's admission Record (Face Sheet) showed diagnoses to include chronic venous ulcer of the left leg, stage 4 pressure ulcer of the buttock, and diabetes. On 9/23/25 at 10:31 AM, R58 was in his room. R58's cotton gauze dressing to his left leg extended from just below his knee to his foot. The dressing had a 4-inch circle of bloody drainage visible on the exterior of the dressing. On 9/23/2025 at 11:18 AM, V7 Licensed Practical Nurse (LPN) began preparations to change R58's left leg dressing. V7 used scissors to cut and remove part of R58's soiled dressing. V7 then set the scissors down on her clean tray of dressing supplies; V7 did not sanitize her scissors. After V7 removed R58's dressing, she changed her gloves; however, she did not sanitize or wash her hands prior to donning the new gloves. V7 then cleansed R58's wound, changed her gloves, but V7 did not sanitize or wash her hands. V7 then used her scissors to cut R58's oil emulsion dressing and calcium alginate dressing. V7 then applied the oil emulsion dressings and calcium alginate dressings to R58's open and draining left leg wounds. On 9/24/2025 at 11:12 AM, V2 Director of Nursing (DON) stated scissors should be disinfected after cutting potentially soiled dressings and prior to cutting clean dressing materials. V2 stated the purpose of disinfecting scissors is to prevent cross-contamination and to prevent wound infection. V2 stated, during wound care, nursing staff should be sanitizing with alcohol-based hand sanitizer or washing hands prior to donning new gloves. V2 stated the purpose of hand hygiene prior to donning gloves, is to prevent cross-contamination and to prevent possible wound infection. The facility's PPE (Personal Protective Equipment) Gloves policy (Approved 7/2017) showed, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin.8. Wash your hands after removing gloves. The facility's Skin Management (Wound Policy; Revised 9/2024) showed, Goals: Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed, and provided appropriate treatment to promote healing. 2. On 9/23/25 at 11:16 AM, R61 was sitting in a padded wheelchair in the dining room with family visiting her. R61's feet were elevated on the footrest. R61 did not have the tubular compression stockings on her bilateral lower extremities. On 9/23/25 at 1:52 PM, R61 was on her back in bed. V11 Certified Nursing Assistant (CNA) was asked to check R61's legs with the surveyor. V11 pulled the sheet back that were covering R61's legs and R61's pants were down around her ankles. R61's legs were bare; she did not have any tubular compression stocking in place. On 9/23/2025 at 1:54 PM, V12 Registered Nurse (RN) stated R61's tubular compression stockings are put on early in the morning by the night nurse. The nurse should have documented if there was a problem. V12 stated she did not hear anything in report regarding R61's tubular compression stockings. On 9/24/25 at 9:54 V2 Director of Nursing (DON) stated, every physician order should be followed. If an order is not followed, it should be documented why the order was not followed. The nurse should reach out to the physician and get orders. Staff are expected to let the nurse practitioner know if a resident refuses something that is ordered and they should document if a new order or no new orders were received. V2 stated the tubular compression stocking order for R61 should be followed. On 9/25/25 at 11:33 AM, V1 Administrator stated the facility did not have a policy for following physician orders. A review of R61's Progress Notes dated 9/16/25 to 9/23/25 did not show any documentation of refusal and/or problems with tubular compression stockings. The September 2025 Medication Administration Record for R61 showed to apply the tubular compression stockings in the morning and to remove at bedtime. R61's MAR showed on 9/23/25 at 7:00 AM the nurse signed off that the tubular compression stockings were applied. The Care Plan dated 9/22/25 for R61 showed she is at risk for impaired skin integrity related to fragile skin, bilateral lower extremity edema with need for knee high socks/tubular compression stockings. R61's care plan did not have any other information regarding the use, application, and removal of the stockings. The Face Sheet dated 9/24/25 for R61 showed diagnoses including chronic kidney disease, dementia, peripheral vascular disease, hypothyroidism, hypertension, generalized edema, and heart failure.

Based on observation, interview, and record review the facility failed to ensure a catheter tubing secure device was in place and did not clean the drainage spout on the catheter after emptying the drainage bag for 2 of 2 residents (R29 & R11) reviewed for catheters in the sample of 35. The findings include: 1. On 9/23/25 at 1:57 PM, V12 Registered Nurse (RN) was at R29's bedside to change the dressing to the resident's pressure ulcer on her sacrum. R29 had an indwelling urinary catheter with a lot of sediment in the tube and amber urine in drainage bag. The catheter tubing was hanging and pulling to the side; no secure device was in place. V12 stated they use a secure device on catheter tubing, and no one let her know that R29 did not have one in place. V12 stated the secure devices are used to prevent the catheter from getting pulled out. On 9/24/25 at 9:54 AM V2 Director of Nursing (DON) stated the facility has leg straps that are used for anyone with a foley. The straps should be in place. V2 stated the straps help stop the pulling and tugging of the tubing. The strap secures the tubing in place, helps to prevent breakdown in that area, and the catheter from coming out. The Face Sheet dated 9/24/25 for R29 showed diagnoses including anxiety disorder, hypertension, depression, mild protein calorie malnutrition, postherpetic polyneuropathy, chronic obstructive pulmonary disease, neuromuscular dysfunction, edema, and multiple sclerosis. The Physician Orders dated September 2025 for R29 showed Indwelling urinary catheter: 16 or 18 French; No more than 10cc in balloon. May change catheter if displaced, clogged or no urine output to assure catheter patency related to neurogenic bladder. The Care Plan dated 7/28/25 for R29 showed she has an indwelling urinary catheter related to neuromuscular dysfunction of the bladder. Monitor placement of tubing. R29 will adjust placement of tubing at times and not realize it is on the floor. The care plan did not show the use of a device to anchor the resident's catheter tubing. The facility's Indwelling Catheter Care and Maintenance policy (3/2025) did not show any information regarding the use of a device to secure the catheter tubing. 2. R11's admission Record, printed on 9/24/2025, showed she had diagnoses including, but not limited to neuromuscular dysfunction of bladder, paraplegia, autonomic neuropathy, and anxiety disorder. R11's Order Summary Report, printed on 9/24/2025, showed an order for an indwelling catheter related to a diagnosis of neurogenic bladder (a condition in which a person lacks bladder control due to brain, spinal cord or nerve problems). The Order Summary Report showed an order to maintain enhanced barrier precautions to prevent infections related to indwelling catheter. R11's care plans showed she was on Enhanced Barrier Precautions related to an indwelling catheter and history of MRSA (methicillin-resistant Staphylococcus aureus). The care plan showed staff should wear gowns and gloves when having high-contact resident care activities. R11's care plans showed she has an indwelling catheter and a colostomy and is dependent on staff for toileting/peri-cares. R11's 8/20/2025 facility assessment showed she is cognitively intact. On 9/24/2025 at 1:14 PM, V6 (Certified Nursing Assistant-CNA) went with R11 to her room to empty her urinary drainage bag. While emptying the urinary drainage bag, the end of the catheter tubing touched the container she was emptying it into twice. 300 milliliters of orangish-colored urine was emptied into the container. V6 did not clean the end of the tubing and reattached the tubing to the catheter bag. On 9/25/25 at 9:27 AM, V2 (Director of Nursing-DON) said if the catheter tubing touched the container, it should have been cleaned with alcohol swabs. The expectation is that the end of tubing would not touch the container. V2 said after the urinary drainage bag is emptied, the tubing should be wiped with an alcohol pad, even if it does not touch the container, to prevent infection and to keep it clean. V2 said the containers are just rinsed out, not disinfected. The facility's policy titled Indwelling Catheter care and Maintenance, with a reviewed date of March 2025, showed CARE OF INDWELLING CATHETERS: 1. Indwelling catheters should be cleansed at least daily; with focus on the site where the catheter enters the body, and the tubing, (see Peri-Care Policy). 2. Keep the drainage bag below the level of resident's bladder. 3. Keep the drainage bag off the floor 4. Keep the catheter tubing free of kinking to prevent blocking the flow of urine in the tubing. 5. Provide resident dignity by placing the drainage bag in a dignity bag when in public areas 6. Empty the drainage bag every shift and as needed. The policy does not address cleaning the end of the tubing (spicket) after emptying or avoiding contact of end of tubing (spicket) with the container.

Based on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 25 opportunities with 3 errors resulting in a 12% medication error rate.The findings include: R47's electronic face sheet printed on 9/24/25 showed R47 has diagnoses including but not limited to psychotic disorder with delusions, dementia without behaviors, anxiety disorder, and adjustment disorder.R47's medication administration record for September 2025 showed R47 receives Hydroxyzine 50mg at 8AM and 4PM, Seroquel 25mg at 8AM, 12PM, and 8PM, and Lorazepam 2mg at 8AM, 12PM, and 4PM.On 9/23/25 at 9:50AM, V5 (Licensed Practical Nurse) administered R47's Hydroxyzine 50mg, Seroquel 50mg, and Lorazepam 2mg. (1 hour and 50 minutes past the scheduled administration time).On 9/23/25 at 10:25AM, V5 stated there is no reason why she is administering medications late other than she is a newer nurse still trying to learn the process. During the medication observation, 2 other nurses were observed completed with their medication pass and available to assist V5. V5 stated she did not ask for any assistance with completing her medication pass because she needs to learn a routine to keep herself on track. When asked how many residents still needed to receive their medications, V5 stated, a lot.On 9/24/25 at 1:56PM, V2 (Director of Nursing) stated, All medications should be given 1 hour before or 1 hour after their scheduled administration times. There are 3 nurses working on day shift so if a nurse needs help all she needs to do is ask. Timing of medications is one of the 5 rights of medication administration so if it is given at the wrong time then it is an error.The facility's policy titled, Medication Administration-General Guidelines dated November 2021 showed, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.4. Five rights- right resident, right drug, right dose, right route, and right time are applied for each medication being administered.12) Medications are administered within 60 minutes of scheduled time, except before, with or after meal orders.

Based on interview and record review the facility failed to identify two areas of pressure until becoming unstageable. This failure resulted in one of the wounds requiring debridement and becoming a stage 4 pressure ulcer. This applies to one of three residents (R1) reviewed for pressure in the sample of three.The findings include:The facility face sheet shows R1 to have diagnoses to include Type 2 Diabetes Mellitus, peripheral vascular disease, stage three pressure ulcer of left buttock and stage four pressure ulcer of the right buttock. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires moderate assistance with his personal hygiene. The Physician Order Record (MAR) shows an order dated 2/3/2025 for a skin check to be completed two times per week.The wound assessment details report dated 4/19/2025 shows a new area of pressure was identified to R1's left buttock measuring 4 by 2.25 by 0.25 centimeters (CM) and was listed as unstageable and facility acquired. A second wound assessment details report dated 4/19/2025 shows another area of pressure was identified to R1's right buttock measuring 6.5 by 6 by 0.25 CM with soft necrotic (dead tissue) present and was listed as unstageable and facility acquired.The wound evaluation and management summary dated 4/23/2025 completed by the wound care Physician shows R1 to have two new areas of pressure to his left and right buttock. The right buttock wound was debrided by the Physician and a note was added showing [the previously unstageable necrotic wound has revealed the underlying deep tissue at the muscle/fascia level which had been obscured by necrosis prior to this point. This wound has now revealed itself to be a stage four pressure injury.] The wound measures 6.7 by 7.8 by 1.9 CM. The same summary shows the left buttock to have a stage three pressure injury measuring 3.2 by 2.6 by 0.1 CM.On 9/11/2025 at 12:00 PM, V3 Assistant Director of Nursing (ADON) said she was the nurse who was first alerted by staff that R1 had new sores to his buttocks. V3 said R1 always wanted to sit up in his wheelchair and would use the bed pan in his wheelchair to have a bowel movement. R1 would sit on the bed pan for long periods of time and when he was done, he would lift up and the staff would help him to wipe. V3 said the staff would not have been able to see the skin to R1's buttocks this way. V3 said R1 refused showers and would sit up all day and only get into bed late at night. V3 said the new pressure ulcers should have been found before becoming a stage three and a stage four.On 9/11/2025 at 4:00 PM, V2 Director of Nursing (DON) said the purpose of skin checks are to check the skin for redness, ulcers and to check the healing of any skin issues. V2 said the staff providing care for R1 are the ones responsible for doing the skin checks.On 9/11/2025 at 2:30 PM, V4 Wound Care Physician said The reason he has the pressure ulcer is due to the fact he is always up. He refuses to lie in bed. Plus, he has so much pain to his hips and it's worse during transfers, so he is reluctant to move much. Certainly, when he is cleaned up after using the bathroom the staff could have seen changes to his skin. I can't say they should have seen it or how quickly a wound can become necrotic. If you look at my notes, you will see the wound was very advanced when I first saw it. Every time I am there and see him, he is up in his wheelchair.The undated facility policy for skin management program shows it is the facility's policy that a resident does not develop pressure injury unless it is clinically unavoidable. The Certified Nursing Assistants will report any new skin impairments to the licensed nurse identified during daily care.

Based on interview and record review the facility failed to administer medications as ordered to a resident newly admitted to the facility. This applies to 1 of 4 residents (R1) reviewed for medication administration in the sample of 6. The findings include: R1's Progress Notes and Face Sheet show that R1 was admitted to the facility on [DATE] at approximately 3:00PM. R1's diagnoses include Diabetes Mellitus, Malnutrition, Hodgkin's Lymphoma, Chronic Gout, Benign Prostatic Hyperplasia (BPH) and Weakness. R1's Medication Administration Record for February shows orders for Allopurinol 300 mg in the evening (for Gout), Atorvastatin 80 mg in the evening (For High Cholesterol), Flomax 0.4 mg in the evening (for BPH), Lantus 12 units in the evening (for Diabetes), Eliquis 2.5 mg two times a day (Blood thinner), Famotidine 20 mg twice a day (Prophylaxis GI upset), Magnesium Oxide 400 mg twice a day (Supplement), Metformin 1000 mg twice a day (for Diabetes), and Senna Plus 1 tablet twice a day (Constipation). This document shows that none of these medications were signed out/ administered for the 7:00PM dose on 2/19/25. On 3/17/25 at 12:00PM V3 (RN) stated, (On 2/20/25) The daughter brought in all of his medications and gave them to me. I told her we ordered them from our pharmacy. He didn't ask or seem to need a pain pill before they got there. The meds all came from the pharmacy during my shift. On 3/17/25 V2 (Director of Nursing) confirmed that the facility does have a convenience box that the nurse's can pull medications from if they need to. V2 also stated that staff should call the doctor and get orders to substitute medications if they are not available in the convenience box. The undated facility policy entitled General Guidelines for the Administration of Medications states, The facility staff will provide safe and accurate medication administration to the residents.

Based on observation, interview, and record review the facility failed to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility, this failure has the potential to affect all 64 residents in the facility. The facility's 671 Application for Medicare and Medicaid dated 11/18/2024 shows, 64 residents in the facility and a Medication Administration error rate of 31.25 percent. The findings include: 1. On 11/19/24 at 9:55 AM, R29 said, I waited 2.5 hours to get help changing my incontinent brief. (R45) was watching the clock to confirm how long it took. The afternoon shift and the weekend shifts are the hardest on the residents. On 11/20/24 at 8:25 AM, R29 said, The other night (11/18/24 evening shift) when I was lying in bed incontinent of urine and stool, I felt like the facility kind of forgotten us. I need help. I need help getting out of bed and into bed. I need help moving around in bed. I wish I could do it on my own. On 11/20/24 at 8:26 AM, R45 said, On Monday evening (11/18/24) (R29) waited from 6:30 PM, to 9:00 PM, to get help. Last night (11/19), again at 6:25 PM, (R29) asked for help, it took 2 hours to get help. She had wounds. The wounds could come back. It's not comfortable for me when (R29) is incontinent of stool and has to lay like that. I am independent, I do not get any help. I have fallen eight times; I use the bed rail and the arm of the wheelchair to transfer. If I did not have the bed rail I could not move. 2. On 11/19/24 at 9:50 AM, R17 (Resident Council President), R28, R29, R45, R60, and the Ombudsmen attended the Resident Council Meeting. On 11/19/24 at 9:55 AM, R28 said, We've had call lights on, and the CNAs (Certified Nursing Assistants) are always on their cell phones or talking at the nurses' station. The cell phones seem to be the issue. The facility has rules of no phones on the floor. I would think they could put their phones in their lockers. I think the staff should keep moving and not be playing on their phones when they should be giving us help. We need more staff and the staff we do have need to stay off their phones. It would help stop people from falling. Resident Council meeting minutes dated 10/09/2024 shows, Nursing: Customer Services concerns and concerns about cell phone usage. 3. On 11/19/24 at 10:00 AM, R17, R28, R29, R45, and R60 agreed they are not offered snacks. On 11/19/24 at 10:01 AM, R45 said, We use to get snacks. R29 said, We must get our own snacks. One of the resident's family members just brought snacks for us. (R45) and I will have to ration it for the next few days. On 11/19/24 at 10:57 AM, V8 (Dietary Manager) said, In the evening, to ensure the resident's dietary needs are met and compliance with their dietary order, I send down multiple types of snacks. Pudding or sweetened/flavored gelatin for puree and cookies for general texture diets. I provide them to the nurse on the floor. The nursing staff distribute the snacks to the residents. On 11/19/24 at 9:50 AM, R17, R28, R29, R45, and R60 agreed there are not enough CNAs on the evening shift. The facility's Nourishments (Night-Time Snacks) policy dated 2021 shows, Nursing will distribute the bedtime nourishments. 4. R1, R21, R36, and R40 are dependent upon staff for ADL's (Activities of Daily Living) including toileting. On 11/18/24 at 10:10 AM, V7 (CNA) stated R1's incontinence brief was last changed at 7:00 AM. On 11/18/24 at 11:29 AM, V7 (CNA) and V5 (CNA) transferred R1 into bed from her wheelchair. V7 and V5 repositioned R1 in bed and removed R1's incontinence brief. R1's brief was saturated with urine. R1's buttocks appeared red. On 11/18/24 at 11:40 AM, V5 (CNA) and V7 (CNA) transferred R21 into bed from her wheelchair. The pad on the seat of R21's wheelchair was wet with urine. The groin area of R21's pants was wet with urine. V5 and V7 removed R21's saturated incontinence brief. V7 stated she had last changed R21's incontinence brief at 7:00 AM that morning. On 11/18/24 at 11:06 AM, V4 (CNA) wheeled R40 into the bathroom and transferred him to the toilet. V4 removed R40's incontinence brief which was saturated with urine. R40's buttocks and groin were bright red in color. V4 stated she had last toileted R40 at 7:30 AM. R36's Wound Assessment reports dated 9/4/24-11/15/24 were reviewed. R36's report dated 9/4/24 showed R36 had developed a new unstageable pressure injury to her sacral area measuring 2 cm (centimeters) x 1.5 cm x 0.1 cm. The report showed only one weekly wound assessment was completed on R36's pressure injury in October 2024. R36's physician order dated 9/6/24 showed R36's sacral pressure injury was to be cleansed with Dakin's solution (wound antiseptic) with Thera Honey (wound healing creme) applied to the wound bed, and covered with a gauze dressing, every Monday, Wednesday, Friday and PRN (as needed). On 11/18/24 at 10:55 AM, V4 (CNA) and V5 (CNA) provided incontinence care to R36. Upon removal of R36's soiled brief, no dressing was noted to R36's sacral pressure injury. R36's sacrum appeared red with a dime-sized open area noted to the sacrum. A small amount of dried blood was noted to the wound. V4 and V5 placed R36 in a clean brief. On 11/19/24 at 9:10 AM, V4 and V5 again provided incontinence care to R36. Upon removal of R36's soiled brief, no dressing was noted to R36's sacral pressure injury. V4 and V5 cleansed R36 and placed R36 in a clean incontinence brief. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated, Pressure injuries are to be assessed and measured weekly until healed. I can tell you weekly measurements were not done on (R36). My wound nurse left and my DON (Director of Nursing) walked out in October (2024). (R36's) wound should be covered with a dressing. If staff see there isn't one, they need to tell the nurse to make sure one is put on. 5. On 11/18/24 at 9:59 AM, R60, R117's and R11's 8:00 AM medications were not provided on time due to their nurse needing to attend to another resident. This resulted in a 31.25 percent medication error rate due to late medications. 6. The facility's PBJ-Payroll Based Journal Staffing Data Report dated April 1 to June 30 2024 shows, One Star Staffing Rating was triggered.

Based on observation, interview, and record review the facility failed to wear Personal Protective Equipment (PPE) in a contact isolation room, failed to implement Enhanced Barrier Precautions (EBP) for a resident with a pressure injury, and failed to change gloves during incontinence care in a manner to prevent cross contamination. This failure applies to 4 of 4 residents (R116, R36, R39, R57) reviewed for infection control. The findings include: The Resident Census and Condition Form (CMS 671) shows there are 64 residents residing in the facility. 1. On 11/18/24 9:26 AM, R116 was sitting in her wheelchair in her room. There was a contact isolation sign on R116's door. V12 (Certified Nursing Assistant/CNA) entered the room without donning PPE and stood at R116's side. R116 said she needed to go to the bathroom and needed her pants changed due to being incontinent. V12 asked R116 how she transferred and R116 said this was her first time up in the wheelchair. V12 left the room, without hand washing, and got V11 (Restorative Aid). V11 donned gloves and V12 (CNA) did not don any PPE. V11 and V12 put a gait belt around R116 and transferred R116 to bed to use the bedpan and changed R116's soiled clothes and incontinence brief without wearing PPE. R116's shorts were visibly wet with urine. R116's Physician Orders shows R116 is on contact isolation for ESBL (a multi-drug resistant organism) in the urine. On 11/19/24 at 9:53 AM, V2 (Director of Nursing) said for residents on contact isolation, staff should don PPE before entering the room and should be wearing gown and glove when providing care. 35541 2. R36's physician order dated 11/4/24 showed, Maintain enhanced barrier precautions (EBP) to prevent infections related to wound . R36's current care plan showed R36 required EBP due to her sacral pressure injury. The care plan showed, Ensure all staff and visitors are aware of precautions . Utilize appropriate PPE (personal protective equipment) . On 11/18/24 at 10:55 AM, V4 (CNA) and V5 (CNA) wheeled R36 into her room. An enhanced barrier precautions isolation sign on the door to R36's room. V4 and V5 transferred R36 into bed and provided incontinence care to R36, which included cleansing over and around R36's sacral pressure injury. Neither V4 nor V5 donned a protective gown prior to providing cares. On 11/19/24 at 9:10 AM, V4 (CNA) and V5 (CNA) again wheeled R36 into her room. An enhanced barrier precautions isolation sign on the door to R36's room. V4 and V5 transferred R36 into bed and provided incontinence care to R36; which included cleansing over and around R36's sacral pressure injury. Neither V4 nor V5 donned a protective gown prior to providing cares. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated if staff are providing incontinence care to a resident with a sacral wound, they are to don a protective gown and gloves prior to providing cares as per the enhanced barrier precautions guidelines. The facility's Enhanced Barrier Precautions policy dated 4/16/24 showed, Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of S. aureus and Multidrug Resistant Organisms (MDRO) . EBP may be applied to residents with any of the following: wounds or indwelling medical devices . Examples of high contact resident care activities: dressing, bathing, transferring, hygiene, changing linens, changing briefs . 3. On 11/18/24 at 10:42 AM, V4 (CNA) and V5 (CNA) transferred R39 into bed to provide cares. V5 pulled down the front of R39's incontinence brief. V5 began wiping R39's groin and perineal area as dried stool was noted to the area. Without changing her contaminated gloves, V5 helped reposition R39 on her side as V4 wiped R39's buttocks. Without changing her contaminated gloves, V4 placed a clean incontinence brief under R39. 4. On 11/18/24 at 9:10 AM, V4 (CNA) and V5 (CNA) transferred R57 into bed to provide cares. V4 pulled down the front of R57's incontinence brief. R57 was incontinent of urine and stool. V4 provided incontinence care R57. Upon completion of these cares, V4 did not change her gloves. While wearing the contaminated gloves, V4 helped place R57 in a clean brief; touching R57, R57's bedding, and R57's bed with the soiled gloves. On 11/19/24 at 12:08 PM, V1 (Administrator/Registered Nurse) stated staff are to change gloves when they are dirty and before touching anything clean to prevent cross contamination.

Based on observation, interview and record review the facility failed to ensure opened, multi-dose insulin bottles and insulin pens were labeled with expiration dates for 4 of 4 residents (R3, R1, R29, R169) reviewed for medication storage in the sample of 16. The findings include: R3's physician order dated 10/25/24 showed R3 received 26 units of Lantus insulin, subcutaneously once a day. R1's physician order dated 5/23/23 showed R1 received 10 units of Aspart insulin, subcutaneously twice a day. R29's physician order dated 8/21/24 showed R29 received 40 units of Lantus insulin, subcutaneously once a day. R169's physician order dated 10/11/24 showed R169 received 6 units of Lispro insulin, subcutaneously three times a day. On 11/18/24 at 9:55 AM, the facility's 100 wing medication cart was reviewed with V6 (Licensed Practical Nurse/LPN). The following medication insulin pens/bottles were found opened with no expiration dates: one (1) Lantus insulin pen for R3, one Aspart insulin pen for R1, one bottle of Lantus insulin for R29, and one Lispro insulin pen for R169. V6 (LPN) stated all insulin bottles/pens must be dated when opened to know when the medication will expire. V6 stated, Most insulin expires 28 days after opened. The facility's Medication Storage in the Facility policy dated November 2021 showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Certain medications or package types, such as IV solutions, multiple dose injectable vials, certain ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency . The nurse shall place a date opened sticker on the medication and enter the date opened and the new expiration date, if applicable. Examples of medications with shortened expiration dates include insulins and inhalers .

Based on observation, interview, and record review the facility failed to ensure residents were provided ADL's (Activities of Daily Living) care in a dignified manner for 1 of 3 residents (R44) reviewed for resident rights in the sample of 64. The findings include: On 11/19/24 at 1:30 PM, R44's room door was open. R44 was laying on her right side as V5 (CNA-Certified Nursing Assistant) was providing peri-care. R44's buttock and posterior thighs were visible from the hallway. At 1:34 PM, R44 was sitting in a shower chair with her pants around her knees. R44's buttock was visible as V5 (CNA) pushed R44 down the hallway in a wheeled shower chair. Every eight to ten feet a drop of fecal matter fell from R44 onto the hallway floor. On 11/20/24 at 12:23 PM, V17 (CNA) said, prior to providing peri-care, I will wash my hands, don appropriate PPE-Personal Protective Equipment, and close the resident's room door to provide privacy. The facility's Incontinence Care policy revision 05/2024 shows, provide privacy for the resident.

Based on observation, interview, and record review the facility failed to ensure residents were transferred in a safe manner for 2 of 3 residents (R1, R2) reviewed for safety in the sample of 5. This failure resulted in R1 sustaining a right femur fracture and R2 sustaining a laceration requiring 21 sutures. The findings include: 1. The facility's Incident Report dated [DATE] shows R1 is an [AGE] year old male resident who resides at the facility for long term care services since [DATE]. On [DATE], at approximately 5:30 PM, staff were assisting resident with bed linen change. Resident was sitting at the side of the bed and staff was going to stand him at bedside to adjust his pants when resident attempted to self transfer to the wheelchair. Resident's legs crossed causing him to fall to the floor onto his right side. Assessment completed with external rotation, shortening and deformity observed to upper right leg. Hospice, Power of Attorney, and Physician notified with orders to send to the emergency room for further evaluation. Notified by emergency room that resident admitted with a diagnosis of right hip fracture. On [DATE] at 9:25 AM, V3 Licensed Practical Nurse said R1 is a frequent faller and will transfer himself to bed without waiting for staff. V3 said R1 is alert and oriented to person, is impulsive, and can stand with a gait belt and one assist with frequent cueing. V3 said she was called into R1's room by the Certified Nursing Assistant (CNA) and found R1 on the floor on his right side with his legs under the bed. V3 said R1 kept trying to pull himself up and would not be still so she could assess him. V3 said R1 was saying Ouch, but would not say where the pain was. V3 said she was unable to assess R1 on the floor and was afraid R1 was going to hurt himself more trying to pull himself up, so herself and V4 and V5 CNA transferred him to bed. V3 said when R1 was in bed, she noticed R1's right leg was rotated out and was shortened. V3 said R1 was saying Ouch my leg. V3 said at the time of the fall, V4 and V5 were getting R1 up for supper and R1 was sitting on the side of bed with his pants down around his ankles. V3 stated you always use a gait belt for transfer so you don't hurt their arms by using them to help stand. In this case, they didn't even have pants to grab onto to. V3 said R1 had his shoes on, an incontinence brief, and his pants were down at his ankles. V3 said R1 did not have a gait belt on. V3 said R1 was sent to the emergency room and had a right hip fracture. V3 said R1 returned to the facility with continued hospice and expired at the facility. On [DATE] at 9:38 AM, V4 CNA said she was getting R1 up for dinner at the time of the fall. V4 said R1 was wobbly and anxious that day so she asked V5 CNA for help getting him up. V4 said they had rolled him in bed, changed his linens and his brief, and assisted R1 to sit at bedside. V4 said R1 was sitting with his legs crossed and his pants down at his ankles. V4 said V5 was on the opposite side of the bed and she was next to R1 getting the wheelchair in position. V4 said R1 tried to stand by himself and his right hand reached for the wheelchair which moved (was not locked due to not in position yet) and R1 fell forward onto the floor on his right side. V4 said R1 kept saying ouch, but was moving around on the floor. V4 said she sent V5 to get the nurse. V4 said R1 didn't have a gait belt on, the plan was to hold R1 by the pants to transfer him. On [DATE], V5 was attempted to be reached via phone two times and messages left, with no return call. The facility's Incident Staff Statement from V5 shows R1 stood up with pants down without support, slipped on pants and fell criss-cross on his right leg. I heard him scream ow my leg repeatedly. R1's Progress Note dated [DATE] shows called to room by CNA and observed resident sitting on the floor with legs crossed under the bed facing the doorway. Resident was attempting to get up form floor independently and would not follow request to wait until assessment was completed. When asked what happened resident stated, I fell . Assist resident into bed, assessment completed, noted external rotation, shortening, and deformity noted to upper right leg no other injuries observed. On [DATE] at 10:01 AM, V2 Assistant Director of Nursing said R1 had poor safety awareness, was cognitively impaired, and was impulsive. V2 said R1 transferred via stand pivot with one assist to the wheelchair. V2 said staff are supposed to use a gait belt for transfers per the facility policy and for safety. V2 said the gait belt helps with stability and helps staff have some control during the transfer and staff can hold the gait belt to lower the resident to the floor during a fall. V2 said after speaking with the staff, R1 was sitting at the bedside and before staff was able to assist, R1 attempted to stand but has his legs crossed and fell to the right onto the floor. V2 said at the time, R1 did not have a gait belt on. On [DATE] at 2:05 PM, V10 Nurse Practitioner said R1 had progressing dementia and was on hospice at the time of his fall. V10 said resident's Care Plans and facility policy should be followed when transferring residents. R1's Fall Risk Screen dated [DATE] shows R1 is at high risk for falls due to history of multiple falls and R1 exhibits loss of balance while standing. R1's Hospital After Visit Summary shows R1 has a periprosthetic fracture of proximal end of right femur. R1's Care Plan shows R1 is at risk for injury from falls related to unsteady gait, reduced strength, poor decision making related to dementia. The same Care Plan shows R1 is a restorative program for ambulation with interventions to give verbal cues and assistance to don gait belt, stand upright and avoid leaning, and stand using a wide support base. The facility's undated Safe Resident Policy shows Gait belt usage is mandatory for all residents handling with the exception of bed mobility and medical contraindications. 2. On [DATE] at 12:10 PM, R2 was sitting at the dining room table with her husband V11. R2 had visible blood crusted sutures along her hair line extending from the middle toward the right side. R2 had yellowish colored bruising on her right to middle forehead and some purple/red colored bruising under her right eye. R2's left arm was in a brace. V11 said R2 has 21 sutures from her fall on [DATE]. R2 nodded and touched her hairline and continued eating. V11 said that day it was so windy, there was 50 mph wind gusts and R2 had a doctor appointment. V11 said they were coming down the sidewalk of the facility to the van and there is a slope in the sidewalk after going around the flagpole to go down to get to the ramp of the van. V11 said the slope of the sidewalk made the wheelchair lean forward a bit and R2 fell forward out of the wheelchair onto the ramp of the van. V11 said he was at the back of the wheelchair and there was the van driver trying to get R2's wheelchair down the slope of the sidewalk and onto the ramp. V11 said the sidewalk goes around the flag pole area and then slopes down sharply to meet the sloped area of the sidewalk going into the drive. V11 said there are better areas of the sidewalk to load a wheelchair from where the slope is less steep and you don't have to maneuver around the flagpole. V11 said there was only one staff member and himself trying to get R2 onto the van. On [DATE] at 12:18 PM, this surveyor observed the facility sidewalk leading from the entrance to the driveway of facility. The sidewalk from the facility entrance leads perpendicular to the driveway. There is a sidewalk that runs along side the driveway and intersects with the entrance sidewalk. At the intersection there is a triangular flower bed with a flag pole in the center. In order to reach the sloped area from the sidewalk into the driveway, you have to walk around the flag pole area and go down a sharp incline to then reach the sloped area of the sidewalk going down to the driveway. A wheelchair would have to go left or right around the flag pole, propel forward (parallel to the driveway) go down the sharp incline, then turn perpendicular to the driveway to go down the slope in the sidewalk that connects with the driveway. On [DATE] at 10:01 AM, V2 Assistant Director of Nursing said she was in the administrators office by the facility entrance when staff came and told her a resident had fallen outside. V2 said she ran outside and found R2 on the ground with her face on the wheelchair ramp of the transport van. V2 said V11 told her R2 had leaned forward and fell out of the wheelchair. V2 said she could see blood pooling but could not tell where it was coming from and didn't want R2 to move. V2 said V10 Nurse Practitioner had also come outside and was helping stabilize R2's head and hold pressure. V2 said it was extremely windy and started to pour down rain on them. V2 said V11 was propelling R2 in the wheelchair up until V7 Activity Aid took over at some point. V2 said there is a dip in the sidewalk leading to the slope of sidewalk where the wheelchair lift of the van was. On [DATE] at 12:26 PM, V7 said she is the driver of the van that takes residents to appointments. V7 said she is an activity aid and is not a CNA. V7 said V11 pushed R2 in her wheelchair from the front door, down the sidewalk, around the flag pole and down the sidewalk incline to the sloped area of the sidewalk leading to the driveway. V7 said she took over pushing R2 and then R2 leaned forward and fell out of the wheelchair. V7 said it was very windy that day and almost immediately started pouring when R2 fell . V7 said there was no other staff that assisted her that day. V7 said she should have asked someone to come along since it was so windy. V7 said R2 did not have any foot pedals on her wheelchair and had her left arm in a brace so was not able to stop herself when she was falling forward. On [DATE] at 1:12 PM, V8 Restorative Aid said R2's left arm is broken and is in a brace so R2 can't propel herself and can't stand without staff assistance. V8 said she issues foot pedals to all new residents. V8 said R2 should have had foot pedals on since R2 can't propel or stabilize herself in the wheelchair. V8 said she got R2 up for the day and took her to therapy. V8 said she didn't put foot pedals on R2's wheelchair at that time. V8 said after therapy, R2 went to breakfast and then was leaving to go to a doctors appointment. V8 said she was not R2's CNA that day, and had just helped by getting her up that morning. V8 said she was not sure if R2 left for the appointment with her foot pedals on the wheelchair. On [DATE] at 1:15 PM, V9 Nurse Practitioner said R2 is so fearful of falling and is not able to stand for any significant amount of time. V9 said R2 had Parkinson's and has an elbow fracture from a fall at home. V9 said R2's left arm is in a brace and R2 has generalized weakness and unsteadiness due to Parkinson's V9 said R2 has no ability to stop herself from falling forward from the wheelchair. On [DATE] at 1:32 PM, R2 was sitting up in her wheelchair in her room, there were no foot pedals on her wheelchair. R2 said when she fell , she was going downhill and leaned forward and couldn't stop herself from falling since her left arm was in a brace. R2 said she didn't have foot pedals on her wheelchair. R2's Hospital After Visit Summary dated [DATE] shows 7 sutures place in [NAME] (layer of scalp) and 14 sutures placed superficially. The facility's Fall Report dated [DATE] shows V7 statement I was transporting R2 to her doctor appointment today. It was approximately 10:20 AM. I was pulling the bus to the front door and R2 and V11 were waiting at the front door to come out the bus. I pulled up and and V11 started pushing R2 down the sidewalk towards the bus and when he got R2's wheelchair to the edge of the sidewalk/start of the wheelchair lift I was trying to turn R2's wheelchair so that I could put her wheelchair on the lift, but it was extremely windy causing problems turning R2 and V11 was in a rush to get her to her appointment. I went to push her onto the wheelchair ramp and she tipped forward and fell forward onto the ramp. I told V11 to get someone right away in the building. R2's Care Plan shows R2 has diagnoses of muscle weakness (generalized), unsteadiness on feet, difficulty walking, Parkinson's disease with dyskinesia with fluctuations and injury of left elbow. The same Care Plan shows R2 has a hinged brace to her left arm related to a fracture, demonstrates a self-care deficit and requires assist with activities of daily living related to limited mobility and impaired balance, non-weight bearing to left upper extremity, needs assist of 2 for transfers. The Care Plan shows R2 has potential for falls and is at risk for injury from falls. The same Care Plan was updated after R2's fall on [DATE] with the intervention staff to ensure resident foot pedals are on wheelchair prior to propelling resident, Ensure resident positioned properly in wheelchair. R2's Occupational Therapy Evaluation and Plan of Treatment dated [DATE] shows R2 has impaired range of motion to her upper extremities and R2's sitting balance during activities of daily living is fair (reach to ipsilateral side and unable to weight shift). Clinical Impressions: Patient presents with reduced functional activity tolerance, balance and strength affecting safety, ease and independence with activities of daily living and functional mobility. Risk factors: Due to the documented physical impairments and associated functional deficits the patient is at risk for falls, further decline in function and increase dependency upon caregivers.

Based on observation, interview, and record review the facility failed to monitor temperatures of hot beverages prior to serving to residents, resulting in R1 sustaining full thickness (third degree) and partial thickness (second degree) burns to her thighs. This failure had the potential to affect 50 out of 75 residents residing in the facility that drink hot beverages and resulted in Immediate Jeopardy to their health and safety. The Immediate Jeopardy began on 9/15/24 when R1 sustained burns to her inner thighs from hot coffee. V1 Administrator was informed of the Immediate Jeopardy on 10/1/24 at 3:29 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/2/24 but compliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility's Residents who drink hot liquids form dated 9/30/24 shows 50 out of 75 residents drink hot liquids. On 9/30/24 at 8:25 AM, residents were observed drinking coffee at the breakfast meal. On 9/30/24 at 8:27 AM, V3 (Dietary Manager) showed this surveyor the hot water machine. The digital temperature reading on the hot water machine showed 155 degrees Fahrenheit (F). On 9/30/24 at 8:27 AM, V3 (Dietary Manager) said the facility uses instant coffee packets which are put into a carafe, hot water from the machine is poured into carafe, and then the carafe is sent out to the dining room to serve the residents. V3 said hot water for tea is put into a carafe as well and served. On 9/30/24 at 9:50 AM, V4 (Dietary Aid) said the coffee is pre-made in a packet which is dumped into a carafe and then you pour water from the machine into the carafe. V4 said all coffee for the facility is made from this machine. V4 said the coffee temperature is not checked before putting the carafes out in serving area for staff to serve the residents. V4 said there is no temperature log for hot beverages. On 9/30/24 at 9:55 AM, V3 (Dietary Manager) said they do not check temperature of coffee or hot water before it is served to the residents. V3 said she has never temped the coffee since she started at the facility in July of 2024. V3 said she was not aware of any issues with the hot water machine and there were no work orders for it. At 10:05 AM, V3 said a resident (R1) recently got burned from the coffee and V1 (Administrator) had her turn the machine down to 135 degrees F. V3 said prior to the resident getting burned the machine was set at 165 degrees F. V3 said after she turned it down to 135 degrees F the residents complained and so she turned it back up to 155 degrees F. V3 said she doesn't have a owner's manual for the hot water machine, she just Googled what temperature to set the machine to. V3 was not aware of what temperature to serve hot liquids at. V3 said when R1 got burned it was a Sunday, and she came in and temped the coffee but she didn't document it. V3 said there was no process change for making coffee after the incident and she did not start temping the coffee or hot water before serving. On 9/30/24 at 9:55 AM, V3 (Dietary Manager) poured hot water from the machine and temped the water. The thermometer read 146.9 degrees F. On 9/30/24 at 10:15 AM, V5 (Assistant Maintenance Director) with this surveyor, calibrated his thermometer with ice water and got a temperature of 33 degrees F. V5 then poured hot water from the hot water machine into a coffee cup (used to serve residents) and got a temperature of 143.2 degrees F. V5 said he is not aware of any problems with the hot water machine. On 9/30/24 at 11:05 AM, V6 (Licensed Practical Nurse/LPN) said on 9/15/24, R1 had coffee in an insulated metal to go cup that her family supplied and had spilled the coffee on her lap. V6 said V7 (Certified Nursing Assistant/CNA) had brought R1 from the dining room to the resident hallway outside of R1's room. V6 said she heard R1 yell it's burning! V6 said she had V15 (CNA) lay R1 down in bed to remove her pants. V6 said R1 had redness to her left inner thigh area. V6 said R1's family was at the facility and wanted R1 to get back up to her chair and go the the dining room. V6 said she notified V2 (Director of Nursing), V9 (Nurse Practitioner), and V11 (hospice nurse). V6 said she worked on R1's section for the morning shift and then worked in another section for the PM shift. V6 said V10 (LPN) (who was taking care of R1's section for the PM shift) called her over to look at R1's legs. V6 said both legs around the inner thigh were blistered. V6 said she didn't measure the burns at the time, but the left inner thigh was about the size of a softball and the right inner thigh had multiple blisters of all sizes from just below the groin down her thigh to about 4 inches above her knee. On 9/30/24 at 11:22 AM, V7 (CNA) said she had brought R1 back from the dining room to her hallway and R1 started pulling on her pants and yelling it's hot! V7 said at that time she noticed R1's pants were wet on her inner thighs. On 9/30/24 at 1:48 PM, V1 (Administrator) said when she was notified of R1's burns on 9/15/24, she had V3 (Dietary Manager) tell her the temperature that the hot water machine was set at, and had her lower it. V1 said she didn't have any one check temperatures of the hot water at that time or have had kitchen staff monitoring the temperatures of the hot water since. R1's most recent Care Plan shows R1 has diagnoses of spinal stenosis, unspecified dementia, Parkinson's disease with dyskinesia, and unspecified neuropathy of lower limbs. This same Care Plan shows R1 has severe impaired cognitive function related to dementia, has Parkinson's with tremors, neck contracture, and decreased safety awareness. R1's Progress Note dated 9/15/24 at 9:14 AM, by V6 (LPN) shows resident spilled coffee on her left leg, redness and irritation. R1's Wound Summary dated 9/16/24 by V8 (Wound LPN), shows right medial thigh, burn, 2nd degree, facility acquired, measuring 13.0 x 6.0 x 0.1 cm (centimeters). R1's Wound Summary dated 9/16/24 by V8 shows left medial thigh, burn, second degree, facility acquired, measuring 18.0 x 18.0 x 0.1 cm. R1's Physician Wound Evaluation and Management Summary dated 9/18/24 (3 days after sustaining burns) shows: Burn of the left anterior thigh full thickness (3rd degree), etiology: hot liquid, wound size: 2.7 x 7.5 x 0.1 cm. Burn of the right medial thigh partial thickness (2nd degree), etiology: hot liquid, wound size: 7.5 x 6.0 x 0.1 cm. Burn of the left medial thigh, etiology hot liquid, wound size: 2.5 x 4.0 x not measurable cm, fluid filled blister. The facility's undated Hot Beverage Policy shows hot beverages are provided to the clients in a safe manner. There is no specific temperature at which hot beverages should be served. Palatability versus the risk of scalding are factors the community takes into consideration when serving hot beverages. On 10/1/24 at 1:12 PM, V1 (Administrator) said she reached out to the kitchen provider for safe temperatures for serving hot liquid and the preferred temperature for consuming is 120-135 degrees F, which they will be implementing. 10/1/24 at 1:05 PM, V17 (Dietitian) said she didn't know the safe temperature range to serve hot beverages at, she would need to consult her manual. V17 said the kitchen should have a policy on temperatures, how to monitor temperatures and by whom. The Immediate Jeopardy that began on 9/15/24 was removed on 10/2/24 when the facility took the following actions to remove the immediacy: -Procedure developed and implemented to ensure safety with hot beverages, including checking and logging temperatures prior to the beverages leaving the kitchen and beverages not being served if they do not meet the appropriate temperature range of 120 F to 135 F. -Preferred temperature for consuming coffee/tea is 135 F =/- 15 F. (120 F to 135 F). Procedure includes acceptable temperature range. -100% of kitchen staff in-serviced on procedure to check hot beverage temperatures. Hot beverages are only prepared by kitchen staff. -100% of kitchen staff in-serviced on safe temperature range for consuming hot beverages. -Appropriate thermometer present in kitchen with ability to be calibrated. Temperature range 0 F to 220 F. -Four additional thermometers were ordered with the ability to be calibrated with a temperature range 0 F to 220 F to be delivered on 10/2/24. -The fifty residents currently residing in the facility that were identified to prefer hot beverages had screening completed to assess for safe handling of hot beverages. -The remaining twenty five residents in the facility that were not identified to prefer hot beverages will have screening completed to assess for safe handling of hot beverages in case of preference change. -Effective 10/2/24, all residents will be screened by therapy/nursing using the Interdisciplinary therapy screening tool to determine safe handling of hot beverages. Diet order, diet tray card and individualized care plan will be updated accordingly. -Staff training to be 100% completed by 10/2/24. -Screening for safe handling of hot beverages audit tool to be completed by DON/designee: 3 x/wk [times per week] for 2 weeks, then 2 x/wk for 2 weeks then weekly times 2 weeks and results reviewed at QAPI [Quality Assurance and Performance Improvement] with Interdisciplinary Team (IDT) and Medical Director. -Hot beverage temperature audit tool to be completed by Dietary Manager/Administrator: 5 x/wk for 2 weeks, then 3 x/wk for 2 weeks then 2 x/wk for 2 weeks, then weekly times 2 weeks and results reviewed at QAPI with Interdisciplinary Team (IDT) and Medical Director.

Based on observation, interview and record review the facility failed to ensure that a resident with a history of wandering and elopement attempts and a diagnosis of Frontotemporal Neurocognitive Disorder did not leave the facility unsupervised. The facility failed to have a policy and procedure in place to account for all residents after the emergency exit door alarm sounded and no residents could be observed outside. This failure resulted in R1 eloping from the facility at 7:15 PM on [DATE] and was found at approximately 8:55 PM on [DATE] by V13 (CNA) in the rear parking lot of a local business over 800 feet from the facility. On [DATE], R1 was last seen by facility staff between 6:00 PM-6:30 PM. The door alarm sounded at approximately 7:15 PM. The facility began a search for R1 when they discovered R1 missing from her room between 8:00 PM and 8:30 PM. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5. The Immediate Jeopardy began on [DATE] when R1 eloped from the facility. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:05 PM. The Surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on [DATE] at 3:30 PM however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's Incident Report dated [DATE] states, The nurse noted the resident was not in her room. A search was initiated inside the building. The resident was unable to be located. Elopement procedure was initiated. Staff began searching building and perimeter. 911 was called. On-call nurse (manager) made aware. Officers and medic arrived at approximately 8:55 PM. Resident located prior to police and ambulance arrival. Resident was returned to her room and EMT assessed resident. After EMT left, this nurse did full body assessment of the resident. No bruising, skin tears or scratches observed. VS (vital signs) stable. BS (blood sugar) checked and neuro-check done and were within normal limits. Resident was asked if she had any pain and she denied pain or discomfort. When resident asked what she had been doing, she stated, I was just out for a walk. I may have tripped but I am okay. Resident stated that she was a little bit cold. Resident was given a blanket and made comfortable in bed. Fifteen minute checks initiated. POA and Providers were called and notified. R1's Physician's Order Sheet dated [DATE] shows that R1 has diagnoses including Frontotemporal Neurocognitive Disorder, Atrial Fibrillation and Polyosteoarthritis. R1's Minimum Data Set of [DATE] shows that R1 has moderate cognitive deficit. (8 on a scale of ,d+[DATE]) This same document shows that R1 requires supervision for walking in her room and in the corridor. R1's Elopement Screen date [DATE] shows that R1 is High Risk for elopement. On [DATE] at 10:20 AM V10 (RN) stated, My shift ended at 6:00PM, I had already given report and I was finishing my charting so I could leave. I heard the alarm, I got up and checked the doors by the nurse's station in the 200 wing. There is a panel by the nurse's station and it says front door, side door etc. There were no lights on the panel but the alarm was going off. (V4-LPN) said she was going to check the back door of the 200 wing and she was going to walk the perimeter of the building. The alarm was going off about 6:30 PM and I left the building about 7:00PM. The alarm was not going off anymore when I left. The CNAs both said they checked their rooms and everyone was there. I saw (V4) as I was leaving and I think I said to her- Everything good? and she said yes. On [DATE] at 2:30 PM V9 (CNA) stated, I came in at 6:00 PM. I spent time in Dining Room and I took care of (R1's) roommate about 6:15 PM- 6:20 PM and (R1) was in her room. When the alarm went off I was on the floor, I was on the end of the hallway so I checked the door. I don't remember if (V4) was down there. The CNAs are usually the ones to check the doors. I looked out the door, this alarm was going off a very long time. Longer than usual. I checked both doors (on the 200 wing). I don't know which door is making the alarm. The alarm to the porch door has a code-I put the code in and the the alarm didn't stop. That is the most popular door that people use. The door at the end is the Fire exit- I checked that one too. I can look out the door but can not get out that door. The alarm kept going. I don't know how the alarm turned off. I went to nurse's station. V10 was checking the alarms. I continued working and I didn't see anyone else around. (V4) was sitting by the computer and the alarm was going off. (V10) just said we don't know what happened. I didn't get any orders from anyone- it was chaotic, ,d+[DATE] minutes all this was going on. When I realized there was no one on the floor, I just stayed on the floor. I did not go outside and look for anyone. On [DATE] at 9:10 AM V4 (LPN) stated, I went to give (R1) her meds at 8:,d+[DATE]:40 PM and she wasn't there (in her room). We searched the building and she wasn't there. We didn't find her. We called V3 (Assistant Director of Nursing) and then we called 911 and started looking outside. CNAs went out all over and one of the CNAs drove up towards the animal control building and (R1) was up there. She was just standing around and V13 (CNA- Certified Nursing Assistant) said she thought she was a volunteer. Then she got (R1) to get into the car. That all took about 20 minutes. The last time I saw (R1) was at dinner. Dinner is about 6:00 PM. I think (R1) went out one of the doors in the back of the 200 wing. We heard the alarm go off and I did a search and I didn't see anyone. I went to the side door and walked around the whole building and I didn't see anyone. That was about 7:15 PM. I was at the nurse's station (when the alarm went off). I had two CNAs- (V5 and V9- CNAs) (V13) is the CNA that found her. (R1) got into (V13's) car and came willingly back to the facility. (R1) had no injuries. She said that she tripped but she is not a good historian. She was found about 8:55 PM. 911 arrived the same time she was found. They assessed her and then they left. (V2 -Director of Nursing) and (V3) also came to the facility. (R1) has a (Electronic Monitoring Device). We try to notice what she is doing. She wanders around the building after dinner most of the time. It was just me that looked when the alarm went off about 7:15 PM. I just assumed that since people push on that door all the time it alarms and then they walk away, I assumed that is what had happened. The Sheriff's Department Call for Service Report dated [DATE] shows that the call came in to them regarding a missing person at 8:51 PM. On [DATE] at 10:00 AM V2 and V3 (interviewed together) stated, We have discovered through our investigation that it was the alarm at the end of the 200 wing. It went off about 7:,d+[DATE]:15 PM. (V4) said she was there at the nurse's station. She looked out the door then went out the door across from the nurse's station, looked around by the screen porch. Then she turned left (going towards the door that was alarming) and walked around the building and then came back in and assumed someone had pushed the bar and not gone out. Around 8:30 PM (V4) went to administer (R1's) medication and (R1) was not in her room and she looked around the 200 wing and talked to the 100 wing nurse and asked if she had seen (R1). (V4) instructed everyone to look for (R1). They did not find her so (V4) sent staff outside to look for (R1). At 8:45 PM (V4) called (V3) and (V4) was instructed to look in every room at the facility. They had already initiated the search outside so (V3) instructed (V4) to call 911. V3 said she then notified (V1-Administrator) and (V2 -Director of Nursing). V2 stated, I live about 5 minutes away. Staff were all out looking for (R1) when I pulled in. (V13) found her at the animal control building and put her in the car and brought her back- (R1) was in the front seat, giggling. (R1) said I went out for a walk. The EMT went to the room and assessed her when he left he said she seems fine. No reason to transport (R1) to the ER. (R1) will usually walk out there with the CNAs. Her family takes her out for ice cream. R1's private caregiver takes her out for walks. We have never seen her attempt to open the door and go out. V3 stated, (R1) needs to be with people that are similar to her. Now we are doing 15 minute checks, we have had the (Electronic Monitoring Device) on her. We try to redirect her to activities and she is usually easily redirected. V2 stated, That night she was wearing pants, a jacket and a hat. She had her (Electronic Monitoring Device) on her shoe- white rubber shoes. We put it on the shoes because she keeps taking it off. We are still investigating. (V4) said she walked the whole perimeter of the building and she did not see anybody. (R1) walks well but I don't know how she walks on uneven ground. V3 stated, When the alarm triggers- (V4) said she walked around the perimeter. Two people should go and then do a head count if no residents are found outside. We should at least look for those residents that are at risk or elopement. On [DATE] at 9:30 AM, V8 (Maintenance) stated, I check the alarms every Friday. I remember what happened next door and I don't want that to happen here. A lady died . On [DATE] at 10:45 AM V8 stated, The door panel is not part of the system and has not worked for at least [AGE] years, since I have been here. There is no way to tell which door is alarming, If a door alarms you have to go to THAT door and push the button or enter the code in order to turn the alarm off. Someone has to physically push the button to stop the alarm from sounding. At 9:35 AM, Surveyor and V8 walked the suspected route that R1 took from the exit door at the end of the 200 wing to the Animal Control Building, across the grassy field. V8 used a wheeled measuring device and measured 798 feet from the facility door to front door of the business. (It was later discovered that R1 was found in the back of the building). The grassy field was bumpy and uneven with many divots. On [DATE] at 2:27 PM V5 (CNA) stated, I was working on the 200 wing when (V13-CNA) came down and asked if I had seen (R1). That was about 8:00 PM. About 7:15 PM the alarm had gone off. I was toileting a resident in the hall bathroom and when I came out the alarm was going off. Everyone was running around looking for the alarm so I took the resident back to their room. (V10-RN, V4-LPN and V9- CNA) were all looking for the alarm. Then the alarm shut off. Then about 7:30 PM the alarm went off again. (V10 ) was up at the front door with a resident from the 100 wing (R2) and her (Electronic Monitoring Device) had set off the alarm. (V10) took (R2) back to her room and I went back to working on my hall. Then about 8:00 PM, me and (V9) were in a room putting a resident to bed with a (mechanical lift). (V13) came and asked me if I had seen (R1) and I told her I had not seen her since after dinner. I told (V9) I was going to go outside and I told her to stay on the floor. (V13) went outside with me. Then (V13) said she was going to go get her keys and go out in her car. We continued to look around the building. Other staff came out too. Then I called (V13) and I was on the phone with her when she found (R1). (When (R1) came back to the facility) (R1) was in the car and smiling as usual. She didn't have an injuries and (R1) just said, I went for a walk. I have heard that (R1) has tried to get out a couple of times but she has never actually gotten out. On [DATE] at 2:40 PM V13 stated, I saw (R1) at supper about 6:15 PM when we were taking everyone back to their rooms. Me and the other CNA on the 100 wing were putting someone to bed when (V4) and the other nurse asked us if we had seen (R1). The other CNA went outside right away and I started looking all over the building, every room I could get to. I saw (V5) and (V9) and asked them if they had seen (R1). (V5) went outside and (V9) stayed on the floor. Then I went outside and we were looking through the fields with our cell phone flash lights. I said to (V4), Should we call the police? and she told me to calm down, we are going to find her and to just keep looking. I decided to go in and get my keys and take my car and start driving around. I told everyone I was going to drive over to the cemetery (across the street from the facility) and then they all came over and started looking through the cemetery too. We were driving around and then the other CNA got in my car and we drove over to (Assisted Living Facility) (Located on the opposite side of the facility from the cemetery) because (R1) used to live there so I thought maybe she went over there. We went to the front door and it was locked so we pushed the buzzer and asked if they had seen a lady walking around outside. They said No so the other CNA walked back to the facility and I decided to turn right (came from the left) out of the parking lot and go up by the animal control building. It was dark so I really don't know where I pulled in but I saw a white van so I kind of pulled in at an angle. I turned on the road just past the building (back of the building) and I thought I saw someone. At first I thought is was her and then I thought it was a man so I started to back up and leave. Then I thought I could ask the man if he had seen a lady walking around. I pulled forward again and realized it was (R1). I told (V5) on the phone that I think I found her. I got out of the car and called her name. She was between the building and a white van that was parked there. I could hear a lot of dogs barking. (R1) saw me and she smiled. She said, I was looking for everyone. I told her we have been looking for her and I was going to take her back home. I helped her get in my car and I told her I was going to honk the horn and not to be scared. Then I honked the horn several times to let everyone else know that I had found (R1). When I pulled into the parking lot there were ,d+[DATE] cop cars and about 6 staff members. (V2 and V3) were there and a couple of family members that were visiting another resident were out there too. (R1) seemed happy and content. The police went up to her and talked to her. She didn't have any dirt on her or anything. She looked fine. On [DATE] at 2:00 PM, V7 (R1's Physician) stated, As I understand it, she wandered outside away from the facility The problem is she wants to leave and she can't. The family does not want her in a locked unit which would be the second floor at (Sister Facility). The facility is between a rock and a hard place. We need (The State Health Department) to help us out. (R1) is in danger if she goes out, I can agree with that but what are we supposed to do? The family doesn't want her at (Sister Facility). Aside from monitoring the doors as much as they can, with the weather being so nice people want to be outside and even if things are controlled, things are going to happen. On [DATE] at 11:35 AM, R1 was in her room, walking in just socks, talking to staff. R1 sat down on the bed with Surveyor to talk. R1 stated, There are wonderful people here, I love it here. Surveyor asked about her walk she took the other night. R1 stated, I never thought it was such a big deal. I don't remember what door I went out but I'm sure I went out a door. I didn't climb through the window. I was going out for some air- some cooler air. That sounds weird because I am always freezing. I went to the green trees. Like the ladies bathroom has but theirs are gold. Like little leaves, very simple. I think I came back in the wheelchair, it wasn't cold outside or raining. I wouldn't go out in the rain. I didn't fall or hurt myself. I was at the green seats and we talked and then she left and I said ok I'll go in now. I just went out to get some cool air. It frustrates me sometimes. I just feel so light and just want to be outside . My daughter got me these good shoes (pointing to shoes on the floor in front of her) I try not to get too involved with the drama around here. I try to keep everyone happy. R1 picked up her shoes to put them on. R1 stated, That is a little alarm ( R1 pointed to the electronic monitoring device on her right shoe) so I don't go out! R1 got up and walked to the hallway. R1 stated Want to see the green room? It is at the end of the hall. Surveyor walked with R1 down the hall as R1 left her wheelchair outside of her room and walked unassisted with slow steady gait. As we approached the 2 chairs at the end of the hall, R1 stated, Oh, those chairs are gold, I see them as green. We just sit here and talk or read. R1 motioned for Surveyor to sit in one of the chairs. ( The chairs are located next to the Exit door R1 used on [DATE]) R1 sat for a minute. Surveyor asked R1 if she ever went out the door. R1 got up from the chair and walked to the door. R1 stated, This door, I opened it. R1 was pointing to the door on the right of the double doors. R1 tried to push on the door on the left but did not use much force. R1 stated, Oh, this one must be locked for a reason. (Door was opened earlier by V8 and Surveyor- alarm sounded without difficulty) R1 sat back in the chair and talked about the books on the table between the chairs. I look at all the books and find one I like to read. R1 looked at Surveyor and smiled, I would really like to set off that alarm and let you hear it. Surveyor asked R1 if the alarm goes off often and R1 stated, No only once about every 2 years. Surveyor then encouraged R1 to walk back to her wheelchair and get ready for lunch. R1 stated she was thirsty and hungry. R1 ambulated back down the hall and found her wheelchair in the hallway where she left it. Staff then assisted R1 to sit in the chair and wheeled her to the dining room. While passing the restrooms in the hallway outside the dining room, R1 stated, When did they change those cushions? (2 benches outside the restrooms with a similar pattern as the chairs at the end of the 200 hall) They used to be green and now they are gold. R1 continued into the dining room, smiling and very pleasant. On [DATE] at 3:45 PM, V1 (Administrator) stated that the facility did not have a policy regarding expected staff response to triggered alarms. The Police Report dated [DATE] states, On [DATE] at approximately 2055 hours (8:55 PM) I (V14) received a call from dispatch for a missing person from (Facility) which is a local nursing home in (Facility City) . I then spoke with (V4) . I asked (V4) when the last time she did rounds to ensure patients were accounted for. (V4) replied that there was no scheduled checks for individuals but rather they monitor the citizens by walking down the hall periodically throughout their shift. I then asked (V4) when she last saw (R1) and she replied she last saw (R1) at dinner time which is around 1800 (6:00 PM). I then asked (V4) about the alarm that tripped on the door and at what time that was. (V4) stated it was between ,d+[DATE] hours (7:00 PM- 7:11 PM). I asked (V4) if she checked the door immediately once the alarm triggered and she states she checked it within ,d+[DATE] minutes of the door triggering. (V4) stated she checked the interior and the exterior and did not see any citizens so assumed it was a false trigger. I then asked (V4) at what time did she notice the (R1) was missing. (V4) stated at approximately 2045 hours (8:45 PM) she was performing medication rounds and found that (R1) was not in her room. (V4) stated she then checked the interior of the building in an attempt to locate (R1) as she sometimes wanders into other citizen's rooms. (V4) stated that when she could not locate (R1) she called 911 . R1's Progress Notes dated [DATE] state, Patient presented with an altered mental status, increased confusion and aggression. She packed up her belongings into a wheelchair and she ran towards front entrance and attempted to elope. Staff redirected her, but she was combative, hitting and pinching staff. Four staff attempted to redirect her with ineffective results. NP (Nurse Practitioner) witnessed patient's manic episode, ordered Haldol (Antipsychotic) shot, one time dose. Notified POA, he asked to speak with her and get (her) to head back to her room. Patient was at door, on her phone for another hour before redirection was effective. Did not administer shot at this time. R1's Care Plan dated [DATE] states, (R1) has exhibited movement behavior that may be interpreted as wandering or roaming as she is able to propel self in wheelchair independently in the facility. Resident exhibits short term memory deficits and impaired decision making skills. The interventions related to safety include, (Electronic Monitoring Device) for safety. (Electronic Monitoring Device) placed on R1's shoe. R1's Care Plan also states, (R1) may be at risk for potential abuse related to cognitive deficits. elopement attempts. refusing care. verbal/physical aggression at times, being impulsive and not remember her physical limitations, fall risk due to her impulsiveness and cognitive deficits, need for physical care and supervision. On [DATE] at 3:35 PM, V3 stated that the interventions that were put in place on [DATE] worked because R1 did not elope. So there was no need to put any other interventions in place. The undated facility policy (Created on [DATE]) states, No alarm should ever be shut off without verifying the cause. If no identifiable cause for the triggering of the alarm can be found, you must leave the alarm on until the cause of the alarm is identified and follow the steps below. a) Ask staff, visitors, venders or residents in the vicinity if they saw anyone trigger the alarm. b) Search the perimeter outside the door that alarmed for the cause of the alarm. c) Account for all residents identified to be at risk for elopement. d) Account for all residents residing in the facility. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. The facility Regional Nurse provided the Administrator and DON a policy and procedure for a (Facility Corporation) locked memory care unit on elopement. Regional Nurse, Administrator and DON amended the policy to fit the facility's needs and include response to door alarms. ([DATE]) 2. Administrator and DON trained the facility IDT on [DATE] of the revisions to the elopement policy and procedure. 3. Education and training was provided to all current staff regarding staff responsibility to ensure the safety of residents at high risk for elopement, the process of door alarms sounding and the facility elopement policy and procedure on [DATE] by the Administrator, the nurse management team and the IDT. Any current staff members who have not been educated in person or via phone will not be allowed to work until they receive education. Education will be conducted twice monthly beginning [DATE] for 3 months then quarterly thereafter by the DON or designee. All new hires will be trained by the DON or designee in new hire orientation upon hire. 4. Door alarm checks were completed to ensure they are functioning properly on [DATE] by the Maintenance Director and documented on the facility weekly door alarm inspection log. Door alarm checks will be completed on all access doors every week on Friday for 4 weeks and thereafter weekly by the Maintenance Director or designee. The door alarm checks will be documented on the weekly door alarm inspection log. 5. A Master list of residents at risk for elopement was reviewed on [DATE] to ensure accuracy and was place in all the required locations by the Administrator. A master list was added to the break room. 6. A Responding to door alarms guide was created by the administrator on [DATE] and placed at the front desk, kitchen, laundry room, therapy room, maintenance, all manager offices, break room and nurse's stations. 7. All residents were reassessed ( [DATE]) for risk of elopement by the nurse management team. All residents at high risk for elopement, care plans were reviewed, interventions were reviewed and orders were reviewed and revised as necessary by the nurse management team. 8. Elopement drills will be conducted on random shifts twice a week for 6 weeks and monthly thereafter, Elopement drills will begin on [DATE] according to the elopement drill schedule. Maintenance or designee will perform the monthly elopement drill. The elopement drill will be documented on the facility record of drill form. Staff participating in the drill will sign an education form. 9. The facility's elopement policy and procedure was revised to include staff response to sounding of door alarms, procedure to follow to ensure resident safety and interventions to follow for exit seeking residents. [DATE] 10. The facility IDT held and ad hoc QAPI meeting to review the facility abatement plan on [DATE] for any further recommendations and or resolutions. 11. The results of audits, drills and educations will be reviewed monthly in the QAPI meeting until the facility has maintained a 100% effective rate for 3 consecutive months. Measure rates under 90% will be evaluated for cause and effectiveness. Revisions will be made based on identifications of cause or ineffectiveness. 12. The facility abatement plan, response to door alarm guide and the revision to elopement policy and procedure were reviewed with the facility medical director on [DATE]. The facility medical director approved the revision to the facility elopement policy and procedure and the response to door alarms guide created on [DATE].

Based on observation, interview, and record review the facility failed to provide adequate supervision for a resident (R10) with a history of falls and failed to ensure safety interventions were in place. These failures resulted in R10 having an unwitnessed fall and sustaining a laceration to her eye brow and a maxilla (facial) fracture. The facility failed to provide adequate supervision for a resident (R49) with a history of falls and failed to ensure a resident was positioned properly while dining alone in her room (R7). This applies to 3 of 5 residents (R10, R7, R49) reviewed for safety and supervision in the sample of 20. The findings include: 1. On 8/16/22 at 11:24 AM, R10 was lying on her back in bed, at a diagonal angle. Her head was near the bottom of the right side rail and her feet were hanging off the opposite side of the bed. R10's feet were touching the wheelchair, parked next to R10's bed. R10's left eyebrow had a glued laceration and the left side of her face had bruises at various stages of healing. R10 had greenish yellow bruising noted under her left eye. There was deep purple bruising to her left eye brow and above her left eye. R10's left cheek had several bruised areas with varying colors of light purple and greenish yellow. R10 did not have any fall mats in her room. R10 said she wasn't sure what happened to her eye, but it does hurt sometimes. R10 said she thinks whatever happened, it was at night. On 8/17/22 at 9:51 AM, R10 was lying on top of her bed linens, fully clothed with her shoes on. R10 was lying diagonally across the bed with her head near the bottom of the right side rail and her legs hanging off the side of the bed. R10's wheelchair was parked next to the bed and it appeared resident had self-transferred. There were no fall mats on the floor. On 8/17/22 at 11:30 AM, R10 was lying in bed awake. R10 was lying diagonally across the bed with her legs hanging off the bed, from her knees down. At 2:25 PM, R10 was lying on her right side in bed. R10's head was near the side rails and her legs were bent slightly. R10 had her lower legs, from her feet to her knees, resting on the seat of the wheelchair. (During all the above observations, R10's door was open and she was visible from the hallway. The facility staff walked passed R10's room numerous times and did not reposition R10. The facility's Incident Report Form dated 8/13/22 showed R10 fell at 1:48 AM and sustained a left maxilla fracture and 2 centimeter laceration to her left eyebrow. This document showed, Resident self-transferring and sustained a fall, bleeding noted to left eyebrow, pressure applied. NP (Nurse Practitioner) notified and orders to send to the hospital obtained . Resident was self-transferring without shoes on and fell in the hallway. Resident returns to facility at 8 AM with a fractured left maxilla and 2 cm laceration to left eyebrow that was closed with glue . Gripper socks to be applied at night . R10's Facesheet dated 8/17/22 showed R10 had diagnoses to include, but not limited to: anxiety disorder, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], dementia without behavioral disturbance, major depressive disorder, unspecified fall, and stroke. R10's facility assessment dated [DATE] showed she had severe cognitive impairment; required extensive assistance of 2 or more staff for bed mobility, transfers, and toilet use; required extensive assistance of 1 staff for personal hygiene and bathing; was not steady without staff assistance; and had 2 or more falls since admission. R10's Fall Risk assessment dated [DATE] showed she was at high risk for falls. R10's EMR (Electronic Medical Record) showed 8 fall events since 1/1/22. R10 had falls on 1/6, 1/16, 3/1, 3/27, 4/26, 4/30, 7/24, and 8/13. R10's Fall Event dated 8/13/22 showed was found in the hallway. R10 had hit her head. R10's left pupil was misshapen/sluggish response. R10 had regular socks on. R10 had a laceration to her left eyebrow. R10's Progress Note dated 8/13/22 at 3:39 AM, showed, 100 wing nurse informed this writer that R10 was on the floor on 100. Assessed and noted R10 laying face down, partially on her left side, in front of room 100, fully clothed with regular socks on, moderate amount of blood draining from face, body kept in alignment and rolled over; 2 inch deep laceration noted to left eyebrow, resident kept immobile. NP and hospice notified and received order to send to emergency room . R10's Progress Note dated 8/13/22 at 8:15 AM showed, Returned from local hospital with closed fracture of left side of maxilla and facial laceration. The laceration was closed with glue. Tylenol given for facial discomfort. Hospice in facility and stated that they will order her safety mats for the floor while in bed. Gripper socks were provided for when out of bed . R10's Interdisciplinary Note dated 8/15/22 showed, R10 fell on ,d+[DATE] at 1:30 AM. Resident was found in the 100 hall facedown after self-transferring. Root Cause: resident has poor safety awareness and attempts to self-transfer and ambulate. She was fully dressed with regular socks and no shoes . R10's Nurse Practitioner Narrative dated 8/16/22 showed, . Resident is seen for follow-up after being seen in the emergency room related to a fall during the middle of the night. She tried to ambulate alone and fell face first on the floor. She sustained a laceration to her left forehead that was glued. She also sustained a fracture to the left maxilla . She complained of the left side of her face is sore . She has some bruising in left orbital (eye) area and also on left check/jaw area . Laceration to left temporal area scabbed and approximated with glue .Facial pain related to maxillary fracture and laceration. Pain controlled with Tylenol . R10's Actual Fall Care Plan initiated 7/29/22 showed interventions to include: Educate staff to monitor resident frequently for transfer needs. Encourage resident to wait for assistance . R10's Potential for Falls Care Plan initiated 10/26/21 showed, Resident at risk for injury from falls due to unsteady gait. Goal: The facility will reduce the likelihood of the resident experiencing an injury related to a fall . Interventions include: .Event occurred 11/14: Gripper socks placed on resident . Event occurred 4/30: Staff to continue increased rounds; if resident is anxious offer to get resident up and dressed for the day. On 8/17/22 at 4:32 PM, V3 (Wound Care Coordinator) said she saw R10 recently because she had a laceration to her forehead from a fall and to go to the emergency room . She likes to self-transfer and we have to keep a close eye on her. She doesn't realize she needs help. On 8/18/22 at 7:35 AM, V10 (Licensed Practical Nurse - LPN/Night Shift Clinical Supervisor) said he was working the night of 8/13/22, when R10 fell . V10 said he was assigned 200 hall and the first part of 100 hall. V10 said he had seen R10 earlier in the night and she was resting in bed. R10 is alert to self, is unsteady with transfers, and had extremely poor cognition. R10 came from assisted living to the facility because she was falling excessively. R10 keeps falling, as she continues to decline overall. R10 has had multiple falls. I did not see R10 fall. I was on the 200 hall and V12 (100 hall Registered Nurse - RN) came and told me R10 had fallen and was bleeding. The night she fell , she was fully clothed and 2-3 doors down from her room, in the hallway. I'm not sure how she dressed herself and got down the hallway that far. R10's head was facing the nurses' station. She was lying face down, partially on her left side. Her left arm was tucked underneath her. She didn't really say anything. She didn't know what happened. She just wanted to get up and put her shoes on. R10 had regular socks on, but no shoes. We carefully log rolled R10 onto her back to see where the blood was coming from. R10 had blood on her face and had a heck of a head injury. There was a laceration that was bleeding, so we held pressure and she had bruising and swelling from landing on her face. The facial swelling was quite pronounced and by the time she left with EMS her left eye was almost swollen shut. V13 (CNA) stayed with R10. V11 (CNA) came in at 2:00 AM and sat with R10 until EMS arrived. It was the craziest thing. She had on an incontinence brief, pants, shirt, socks and no one heard a thing. R10 came back from the emergency room later that morning. R10 doesn't mean to cause any problems or break rules, it's just her cognition declining. She doesn't realize she can't get up without help. If R10 is in bed, the bed should be in the lowest position and she should have fall mats now. R10's legs should not be hanging off the bed. It's bad for circulation and tempts her to get up and take off. On 8/18/22 at 1:01 PM, V7 (NP) said she is familiar with R10. R10 is confused and has a wheelchair. The facility called me the other night and said she had gotten out of bed and fell face first, hitting her head. R10 was sent to the ER and she sustained a laceration to her head and a maxillary fracture. The injuries were caused by the fall, she did not have either injury prior to falling. R10 has had previous falls. She needs to be watched closely. It would not be safe for R10 to be lying in bed with her legs hanging over the side or resting on the seat of the wheelchair. On 8/18/22 at 2:05 PM, V12 (RN) said she was the nurse assigned to R10's hall when she fell (8/13/22). V13 (CNA) was working with me that night. She went to answer a call light at the other end of the hall and I was in the bathroom, by the nurses' station. We did not see R10 fall. V13 told me R10 had fallen and was on the floor in the hallway. I went to check R10. She was lying on her left side and V13 said she thought she saw blood. I told her not to move R10 and I went to get V10 (LPN). V10 came back with me and we carefully turned R10 onto her back. There was blood on the floor and the side of her face. There was a laceration above her left eyebrow that was bleeding, so we cleaned her up and applied pressure. V13 told me that R10 was in bed the last time she saw her before the fall. R10 has done this before. She wakes up in the middle of the night and thinks it's time to get up. She will get herself dressed and walk into the hall. R10 wasn't saying much when she was on the floor. She said she wanted to get up and she thought it was time to go to breakfast. The facility's Fall Management Policy reviewed 6/21 showed, The facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventative strategies, and facilitate as safe an environment as possible . 2. Residents at risk for falls will have Fall Risk Identified on the interim plan of care with interventions implemented to minimize fall risk . 2. On 8/16/22 at 9:28 AM, R7 was yelling for help. R7 yelled three times, but no staff responded. R7 was lying in bed. The head of the bed was elevated at approximately 50 degrees. R7 was positioned down in the bed, so her head and shoulders were positioned over the bed in the bed. This caused R7's head to be pushed forward with her chin touching her chest. R7 had her breakfast tray on the overbed table, in front of her. R7's head was below the level of the tray. R7 had sausage and toast on her plate, a cup of coffee sitting on the table (near the edge of the overbed table, not on the dietary tray), and a bowl of oatmeal resting on her chest. R7 was attempting to eat her oatmeal with a spoon. The surveyor asked R7 if she needed help. R7 replied, Obviously! I need to be pulled up in bed, so I can eat. It's very hard to eat like this. It's hard to swallow. I want to have my coffee, but I don't want to spill it on myself. R7 did not have dentures in her mouth. R7's Face Sheet dated 8/17/22 showed diagnoses to include, but not limited to: [CONDITION(S)], heart failure, seizures, [CONDITION(S)], dysphagia, lack of coordination, dysarthria, [CONDITION(S)], right side weakness, anxiety disorder, stroke, peripheral vascular disease, and major depressive disorder. R7's facility assessment dated [DATE] showed R7 had severe cognitive impairment; required extensive assistance of two persons for bed mobility, transfers, and toilet use; required extensive assist of one person for personal hygiene; and was always incontinent of bowel and bladder. R7's Speech Therapy Evaluation and Plan of Treatment dated 6/21/22 showed, Patient was referred to ST due to coughing episode witnessed by nursing staff indicating the need for ST to assess/evaluated least restrictive oral intake. R10 has a complicated medical history including a stroke and seizures. R10 had no postural difficulties (ability to maintain posture while eating). R10's recommendations to facilitate safety and efficiency was for R10 to follow general swallow techniques and precautions. On 8/17/22 at 3:10 PM, V4 (Restorative Nurse) said the residents should be up and out of bed in a chair or in the dining room for meals. Sometimes R7 wants to stay in bed. If R7 stays in bed, then the head of the bed should be elevated and her body should be in good alignment. The staff should be aware of R7's needs. V4 was asked if R7's head should be below the level of the tray. V4 replied, No, unpleasant things could have happened. She could have choked or burned herself. On 8/18/22 at 8:48 AM, V27 (Speech Language Pathologist) said all residents should be upright when eating, as close to 90 degrees as possible, for safety. If a resident is lying back, the food can fall back and block their airway. They are usually more alert when they are in an upright position. I did evaluate R7, but she didn't need any special recommendations. General Swallow Precautions include: eating at a slow rate, proper positioning, and nothing in their mouth when they lay down. R7 should not be slouched down in the bed. That would be a problem and a safety concern. R7 should have been assisted with positioning when her tray was delivered. On 8/18/22 at 9:02 AM, V1 (Administrator) said the facility did not have a Swallowing Policy or a Policy that described General Swallow Precautions. 3. R49's facesheet shows that she was admitted on [DATE] with diagnoses to include metabolic encephalopathy; disorder of muscle, unspecified; lack of coordination; generalized muscle weakness, and cognitive communication deficit. The facility assessment dated [DATE], showed R49 has no cognitive impairment and requires extensive assistance of 1 staff member for dressing. R49's Fall Risk Screen dated 07/20/22, shows that R49 is a high risk for falls and has a history of multiple falls. The same assessment shows that R49 is unable to independently come to a standing position. R49's Fall Event dated 8/14/22 showed R49 experienced a fall on 8/14/22 at 08:00 AM. The same document showed R49 hit her head and reported a headache and a pain level of 3 (on a scale of 1-10), and she was sent to the emergency room for evaluation. R49's Care Plan initiated on 6/15/22 shows,Potential for falls, Resident is at risk for injury from falls .interventions get to know resident's habits to anticipate resident's needs . check on resident frequently and place resident in visible view of the staff when up in chair when resident will allow. R49's Care Plan initiated on 7/20/21 shows, [R49] has an Activities of Daily Living (ADL) Self Care Performance Deficit related to weakness Interventions . Transfer: [R49] requires 1 staff participation with transfers . Dressing: [R49] requires 1 staff participation to dress. The Fall Incident log provided by the facility on 8/18/22 shows that R49 fell five times from 3/5/22 to 8/14/22. On 8/16/22 at 09:56 AM, R49 was sitting in her wheelchair in her room. R49 had a bluish, red discoloration on the right side of her forehead. On 8/16/22 at 09:56 AM, R49 said that she fell this past Sunday (08/14/22) in the morning when she was trying to put on her pants. R49 said she does not receive the assistance she needs. R49 said on the day of her fall, the Certified Nurse Assistant (CNA) came into her room, handed her clothes to her and told her that she could get dressed herself, then left the room. While R49 was trying to put on her pants, she fell off the bed onto the floor and hit her head. R49 said she yelled for help and the CNA came back in. R49's Inter Disciplinary Team (IDT) note dated 8/15/22 at 01:05 PM showed, [R49] had a fall on 8/15 at 0830. Resident was found on floor in between bed and closet. Resident states she pulled up her pants and just fell over . On 8/17/22 at 2:15 PM, V15, Licensed Practical Nurse (LPN) said, [R49] usually doesn't dress herself. She can dress upper body herself, but needs help with her lower body. On 8/17/22 at 2:20 PM V26, CNA, said that she was on duty on the day of R49's fall. V26 said, I have not seen her dress herself, but she can. On 8/17/22 at 3:10 PM, V4, Restorative Nurse said, From what I heard [R49] was trying to adjust her pants. She stood up and went to adjust them and fell to the floor. She will self transfer and our staff knows to kind of keep an eye on her. She will ask for help at times. In the morning when staff round, the night shift will offer to get her up and dressed. She can stand on her own but she shouldn't. V4 said that R49's clothes should not have been given to her. The facility's policy titled 'Falls Management' with review date of 06/21 showed This facility is committed to maximizing each resident's physical, mental and psychosocial wellbeing. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed .

Based on observation, interview and record review, the facility failed to assess and effectively manage R1's pain. These failures resulted in R1 experiencing unrelieved pain for a period of 3 days, and a delay in treatment. R1 was found to have bilateral arm fractures on January 3, 2017. This applies to 1 out of 3 residents (R1) reviewed for resident injury/ pain in the sample of 6. The findings include: R1's Physician order [REDACTED]. R1's Minimum Data Set, dated dated dated [DATE] showed R1's Brief Interview for Mental Status (BIMS) was a score of 14-cognitively intact. The same MDS shows that R1 only needs set up and supervision for meals and has no impairment of range of motion in upper arms. On January 5, 2016, at 8AM, R1 was in a local hospital. R1 was in bed with slings on her right and left arm. R1 stated she has a fracture of both upper arms. R1 said she remembered being gotten up, and a staff grabbed her arms as she fell backwards in the bed. R1 said this happened a couple of days ago before she was sent out to the hospital. R1 said after the incident she started having pain in both her arms. R1 said she was given Tylenol but it did not help much. R1 said as she continued to complain about her arms being painful, no one from the facility staff checked her arms or assessed her why she was in so much pain. R1 said she was just given Tylenol. R1 said she stayed in bed last Sunday January 1, 2017. R1 said by then, she was unable to use her arms and was not able to eat lunch. Staff still did not check her arms. R1 said the next day Monday (January 2, 2016,) she could not move her arms and staff had to feed her. R1 said she told the nurses that Tylenol is not relieving her pain. R1 said she continued to have severe pain almost all day Monday and was being given Tylenol with no relief. She said not one staff checked her arms to see why it was hurting so much. R1 said, last Tuesday (January 3, 2016) she was finally sent out to the hospital. R1 stated, I felt the staff were disgusted because of my complaining but I was in so much pain. R1said, she was very disappointed this happened (fractured both of her arms) because she was supposed to be going home in 2 weeks. R1's hospital records dated January 3, 2016 at 11:48 AM showed: R1 reports weakness in right arm and left arm. Complains of pain in right arm, left arm . R1's pain currently is 10 out of 10 on a pain scale. R1's Radiology report dated January 3, 2016 showed compression fracture of left humerus. Radiology report of right humerus showed [MEDICAL CONDITION] neck of the proximal humerus. An orthopedic consultation by Z9 (Physician Assistant) dated January 3, 2017 showed: R1 was sent to a local hospital due to R1's progressive bilateral arm pain and weakness for 5 days. R1 was unable to feed herself. Right humerus x-ray: fracture involving the surgical neck of the proximal humerus. Left humerus x-ray: [MEDICAL CONDITION] humerus. Right shoulder x-ray: Acute proximal surgical neck [MEDICAL CONDITION] which is comminuted and mildly displaced. A progress note by Z10 (Ortho MD) dated January 4, 2016 showed: (R1) has bilateral slings in place. (R1) sustained injuries to bilateral shoulders at her nursing facility. Assessment: [AGE] year old female with bilateral proximal humerus surgical neck fractures. R1 will likely require new facility placement The Facility incident report dated January 3, 2017 submitted to the state department (IDPH) shows: Type of occurrence: Serious Injury. Final report showed The soure of bilateral fractures remains unknown. On January 4, 2017 at 1:34 PM. Z5 said R1 was in so much pain , a 10/10 upon arrival to the emergency room . Z5 said R1 reports she has been having pain in her arms for 2 days. Per Z5 she spoke to E2 (Director of Nursing) E2 said that R1 has been complaining of pain in the nursing facility for 2-3 days. Z5 said R1 has pain due to bilateral fracture of her arms. On January 4, 2016 at 8:08 AM, E2 Director of Nursing, said that R1 started complaining of weakness and pain of her upper extremities, and required more assistance from the Certified Nursing Assistants (CNA). E2 said this was first noticed around Sunday January 1, 2017. On January 4, 2017 at 8:25 AM E4 (Certified Nursing Assistant-CNA) said she got R1 up from bed on Monday morning January 2, 2016, R1 was complaining of hurting all over. E4 said R1 cannot even lift her arms to put her dentures in. E4 said it was a significant change for R1. E4 said she did not report this to the nurse. On January 4, 2017 at 8: 35 AM, E5-CNA said R1 was complaining of discomfort of her arms that she had to be fed last Monday, January 2, 2016, E5 said R1was in so much pain she could not hold her arm up when E5 needed to check R1's blood pressure. E5 said she had to get another staff to hold R1's arm. On January 4 2017 at 9:50 AM, E11 Registered Nurse (RN) said that on Monday, January 2, 2017, R1 had significant increase of pain in her arms and Tylenol was not relieving the pain. E11 said she sent a fax to the medical doctor (Z11). E11 said she did not make a follow up call to the MD. E11 said it was the holiday so she was not expecting any response that day. E11 also said that staff thinks R1 was just making excuses and exaggerating the pain because R1 did not want to walk to meals. On January 4, 2016 at 2:05 PM, E9 CNA said R1 did not eat lunch last Sunday, January 1, 2016. E9 said R1 stayed in bed and was complaining of not feeling well. E9 said this is unusual for R1 since R1 wants up most of the time. E9 said she informed E3 (RN) On January 4, 2016 at 10:40 AM, E3 RN, stated I was late in giving R1's morning medications. E3 said R1 told her she cannot move her arms and her pain is 6 (out of 10 pain scale) E3 said R1 does not have anything stronger than Tylenol. E3 said she did not call the doctor to update R1's pain or change in condition. E3 said she thought R1 was just trying to not have to walk to meals. On January 4, 2017 at 2:15 PM E13 License Practical Nurse- LPN said she was informed that R1 was staying in bed the rest of the shift. E13 said she did not ask why R1 was staying in bed. E13 said she is not familiar with R1 ' s morning routine. On January 4, 2017 at 9:35 AM, E7 CNA said R1's usual disposition is, she is never in her room, she is very active and does not stay in bed. The past few days she was staying in bed, this is a big change for R1. On January 4, 2016 at 10:30 AM, Z2 ( Physical Therapy Assistant) said she worked with R1 almost daily and she was in the process of being discharged in 2 weeks. Z2 said when she saw R1 on Monday, (January 2, 2017) she worked only with R1's lower extremities and did not work with R1's upper arms. Z2 said R1 was having a difficult time moving her arms. Z2 said she reported this to E11 (RN) and E11 said R1 has been given Tylenol. On January 4, 2017 at 12:30 PM, Z4 (speech therapist) said R1 had therapy on Monday January 2, 2017 around 2:00 PM, but only worked on orientation. Z4 said R1 told her that her arms are so sore and painful that R1 cannot lift them. On January 4, 2016 at 8:35 AM, E6 stated I got R1 up on Tuesday morning. She said she hurt all over. R1 was not moving her arms at all. I had therapy assist me in getting her up. On January 4, 2016 at 8:57 AM, Z1 (Physical Therapist) said R1 had a significant medical decline on Tuesday January 3, 2106 compared to last week. Z1 stated, R1 was sitting at the edge of her bed not moving her arms. R1 told me her pain in her arms was 8 out of 10. I told the nurses. Z1 said she wheeled R1 to the dining room for breakfast, R1 could not move her arms she had to be totally fed at breakfast. Z1 said she informed E2. On January 4, 2016 at 12:35 PM, E14 MDC/CP Restorative Nurse said R1 had a discharge plan to be home in 2 weeks, and had started a walk to dine program. E14 said unfortunately this happened and now R1 is in the hospital. Z10 said R1's fractures caused a lot of discomfort. Z10 said this type of fracture is from trauma. With her age, it does not take a lot of force to cause a fracture. The nurses notes dated January 2, 2017 at 9:50 AM showed Floor nurse (E3) approached this nurse about R1 having increased pain in upper arms .PRN Tylenol not effective to reduce pain to acceptable level The nurses notes did not show any assessment or evaluation on why R1 was having persistent, unrelived pain in her arms. The nurses note for R1 dated January 2, 2017 (Monday) at 13:42 showed: complains of pain in upper extremities .prn-(as needed) Tylenol was given with little to no results . The nurses notes did not show any assessment or evaluation on why R1 continued to have persistent pain in her arms. On December 5, 2016 at 1:18 PM, E2 (Director of Nursing) said nurses should do an assessment, to determine why the patient is having pain, and check the source of pain. Nurses should call the doctor as soon as possible. If a fax was sent, it should be followed up in a couple of hours. Weekends and holidays are the same, doctors can be called anytime. The facility policy on Change in condition dated September 2016 states : 1. Nursing will notify resident ' s physician or nurse practioner when: b.There is a significant change in resident ' s physical, mental or emotional status. The facility policy on pain management dated July 2, 2012 showed: 1. The pain management program is based on a facility-wide commitment to resident comfort. Pain is defined as whatever the experiencing person says it is and exists whenever he or she says it does. 7. If pain hs not been managed consistent with the resident's goals, the interdisciplinary team may may need to reconsider current interventions and revise those interventions as needed .the nursing staff will work with the physician . On January 9, 2017 at 1:50 PM, E2 said the facility had no additional information to present for review concerning R1.

Based on observation, interview, and record review the facility failed to identify pressure ulcers advanced stages, failed to have physician orders [REDACTED]. These failures contributed to R4 developing multiple advanced stage pressure ulcers. This is for 3 of 7 residents ( R4, R5, R12) reviewed for pressure ulcers in the sample of 16. The findings include: 1. R4's December physician's orders [REDACTED]. R4's Quarterly Minimum Data Set (MDS) assessment of 11/20/13 documents that R4 has moderate cognitive impairment. R4 requires extensive assistance of 2 or more persons for transfer and bed mobility. R4 is frequently incontinent of bowel and bladder. No skin abnormalities are documented. R4's Laboratory Report of 12/06/13 shows an [MEDICATION NAME] level of 3.0 (normal 3.4 - 4.8 gm/dl). R4's Wound Assessments dated 10/10/13 documents R4's Braden Scale (risk for pressure ulcer ) score is 16. (At risk) The same report shows that an unstageable pressure ulcer to her right trochanter was identified on 10/10/13. The surrounding skin is red. The wound measures 1.8 cm x 1.00 cm . The wound is described as 100% firm necrotic tissue. The same assessment documents: R4 was observed with a necrotic wound to her right trochanter. R4 recently notified staff that her right side was hurting. R4 likes to lay on her right side and says it hurts to lay on her left. She eats 75-100% of her meals. The Wound Assessment of 10/17/13 documents that the wound on the right trochanter is 1.0 cm x 1.0 cm with light serous drainage. The same assessment documents that R4 is now trying to lay on her left side and back. The Wound Assessment of 11/19/13 shows that R4 developed a pressure ulcer on the right foot (bunion) that was unstagable, 100 % necrotic slough. The wound was identified on 11/19/13. The wound measures 1.50 cm x 1.80 cm. The same assessment documents that R4 moves her feet at night and creates friction. R4 lays on her left side due to wound on right hip. The plan is to off-load the heel with protective boots. The Wound Assessment of 12/4/13 documents that the wound has developed depth, undermining, and heavy serosanquineos drainage The wound measurements are 0.60 cm x 0.50 cm x 0.80 cm with undermining at 10 o'clock area that is 2.50 cm. Another Wound Assessment of 11/27/13 shows that R4 has developed another pressure ulcer on the left medial foot. The wound measures 0.90 cm 0.70 cm x 0.30 cm with heavy serous exudates. R4 has pain scores as 6. (pain scale 1-10) The Wound Assessment of 12/5/13 shows that R4 has developed a pressure ulcer to the left medial foot. The ulcer was identified on 11/27/13. The ulcer measures 3.00 cm x 3.00 cm. The ulcer is unstagable, 100% necrotic tissue. The wound has heavy purulent and odorous exudates. On 12/17/13 at 10:35 AM, E5 (Wound Nurse) was observed doing R4's treatments. R4 kept calling out, "be careful, be gentle, oh that hurts" whenever her lower legs were touched to do the treatments. On 12/17/13 at 9:45 AM, R4's mattress was observed. R4 was laying on an air mattress, the air mattress was in static mode (not alternating pressure). The mattress control showed that the mattress could only be adjusted to soft or firm, there was no evidence that the mattress had any alternating air for pressure redistribution. On 12/17/13 at 8:55 AM, E5 (Wound Care Nurse) stated during interview that she was not sure of the etiology of R4's pressure ulcers. E5 said the pressure ulcers developed at the facility. R4's Care Plan dated through 2/18/14 documents that R4 has potential for skin breakdown due to immobility. The goal is that she will have intact skin, free of redness, blisters, or discoloration through the next review. The approaches include reposition at least every 2 hours or more often as needed or requested. The Care Plan initiated on 11/8/13 through 2/18/14 documents alteration in skin integrity. R4 has stage IV pressure ulcer, stage III pressure ulcer, unstageable, and a stage II pressure ulcer. The sites include right hip, right foot, left ankle, left foot, and left elbow. The approaches include to provide pressure reduction mattress, or low air loss, and daily skin checks. R4's daily skin check documentation dated 8/4/13 through 12/17/13 were reviewed. All checks are documented as skin is intact and/or unchanged. Only 2 entries show any skin abnormality an open area on 10/8/13, and 12/11/13 redness. On 12/17/13 at 11:45 PM, E2 (Director of Nursing) stated during interview that they were looking at changing the schedule of Certified Nursing Assistants (CNA) back to 7:00 AM - 3:00 PM instead of 5:00 AM until 1:00 PM. She said that she thought the staff were rushing to get their work done. The facility policy for Pressure Ulcer Prevention shows the following: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease in circulation to that area and subsequent destruction of tissue. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, and reported. 2. The 10/4/13 Minimum Data Set Assessment (MDS) shows R5 needs extensive assistance of two staff for bed mobility, transfers, and toilet use. R5 was assessed for being at risk for pressure ulcers and had no skin issues as of 10/4/13. On 12/17/13 at 9:45 AM, E5 (Wound Nurse) changed the dressing on R5's right heel. R5 had a large dry, black tissue area on the back of his heel. E5 painted R5's heel with [MEDICATION NAME]. The heel was then padded with 4x4 gauze and wrapped with roller gauze. R5 said she did not know how R5 got the wound. It was reported to her and she follows up on the treatment and documentation. R5's Wound Assessment Details Report shows on 10/29/13 a large maroon fluid filled blister was noticed to the back of R5's right heel. The unstageable area was dry, boggy skin, and tender. The blister measured 4.5 X 6.0 X 0.0 centimeters (cm). R5's 12/10/13 Report shows the area is the same size, is firm, and the necrotic tissue remains intact without drainage. Plan to continue with 4x4 gauze and roller gauze. R5's 10/7/13 Care Plan (initiated on 6/28/12) states R5 has potential for skin breakdown related to immobility. Assist to turn/reposition at least every 2 hours, more often as needed or requested. R5's 10/29/13 Alteration in skin integrity Care Plan states R5 has an unstageable pressure ulcer to the right heel. Do daily skin checks, reposition every 2 hours or as requested by the resident, treat as ordered by the physician (see treatment record). 3. R12's 11/8/13 Skin Condition Screen shows no concerns and R12's skin was intact on admission. R12's 11/15/13 MDS shows R12 needs extensive assistance of one staff for bed mobility, transfers, ambulation, dressing, hygiene, and toilet use. R12 was assessed as being at risk for pressure ulcers. On 12/18/13 at 1:20 PM, E5 (Wound Nurse) cleaned a dime sized (approximate) dry pale pink area on R12's left upper buttock (coccyx) with saline. E5 covered the area with a foam dressing. R12's potential for pressure ulcer development related to immobility Care Plan (revised 11/8/13) shows R12 needs assistance to turn/reposition at least every 2 hours. On 12/18/13 at 1:30 PM, E11 (Certified Nursing Assistant) said that R12 turns herself. R12's 12/3/13 Wound Assessment Details Report shows a stage 2 open red area to the right upper buttock near the sacral area measuring 1.0 X 1.0 X 0.0 cm. Area cleansed and covered with a clear occlusive dressing. R12's 12/10/13 Report shows the right upper buttock wound measurements of 0.5 X 0.5 X 0.0 cm. Wound bed is red and dry. Continue with current plan of treatment. R12's Alteration in skin integrity Care Plan states R12 has a stage 2 pressure ulcer to the coccyx, reposition every 2 hours or as indicated, and treat as ordered by the physician (see treatment record). R12's December 2013 Physician order [REDACTED]. On 12/18/13 at 3:00 PM, E9 (Registered Nurse) stated, R12 had no wound care orders in the chart. On 12/18/13 at 3:05 PM, E5 said sometimes the documentation gets put in one computer program and not into the other computer program. E5 confirmed there was "no order for the foam dressing." The facility's October 2010 Pressure Ulcers/Skin Breakdown - Clinical Protocol states, "The physician will authorize pertinent orders related to wound treatments, including wound cleansing approaches and dressings (occlusive, absorptive, etc.)"

Based on observation, interview and record review the facility failed to supervise a confused and agitated resident while the resident was sitting on the edge of the bed. This failure resulted in R8 lunging forward and sustaining a large hematoma to her left forehead, a telescoping fracture of the left femur and a compression fracture of the left tibia on [DATE]. The facility also failed to monitor R11, R12 while on the toilet/bedside commode to prevent the resident from falling off and sustaining an injury, failed to ensure that R4 who requires 2 assist for transfers was transferred from the bed to the bedside commode by 2 staff members to avoid injury to the resident's leg and failed to ensure that R10, R4 were wearing non-skid footwear during transfers to prevent slipping on the floor and falling. This applies to 5 of 9 residents (R8, R12, R4, R11, R10) reviewed for falls/injuries in a sample of 13. The findings include: 1. The physician's orders [REDACTED]. The Unusual Occurrence Report dated [DATE] at 5:30 AM states, "CNA (E9) reported that when dressing (R8), they bumped heads- (R8) had a 2 cm x 2.5 cm hematoma on left forehead approximately the size of an apricot, cold pack applied immediately, red lines noted superiorly and inferiorly on hematoma but no open areas, bruising was faint at first then darkened as noted at 6:30 AM and hematoma became flatter a little and spread over left forehead from hairline to eyebrow with only red line noted superiorly- remained alert, talking, smiling, laughing. Denied pain at 5:30 AM, then stated it hurt later." The Minimum Data Set of [DATE] shows that R8 requires extensive assist of 2 staff for transfers and toilet use. This same document shows that R8 is not steady and is only able to stabilize with human assistance when transferring from surface to surface R8's Fall Risk assessment dated [DATE] shows that R8 scored a 16= High Risk. R8's careplan revised and initiated on [DATE] (resident expired [DATE]) states, "(R8) is high risk for falls related to unaware of safety need, Deconditioning." One of the interventions listed states, "All care of (R8). should be done with two assists at all times. This same care plan states, "Behaviors- combative behaviors during personal care." One intervention listed for this problem states, "When (R8) is agitated, make sure she is safe and secure, give her ,[DATE] minutes to calm down. Upon returning thank her for waiting for you, give explanation of task intended showing visual aids, tell her you would like to help... Use 2 CNAs if needed." The facility Department of Public Health Reporting Form dated [DATE] states, " Approximately 5:00 AM on [DATE], resident was being assisted with AM care. Aide summoned nurse because R8 had struck head with the CNA and was getting a bump. Nurse(E10- LPN) noted and egg sized bump raising on the left side of patients forehead. The aide stated she was bumped on the right side of her head behind her ear... POA refused recommended CT scan. 30 minutes later resident agreeable to getting up for breakfast. C/O leg pain upon movement. Resident remained in bed and x-rays were obtained which revealed a telescoping fracture of the left femur/hip and a slight compression fracture of the tibial shelf. Pt apparently struck left knee on the floor when she lunged/fell to the side. Hospital recommended. POA refused, requesting pain control/comfort care. Pt is on hospice for end stage dementia." R8 expired on [DATE]. The Radiology Report of R8's left hip dated [DATE] states, " There is an acute fracture through the left femoral neck with telescoping." A Radiology Report of R8's left knee also dated [DATE] states, "Due to overlap, the lateral tibial plateau is not well-seen, however, findings are very suspicious for a compression type fracture of the lateral tibial plateau of indeterminate age." The facility form entitled, Follow-up Investigation of Injury states, "I spoke with (E9-CNA) on Sunday, [DATE] at 10:24 AM. I asked her to tell me exactly what happened the (R8). (E9) said (R8) was doing fine with her. She had washed her, put on her diaper. (R8) started hitting at (E9). (E9) says she pushed (R8's) arms away from her face. (R8) wouldn't put her arms up. (E9) put her upper clothes on her. (E9) says she was holding (R8) up in the bed with 1 arm. (E9) says she was reaching to end table to get (R8's) glasses and (R8) threw her head into the back of (E9's) head. (E9) said she stared crying and laid (R8) down. Went and told (E10-LPN) . (E9)says (E10) came in the room, another aide came with her, (E9) did not know her name. (E10) iced (R8's) head and left her in bed. (E9) says she kept checking on (R8). I asked her why she was checking on (R8) and (E9) said to make sure the ice was still on her head. (E9) told me this happened between 5:15 AM and 5:30 AM. I asked (E9) if (R8) had fallen out of the bed and she said no. (E9) said she didn't fall out of bed." On [DATE] at 10:45, Z1 (R8's Physician) stated, "About ,[DATE] months ago the family had had a really good experience with hospice and wanted her to be on hospice too. I wouldn't sign the paper because I didn't think she was going to die in 6 months. She would sit in the hallway and talk and smile. If she didn't want to be messed with she would push you away. I saw her a couple days after the incident and she looked terrible. She had a bump on her forehead, that raccoon look around her eyes and an open area between between her eyes. They (facility) said her daughter didn't want anything done. I was told she had head bumped someone. If she was a non-hospice pt she would have had a CT of the brain. I am sure she had a subdural bleed or something catastrophic happened to her brain." Z1 was asked if he felt that the head injury led to R8's death. Z1 stated, "I think so. Something terrible happened to her brain. When I saw her she was definitely post trauma unresponsive. I think without the fall she would have lasted quite a while. I was told about the leg trauma later and was told that the daughter didn't want to do anything with that either. I reviewed the X-rays. I think she had a femur fracture and a tibia fracture." On [DATE] at 1:25 PM E2 (DON) stated, "I know she hit something harder than the CNAs head. Looking at her injury, I'm sure she hit the bedside table- she had 2 lines- one on the top and one on the bottom of the bump. The telescoping fracture- she had a white area on her left knee with an ecchymotic area around it. She had to have hit her knee on the floor. That had to be the mechanism of injury- it just fits. We interviewed E9 for 3 hours. I came to the conclusion that either she really didn't know what happened and was incompetent or she does know what happened and she is being deceitful. Either way I couldn't trust her with another resident." 2. The physician's orders [REDACTED]. R12's Fall Risk assessment dated [DATE] shows that R12 scored a 28= High Risk. The Minimum Data Set of [DATE] shows that R12 requires extensive assist of 2 staff for transfers and toilet use. This same document shows that R12 is not steady and only able to stabilize with human assistance when moving on and off the toilet. The Unusual Occurrence Report dated [DATE] at 4:40 AM states, "CNA reported left resident on the Bedside Commode to go get the (mechanical lift), observed resident lying on floor on her left side, holding head up and talking, but speech unclear, disorganized, able to move all extremities as condition allows. Skin tear noted on left forearm near elbow and no head trauma noted to head until 7:15 AM. Then has bump and bruise on left forehead approximately size of a large egg." R12's care plan initiated on [DATE] states, "(R12) is high risk for falls related to unaware of safety needs, deconditioning and psychoactive drug use." One of the interventions listed for this problem states, "Monitor (R12) while she is in the bathroom and transfer with assist of 2 people and gait belt." On [DATE] at 3:05 PM, E4 (Restorative Nurse) stated, "(R12) should not have been left alone on the commode. That was the intervention we added to the care plan." 3. The physician's orders [REDACTED]. R4's Minimum Data Set of [DATE] shows that R4 requires extensive assist of 2 staff for transfers. The Unusual Occurrence Report dated [DATE] states, "While transferring (R4) from the bed to the bedside commode (R4) started to slide feet forward, right buttocks coming off of the bed. This writer (E8- RN) put knees in squat position against resident to keep resident from sliding off bed. Skin tear to left shin noted from writer's right knee. Size 2.0 x 0.5 cm. It is also shown that R4 was "barefoot" during the transfer. An intervention listed on this same form states, "TX per protocol :Always use 2 staff to transfer (R4)." On [DATE] at 3:11 PM, E4 stated, "If it were me I would have transferred (R4) with 2 people." R4's care plan initiated [DATE] states,"Restorative, toileting, transfer: (R4) has an ADL Self Care Performance deficit related to/ Parkinson's Disease;s and Osteoarthritis." An intervention for this problem states, "Transfer:(R4) requires extensive assist of two staff participation with transfers. At times needing a mechanical device." 4. The [DATE] physician's orders [REDACTED]. R10's Minimum Data Set (MDS) Assessment of [DATE] shows R10 has severe cognitive impairment and long and short-term memory loss. R10 requires extensive assistance of one staff for transferring, toileting and bed mobility. R10 has range of motion impairment of both lower extremities. R10 is frequently incontinent of bowel and bladder. The facility's Unusual Occurrence Report for R10 dated [DATE] at 2:45 PM showed, "CNA responded to the call light, observed patient sitting on her bottom on the floor with her back resting up against the bed. The report documented R10 had on slippery socks in the bed which caused her to slide down the side of the bed." R10's falls care plan dated [DATE] showed an approach that was added on [DATE] which documented, "Remove socks when in bed. If feet are cold, apply non-skid slipper socks so R10 does not slide out of bed." The facility's Unusual Occurrence Report for R10 dated [DATE] at 1:30 PM showed, "Resident was observed found on the floor by the bed in her room. The report documented R10 was wearing slippery socks in bed." The report further documented that staff were again advised to follow the intervention mentioned in R10's care plan to prevent falls. On [DATE] at 3:00 PM, E4 (Restorative RN) stated, (Before R10 fell out of bed the second time), "I told them (staff) to put non-skid socks on her if her feet are cold or no socks when she's in bed." 5. The [DATE] physician's orders [REDACTED]. The Physical Therapy Note of [DATE] showed R11 was recently hospitalized for [REDACTED]. Patient has increased falls." R11's Minimum Data Set (MDS) Assessment of [DATE] showed R11 required extensive assistance of two staff for transferring, toileting and bed mobility. R11 had range of motion impairments of both upper and lower extremities. R11 was assessed as occasionally incontinent of bowel. The test for balance showed R11 was not steady moving on and off the toilet and required physical help to stabilize. The ADL (Activities of Daily Living) care plan documented, R11 has self care deficit related to having a Stroke. The interventions initiated on [DATE] showed , "R11 requires extensive assist of two for toilet use. R11 has left side neglect. Needs extensive assist with the left side of his body." The facility's Unusual Occurrence Report for R11 dated [DATE] at 6:40 PM showed, Resident fell when sitting on the toilet and slipped to the floor landing on his buttocks. "R11 had been alone in the bathroom." Report further documented, "Do not leave R11 on the toilet by himself. Staff to stay with him at all times(when he is) on the toilet . Certified Nursing Assistant (CNA) had not been in the bathroom with him. On [DATE] at 3:05 PM, E4 (Restorative RN) said R11 should not have been left alone on the toilet.

Based on observation, interview and record review, the facility failed to prevent and failed to identify the presence of a pressure ulcer for a resident at high risk for skin breakdown (R79). These failures resulted in the development of a Stage II pressure ulcer to R79's right outer ankle. The facility also failed to assess and notify the physician that a pressure ulcer showed no signs of improvement for 3 months, R4. This is for 2 of 4 residents reviewed at risk for pressure ulcers. (R4 & R79) Findings includes: 1. R79's 9/13/10 MDS documents a [DIAGNOSES REDACTED]. MDS also shows total dependence or full staff performance for ambulation, hygiene, and bathing. On 10/27/10 at 10:05 AM, E8 (Treatment Nurse) said R79 had no open areas on his skin. On 10/27/10 at 10:10 AM, E8 removed R79's right sock to expose a taped, undated dressing over the right outer ankle. The dressing had an irregular nickel size area of very dark brown (almost black) dried drainage present. As E8 removed the tape the pink foam of the dressing was stuck to R79's right ankle. Removal of the dressing pulled off skin and left a centimeter size open area with bright red drainage. R79's 10/3/10 Daily Skin Assessment/Wound Status shows an entry of "B"-Change in skin condition. State location - right ankle. R79's 10/14/10 Nurse's Notes documents "Dressing right ankle intact." and no other assessment information about the right ankle. R79's 10/1 - 10/26/10 Physician order [REDACTED]. R79's Weekly Wound Narrative Documentation Form shows an entry on 8/11/10, "Outer malleolus ankle wound resolved." On 10/27/10 at 10:10 AM, E8 confirmed that R79 had no treatment orders, or wound documentation for his right ankle at this time. R79's 7/8/10 Norton Plus Pressure Ulcer Scale shows a score of 9. (Score 10 or less = High Risk) R79 had no care plan identifying a pressure ulcer on his right ankle. The facility's 10/20/10 Pressure Ulcer Log did not identify R79 as having a pressure ulcer. 2. R4 is a [AGE] year old female resident with [DIAGNOSES REDACTED]. The facilities Comprehensive Admission, Readmission or New Site Documentation dated 7/8/10 identified R4 had developed a Stage II Pressure area measuring 0.8 X 0.5 X 0.2 to her coccyx. The PUSH (Pressure Ulcer Scale for Healing) tool dated 7/8/10 showed R4 with a score of "4" for the pressure ulcer to her coccyx. The Norton Pressure Ulcer Scale dated 6/12/10 and 9/3/10 for R4, identified her as having a score of "8" (<10 = high risk). The facility treatment record for 7/10 showed a handwritten order was entered on 7/8/10. The treatment reads: "Cleanse coccyx wound with N.S. (normal saline) then skin prep then cover wound with [MEDICATION NAME] dressing. Change every 3 days." The facility's Weekly Comprehensive Wound Assessment Documentation, completed by E8 (Treatment Nurse), for R4 showed the following for July and August: ? 7/14/10 - Coccyx (pressure) wound measuring 0.3 X 0.2 X 0.2. Bed wound with depth ? 7/21/10 - Coccyx (pressure) wound measuring 0.3 X 0.2 X 0.2. No change to bed wound depth ? 7/28/10 - Coccyx (pressure) wound measuring 0.5 X 0.3 X 0.2. Wound with increased length ? 8/04/10 - Coccyx (pressure) wound measuring 0.5 X 0.3 X 0.1. Bed wound remains stagnant ? 8/11/10 - Coccyx (pressure) wound measuring 0.8 X 0.1 X 0.1. ? 8/18/10 - Coccyx wound stagnant ? 8/25/10 - Wound not filling in On 8/26/10, the treatment administration records had a new hand written order dated 8/26/10 which discontinued the [MEDICATION NAME] dressing and states R4 is to now have "[MEDICATION NAME] Extra thin dressing. Apply to coccyx wound after cleansing with Normal Saline and skin prep. Change every 3 days." E8 continued to document weekly on the wound. The 9/15/10 documentation showed a depth increase to 0.2. The treatment records showed no treatment changes were implemented, (after 8/26/10), and there was no improvement to the wound according to the measurement documentation on the Comprehensive Wound Assessment sheets from 9/15/10 to the present (10/28/10). On 10/18/10, Z2 (Wound/Ostomy Nurse) documented she was informed of the non-healing wound to R4's coccyx. Z2 documented "treatments have not been effective." On 10/28/10 at 2:30 PM, Z2 was interviewed regarding R4's coccyx wound. Z2 stated she was not made aware of Z2's wound until last week. Z2 stated she looked at R4's wounds on 10/18/10 and again on 10/28/10. Z2 stated she told the treatment nurse (E8) to notify the physician of R4's current wound findings and obtain new orders for treatment. Z2 told this surveyor, E8 should have notified the physician and obtained new orders 7/28/10 when she noted the wound had increased in size. Z2 agreed that waiting for more than 3 months to notify her of a non-healing wound was not appropriate. Z2 stated "that is why I told her (E8) yesterday to call the doctor now and get the order changed." R4 had no care plan in place until 9/7/10, more than two months after identification of the open area.