Every finding on record at The Sapphire at Northwoods

Based on observation, interview, and record review the facility failed to ensure a process for monitoring cool-down and reheating temperatures for leftovers was implemented and failed to ensure opened foods were labeled and stored in a food-safe manner. This has the potential to effect all residents receiving food from the kitchen. The findings include: 1- Facility Data Sheet completed on 5/14/26, shows there are 88 residents residing in the facility. On 5/14/26 at 9:08 AM, a plastic food service container containing oatmeal from breakfast was sitting in the top shelf of the cooler. It was warm to the touch. A four inch, half size hotel pan containing scrambled eggs were also in the cooler covered with a steam table lid. The pan was warm to the touch. A six inch, half size hotel pan containing hard boiled eggs was also in the cooler covered with a steam table pan. The pan was warm to the touch.On 5/14/26 at 9:13 AM, V5 (Cook) said she started working at the facility approximately a month ago and didn't receive much training. V5 received multiple food safety certifications last year while in school. V5 said she was never trained on or provided a cool-down log when putting leftovers into the cooler. V5 said she did not personally put the leftovers in the cooler after breakfast on 5/14/26 and believes one of the dietary aides must have put them in the cooler. V5 did not cook a new batch of scrambled eggs on 5/14/26 and pulled them from the cooler to use. V5 said she typically only reheats leftovers to 135 degrees Fahrenheit. On 5/14/26 at 9:40 AM, V4 (Food Service Director) said they don't usually have a lot of leftovers, but they will save some items including meats, vegetables, and scrambled eggs. V4 said the facility does not currently use a cool-down log to track the temperatures of leftovers. V4 said leftovers should be cooked to 165 degrees Fahrenheit and any leftovers that have been cooked, cooled, reheated and used for a meal should be discarded after the meal has been served. V4 said the facility does not have a policy for monitoring cooled foods.Facility Reheating policy dated 5/2/2014 states, Cooked food which is cooled in the refrigerator and is reheated for hot holding is reheated to 165 degrees F (Fahrenheit) for 15 seconds . Leftovers will be used up within six (6) days or less; after that time They will be discarded. Leftovers will not be reheated more than once.2- On 5/14/26 at 9:06 AM, an opened bag of egg beater mix was placed into a pitcher without a top. The plastic bag of egg beater was opened and by the opening was dried, crusty old egg beater mix. The date on the label was 4/28/26. On 5/14/26 at 9:08 AM, There was a plastic food service container of oatmeal, a half size four-inch hotel pan of scrambled eggs, and a half size six-inch hotel pan of hard boiled eggs. The scrambled eggs had a label with a date of 5/12/26. The oatmeal and hard boiled eggs did not have a label. On 5/14/26 at 9:40 AM, V4 said all items that have been opened, should be reclosed and probably put into a ziplock bag or put into a sealed container. It shouldn't be open to the air. V4 also said all items in the cooler should be labeled and dated. Facility Labeling and Dating Foods policy dated 5/20/2014 states, To decrease the risk of food borne illness and to provide the highest quality, foods is labeled with the date received, the date opened and the date by which the item should be discarded.

Based on interview and record review, the facility failed to ensure restorative services were provided for three of four residents (R1, R3, R4) reviewed for restorative services in the sample of four.The findings include:1. On February 18, 2026 at 9:30 AM, R1 was in his room sitting in his wheelchair. R1's walker was in the corner of his room. R1 said they cut me out of therapy. R1 said he can walk but needs to hold onto something. He said staff do not walk him, they are so busy, it's pitiful. R1 said he would like to be walked but the staff are too busy.On 2/18/26 at 10:09 AM, V4 (Certified Nursing Assistant/Previous Restorative Aide) said she was the restorative aide but stepped down about two weeks ago and now is working the floor. The floor CNAs should be doing the restorative program with the residents including walking. R1 is alert and oriented and is on a daily walking program.R1's Restorative Progress note dated 12/16/24 shows he is on a walking program twice a day. R1 will ambulate 25-50' feet using a two wheeled walker and with hands on assist and continuous reminders to step into then advance 2w/walker as he takes each step and not push the walker far ahead during ambulation task provided by staff.R1's CNA Nursing Rehab Task report for walking provided on 2/18/26 shows 11 out of 30 days not applicable he did not receive the service.R1's current care plan does not show his restorative program and services to be provided.2. R4's admission Record shows he was admitted to the facility on [DATE], with diagnoses including cardiac pacemaker, muscle weakness, high blood pressure, malnutrition, metabolic encephalopathy, atrial fibrillation, major depressive disorder, and dizziness.R4's Order Summary Report shows an order dated February 9, 2026, to please walk resident for 15-20 minutes on first and second shift for restorative.R4's Medication Administration Record dated February 1, 2026-February 28, 2026, shows the nurse documented R4 was being walked twice per day including during this investigation on the first shift by V8-Licensed Practical Nurse (LPN).On February 18, 2026, at 11:02 AM, R4 said his care at the facility has been going very well with the exception of no being able to get walked daily. R4 said that V4 certified nursing assistant (CNA)/previous restorative aide used to walk with him every day at 9:30 AM, and now she is no longer in that position. R4 said he needs someone to walk with him. R4 said he was doing 12 laps in the facility with V4 now he has only received about three walks in the last two weeks with only three laps. R4 said there is an order for R4 to get walked for ten minutes but it doesn't always happen. I only get three laps in ten minutes instead of 12. But three laps is better than none.On February 18, 2026, at 11:10 AM, V8 Licensed Practical Nurse (LPN) said R4 eats meals in his room. V8 said R4 needs one assist of staff to get out of bed. V8 said that R4 is able to walk with staff assistance. V8 said she documents it on R4's Medication Administration Record when V8 walks. V8 said the CNA walks R4.On February 18, 2026, at 11:14 AM, V9 R4's CNA for the day said R4 is able to walk. V9 said restorative is able to walk R4 up and down the hallway. V9 said R4 used to be walked by V4 CNA/previous restorative CNA but V4 went to working the floor instead of restorative. V9 said it has been a few days since she has seen R4 being walked. V9 said R4 is not necessarily walked on a consistent basis anymore since V4 stepped down. V9 said the CNAS on the floor can walk R4 if they have time to do so. V9 said there is only three CNAS today, so she hasn't been able to walk R4. V9 said no staff have walked R4 today. V9 said there are times when it's hard to walk the residents when there are a lot of residents to take care of. V9 said R4 wants to walk in the morning, not in the evening. V9 said if a CNA walks a resident, then they document it in the task documentation and the number of minutes that the resident walks is documented.R4's CNA task documentation does not include walking the resident on even surfaces. R4's CNA task documentation only includes walking R4 on uneven or sloping surfaces.R4's Care plan does not include a restorative program. R4's Care plan revised on January 6, 2026, shows, ADL (Activities of Daily Living) self-care deficit, require assist with adls related to limited mobility, debility, and impaired balance. Transfers: I need extensive assist of one staff to help me.3. R3's admission Record shows he was admitted to the facility on [DATE], with diagnoses including primary disorder of muscle, bipolar disorder, depression, difficulty in walking, abnormal posture, and muscle weakness.R3's Care Plan revised on June 7, 2024, shows, Restorative Program: Ambulation limited ability to ambulate with staff assistance. Goal: Will ambulate 110-200 feet using a four wheeled walker with extensive assist and wheelchair follow in the hallway.R3's CNA task documentation to walk 150 feet-extensive with one and one to follow with wheelchair using a four wheeled walker two times daily shows not applicable was documented 22/26 times in the last 14 days. R3 required maximal assistance or was dependent six of the six times he was walked. R3's CNA task documentation for number of minutes spent training and skill practice in walking, shows R3 was walked one time a day on February 5-8, 2026, February 10-13, 2026, and February 15-16, 2026.On February 18, 2026, at 10:15 AM, V6 LPN said that R3 is able to walk with staff assistance and a walker. At 10:21 AM, R3 said staff do not walk him.On February 18, 2026, at 9:30 AM, V2 Director of Nursing (DON) said V7 Wound Care Nurse/Restorative Nurse is in charge of the restorative program and V4 Certified Nursing Assistant was in charge of performing the restorative exercises but has recently stepped down from the position. V2 said all residents that are not doing therapy should have two restorative programs which depends on each resident. Restorative plans are documented in the residents' care plans.On February 18, 2026, at 9:44 AM, V3 Assistant Director of Nursing said the restorative program is in place to help resident stay at the current level of functioning. V3 said restorative minutes should be documented in the computer. The Certified Nursing Assistants (CNAs) document the minutes as they walk the residents. V3 said each resident's specific restorative program should be in the residents' care plan. V3 said the previous CNA that was in charge of walking residents has stepped down. V3 said the facility is in the process of hiring another restorative CNA.On February 18, 2026, at 9:31 AM, V5 CNA said the restorative aide stepped down and the cnas working the floor are responsible for providing restorative services to the residents. V5 said that R1 and R3 are on a walking program. At 9:39 AM, V6 LPN said she the facility does not currently have a designated staff for restorative. V6 said she does not know who is walking with the residents nor did she know which residents were on a restorative program.On February 18, 2026, at 10:09 AM V4 CNA/previous restorative aide said she was a restorative cna, but stepped down. V4 said she still helps out a little. V4 said she stepped down because she preferred to work the floor. V4 said R4 like to get his walking in. V4 said she would walk R4 at a specific time. V4 said that R4 expects to get walked the same amount of time as before, but it is hard to do because there are floor responsibilities. V4 said R3 can be non-compliant at times, but in a good week, he will walk 2-3 times. V4 said R1 is on a walking program, and he is alert and oriented. At 11:08 AM, V7 Wound Care Nurse/Restorative Nurse said she works 2:00 PM-10:00 PM. V7 said there has been a lot of changes with staff. V7 said she is in charge of the restorative program and is responsible for doing the assessments. V7 said she will need help with restorative and wounds so that everything can be reviewed so nothing gets missed.The facility Nursing Rehab policy approved March 2018 shows, The interdisciplinary team develops (as part of the care plan) and implements interventions that are safe and appropriate in order to achieve the expected goals. Nursing Rehab Tasks are recorded as part of daily care tasks thru POC (Plan of Care).

Based on interview and record review, the facility failed to implement fall interventions to prevent and/or minimize injury due to falls for 1 of 6 residents (R1) reviewed for safety and supervision in the sample of 6. These failures resulted in R1 sustaining a fall resulting in multiple vertebral fractures which lead to his demise.The findings include:On [DATE] at 3:43 PM, V4, Licensed Practical Nurse (LPN), said R1 was a very high risk for falling. R1 was confused and he would just get up, but he wasn't really able to walk at that time. V4 said R1 just returned during her shift (on [DATE]) from the hospital after falling earlier. V4 said she could hear the thud at the nurse's station, and she automatically knew R1 fell again because he kept falling. V4 said R1 was face down on his stomach with blood around his head. V4 said R1 probably hit his head on the floor because he was not near any furniture. V4 said they had not put the fall mat down because R1 would trip over the mat; it would have put him at a higher risk. V4 said she automatically called 911 and got him out of there.On [DATE] at 1:22 PM, V2, Director of Nursing (DON), said she did one report on all three of R1's falls since they happened so close together. V2 said R1 went to the hospital after his second fall that shift (on [DATE]) and had to have staples for a laceration to his scalp. V2 said they implemented a one-inch floor mat to be placed next to R1's bed after his second fall that day. V2 said R1 returned from the hospital and fell again about an hour later. V2 R1 was found over by his roommate's bed. V2 said R1 had dementia and was confused at his baseline and was definitely a fall risk. V2 said R1 was again sent to the hospital. V2 said R1 sustained a cervical fracture, started having swallowing difficulties, and expired in the hospital. On [DATE] at 11:02 AM, V7, LPN, said R1 kept trying to get out of bed. R1 was very agitated that morning ([DATE]), then he slid out of bed; it was witnessed. V7 said he didn't have any floor mats. V7 said R1 had a skin tear on his arm as a result. V7 said R1 was a fall risk, he was confused and he had dementia. V7 said R1 did not go to the hospital after that fall.On [DATE] at 12:03 PM, V3, Assistant DON, said R1 was a fall risk. V3 said they implemented fall mats after one of R1's falls. V3 said if he had a patient who had fallen twice the previous shift, he would do more frequent checks and may want to have them at the nurse's station to keep a better eye on them. V3 said they would need to be monitored more closely.On [DATE] at 9:31 AM, V5, LPN, said they use mats and low beds for residents who might roll out of bed and those who are at high risk of falling to prevent injury. V5 said they are implemented whenever the resident is in their bed.R1's Progress Notes dated [DATE] at 11:59 PM show R1 is aggravated and attempting to crawl out of bed, then on [DATE] at 1:02 PM, Progress Notes show R1 fell and had a new skin tear. On [DATE] at 1:05 PM, R1's Progress Notes show R1 has had a change in his mobility described as being unable to walk independently. R1's Progress notes dated [DATE] at 7:59 PM show R1 was found on the floor bleeding from his scalp. R1 was sent to the hospital. R1's Progress Notes was dated [DATE] at 1:13 AM show R1 returned to the facility with the following diagnoses: scalp laceration with three staples to his left forehead, skin tear of left upper arm, fall from standing, blunt head injury, and contusion of right knee. R1's Progress Notes written by V4 at [DATE] at 2:49 AM show 911 was called due to a fall.R1's most recent care plan provided by the facility shows R1 was admitted to the facility on [DATE]. His diagnoses include, but are not limited to, dementia, insomnia, hearing loss, adjustment disorder with depressed mood, major depressive disorder, and repeated falls. R1's care plan initiated [DATE] shows R1 has a potential to fall and is at risk of injury from falls. A one-inch floor mat was to be placed beside R1's bed beginning [DATE].R1's hospital records written by V14, Physician (Hospitalist), dated [DATE] at 6:36 PM show R1 was admitted after three falls within 24 hours resulting in closed fractures of the fifth and seventh cervical vertebrae, nasal bone and septal fractures, and a tooth fracture confirmed by CT imaging of the head, face, and cervical spine. R1 also sustained a scalp laceration and blunt head trauma. During hospitalization, new swallowing issues and quadriparesis (weakening in all four limbs) were reported prompting a transition to comfort-based care. Comfort only measures were initiated.R1's Certificate of Death Worksheet shows R1 died [DATE] as an impatient at a local hospital. The cause(s) of R1's death is respiratory failure due to aspiration pneumonitis due to (or as a consequence of) quadriparesis due to multiple vertebral fractures due to (or as a consequence of falls).

Based on observation, interview, and record review the facility failed to ensure food was used or discarded by the use by date, failed to sanitize food preparation equipment, failed to take/record food temperatures prior to serving it, and failed to ensure individuals in the kitchen wear hair nets. These failures have the potential to affect all 81 residents residing in the facility.The findings include: The facility's CMS-671 dated 1/5/26 show the facility census is 81.On 1/5/26 during the kitchen tour beginning at 8:55 AM, the refrigerator in the facility kitchen had a container of apple sauce and a container of sliced apples both dated 12/3-12/9, a container of shredded cheddar cheese with a use by date of 1/3, and half a ham dated 12/28-1/3. V4, Dietary Manager, said the foods should have been used by the date on the container as they write the use by date on the containers. V4 said they are having Caribbean pork roast today as they had to swap it with yesterday's meal because they did not have the roasts yesterday.On 1/5/26 at 9:25 AM and throughout the kitchen tour, V9, Cook, did not wear a hair net, but instead wore a winter type stocking hat.On 1/5/26 at 10:40 AM, V9 took his dirty blender/lid to the three-compartment sink. After washing and rinsing the blender/lid, V9 used the sanitizer liquid hose and rinsed the blender/lid with the solution. There was no solution in the sanitizer compartment of the three-compartment sink, therefore, the blender/lid was not submerged in sanitizer for at least a minute. V9 shook the blender/lid, but did not air dry the blender/lid. After preparing pureed green beans in the blender, V9 poured them into a metal pan. As V9 was pouring the pureed green beans, solution was dripping off the bottom of the blender onto the counter.On 1/5/26 at 11:06 AM, V9 began plating the residents' meals and sending them to the units for the residents to eat.On 1/5/26 at 11:20 AM, the food temperature log (printed 12/31/25) was reviewed for the lunch meal of 1/5/26 and it had no temperatures recorded.On 1/5/26 at 11:26 AM, V9 said he forgot to record the food temperatures.On 1/5/26 at 11:30 AM, V10, Cook, said the cook should temp all foods when they are done cooking and record them in the temperature log, including all foods to be served, even cold foods.On 1/6/26 at 12:18 PM, V4 said anyone and everyone who comes in the kitchen needs to wear a hair net. V4 said she does not know the policy regarding hats and was not sure if they are ok to use instead of a hairnet or not. V4 said dishes/food prep equipment needs to be submerged in the sanitizer solution for at least a minute, (after washing and rinsing) then taken out to air dry, even if it's something that is needed quickly, (you) still have to wait for it to air dry, otherwise it will take away the effect of the sanitizer.The facility's Hair Restraints/Jewelry/Nail Polish Policy (source revised 5/20/14) shows hairnets will be worn at all times in the kitchen.The facility's Storage of Refrigerated Foods Policy (source revised 5/20/14) shows food in the refrigerator is covered, labeled and dated with a use by date.The facility's Preparation/Cooking Policy (source revised 5/20/14) shows the temperature of the food is taken and recorded at end of cooking.The facility's Manual Sanitizing in Three Compartment Sink Policy (source revised 5/20/14) shows a sink with three compartments is used for manually washing, rinsing and sanitizing utensils and equipment that can be submerged. Manufacturer's instructions on the wall poster above the three-compartment sink are followed. After washing and rinsing, equipment is sanitized in the third sink by immersion in chemical sanitizing solution. The Quaternary Sanitizer poster above the three-compartment sink in the facility's kitchen (not dated) shows all surfaces of equipment, ware, or utensils are to be exposed to the sanitizing solution for a period of not less than one minute and then air dried.The facility's Week 1 menu for Fall/Winter 25/26 (printed 1/5/26) shows Caribbean Pork Roast was originally scheduled to be served for the lunch meal on 1/4/26 and Creamed Turkey was originally scheduled to be served for the lunch meal on 1/5/26.

Based on interview and record review, the facility failed to ensure employees were provided with education and offered the COVID-19 vaccine and failed to document their COVID-19 vaccination status. This failure has the potential to affect all 81 residents residing in the facility.The findings include:The facility's CMS-671 dated 1/5/26 show the facility census is 81.On 1/7/26 at 9:34 AM, V14, Infection Prevention Nurse, said they do not offer the COVID-19 vaccine to employees and do not keep a record of which employees have or have not received the COVID-19 vaccine(s).On 1/7/26 at 10:28 AM, V23, Restorative Certified Nursing Assistant (CNA), said she has worked in the facility for 13 years. V23 said the facility is not currently offering COVID-19 vaccines to employees. V23 said no one has asked her about her current COVID-19 vaccine status and she has not been given any education regarding the current COVID-19 vaccine.On 1/7/26 at 2:20 PM, V21, Registered Nurse (RN), said no one has designated areas they work; they go all over the building.On 1/7/26 at 2:22 PM, V11, Licensed Practical Nurse (LPN), said she works wherever she is assigned. It could be anywhere in the building.The facility's Annual Influenza & COVID-19 Vaccines for Employees Policy (reviewed 10/25) shows employees will be offered CDC recommended vaccines annually, including COVID-19. Staff will be provided information and education regarding the vaccine. If an employee declines to receive a CDC recommended vaccine, a declination form must be filled out and put in the employee record. A list of employees that received a vaccine will be kept by the facility infection prevention nurse designee. CMS regulations require that staff receive education on COVID-19 and are offered the vaccine. Staff will complete the COVID-19 staff education form as proof that the education was provided.

Based on observation, interview and record review the facility failed to provide a resident centered activity program with meaningful activities for residents with diagnoses of dementia. This applies to 4 of 18 residents (R92, R16, R35, R34) reviewed for activities in the sample of 18. The findings include:1. R92's EMR (Electronic Medical Record) shows she has a diagnosis of Alzheimer's Disease with Late Onset. R92 was admitted to the facility on [DATE] from another long-term care facility. On1/5/26 at 8:45AM R92 was in her room sitting next to her bed and then wheeled over to her roommate and was talking very sweetly to her roommate, who was also in bed. At 9:00AM V19 Certified Nursing Assistant (CNA) came to R92's room, brushed her hair and took her to the dining room saying to R92, It's almost lunch time. R92 was placed at a table in the dining room along with about 12 other residents. The television was on, playing an 1990's Western Drama. Most of the residents were asleep. V17 and V18 (Activity Aids) were seated a table in the corner of the room with one resident in front of them who was coloring. V17 stated that she was still in training as an Activity Aid. At 10:20 AM R92 propelled her wheelchair to Surveyor who was walking through the dining room and ask how long she had to sit there. R92 stated she wanted to go back to her room. R92 was able to propel her own wheelchair and began to follow Surveyor down the hall. R92 continued, this is torture for a lot of people. Making us sit out there like that. Surveyor asked R92 what she wanted to do. R92 stated, Oh, I don't know, watch TV or something in my room. Surveyor asked about the TV in the dining room and R92 wrinkled her nose and stated, No, I don't like that. Surveyor looked for staff to assist resident but unable to find anyone at that moment. R92 stated that she feels sorry for all the people that just have to sit there in that room with no water. 10:30AM V19 came of the supply room and down the hall to Surveyor and R92. V19 stated that R92 is a fall risk and cannot go back to her room. V19 took R92 to the Nurse's station and gave her a glass of water then left her again in the dining room with no activities. 10:35AM V18 came upstairs and took R92 to a table in the corner. She gave her markers and a paper to color. Surveyor sat down in a chair across the room to observe other residents and R92 waved at Surveyor as she tried to open the markers and color the page. At 12:15PM R92 was again propelling herself down hallway. She was very confused. Talking about the police and the lawyers. Not sure what she wants to do. She knew her room number and was looking for it. Still no activities in the dining room. Same show still playing on the television. R92 stated she needs help with the law stuff. R92 states she doesn't want to be taken down there to sit for 5-6 hours with no water or anything. R92 states she just can't do it. Another CNA arrived and offered R92 a cup of coffee and R92 was very agreeable to that. R92 was taken to a table with a talkative resident and drank a full cup of coffee. Then made her way over to Surveyor and stated she wanted to sit next to Surveyor for a while. Sat and talked until V19 assisted R92 to the restroom. On 1/6/2026 at 10:00 AM R92 was brought to the dining room and placed in front of the television. V19 stated, So you are not alone in your room R92 turned herself around and sat at the table with her back to the TV. There were no activities going on. There were no activity staff interacting with the residents in the dining room. R92's Care Plan dated 12/31/25 does not address R92's activity interests or abilities. R16's EMR shows that she has a diagnosis of Unspecified Dementia. 2. On 1/5/26 at 10:46 AM R16 was sitting in her wheelchair in the dining room holding a baby doll. R16 had been holding the doll all morning and at times holds the baby out and kisses the baby doll on the cheek and then holds it to her chest again. Another resident wheeled up to R16 and took the baby doll from her saying, I gave you one of your own, this one is mine. Resident looking concerned and watched the other resident as she wheeled away with the baby doll. No staff around and no one noticed that baby doll was taken from the R16. Another resident was placed next to R16 and she stated to this resident- they do to you what they do to me, Just set you out here. Real high class. R16 picked up a small activity blanket that was stuffed in the side of her wheelchair. R16 reached down placed the blanket on the floor and stated, someone will pick that up- I don't know who. R16 continued to sit there, doing nothing. No activities going on. Same television show on the TV all morning and no residents are watching it. At 11:00AM V18 came through the dining room and picked up a stuffed animal and a pillow off the table that were not in use and the small blanket that R16 had placed on the floor- all items were taken to another room and put away. R16 was turned around to face the table and R92 was moved away from her coloring to another table to prepare for lunch. R16's Care Plan states, (R16) is a resident on the second floor, she likes to sit and chit chat with other residents. She likes to go outside. She loves dogs and has one of her own, she likes to play card games like poker and rummy. 3. R35's EMR shows that she has a diagnosis of Dementia. On 1/5/26 and 1/6/26 R35 was walking in the hall between the dining room and her room. R35 would sit in the dining room for a few minutes in a chair and then get up and walk back to her room. Over and over again. Surveyor approached R35 on 1/5/26 at 12:30PM and R35 stated she was hungry. R35 stated, Will you show me? R35 took Surveyor's hand and walked to the dining room with Surveyor. Surveyor approached the nurses who stated R35 already had lunch but offered R35 some cookies and placed her in front of the TV with the same show that had been playing all day. R35 sat in the chair, ate her cookies and then walked back to her room. No staff tried to engage R35 in any activities. R35's care plan dated 8/13/24 states, (R35) is a resident on the second-floor unit. She prefers to structure her own leisure time. (R35) speaks mainly Spanish with minimal English. (R35) enjoys being around others but also spends time resting in her room. She enjoys doing arts and crafts, listening to music, enjoys watching bowling and is catholic faith. 4. R34's EMR shows she has a diagnosis of Dementia. In the morning hours of 1/5/26 and 1/6/26 R34 was seated in her wheelchair in the dining room at a table with her back to the television. R34 was not engaged in any activity. R34 was not able to see the television as her back was facing the TV. No staff were engaging with R34. Most of the time R34 sat at the table, asleep. R34's care plan date 8/13/24 states, (R34) is here for LTC (Long term care) and will attend meaningful activities, watching tv, listening to music and being outside when the weather is nice. (R34) also enjoys walking the unit, visiting other residents. Staff will encourage participation as tolerated. On 1/6/26 at 12:56PM V12 (Activity Director) stated, Second floor is supposed to be like first floor. No communal activities at all due to influenza outbreak. Second floor is harder to keep them in their rooms. I tell my girls to stay focused on one-on-one activities based on (V1's- Administrator's) directions. They can Color, do sudoku, crafts- nails, we have a toy kitten - we are not using right now due to influenza, baby dolls, activity pillow and blankets. They are supposed to focus on one resident and then move on to another resident. Try to get them to do things that the residents like to do. They should be moving from resident to resident. We don't have remotes for the TV. The nurses have the remotes. The girls can ask for the remote to change the channel. The activity calendar is the same on both floors. Chair yoga on the second floor - no one really does it. Too many of them are in Broda chairs and can't. We can't do BINGO because it is a group activity. Second floor we make things a little easier than first floor. I saw they were all sitting in the dining room and I asked (V1) and he told me we should still treat it like one-on-one activities. The activity calendar for January shows activities for 1/5/26 9:00AM Chair Yoga 9:30AM Weather and Coffee 10:30AM Name that Tune 1:00PM Bingo 2:00PM One on Ones, 1/6/26 9:00AM Stretch and Flex 9:30 AM Current Events 10:30AM Parachute Games 1:00PM Jeopardy 2:00PM Heart to Heart Visits - None of these activities were observed taking place on 1/5/26 and 1/6/26.

Based on observation, interview, and record review the facility failed to ensure staff removed personal protective equipment (PPE) when exiting an isolation room and failed to securely wear a N95 mask by not placing both loops around their head. The facility failed to ensure staff washed their hands and wore the required PPE when entering an isolation room. This applies to 4 of 18 residents (R39, R74, R2 and R41) reviewed for infection control in the sample of 18. The findings include:1. R39's Order Summary Report printed on 01/06/26 showed an order for contact and droplet isolation for influenza. On 1/5/26 at 9:19 AM, hanging on the outside of R39's door was a contact and droplet isolation sign. The signs indicated to remove PPE before exiting the room. On 01/05/2026 at 9:19 AM, V11 (Licensed Practical Nurse - LPN) entered R39's room with the required PPE. V11 had on a N95 mask. There was no surgical mask over the top of the N95 mask. The N95 mask was not secure on V11's face as the top loop used to secure the mask was not in use. V11 administered R39 their medications. V11 exited the room by removing her isolation gown and gloves. V11did not remove the face shield or N95 mask when exiting the room. R74's Order Summary Report printed in 01/06/26 indicated R74 was not on isolation. On 01/05/2026 at 9:41 AM, V11 entered R74's room wearing the same face shield and N95 mask that was worn in R39's isolation room. V11 administered R74 their medications. On 01/07/2026 at 8:12 AM, V7 (LPN) said when exiting an isolation room all PPE should be removed as it is considered contaminated. V7 added that both loops of a N95 should be used to ensure it is secured correctly. The facility's Donning and Doffing of PPE sign showed when exiting an isolation room the face shield and mask are considered contaminated and should be removed. 2. On 1/5/2026 11:50 AM, R41 was in his room. A door sign was posted in R41's room-droplet and contact precaution. Droplet precaution-perform hand hygiene before entering and prior to exiting room. Eyes, nose and mouth should be fully covered before entering the room. Remove face protection before exiting the room. Contact precaution- perform hand hygiene before entering and prior to exiting room. Put on gloves, gown before room entry. R41's test date of 12/30/25 confirmed R41 was positive for Influenza A. On 1/5/26 during a lunch service-11:20 AM, V13 (Activity Aide) entered R41's room with R41's lunch tray. V13 was only wearing a mask, no gown and no face shield. V13 did not perform any hand hygiene when entering and exiting R41'room. V13 then proceeded to get another lunch tray and delivered to R2 who was in a non-isolation room. R2 was alert and said she does not have the flu. At 12 PM, V14 infection Control Nurse said the facility was on flu outbreak. R41 was confirmed positive for the flu. R2 did not have the flu at this time. All staff entering the isolation room including R41's room should wear mask preferably N95, face shield, gown, staff should be performing hand hygiene-these are all preventative measures to prevent the spread of infection particularly the influenza virus since the facility was on flu outbreak.

Based on interview and record review the facility failed to ensure a resident had a PASARR Screening (Preadmission Screening and Resident Review) done after his initial PASARR Screening gave approval for only a 60-day admission to a nursing facility. This applies to 1 of 4 residents (R4) reviewed for PASARR Screenings in the sample of 18.The findings include: R4's EMR (Electronic Medical Record) shows that he was admitted to the facility on [DATE] from a Rehabilitation Hospital with diagnoses including Anoxic Brain Injury and Bipolar Disorder. R4's PASARR Screening dated 11/29/23 states, PASARR Level 1 Determination: Convalescence Categorical and Approval Period: 60 days. This same document also states, Your PASRR Level1 screening is complete. Your level 1 screen shows you may have a serious mental illness or intellectual/developmental disability (IDD). You meet criteria for Convalescent Care, and you may stay up to 60 calendar days in nursing facility without further PASRR assessment as long as you also require the level of services provided by a nursing facility. On 1/6/2026 at 3:14 PM V15 (Social Service Director) stated, So our corporate office was doing them initially and then social services was supposed to follow up on the ones that had a 60-day limit on them. Whoever was in Social Services at that time didn't do that. I have only been here since April, so I didn't know it needed to be done. I am going to go run it now.

Based on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter drainage bag was kept off the floor for 1 of 2 residents (R13) reviewed for indwelling urinary catheters in the sample of 18.The findings include:R13's Care Plan with a review date of 01/05/26 showed R13 had an indwelling urinary catheter and had a history of a urinary tract infection.On 01/05/26 at 8:58 AM, R13 was in bed. R13's indwelling urinary drainage bag was on the side of R13's bed. The bottom portion of the drainage bag was resting on the floor.On 01/06/26 at 8:38 AM, R13 was in bed. R13's indwelling urinary drainage bag was not hanging from anything and was resting flat on the floor. R13's bedside table wheels we running over the drainage bag.On 01/06/26 at 11:04 AM, V5 (Certified Nursing Assistant) said staff provide all indwelling urinary catheter care/management for R13. V5 said a drainage bag should not touch the floor to prevent contamination/infection.The facility's Indwelling Catheter Care and Maintenance policy with a review date of 03/2025 showed to keep the drainage bag off the floor.

Based on observation, interview, and record review the facility failed to ensure a resident received fortified food for 1 of 5 residents (R64) reviewed for nutrition in the sample of 18.The findings include:R64's Physician Order Summary printed on 01/07/26 showed R64 was to get fortified food three times a day for poor oral intake. R64 was to receive super cereal at breakfast and fortified mashed potatoes at lunch and dinner. On 01/05/2026 at 11:47 AM, R64 was in his room. Sitting on the bedside table was a meal tray with a lid on top of the plate. R64 said he was getting ready to eat. R64 lifted the lid off his tray and there were no potatoes on his tray. R64 said he was supposed to get potatoes but did not get any. R64 added that not getting potatoes happens from time to time.On 01/06/2026 at 11:55 AM, V6 (Dietitian) said fortified mashed potatoes are used to help manage a resident's weight. Fortified potatoes are more than just regular potatoes. They are made with whole milk and protein powder. V6 added that R64 should have received fortified mashed potatoes.On 01/06/2026 at 12:59 PM, V4 (Dietary Manager) said the kitchen knows when to serve fortified foods because it is listed on the resident's meal ticket. V4 said the meal tickets will read fortified foods. V4 looked at R64's meal ticket for lunch on 1/5/25 and confirmed it did not indicate fortified foods. V4 said she helped R64 fill out his meal ticket for lunch on 1/5/26 and mashed potatoes and baked potato were both circled. V4 added R64 should have received mashed potatoes and a baked potato.R64's Dietary Profile with an effective date of 12/23/25 indicated R64 was to receive nutritional supplement of fortified foods and that he liked potatoes. R64's Care Plan with an initiated date of 4/18/25 indicated R64 was at risk for malnutrition. Listed under interventions was to provide fortified foods three times a day with fortified mashed potatoes being served at lunch and dinner.

Based on interview and record review the facility failed to ensure a blood pressure medication was administered according to order parameters for 10 of 31 days resulting in a significant medication error because of the frequency of the error. This applies to 1 of 18 residents (R24) reviewed for pharmacy services in the sample of 18.The findings include:R24's health care provider note dated 12/05/25 showed R24 had liver failure and was not a transplant candidate. The same note showed R24 had complications including hepatorenal syndrome, metabolic encephalopathy, and portal hypertension. R24's Order Summary Report printed on 01/07/26 showed an order for midodrine (a medication that increases blood pressure) to be given three times a day for portal hypertension. The order had a parameter to hold (not give) the medication if the systolic blood pressure was greater then 120 millimeters of mercury (mm Hg). R24's December 2025 Medication Administration Record (MAR) showed R24's systolic blood pressure was above 120 mm Hg and midodrine was checked off as given on the following days: 12/3/25, 12/4/25, 12/5/25, 12/6/25, 12/10/25, 12/13/25, 12/15/25, 12/18/25, 12/22/25, and 12/26/25 (10 out of 31 days).On 01/07/26 at 8:40 AM, V7 (Licensed Practical Nurse), who administered the doses on 12/3/25, 12/10/25, 12/13/25, and 12/15/25, looked at R24's MAR and said a check mark on the MAR indicated the medication was given. On 01/07/26 at 8:45 AM, V2 (Director of Nursing) said the expectation would be for nurses to follow the parameters when administering medication. The facility's Medication Administration - General Guidelines dated November 2021 showed medications are administered in accordance with written orders of the prescriber.

Based on observation, interview and record review the facility failed to ensure insulin pens were dated when opened to 3 of 5 residents (R2, R7, R51) reviewed for medication storage in the sample of 18.The findings include:On 1/6/26 at 9AM, during the medication storage task, this surveyor and V11 (Licensed Practical Nurse-LPN) checked the long hall first floor medication cart. There were insulin pens that were opened but not dated with open date:R2's Kwik pen of Lantus 20 units given in the morning.R7's Kwik Pen of Lantus 20 units at bedtime.R51's Glargine Kwik Pen 30 units in the morning. R51's Kwik pen of Humalog given per sliding scale. V11 (LPN) said all insulin pens should be dated when opened. These insulin pens were only good for 28 days, now we don't know when to discard them or are these insulins still effective since we don't know when they were opened. On 1/7/26 at 10:54 AM, V2 (Director of Nursing) said all insulin pens should be dated when opened, since they are only good for 28 days after date of opening. V2 said education had started to Nurses regarding this issue.The Facility Policy on Insulin Pen Usage dated 8/2025 documents, 2. Insulin pen should be dated with the date of opening and expiration day. The expiration day will be 28 days after opening.

Based on interview and record review, the facility failed to ensure residents were assessed and offered pneumococcal immunizations upon admission for 2 of 5 residents (R16 and R41) reviewed for vaccinations in the sample of 18.The findings include: On 1/6/26 at 1:09 PM R16 and R41's vaccine records showed no information regarding their respective pneumococcal vaccine status.R16's admission Record dated 1/7/26 shows R16 was admitted to the facility on [DATE].R41's admission Record dated 1/7/26 shows R41 was admitted to the facility on [DATE].On 1/7/26 at 9:34 AM, V14, Infection Prevention Nurse, said all residents are screened on admission for pneumococcal vaccine status. If the resident is due for a pneumococcal vaccine, she can order it and administer it in the facility. V14 said she will continue to offer the pneumococcal vaccine annually, as applicable to all residents.On 1/7/26 at 11:48 AM, V14 said R16 and R41 were not offered the pneumococcal vaccine prior to today.The facility's Pneumovax Vaccine Policy (revised 7/2017) shows all guests will be offered the pneumococcal vaccination at the time of his/her move in.

Based on observation, interview, and record review, the facility failed to ensure their nurse staffing was posted on a daily basis. This failure has the potential to affect all 81 residents residing in the facility.The findings include:The facility's CMS-671 dated 1/5/26 show the facility census is 81.On 1/6/26 at 9:19 AM, V22, Scheduler, said V3, the Assistant Director of Nursing (ADON), posts the daily staffing on the bulletin board.On1/6/26 at 10:09 AM, the nurse staffing posted on the facility's bulletin board was dated 1/2/26.The facility's Posting of Staffing Report Policy (reviewed 2/25) shows the facility will post its Staffing Report information in a manner that is consistent with state and federal laws. Staff will complete/update the daily Staffing Report on a daily basis. This form will be posted in a prominent place that is readily accessible to resident and visitors with the daily census and date displayed on the form.

Based on interview and record review the facility failed to assess, intervene and implement treatments in a timely manner for a resident (R2) found to have a new injury/bruising to her left shoulder which resulted in a delay in the diagnosis of and treatment of R2's left shoulder dislocation. This failure applies to 1 of 5 residents (R2) reviewed for the necessary care and services in the sample of 5.The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. The report showed R2 was sent to a local hospital on 9/6/25 for an evaluation of her shoulder dislocation. The report showed hospital recommended surgical intervention to reposition the shoulder; however, V8 (Power of Attorney/POA for R2) declined surgical intervention. R2's hospital records dated 9/6/25 showed a repeat X-ray of R2's left shoulder was performed which showed R2's left shoulder was dislocated with a possible glenoid (shoulder bone) fracture. R2 was discharged back to the facility on 9/6/25, on hospice, with orders for R2's left arm to be kept in a sling for comfort and conservative management of R2's shoulder dislocation. R2's current care plan showed R2 was severely cognitively impaired and primarily nonverbal due to her diagnosis of Alzheimer's disease. R2 was unable to verbalize her needs. R2 was dependent on staff for all cares. R2 was unable to move on her own. R2 required two staff members to safely reposition her in bed. R2 was on hospice.R2's progress note dated 9/5/25 showed at 4:20 AM, facility staff discovered new bruising to R2's left shoulder. The note showed R2's hospice agency was notified of the new bruise on 9/5/25. The note showed no documentation facility staffed notified R2's physician or nurse practitioner of the R2's new bruising. The note showed no documentation that facility staff attempted to obtain a physician order to X-ray R2's shoulder. A physician order dated 9/5/25 at 1:23 PM showed an X-ray of R2's left shoulder was ordered/obtained by V14 (R2's Hospice Nurse) after R2 was assessed by V14. R2's progress notes dated 9/5/25 from 4:20 AM to 9/6/25 at 9:30 PM were reviewed and showed no documentation of facility staff attempting to notify R2's physician or nurse practitioner of the new bruising to R2's shoulder. The progress notes showed no documentation of staff reassessing R2's left shoulder bruising at any time after the bruising was found. The progress notes showed no documentation of staff attempting to contact the facility's mobile X-ray company to ensure the X-ray of R2's left shoulder was completed as soon as possible. R2's progress note dated 9/6/25 at 10:21 AM showed an X-ray was completed in the facility of R2's left shoulder; over 24 hours after the new bruising/injury to R2's left arm was found by staff. R2's progress note dated 9/6/25 at 9:40 PM showed the facility was notified, by R2's hospice agency, of R2's X-ray results which showed her left shoulder was dislocated. R2 was sent to a local hospital for an evaluation due to her injury.On 9/10/25 at 10:48 AM, V10 RN stated she was notified of new bruising to R2's left shoulder by V9 CNA on 9/5/25. V10 stated she immediately went to assess R2 and found R2's left upper arm to be purple in color and warm to the touch. V10 stated she did not complete a range of motion assessment on R2's left arm. V10 stated she notified R2's hospice agency of R2's new bruise. V10 stated she did not notify R2's physician or nurse practitioner of the changes noted to R2's shoulder. V10 stated, I notified hospice. They were coming in to see her later that day (9/5/25). I just assumed hospice would follow up on her shoulder and get an X-ray if she needed it.On 9/10/25 at 11:15 AM, V3 Assistant Director of Nursing (ADON) stated he was notified of the new bruising to R2's left shoulder on the morning of 9/5/25. V3 stated when he observed R2's shoulder on that morning, he noted a new. large bruise to R2's left upper arm. V3 stated he did not contact R2's physician or nurse practitioner to inform them of the bruise and/or obtain an order for an X-ray because we were just kind of waiting on direction from her hospice. V3 stated facility staff are to notify a resident's physician or nurse practitioner immediately with any changes in resident condition. When asked why the facility did not order any X-ray of R2's shoulder themselves and why it took over 24 hours for R2's X-ray to be completed, V3 stated, I believe we could have ordered the X-ray ourselves if we had contacted the physician. I don't know how the X-ray was ordered by hospice. I don't know why it took so long to get it.On 9/10/25 at 11:19 AM, V14 (R2's Hospice Nurse) stated she was notified of the new bruising to R2's shoulder on 9/5/25. V14 came to the facility on 9/5/25 to assess R2. V14 stated, I found bruising to (R2's) left lateral arm and posterior shoulder area. (R2) didn't appear to be in pain. It was her bath day. My hospice CNA went to bathe her and called me immediately. She said that something was wrong with (R2's) shoulder because she said (R2's) shoulder was floppy and seemed unstable. That is when I ordered the X-ray. When asked if she ordered R2's X-ray to be done STAT (immediately), V14 stated she didn't know if it had been ordered STAT. V14 stated, We (hospice and the facility) should have collaborated better and ordered the X-ray sooner. V14 stated the facility could have contacted V15 (R2's Nurse Practitioner) directly when they found the new bruising to R2's shoulder to obtain an order for an X-ray. On 9/10/25 at 11:40 AM, V15 (R2's Nurse Practitioner/NP) stated she never received a call from the facility on 9/5/25 or 9/6/25 informing her of and/or updating her on the new bruising found to R2's left shoulder. V15 stated, The first I learned of the injury was on 9/5/25 when (V14 R2's Hospice Nurse) called me and got an order for the X-ray. V15 stated either V15 or R2's physician should have been notified immediately by the facility when the new bruising to R2's shoulder was found by facility staff. On 9/10/25 at 1:00 PM, V2 Director of Nursing (DON) stated she examined R2's left shoulder on 9/5/25 after she was notified of the new bruising. V2 stated she noted a large bruise to R2's left upper arm. V2 stated she did not complete a full assessment of R2's left arm at that time. V2 stated she did not contact R2's physician or NP to notify them of R2's new bruising or attempt to obtain an X-ray order. V2 stated, We were just waiting to see what hospice would say. The facility is responsible for all patient care and general treatment even with hospice residents. Hospice is kind of a second set of helping hands. We should have called (V15 R2's NP) ourselves to inform her of the bruising and to get the X-ray order. I am not sure why we didn't. V2 DON stated facility staff are to immediately report any changes in a resident's condition to the resident's physician or NP to ensure treatments are implemented as soon as possible.The facility's Responding to an Acute Change of Condition policy dated August 2025 showed, Residents who experience an acute change in condition will have their condition monitored, the attending physician notified, and the responsible party informed when the condition changes and as follow up actions occur. GOAL: 1. To ensure the resident changes are identified, communicated, and addressed timely. 2. To ensure that the attending physician of a resident is notified of changes in condition. The licensed nurse will evaluate the resident to determine the status of the condition change. If the resident is not presenting with a medical emergency but presents with an acute condition that requires prompt care and treatment, the licensed nurse will obtain a baseline assessment. and then contact the physician for further follow up and orders. The medical record should reflect the nurse's observation and assessments, physician notification, and follow-through, including updated plan of care.

Based on observation, interview and record review the facility failed to care for a resident (R2) in a safe manner which resulted in R2 sustaining a left shoulder dislocation. The facility failed to ensure a resident (R2) was safely repositioned in bed, as directed per the resident's care plan. These failures apply to 1 of 5 residents (R2) reviewed for resident safety and supervision in the sample of 5.The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. The report showed R2 was sent to a local hospital on 9/6/25 for an evaluation of her shoulder dislocation. The report showed hospital recommended surgical intervention to reposition the shoulder; however, V8 (Power of Attorney/POA for R2) declined surgical intervention. R2's hospital records dated 9/6/25 showed a repeat X-ray of R2's left shoulder was performed which showed R2's left shoulder was dislocated with a possible glenoid (shoulder bone) fracture. The X-ray results showed no findings of osteopenia or osteoporosis. R2 was discharged back to the facility on 9/6/25. R2's current care plan showed R2 was severely cognitively impaired and primarily nonverbal due to her diagnosis of Alzheimer's disease. R2 was unable to verbalize her needs. R2 was dependent on staff for all cares. R2 was unable to move on her own. R2 required two staff members to safely reposition her in bed. R2 was on hospice related to her diagnosis of Alzheimer's disease. R2's progress note dated 9/5/25 showed at 4:20 AM, facility staff discovered new bruising to R2's left shoulder. The note showed the area of bruising to R2's left shoulder was warm to the touch. R2 was noted to be sleeping, looks comfortable. The note showed R2's hospice agency was notified of the new bruise on 9/5/25. A physician order dated 9/5/25 at 1:23 PM showed an X-ray of R2's left shoulder was ordered. R2's progress note dated 9/6/25 at 10:21 AM showed an X-ray was completed in the facility of R2's left shoulder. R2's progress note dated 9/6/25 at 9:40 PM showed the facility was notified, by R2's hospice agency, of R2's X-ray results which showed her left shoulder was dislocated. R2 was sent to a local hospital for an evaluation due to her injury.On 9/10/25 at 8:30 AM, R2 was asleep in a high-back wheelchair on the facility's memory care unit. A sling was noted around R2's left arm. The sling held her arm in place, close to R2's chest. On 9/10/25 at 11:04 AM, V11 Certified Nursing Assistant (CNA) stated she provided cares to R2 from 2 PM-10 PM on 9/4/25. V11 stated R2 had no bruising to her left shoulder during that time. V11 stated R2 did not have any falls or sustain any injuries during her shift on 9/4/25.On 9/10/25 at 10:28 AM, V9 CNA stated he provided cares to R2 on 9/4/25, from 10 PM - 6 AM. V9 stated from 10 PM on 9/4/25 to approximately 3 AM on 9/5/25, he repositioned R2 in bed and provided her with incontinence care, by himself, two different times. V9 stated R2 was nonverbal and totally dependent on staff for cares but that he always provides these cares, including bed mobility and repositioning, to R2 by himself. V9 stated R2 was dressed in a sweater when he provided cares to R2 from 10 PM-3AM so he was not able to visualize her left shoulder during that time. V9 stated around 4 AM on 9/5/25, he again provided cares to R2, by himself, which included repositioning her in bed, incontinence care, and getting her dressed. R2 stated, When I took her sweater off, I noticed her (left) shoulder was bruised and swollen. It looked abnormal. V9 stated R2 did not appear to be in pain and was not wincing or crying with movement of her left arm. V9 stated he immediately reported the new bruise to V10 Registered Nurse (RN). V9 stated R2 had no falls or injuries while being cared by V9. V9 stated, I don't know what happened to her. I just assumed something happened to her when someone was moving her or removing her shirt. On 9/10/25 at 10:48 AM, V10 RN stated she was notified of the new bruising to R2's left shoulder by V9 CNA on 9/5/25. V10 she immediately went to assess R2 and found R2's left upper arm to be purple in color and warm to the touch. V10 stated R2 did not appear to be in pain as V10 had administered hospice pain medications to R2 one hour prior. V10 stated she had no idea what caused the injury to R2's arm stating R2 was unable to move her extremities on her own. V10 stated she notified R2's hospice agency of R2's new bruise. V10 stated she did not notify R2's physician, nurse practitioner, or V8 (R2's POA) of the changes noted to R2's shoulder. On 9/10/25 at 11:19 AM, V14 (R2's Hospice Nurse) stated she was notified of the new bruising to R2's shoulder on 9/5/25. V14 came to the facility on 9/5/25 to assess R2. V14 stated, I found bruising to (R2's) left lateral arm and posterior shoulder area. (R2) didn't appear to be in pain. It was her bath day. My hospice CNA went to bathe her and called me immediately. She said that something was wrong with (R2's) shoulder because she said (R2's) shoulder was floppy and seemed unstable. That is when I ordered the X-ray. V14 stated R2 was nonverbal and dependent on staff for cares. V14 stated R2 did not have a diagnosis of osteoporosis or osteopenia. V14 stated she was unsure what caused the injury to R2's shoulder but stated, This is not an injury she could have done to herself. She has no physical behaviors and cannot move on her own. This injury will contribute to her decline.On 9/10/25 at 11:40 AM, V15 (R2's Nurse Practitioner/NP) stated R2 is unable to move on her own. V15 stated R2's left shoulder injury was caused by some sort of trauma or force. This is not an injury that spontaneously happens. V15 stated R2 had no underlying diagnoses of osteopenia or osteoarthritis that she was aware of. On 9/10/25 at 1:00 PM, V2 Director of Nursing (DON) stated R2 was nonverbal and fully dependent on staff for all ADL (activity of daily living) cares. V2 stated staff are to refer to the resident's care plan to verify the level of assistance a resident required for cares. V2 stated if R2's care plan showed R2 required the assistance of two staff to be safely repositioned in bed, then two staff members should be repositioning R2.

Based on interview and record review the facility failed to inform a resident's representative of new a injury/bruise found to a resident's shoulder for 1 of 1 residents (R2) reviewed for a resident change in condition in the sample of 5. The findings include:A facility Incident report dated 9/6/25 showed on 9/5/25 at 4:20 AM, facility staff discovered new bruising to R2's left upper arm. The facility notified R2's hospice agency which subsequently ordered an X-ray of R2's left arm. An X-ray of R2's left arm was performed in the facility which showed R2's left shoulder was dislocated. The report showed R2 was sent to a local hospital on 9/6/25 for an evaluation of her shoulder dislocation. R2's progress note dated 9/5/25 showed at 4:20 AM, facility staff discovered new bruising to R2's left shoulder. The note showed R2's hospice agency was notified of the new bruise on 9/5/25 by facility staff. The note showed no documentation facility staff notified V8 (R2's Power of Attorney/POA) of R2's new bruising. A physician order dated 9/5/25 at 1:23 PM showed an X-ray of R2's left shoulder was ordered/obtained by V14 (R2's Hospice Nurse) after R2 was assessed by V14. R2's progress notes dated 9/5/25 from 4:20 AM to 9/6/25 at 9:30 PM were reviewed and showed no documentation facility staff attempted to notify V8 (R2's POA) of the new bruising found on R2's left shoulder. Progress notes showed V8 was contacted by facility staff about a room change for R2 but not informed of the changes noted to R2's left shoulder. R2's progress note dated 9/6/25 at 9:40 PM showed the facility was notified, by R2's hospice agency, of R2's X-ray results which showed her left shoulder was dislocated. The note showed the hospice agency had notified V8 (R2's POA) of R2's X-ray results. R2 was sent to a local hospital for an evaluation due to her injury.On 9/10/25 at 10:37 AM, V8 (R2's POA) stated he upset because the facility never called him to inform him of the new bruising to R2's shoulder or that an X-ray had been ordered of R2's left shoulder. V8 stated, No one called me on September 5th or 6th to tell me about her shoulder. Someone called me on September 5th to tell me they were moving (R2) to a different room, but they didn't say anything to me about her shoulder. The first I heard anything about it was when someone from hospice called me that night (9/6/25) to tell me her shoulder was dislocated, and they needed to send her to the hospital.On 9/10/25 at 10:48 AM, V10 RN stated she was notified of new bruising to R2's left shoulder by V9 CNA on 9/5/25. V10 she immediately went to assess R2 and found R2's left upper arm to be purple in color and warm to the touch. V10 stated she notified R2's hospice agency of R2's new bruise. V10 stated she did not notify V8 (R2's POA) of the new bruising noted to R2's shoulder. On 9/10/25 at 11:15 AM, V3 Assistant Director of Nursing (ADON) stated he was notified of the new bruising to R2's left shoulder on the morning of 9/5/25. V3 stated when he observed R2's shoulder on that morning, he noted a new. large bruise to R2's left upper arm. V3 stated he did not notify V8 (R2's POA) of the new bruising noted to R2's shoulder. On 9/10/25 at 1:00 PM, V2 Director of Nursing (DON) stated she examined R2's left shoulder on 9/5/25 after she was notified of the new bruising. V2 stated she noted a large bruise to R2's left upper arm. V2 stated she did not contact V8 (R2's POA) to notify him of R2's new bruising. V2 DON stated facility staff are to immediately report any changes in a resident's condition to the resident's POA/representative as soon as possible.The facility's Responding to an Acute Change of Condition policy dated August 2025 showed, Residents who experience an acute change in condition will have their condition monitored, the attending physician notified, and the responsible party informed when the condition changes and as follow up actions occur. GOAL . To ensure that the responsible party is notified of a residents change in condition as soon as practical, and plan of care is updated .

Based on interview and record review the facility failed to put interventions in place after a resident fall to protect the resident from future falls. This failure resulted in R1 falling in his room and sustaining 4 fractured ribs on 5/27/25. This applies to 1 of 3 residents (R1) reviewed for fall interventions in the sample of 7. The findings include: R1's EMR (Electronic Medical Record) dated 5/21/25 states, Resident observed laying on the floor next to his bed on his right side. Resident tried to get self up from his bed and slid to the floor. No injuries noted, no pain or discomfort verbalized or demonstrated . Resident transferred back to bed .R1's Care Plan dated 12/17/24 states, Potential for falls, Resident at risk for injury from falls, history of falls. The intervention UA sent to rule out infection shows a date initiated as 5/23/2025. No other interventions were put in place to prevent R1 from falling after the fall on 5/21/25. An incident report dated 5/29/25 states, On 5/27/25 at approximately 6:40PM the resident was reported to have an unwitnessed fall in the resident's room when attempting to self transfer to the restroom. This same report states, On 5/28/25 the resident was noted to be complaining of mild-moderate pain to the right side. An X-ray was ordered and performed on 5/28/25. X-ray results showed acute appearing right lateral 8-11 rib fractures with displacement and mild soft tissue swelling. NP (Nurse Practitioner) updated with results and order was given to transfer resident to the ED (Emergency Department) for further evaluation and treatment. This report also states, The resident has a BIMS (Basic Interview for Mental Status) of 12 on 12/13/24 (mild cognitive impairment). At the time of the resident's fall, the resident stated he was attempting to walk to his bathroom .R1's Radiology Report dated 5/28/25 states, Acute appearing right rib fractures. R1's Hospital admission Report dated 5/28/25 states, He had a mechanical fall- tripped and fell- about 2 days ago. Hitting his right side chest. He was discovered to have 4 broken ribs 8-11. He was brought to the ED tonight for further evaluation. He is complaining of pain onto his lateral right chest and right back. He is having difficulty breathing .Upon arrival in the ED he was hypoxic at 89% on room air at rest. He was tachypneic. Blood pressure was borderline low. On 7/21/25 at 2:30PM V2 (Director of Nursing) stated, (R1) was more confused than normal on the 21st after his first fall. He was with it and could answer questions but something was just off. The (V6- Nurse Practitioner) ordered a UA (Urinalysis). I didn't talk to any of the family before that. We did the UA and we could have started antibiotics based on that but (V6) waited for the culture. The UA looked bad but some of the doctors wait for the culture- I think we should start the antibiotic and change it if we need to when the culture arrives. The UA was done to try to clear up some of the confusion to prevent falls. On the second fall on the 27th the granddaughter came in right after it and thought he was a little confused and I told her that is how he has been and then we sent him out the next day for the rib fractures. I remember he told me that some guys had come into his room and he had to chase them out and then he had to go to the parking lot to get his truck. V2 did not know of any other interventions put in place after R1's first fall while they were waiting for the results of the UA. On 7/21/25 at 2:45PM V6 stated, If the resident is stable and there is no fever, chills, lethargy etc. then we wait for the culture. If the nurse would have told me there were other symptoms than confusion then I may have started the antibiotic before the culture. I could do a UA and start antibiotics on every resident up there just based on confusion. I like to wait for the culture so we are not giving antibiotics unnecessarily to all these elderly people.R1's Physician's Order Sheet for May 2025 shows that R1 has diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Difficulty Walking, Unsteadiness on Feet, Depression, History of Falling and Metabolic Encephalopathy. This form also shows that R1 was started on antibiotics for a Urinary Tract Infection on 5/25/25. R1's Fall Risk assessment dated [DATE] shows that he is a High Risk for Falls.

Based on interview and record review the facility to ensure a resident with acute delusions was monitored and supervised. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnoses including unspecified psychosis, cerebral infarction, hypertension, adjustment disorder with depressed mood, weakness and unsteadiness on feet. R1's face sheet shows she was admitted to the facility on [DATE] from the hospital. On 6/11/25 at 9:57 AM, R2 (R1's roommate) said on Friday night (6/6/25), R1 woke up screaming after the nurse woke her up to give her medications. R1 was screaming your not my nurse, your not my nurse. R1 also alleged the nurse put something on her wrist and was hurting her (blood pressure cuff). R1 kept yelling and finally a male nurse came in V3 (Assistant Director of Nursing-ADON) and tried to calm her down. R1 was looking out the window yelling to call 911, and yelling out for Michael call 911. R2 said V3 sat in the room for a while until R1 calmed down. She said she did not witness any staff hurt R1. R2 said this was the 2nd night in a row she could not sleep because of R1 was not right during the night. R1 was fine during the day, we would talk, but during the night she was not right, not humane. Maybe she was sundowning, she was confused and a different person during the night. On 6/11/25 at 11:31 AM, V3 (ADON) said he came in to cover the first half of the 3rd shift due to a call off. He said sometime after 12:00 AM, he heard yelling from R1's room. R1 was picking up the blinds saying her husband (V7) was outside. There was a car outside, but it was not her husband. V3 said he encouraged R1 to go back to sleep. R1 was alert and oriented and he thought maybe she was not getting enough rest. On 6/11/25 at 11:11 AM, V4 (RN) said she came in at 2:00 AM to 6:00 AM and split the shift with V3. It was reported, R1 had behaviors of agitation but was re-directable. R1 was awake when she started her shift. R1 was placed at the nurses station so she could be supervised about 2:30-3:00 AM. R1 was pleasant when she was at the nurses station. She saw R1 last around 4:45 AM to 5:00 AM at the front lobby near the nurses station. Around 5:15 AM, V5 (Certified Nursing Assistant-CNA) came up to me if I had seen R1. She told V5 to check all the rooms and the basement and V6 (CNA) checked the rooms upstairs. V4 said she went outside to look for her and did not see her. She went back in the building and V5 and V6 reported they did not locate R1. V4 said she went back outside to the end of the driveway and saw R1 in her wheelchair down the street on the sidewalk. She assisted R1 back to the building, notified the POA and V2 (Director of Nursing). R1 told her she was trying to leave because she did not want to be at the facility anymore and reported an allegation of abuse. She said she was being abused by the RN who runs this place. R1 said it was a male nurse with glasses. R1 was very agitated, tearful and delusional. R1 remained with staff until V7 (R1's husband) showed up to the facility. R1 was placed at the nurses station for monitoring, V5 (CNA) got up to answer a call light and when she returned R1 was gone. We initiated a code gray and R1 was found shortly after with no injury. On 6/11/25 at 11:43 AM, V5 (CNA) said on 6/7/25, R1 was placed at the nurses station between 2:30 AM -3:00 AM. We were checking on her every 15 minutes and kept her at the nurses station. She got up to answer a call light before 5:00 AM and assisted a resident with cares and when she returned back to the nurses station, R1 was not at the nurses station. She asked V4 (RN) if she had seen R1 and then they started searching for R1 in the building. They searched every room, downstairs and did not locate R1. When she looked outside V4 (RN) was with R1 and we got R1 back in the building. R1 was in her wheelchair fully dressed when she left the building. She remained with R1 until V7 (R1's husband) arrived. V5 said R1 was calm whle at the nurses station and did not show any signs of elopement. On 6/11/25 at 12:04 PM, V7 said on 6/7/25, he received a call about 5:30 AM that R1 went outside in her wheelchair down the street from the facility. He said when he arrived to the facility about 15 minutes and R1 was very agitated and wanted to leave the facility. She alleged the nurse had slammed her and they were trying to hurt her roommate. She also alleged they put something on her wrist. V7 said he took R1 home and she has been fine since. Recently they made changes to her antipsychotic medications before her admission and she had a recent urinary tract infection. V7 said when R1 gets sick she gets delusional and maybe with the changes in her psych meds could have caused the delusions. V7 said he was R1 for most of the day on 6/6/25 and left the facility about 7:00 PM and R1 was fine. On 6/11/25 at 10:54 AM, V2 (Director of Nursing-DON) said she was notified about 5:15 AM, they could not locate R1. V4 (RN) found R1 outside on the sidewalk about 130 feet away from the facility. Prior to that R1 was at the nurses station being monitored for acute behaviors and V5 (CNA) got up to answer a call light and when she returned R1 was not at the desk. They searched for R1 in the facility and found R1 outside within 30 minutes. She notified V7 (R1's husband) and he went to the facility right away. R1 alleged allegation of abuse during this time and reported to V7 they would notify the police. V7 declined for the police to respond and took her home. R1 was a recent admit from the hospital with UTI, she was cognitively intact, and did not display exit seeking behaviors prior. There was a referred for psych prior and a UA was ordered due the recent behavior. They followed our protocol when they could not locate a resident and she was found with no injury. R1 had not shown exit-seeking behaviors prior. She would expect the staff to supervise a resident with acute cognitive changes. R1's Community Skills Determination form dated 5/27/25 shows she is alert, oriented, and free from confusion allowing her to be considered for independent pass privileges. The facility's Elopement Event Policy revised 8/22 states, The facility has a plan in case of an elopement of a resident from the facility. This enables the missing resident to be found as quickly as possible and to maintain the residents safety, dignity and privacy. If a resident is discovered missing: alert the nursing supervisor, staff on the unit should perform a thorough search of the unit/area. Notify the Administrator/DON immediately and announce facility code overhead. Immediately begin a thorough search of the facility grounds .when the resident is found the DON or administrator will notify the residents representative and police .

Based on interview, and record review the facility failed to ensure a resident (R2) was free from physical abuse for 2 of 6 residents (R1 and R2) reviewed for abuse in the sample 6. The findings include: The facility's Abuse Investigation dated 03/01/2025, showed, around 6:00PM, R1 and R2 were in the dining room at the table. R2 started to wave at R1. R1 was looking down then sat up and noticed R2. R1 suddenly slapped R2 in the face and her glasses fell to the floor. When asked why he hit R2, R1 stated, she had it coming. On 03/13/2025 at 2:24PM, V5 CNA-Certified Nursing Assistant said, R1 and R2 were sitting at the table together. I was down the hall walking towards them. R1 slapped R2 knocking her glasses off. R1 has other aggressive behaviors. We constantly observe him for aggressive behaviors. On 03/12/2025 at 9:00AM, V1 Administrator said, It just came out of the blue, knocked off the glasses. We just did a GDR-Gradual Dose Reduction on R1 ' s quetiapine (anti-psychotic), decreasing it from 50mg to 25mg. R1's current Care Plan on 03/12/2025 shows, R1 exhibits and has a history of behaviors including verbal and physical aggression towards staff and sexually inappropriate comments to staff.

Based on observation, interview, and record review the facility failed ensure safe incontinence care for 1 of 3 residents (R1) reviewed for safety. This failure resulted in R1 rolling off the bed onto the floor and sustaining a cervical fracture, a left clavicle fracture, and laceration to her left eyebrow requiring 3 sutures. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dysphagia, hyperlipidemia, Type 2 Diabetes, spondylosis without myelopathy, generalized anxiety, depression, and arthropathy. R1's facility assessment dated [DATE] showed she has severe cognitive impairment and requires substantial to maximum assist for bed mobility. R1's care plan initiated 6/5/23 showed, . Self care deficit, requires staff assist with ADLs (activities of daily living)related debility, weakness . Bed Mobility- extensive assist Toileting - extensive assist, incontinence care . On 1/2/25 at 11:00 AM, R1 was lying in her bed. R1 had a brace on her neck and a sling on her left arm. R1's acute care hospital documentation dated 12/29/24 showed, . Today's Visit . Reason for Visit: Fall . Diagnoses: Other closed nondisplaced fracture of first cervical vertebra, Closed nondisplaced fracture of acromial end of left clavicle, eye laceration Avulsion of skin of left forearm . R1's facility incident report dated 12/29/24 showed, 12/29/24, at approximately 1:18 AM the resident was reportedly receiving care when the resident rolled out of the bed and landed on her left side. The resident sustained a laceration to the left eyebrow and a skin tear to the left elbow. First aid was immediately rendered. the resident complained of left shoulder pain . The resident was transferred to the local ED (emergency department) via EMS (emergency medical services) where the laceration to the left eyebrow was repaired with three sutures. Additional imaging was performed which displayed new fracture of the C1 vertebrae and acute fracture of the distal clavicle . R1's 12/28/24 nursing note entered at 1:03 PM showed, Alert, pleasantly confused and able to make needs known. Compliant with medications, took crushed in applesauce without difficulty. Appetite adequate and ate both breakfast and lunch in the dining room. able to propel self short distances in wheelchair, without difficulty. Incontinent of bowel and bladder, peri care provided PRN (as needed). Resident up in wheelchair at this time near nurses station. No complaints of signs and symptoms of pain/discomfort verbalized or displayed . R1's 12/29/24 nursing note entered at 1:29 AM showed, Resident was being changed by CNA (Certified Nursing Assistant) at the time of fall. Resident rolled to her right side and she didn't stop rolling which resulted in fall to floor. Landed on her left side on floor. Received cut to left upper, outer eyebrow and a left elbow skin tear. Areas cleaned and dressing applied to left elbow. Pressure held to left eyebrow until bleeding stopped. Resident hoyer lifted back to bed. Complained of left shoulder pain. On call NP notified Resident taken by EMS (emergency medical services) to [acute care hospital] . R1's 12/29/24 nursing note entered at 4:16 AM showed, MD (Medical Doctor) called . Resident being transferred to [a neighboring acute care hospital] for admission due to a C1 (cervical vertebrae) fracture . R1's 12/29/24 nursing note entered at 5:41 AM showed, . ER (emergency room ) called facility and resident is to return to the facility. Need to make appointments with ortho and neurosurgery on Monday. PRN (as needed) Tramadol (pain medication) ordered . Resident came back by ambulance at this time. Aspen collar (neck stabilizer) on and sling to left arm due to collarbone fracture . R1's care plan initiated 4/6/23 showed, Potential for falls, Resident at risk for injury from falls . Interventions: (12/29/24) 2 staff assist resident with turning and repositioning in bed for cares . Aspen collar at all times, may release for skin checks and hygiene . Sling to LUE (left upper extremity) at all times, may remove for showers/skin checks . On 1/2/25 at 1:06 PM, V5 CNA (Certified Nursing Assistant) said she was changing R1 on 12/29/24 when she rolled out of bed and onto the floor. V5 said, I was on her left side and turned her onto her right side. When I turned her she continued to roll out of the bed. I am not sure what happened. I'm not sure if I rolled her too far . She was pretty much asleep when I was changing her After she fell she was saying 'ow ow, I'm in pain' . I had taken care of the her previous night too. She was a difficult turn. She is listed as a one assist but she doesn't help turn at all. On 1/2/25 at 1:13 PM, V3 RN (Registered Nurse) said, I didn't witness anything until after she was on the floor. I was told by the CNA that she was changing her and she rolled out of the bed. I got there and she was sitting on the floor on the left side and she was bleeding. I assessed her and they hoyered her back up into bed. Once I went in and reassessed her she was complaining of pain. I went and called 911 . I thought it was ridiculous . when you turn them you make sure they are stable before you take your hands off of them . On 1/2/25 at 3:05 PM, V6 RN (Registered Nurse) said R1 is an extensive assist of one and sometimes two assist depending on the day. V6 said R1 is definitely a difficult change (incontinence change) and it has been getting harder since she has been declining. V6 said they have usually been using two people but with agency staff she feels like they go and attempt care and don't get assistance until they realize how difficult the resident is. On 1/2/25 at 3:35 PM, V2 DON (Director of Nursing) said R1 was struggling with turning and rolling and being able to assist with that. V2 said after R1's fall, they changed her to a two assist with incontinence care and bed mobility. The facility's policy with revision date of 8/1/23 showed, Fall Prevention Guideline . General: It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries . The facility's policy with revision date of 3/2024 showed, Falls Management . General: 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 preventative strategies, and facility as safe an environment as possible .

Based on interview and record review the facility failed to identify pressure injuries prior to a stage 3 for a resident at risk for pressure with a history of pressure (R1). This failure resulted in a delay in assessing and obtaining treatment orders to prevent pressure injuries from worsening for R1. The facility failed to ensure pressure interventions were in place for a resident with a left heel pressure injury (R72). This applies to 2 of 5 residents (R1, R72) reviewed for pressure injuries in the sample of 18. The findings include: 1.) R1's self -care deficit care plan initiated on 6/5/23 shows R1 requires extensive to total staff dependence with incontinence care, personal hygiene, bed mobility, and transferring. R1's skin integrity care plan initiated on 6/29/24 and revised on 9/27/24 shows she is at risk for impaired skin integrity due to cognitive impairment, immobility and nutrition. The care plan identified that R1 currently has pressure injuries to her left buttock, left hip and left shoulder. R1's Pressure Risk Assessment (Braden scale) completed on 8/12/24 by V12 (former Wound Care Nurse) shows R1 scored a 12 and is at high risk for pressure. The assessment shows that skin should be observed and assessed regularly. A Wound Evaluation and Management Summary completed by V7 (Wound Care Physician) on 9/13/24 shows R1 had a stage 3 pressure injury to her left hip which was healed on 9/13/24. The summary does not show any additional pressure injuries for R1 on 9/13/24. A Wound Care noted completed on 9/21/24 shows that R1 was assessed head to toe and had no acute skin alterations. A nursing progress notes for R1 completed by V13 (LPN) on 9/24/24 states, This nurse observed an open skin area to the hip on the resident. Open sore to hip dark discolored area in center, beefy red tissue surrounding. Acute skin alteration noted to right/left buttocks. Area assessed and foam dressing per wound care nurse. A Wound Assessment Details Report for R1 completed on 9/25/24 by V12 (former Wound Care Nurse) shows R1 had the following new pressure injuries identified: 1. Right Buttock- Stage 2 measuring 1.00 cm. (Centimeters) x 1.00 cm x 0.10 cm. (LxWxD/length width and depth) 2. Left Buttock- Stage 2 measuring 1.0 cm. x 1.5 cm.10 cm. 3. Left Buttock- unstageable measuring 0.5 cm. x 0.5 cm. x unknown depth 4. Right Trochanter (hip)- unstageable measuring 1.50 cm. x 3.40 cm. x .10 cm. this wound is described as 80% pink or red tissue with non-granulating to the skin and 20% of the wound bed necrotic (dead tissue). The picture on the wound assessment clearly shows the black center of the wound bed. 5. Right hip- Stage 1 measuring 7.00 cm. x 5.00 cm. x 0.00 cm. 6. Left Shoulder- Stage 1 measuring 3.00 cm. x 3.00 cm. x 0.00 cm. On 9/27/24 V7 (Wound Care Physician) saw R1 and documented the following pressure injuries with his revised/current stages and additional wounds identified. 1. Left hip a full thickness pressure injury (no left hip pressure injury was documented by V12 on 9/25/24) identified as a stage 3 measuring 3.0 cm x 1.9 cm. x 0.2 cm. This wound is described as having 20% thick adherent devitalized necrotic tissue to the wound bed that required debriding and removal on 9/27/24 by V12, and 20% slough tissue with 60% viable tissue. 2. Left lower medial buttock a full thickness pressure injury a stage 3 measuring 1.0 cm. x 0.6 cm. x 0.2 cm. this wound also required debridement by V12 on 9/27/24. 3. Left upper medial buttock a full thickness pressure injury a stage 3 measuring 3.0 cm. x 1.1 cm x 0.2 cm. 4. Right upper medical buttock partial thickness pressure injury a stage 2 measuring 0.5 cm. x 0.5 cm. x 0.10 cm. 5. Right lower buttock partial thickness pressure injury a stage 2 measuring 1.4 cm. x 1.0 cm. x 0.10 cm. 6. Right hip partial thickness pressure injury a stage 2 measuring 4.2 cm. x 3.5 cm x 0.1 cm. On 9/27/24, V12 identified treatment orders for all wounds listed above to be leptospermum honey with a gauze island bordered dressing to be changed daily and PRN (as needed). On 10/22/24 at 9:23 AM, V3 (Wound Care Nurse) said the former wound care nurse V12 was let go at the facility on 9/25/24 and she was appointed the facility wound care nurse that same day. V3 said she came into the new wounds with R1 and would do her best to answer questions relative to the wounds. V3 said ideally pressure injuries are discovered as a stage 1 and CNA's (Certified Nursing Assistants) should immediately report skin changes to the nurses who should assess the wounds and immediately call for treatment orders. V3 said skin checks should be completed on shower days, when CNA's provide turning and re-positioning and incontinence care to residents. V3 confirmed R1 is a resident who is completely dependent on staff for her cares including re-positioning and incontinence cares. V2 (Director of Nursing) requested to be and was present and collaborated with V3 during the interview about R1's wounds. V2 verified that 6 new wounds were discovered on R1 between 9/24- 9/27 when V7 saw R1. On 10/22/24 at 12:39 PM, V7 (Wound Care Physician) said pressure injuries found past a stage 2 are a little late to the game being identified, especially wounds with necrotic tissue in the wound beds because these wounds are now advanced and more difficult to heal and don't just happen overnight. V7 said that is on the nurses and CNA's for not identifying these wounds sooner if they are providing care to the patient and doing incontinence cares and turning them regularly they should be noticing the areas sooner, multiple stage 3 pressure injuries being identified and pressure injuries to both sides of the body is concerning. V7 said even though R1 had co-morbidities that would contribute to her developing the wounds since she was on hospice he feels sometimes residents on hospice do not get the same care as non hospice residents because the assumption is they are going to die so additional care and treatment sometimes is not done. On 10/23/24 at 8:44 AM, V6 (CNA) said R1 has been totally dependent on staff for her cares for months. V6 said turning and repositioning and incontinence care should be provided for residents every 1-2 hours and skin should be assessed at that time and any abnormalities including pink or redness should be immediately reported to the nurse. On 10/23/24 at 10:36 AM, V2 said that R1 had tested positive for Covid on 9/16/24 and that staff should have been in the room a lot. V2 also verified that as of 9/13/24 R1 had no active pressure injuries on her body. The facility provided Skin Care Prevention policy revised on 10/16 shows residents will be evaluated daily for changes in their skin condition and dependent residents will be assessed during cares for any changes in skin including redness. 2.) R72's care plan shows she has an active stage 4 pressure injury to her left heel, and requires extensive staff assistance with turning and re-positioning. R72's Pressure Risk Assessment History (Braden Scale) shows she scored a 12 which is high risk to develop a pressure injury. A Wound Assessment Details Report completed by V3 (Wound Care Nurse) on 10/16/24 shows she has a healing stage 4 pressure injury and the plan of care is for protective heel boots to be worn. On 10/21/24 at 9:09 AM, V8 and V9 both (CNA's) put R72 to bed. After they were finished with her care they covered her up and left her heels flat against the mattress with no heel protectors on or pillow under her heels offloading them. On 10/21/24 at 11:18 AM, R72 was still in bed with her heels flat against the mattress and not offloaded. On 10/21/24 at 11:14 AM, V3 said for residents at risk for pressure or who have pressure they use offloading of heels with a pillow or heel protectors. On 10/22/24 at 9:50 AM, V3 said she was not aware of R72 not having her heels off loaded but she should have because she does have a current pressure injury. On 10/23/24 at 8:44 AM, V6 (CNA) said R72 has heel protectors that she should have on when she is in bed or up in her wheelchair. The facility provided Skin Care Prevention policy with a revised date of 10/16 shows residents at risk for skin breakdown will have their heels off loaded off the bed surface.

Based on interview and record review the facility failed to notify the dietician in a timely manner of a resident with a significant weight loss of 8 lbs. (pounds) 6.2% in one month. This failure resulted in a delay in dietary interventions being implemented and an additional 3.4 lb. 2.81% weight loss in one week. This applies to 1 of 18 residents (R77) reviewed for weight loss in the sample of 18. The findings include: R77's face sheet shows she was admitted to the facility on [DATE] and has diagnoses including cognitive communication deficit, other disorders of the brain, need for assistance with personal cares, and dysphagia. R77's weight summary sheet shows she weighed 129.2 lbs. on 9/21/24 on 10/14/24 she weighed 121.2 lbs. which is an 8 lbs. 6.2% significant weight loss in 24 days. From 10/14/24 she weighed 121.2 lbs. and on 10/21/24 she weighed 117.8 lbs. which was an additional 3.4 lbs. 2.81% weight loss in 7 days. R77's Dietary Review note completed by V4 (Dietician) on 10/22/24 states, I was notified by DON {V2} on the evening of 10/21/24 that resident {R77} has lost weight as of 10/14. Res. latest weight 117.8# does indicate an 8.6% significant weight x 1 month. Interventions added for R77 include a high calorie drink 120 milliliters (ml.) QID (four times a day), and double portions at lunch and dinner. R77's active Physician Order Summary shows an order for dietary consultation as needed and shows the order for double portions at lunch and dinner and a high calorie drink 120 ml four times a day were added on 10/22/24. R77's nursing progress notes do not show that R77's physician was contacted about her weight loss prior to 10/22/24. On 10/22/24 at 9:40 AM, V2 (Director of Nursing) said she notified V4 last evening of R77's significant weight loss. V2 said she is new to the facility and was not sure of the process for nurses reporting weight loss to the dietician. On 10/22/24 at 10:41 AM, V4 said she was not notified about R77's significant weight loss until the evening of 10/21/24. V4 said she pulls the facility weights at the beginning of each month to review weight loss, and ideally the facility should be notifying her immediately of any significant weight loss in between so she can implement interventions. V4 said if she was notified sooner she would have initiated the same interventions. On 10/23/24 at 8:48 AM, V5 (Licensed Practical Nurse/LPN) said when a resident has weight loss the nurse should notify the unit manager and also the Nurse Practitioner. The facility provided Weight Change Investigation policy with a review date of 7/14 shows the purpose of the policy is to investigate significant or insidious weight changes. The weight investigation will be initiated with a significant weight change of 5% or more in one month. Once the weight change is identified the facility will contact the dietician and health care provider for interventions.

Based on interview and record review the facility failed to identify and treat a pressure ulcer for a resident dependent on staff for care. This failure resulted in R1's pressure ulcer to his right heel not being identified until it was necrotic and unstageable on 3/18/24. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5. The findings include: R1's Face Sheet shows that he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Atrial Fibrillation, Cellulitis of the Left Lower Limb, Lymphedema, Muscle Weakness, Acute Cystitis and Morbid Obesity. R1's Progress Notes dated 3/17/24 state, Necrotic tissue on bottom of Right heel surrounded by slough. Resident Unaware of wound. Wound care nurse notified. NP notified. POA updated. Foam boots applied. R1's Progress Notes dated 3/18/24 state, Resident was notified by staff regards new skin alteration to left heel, upon assessment noted unstageable to right heel, wound bed necrotic, no exudate noted, resident denies any pain to right heel but complains of pain to right leg. Writer notified NP (V4), per (V4) orders to send out to ER for further evaluations and to rule out DVT. On 6/3/24 at 11:15AM V3 (LPN-Wound Nurse) stated, He came from the hospital. He was resistive to all care, pericare, therapy. On Monday (3/18) morning when I came in he had a new skin alteration, he refused to wear the boots, refused to have heels elevated on a pillow because he said it was uncomfortable. I notified (V4) and she said to send him out. I was doing the dressing on his legs prior to that and they were weeping. I changed the dressings on Monday/Wednesday and Friday. He would not allow anymore than that, he said he didn't need it. I am here Monday - Friday-. When I saw the wound on the heel (V4) and I wanted to make sure it was not a DVT. I was doing the leg treatments so this had to have happened over the weekend. I do the wound assessments weekly. He tried to reposition himself but he wouldn't let us reposition him. He was admitted with chronic cellulitis and was always in supine position. He refused boots or pillows. On 6/3/24 at 1:32 PM R1 stated, The heel on my right foot got a terrible pressure sore on it that I am still working on healing today (at another facility). I looked at all my records from when I was in the hospital the first time and there was no mention of a pressure sore so I know I got it there. I was able to move my leg but every morning I would wake up in a puddle on the bed because my legs were weeping so much. I begged for a week for wound care to come and take care of my legs. I never had any boots until about 1/2 an hour before I left. Finally when they noticed my heel was black they sent me out right away. On 6/3/24 at 1:24 PM V5(RN) stated, He had been complaining of right leg pain. He had had therapy earlier and (V7-CNA) was getting him ready for bed. He complained of right heel pain. She asked me to come look at it. It was black and full of necrotizing tissue. I was unsure if anyone knew about it so I contacted wound care, the MD and the POA. There was no other documentation about it so I guess no one had noticed it. I never had any issues with him. I heard he was sometimes non-compliant with therapy during the day but I didn't try to get him to therapy. He was cooperative and took his medications . On 6/3/24 at 2:00PM V4 (Nurse Practitioner) stated, I didn't know anything about his heel. He never complained of pain to his heel, the pain was in his hip. The wound nurse called me and said it was black and it wasn't there before so I told her to send him out . With the heel, I wanted to make sure it wasn't circulatory, make sure it wasn't a DVT. On 6/3/24 at 2:30 PM V7 (CNA) stated, He had his call light on and I went in there and he said his leg was hurting- in the groin area. I put him in bed and then a little while later he wanted to get up to the chair and use the restroom again so I helped him and he said his heel was hurting. I looked at his foot and it was all blackish in color. This was my first day on the short hall so I had not really worked with his before. We are supposed to do skin checks on shower days and then document it on the shower sheet. I reported it to the nurse and she came and looked at it. R1's Wound Assessment Details Report dated 3/18/24 shows that R1 had Unstageable Necrotic, hard, Firm, Adherent- 100% Facility Acquired Pressure Ulcer to his right heel. This form shows the wound measured 5.5 x 7.0 cm. R1's Braden Scale for Predicting Pressure Ulcer Risks dated 2/10/24 shows that he scored a 15 (15-18= At Risk) R1's Physician's Order Sheet dated 2/10/24- 3/18/24 shows no orders for heel lift boots or off-loading of R1's heels. R1's Care Plan dated 3/8/24 states, Potential/At Risk for alteration in skin integrity due to risk factors associated with diabetes The interventions include: Reposition/shift weight at frequent intervals to resident's comfort, Remind/ Assist Resident to reposition frequently and Check skin daily. R1's Hospital Discharge Summary dated 3/18/24- 3/28/24 shows one of R1's admitting and discharge diagnoses as Decubitus Ulcer of right foot- s/p excisional debridement on 3/24/24. This form states, He will be weight bearing as tolerated for transfers and short distances attempting to avoid pressure to the right heel. The facility policy entitled Skin Management Program dated 8/23/23 states, It is the policy of the facility that a guest does not develop pressure injury unless clinically unavoidable. Guests with wounds and/or pressure injury and those at risk for compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal guest outcomes. A Braden Scale will be completed upon admission, weekly for 4 weeks, quarterly and with a significant change of status by a licensed nurse to determine the risk of pressure injury development. Appropriate preventative measures will be implemented on guests identified as risk (a score of 18 or less on the Braden Scale) and the interventions documented on the care plan.

Based on observation, interview and record review the facility failed to ensure residents with cognitive impairment and at a high risk for falls were supervised to prevent repeated falls. This failure resulted in a hospitalization of R81 for a brain bleed and R82 sustaining a fractured upper arm. The facility failed to ensure an electrical outlet cover was in place for a live outlet in a confused resident room. This applies to 3 of 20 residents (R34, R81 and R82) reviewed for safety and supervision in the sample of 20. The findings include: 1. On (MONTH) 11, (YEAR) at 10:48 AM, R81 was sitting in a recliner in the common area with the foot rest up. R81 was restless in the chair, trying to get out of the chair and push the foot rest down. R81's helmet was not on her head or near the recliner. On (MONTH) 13, (YEAR) at 11:57 AM, V11 (Restorative Nurse) said she is responsible for the fall program at the facility. V11 stated R81 likes to fall; she falls a lot. V11 said on (MONTH) 11, (YEAR) she was notified R81 fell . V11 said she saw R81 lying on the floor on her right side and blood was coming from her head. V11 said V4 (Licensed Practical Nurse - LPN) was holding pressure on R81's head wound. On (MONTH) 13, (YEAR) at 12:49 PM, V4 (LPN) said she was taking care of R81 on (MONTH) 11, (YEAR). V4 said she was in the nurses' station charting and she heard V17 (Certified Nursing Assistant - CNA) yelling her name. V4 said R81 was on the floor of the dining room and stated, It looked like (R81's) eyebrow was indented and there was blood coming from that area. V4 said when the Emergency Medical Technicians (EMTs) arrived, R81 started nodding off for 30 seconds. V4 said R81 was taken to the closest emergency room , then transferred to another hospital. V4 said she called the hospital to check R81's status and she was told R81 had a subarachnoid hemorrhage (brain bleed) and would be admitted to the hospital to monitor the bleeding. On (MONTH) 13, (YEAR) at 01:35 PM, V17 (CNA) said on (MONTH) 11, (YEAR) she was taking a resident to the bathroom and R81 was sitting in a chair in the dining room. V17 said R81 always leans forward, so I pushed her legs back so R81 would be sitting back against the chair with her feet on the floor. V17 said on her way out of the bathroom with the other resident, she saw R81 leaning too far forward and she fell on her head. On (MONTH) 13, (YEAR) at 02:57 PM, V18 (Nurse Practitioner - NP) she has been R81's NP since R81 was admitted in (MONTH) (YEAR). V18 stated, If I documented R81 had an acute brain bleed after the fall on (MONTH) 11, (YEAR), then I'd have to say it (the brain bleed) was new. On (MONTH) 13, (YEAR) at 02:26 PM, V2 (DON) stated, the paperwork from the emergency room does show that R81's brain bleed was new from the fall on (MONTH) 11, (YEAR). R81's records from the local emergency roiagnom on (MONTH) 11, (YEAR) showed the result of the Computed Tomography (CT) scan of the head was, Acute [MEDICATION NAME] hemorrhage and subarachnoid hemorrhage. [MEDICAL CONDITION]. R81's Nursing Home Visit dated (MONTH) 27, (YEAR) does not show nontraumatic subdural hemorrhage, unspecified as a current or historical diagnosis. R81's Nursing Home Visit dated (MONTH) 15, (YEAR) showed current [DIAGNOSES REDACTED]. This document showed 1. subdural hematoma status [REDACTED]. R81's Electronic Medical Record (EMR) on (MONTH) 13, (YEAR) showed R81 had thirteen falls from (MONTH) 11, (YEAR) to (MONTH) 25, (YEAR). R81's Fall Event dated (MONTH) 16, (YEAR) showed she was walking, fell and hit her head, resulting in a lump above her left eye brow. R81's Fall Event dated (MONTH) 29, (YEAR) showed R81 tried to pick something off the floor, fell and hit her head, resulting in a laceration over her left eyebrow. R81's Fall Event dated (MONTH) 28, (YEAR) showed she was walking, fell and hit her head, resulting in a swollen tissue around her left eye. R81's Fall Event dated (MONTH) 11, (YEAR) showed R81 was reaching, fell and hit her head, resulting in a laceration above the right eye brow. R81's Fall Risk Screen dated (MONTH) 25, (YEAR) showed R81 is a High Fall Risk. R81's Admission Record printed (MONTH) 12, (YEAR) showed R81 has [DIAGNOSES REDACTED]. R81's Minimum Data Set (MDS) dated (MONTH) 28, (YEAR) showed R81 has severe cognitive impairment; requires extensive assistance of two or more staff members for bed mobility, transfers, walking, dressing, and toilet use; and has had two or more falls since admission. R81's Fall Care Plan (revised (MONTH) 13, (YEAR)) showed R81 has the potential for falls and is at risk for injury from falls. This care plan shows R81 has a soft helmet for ambulation but does remove it herself, ambulates with an unsteady gait, and has weakness and dementia. The interventions include continue to provide frequent visual monitoring to ensure safety. R81's Abnormal Involuntary Movement Scale (AIMS) dated (MONTH) 14, (YEAR) showed R81 is a low risk of movement disorder. The facility's Fall policy (revised (MONTH) 2014) showed, The facility is committed to maximizing each resident's physical, mental, and psychosocial well-being the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. 2. On (MONTH) 11, (YEAR) at 12:00 PM, R82 was sitting in the recliner with the feet up. R82 turning side to side in recliner, trying to kick up her leg. V13 (LPN) stopped to talk to R82 briefly, as V13 walked away from R82 she stated to another staff member, (R82) is rolling around and that's how she gets when she rolls out of those chairs. On (MONTH) 13, (YEAR) at 12:30 PM, V11 (Restorative Nurse) said on (MONTH) 14, (YEAR) 12:00 PM, R82 rolled out of bed, fell on her left arm and fractured her humerus. V11 said the fall was unwitnessed. V11 said the CNA that found R82 on the floor was V16 (CNA) and R82's nurse that day was V21 (Registered Nurse - RN). On (MONTH) 13, (YEAR) at 3:03 PM, this surveyor left a message for V21 (RN). V21 did not return the call. On (MONTH) 13, (YEAR) at 03:08 PM, V16 (CNA) said she does not remember finding R82 on the floor. On (MONTH) 13, (YEAR), R82's Electronic Medical Record (EMR) showed R82 had 11 falls in (YEAR). R82's Fall Event dated (MONTH) 14, (YEAR) showed R82 was found face down, next to her bed, resulting in a left [MEDICAL CONDITION] and hematoma. R82's Fall Event dated 5/30/18 showed she was reclined in the recliner and fell , resulting in a 3 cm laceration above her left eyebrow. R82's Fall Event dated (MONTH) 12, (YEAR) showed was sleeping in the recliner and fell , resulting in a bloody nose and possible closed fracture of her nose. R82's Fall Event dated (MONTH) 9, (YEAR) showed R82 rolled out the left side of the recliner and hit her head on the wall, resulting in a hematoma to her left forehead. R82's Fall Event dated (MONTH) 21, (YEAR) showed R82 rolled out of the side of the recliner and hit her head and face on the wall, resulting in bruising to her forehead and nose. The facility's Incident Report completed on (MONTH) 14, (YEAR) by V2 (DON) showed V16 (CNA) exited R82's room and heard a thud. This document showed V16 found R82 lying on floor on left side with a 2 cm laceration to her forehead, which was bleeding profusely. This document continued to show R82 grimaced with movement to left upper extremity (arm); X-ray results reveal left proximal humeral fracture (broken arm). R82's local emergency department records dated (MONTH) 14, (YEAR) showed Diagnosis: [REDACTED]. This document also showed, (R82) has a moderate sized swollen, raised bruised area to the left side of forehead. R82 has a small skin tear to the area with bleeding controlled. R82 has 2 inch laceration the top of the scalp. R82's Admission Record printed (MONTH) 12, (YEAR) showed R82 has [DIAGNOSES REDACTED]. R82's MDS dated (MONTH) 28, (YEAR) showed R82 had severe cognitive impairment; and required extensive assistance of two or more staff members for bed mobility, transfers, walking, dressing, and toilet use. R82's Fall Risk Screen dated (MONTH) 21, (YEAR) showed she is at High Risk for falls. R82's Care Plan (revised (MONTH) 6, (YEAR)) showed R82 has the potential for falls and is at risk for injury due to poor safety awareness/impulsiveness, attempts to roll out of recliner, and stand alone without assistance. The interventions include continue to provide close visual monitoring when R82 is out of bed and provide staff reminders regarding need for constant supervision when R82 is out of bed. R82's Abnormal Involuntary Movement Scale dated (MONTH) 5, (YEAR) showed R82 is a low risk of movement disorder. 3. On (MONTH) 11, (YEAR) at 09:25 AM, R34's room was observed to have a electrical outlet approximetley 4 feet off the ground on the wall where the resident's head of bed was located. The electrical outlet was missing it's cover plate and no pieces of the outlet cover were observed in the vacinity of the outlet. R34's bed was plugged into this outlet. On (MONTH) 1, (YEAR) at 11:04 AM, V16 Certified Nursing Assistant, stated the electrical outlet cover had been missing for a few days and she believed it had been reported. On (MONTH) 11, (YEAR) at 10:49 AM, V15 Maintenence, stated the outlet with the missing cover was live and the purpose of the outlet cover is to protect the outlet and to keep people from sticking their fingers in it. V15 stated if someone would stick their fingers in the outlet they would get electrocuted. V15 stated he was not aware of the broken outlet cover. On (MONTH) 11, (YEAR) at 10:49 AM, the facility's Maintenance Work Order Request log was reviewed with V15 and the missing outlet cover had not been documented at that time. On (MONTH) 11, (YEAR) at 12:28 PM, R34 was observed in the dining room self propelling herself to the door. R34's (MONTH) 17, (YEAR) Minimum Data Set showed her cognitive ability to be severly impared. R34's [DIAGNOSES REDACTED].

I. Based on observation, interview and record review the facility failed to supervise a resident during meal times to avoid consumption of foods and fluids that placed the resident at risk of aspiration. This failure resulted in R4 developing aspiration pneumonia after ingesting thin liquids from another resident's tray in mid October, 2010. On 12/6/10, R4 consumed a dinner roll from another resident's tray while at a supervised meal, while on a prescribed puree diet with nectar thickened liquids. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 12/7/10. It began on 10/18/10 when R4 developed aspiration pneumonia after consuming thin liquids while being supervised by facility staff. The Immediacy was removed on 12/7/10 when the facility put safety interventions in place for R4, revised the resident care plan and inserviced staff feeding and monitoring residents in the dining room. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of corrective measures put in place, and monitor and evaluate the effectiveness of the care changes. This applies to 1 of 7 residents on thickened liquids who is at risk for aspiration. (R4) The example includes: 1. On 12/6/10 at 11:15 AM, R4 was seated at the dining room table. R4's lunch tray was delivered to the table, but was pushed back from R4's reach. No food or fluids were given to R4 while the remaining trays were passed. The resident tried to reach for her food, and attempted to remove the metal plate cover. R4 then reached over and removed a dinner roll wrapped in plastic wrap from a table mate's tray. R4 tried to take a bites out of the roll with the plastic wrap still on the bread; then put her fingers into her food trying to feed herself. E23 (Activity Aide) was seated at the table assisting 2 other residents with their meal, while R4 tried to eat the dinner roll and played in her food. E15 (Activity Aide/Feeding Assistant) returned to the table to feed R4. R4 ate the whole roll without staff intervening. After the observation of R4 consuming the dinner roll, the medical record was reviewed. The Physician order [REDACTED]. R4 is prescribed to receive puree foods with nectar thickened liquids. The Minimum Data Set of 10/21/10 documents R4 requires supervision and staff assistance for eating. R4's care plan states to "Monitor for Chewing/swallowing problems and for signs and symptoms of aspiration: Gasping for air, gurgling sounds, shortness of breath, ashen color and report to nurse". The nurses' notes dated 10/18/10 (Monday) documents, "Resident is awake but sleepy. Lungs with loud expiratory rhonchi heard bilaterally, suctioned with a moderate amount of thick light yellow secretions". The x-ray report dated 10/21/10 documents R4 had a right lower lobe infiltrate and small left pleural effusion. On 12/6/10 at 3:00 PM, Z3 stated, "My wife was quite ill about 1 month ago. I still haven't received an explanation of what made her so sick. I visited her on Sunday and she was OK. The next day they called to tell me how sick she was and they wanted to send her to the hospital." On 12/6/10 at 9:45 AM, during a (confidential staff nurse interview) stated, "R4 had aspiration pneumonia a few months ago. R4 probably aspirated when she grabbed liquids from another table mate's tray and drank them. She should have nectar thick liquids. The liquid she drank was not thickened. R4 tries to take others' food and fluids". The incident was not reported on the facility accident log, and the nurses' notes did not contain any information about incident. R4's care plan was not revised to reflect interventions to prevent R4 from receiving the wrong diet or fluids. E1 (Administrator) was informed of the Immediate Jeopardy on 12/7/10 at 4:45 PM. The survey team confirmed through interview, observation and record review, the facility took the following actions to remove the immediacy: On 12/7/10 R4 was positioned at the dining room table with a table extension to prevent R4 from reaching others' foods and fluids from their trays. R4's care plan was revised to include R4's behavior, and interventions to prevent R4 from access of foods and fluids which increase her risk of aspiration. Staff inservices were provided to address supervision of residents at meal times, and resident observations of inappropriate behaviors at meal times. II. Based on observation, interview and record review the facility failed to reposition a resident in a manner to avoid striking her head on the bed frame which resulted in R4 receiving a laceration to the top of the head. This applies to 1 resident in the sample that sustained an injury. (R4) The example includes: The nurses' notes dated 11/24/10 at 10:45 PM, states, "Nurse called to the room by the evening shift CNA. The CNA stated when they moved resident up in bed, she struck her head on the headboard. resident sustained [REDACTED]. On 12/6/10 at 11:45 AM, E14 (Licensed Practical Nurse - LPN) stated, "R4 had a small laceration on the top of her head. She hit her head on the headboard when the staff pulled her up in bed." E13 stated, "There are some new CNA's on the night shift." The Minimum Data Set of 10/21/10 documents R4 requires extensive assistance with 2 staff members for repositioning in bed. The care plan does not address how the facility will prevent further injury when repositioning R4 in bed. On 12/6/10 at 3:00 PM, R4 was observed lying in bed. The headboard was made of wood and had an ornate decorative design with notable sharp edges. On 12/6/10 at 3:00 PM, Z3 stated, "When they repositioned her she hit her head on the head board. It's too bad the head board is not smooth. It looks very nice, but she must have cut her head on the sharp edges. It's healed up now." Z3 stated she had not changed beds, and she had a facility owned bed.

Based on observation, interview and record review the facility failed to ensure residents with complicated eating and drinking problems were not fed by a feeding assistant/resident attendants. R4's clinical record failed to show the resident had been assessed by the charge nurse for eligibility to be fed by a feeding assistant/resident attendant. The facility failed to ensure the state approved feeding assistant /resident attendant program was renewed prior to the [DATE]. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE]. It began on [DATE] when R4 developed aspiration pneumonia after consuming thin liquids while being supervised by facility staff. R4 consumed a dinner roll on [DATE] while being supervised by a feeding assistant/resident attendant. The Immediacy was removed on [DATE] when the facility terminated the resident attendant program and the care plan was revised and safety interventions during meals was put into place for R4. The facility remains out of compliance at a level 2 due to the need to evaluate the staffing needs to ensure the residents who require assistance with feeding are accommodated; revise the resident attendant policy and procedure and to monitor and evaluate the effectiveness of the care changes. This applies to 1 resident identified at risk for aspiration being fed by an feeding assistant/resident attendant (R4) on the second floor. The example includes: On [DATE] at 5:45 PM, R4 was seated at the dining room table in a wheelchair. E15 (Activity Aide/Resident Attendant) was seated next to R4 and was feeding her the evening meal. R4 ate and drank 100% of the puree foods and thickened fluids provided. On [DATE] at 6:00 PM, E2 (Director of Nurses) was observed monitoring the dining room activity. E2 stated E15 was not a Certified Nursing Assistant, but a trained staff member of the paid resident attendant program at the facility. E2 stated their license expired in October of 2010, but the application and paper work had been sent to Springfield for renewal. On [DATE] at 11:15 AM, R4 was seated at the dining room table. R4's lunch tray was delivered to the table, but was pushed back from R4's reach. No food or fluids were given to R4 while the remaining trays were passed. The resident tried to reach for her food, and attempted to remove the metal plate cover. R4 then reached over and removed a dinner roll wrapped in plastic wrap from a table mate's tray. R4 tried to take a bites out of the roll with the plastic wrap still on the bread; then put her fingers into her food trying to feed herself. E23 (Activity Aide) was seated at the table assisting 2 other residents with their meal, while R4 tried to eat the dinner roll and played in her food. E15 (Activity Aide/Resident Attendant) returned to the table to feed R4. R4 ate the whole roll without staff intervening. After the observation of R4 consuming the dinner roll, the medical record was reviewed. The Physician order [REDACTED]. On [DATE], R4 was prescribed to receive puree foods with nectar thickened liquids. The Minimum Data Set of [DATE] documents R4 requires supervision and staff assistance for eating. R4's care plan states to "Monitor for Chewing/swallowing problems and for signs and symptoms of aspiration: Gasping for air, gurgling sounds, shortness of breath, ashen color and report to nurse". There was no speech therapy assessment or evaluation in the record during the survey. The nurses' notes for R4 dated [DATE] documents, "Lungs with loud expiratory rhonchi heard bilaterally, suctioned with a moderate amount of thick light yellow secretions". The x-ray report dated [DATE] documents R4 had a right lower lobe infiltrate and small left pleural effusion. On [DATE] at 3:00 PM, Z3 stated, "My wife was quite ill about 1 month ago. I still haven't received an explanation of what made her so sick. I visited her on Sunday and she was OK. The next day they called to tell me how sick she was and they wanted to send her to the hospital." On [DATE] at 9:45 AM, during a (confidential staff nurse interview) stated, "R4 had aspiration pneumonia a few months ago. R4 probably aspirated when she grabbed liquids from another table mate's tray and drank them. She should have nectar thick liquids. The liquid she drank was not thickened. R4 tries to take others' food and fluids". R4's care plan does not contain specific feeding interventions that are necessary to prevent R4 from aspiration of food or fluids. At [DATE] at 9:30 AM, E14 (Licensed Practical Nurse - LPN/2nd floor Charge Nurse) stated, "The nurse monitors the dining room during meals. The feeding assistants can feed residents with puree foods, but not if they have thickened liquids." On [DATE] at 10:15 AM, E15 (Activity Aide/Feeding Assistant/Resident Attendant) stated, "At meal times, we pass the trays then we just see who needs to be fed and we sit down and feed them. I have fed R4 many times." On ,[DATE]//10 at 11:40 AM, E11 (Registered Nurse - RN) stated, "Only CNA's can feed residents on thickened liquids. R4 should be fed by a CNA." E11 confirmed that E15 is not a CNA, but has had the feeding assistant training. On [DATE] at 3:20 PM, E11 (RN) stated, "CNA should feed residents with Aspiration Precautions or thickened liquids. The charge nurse decides who the feeding assistants should feed. I don't do any swallow assessments, speech therapy will do the assessments and let us know who needs thickened liquids. All residents with thickened liquids are at risk for aspiration." On [DATE] at 11:10 AM, E2 (Director of Nurses - DON) presented the cover letter sent to Springfield for the renewal of the resident assistant program. E2 stated the previous program approval expired on [DATE]. E2 stated she mailed the renewal application and required information on approximately [DATE] or [DATE]. The facility Resident Attendant policy states, "Residents with complicated feeding problems including, but not limited to, difficulty swallowing, recurrent lung aspirations and tube or [MEDICATION NAME]/IV feedings shall not be fed by Resident Attendants." The policy does not contain facility specific information regarding assessment of the residents, resident attendant assignments, and supervision of the resident attendants. On [DATE] at 12:20 PM, E1 (Administrator) stated the facility does not have a job description for the resident attendant/feeding assistant position. Memo dated [DATE] from the Rockford Regional office to the survey team confirms the facility did not have a current Department approved Resident Attendant Program and the previous program expired on [DATE]. The Department confirmed the facility's request for re-approval was received on [DATE]. E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 4:45 PM. The survey team confirmed through interview, observation and record review, the facility took the following actions to remove the immediacy: On [DATE] at 3:15 PM, E1 posted a memo stating only CNA's and nurses are to feed all residents. E1 stated the resident assistant program is terminated until renewal is received from the Department. Staffing schedules were revised; additional CNA staff were assigned during meal times to assist residents with eating. Staff inservices were provided to address supervision of residents at meal times, and resident observations of inappropriate behaviors at meal times.

Based on Interview and Record Review the facility failed to assess and monitor R8 when a hematoma was observed on her right lower leg on 10/18/10 at 11:00am. The facility failed to evaluate R8's response to treatments and/or interventions provided for R8 on 10/17/10. R8's "half dollar" size hematoma changed to extending down her right lower leg from below her knee to 1.5 inches above her ankle during the time the facility did not adequately monitor and assess the area. At 2:00pm on 10/17/10 R8's skin split open and started "oozing" blood. A pressure dressing was applied. When R8 was observed again at 6:30pm (4.5 hours later) she was observed with blood soaked bedding and dressing on her right lower leg. R8 was transported to the emergency room and had surgery for [REDACTED]. R8 had acute blood loss [MEDICAL CONDITION] and received a blood transfusion of 2 units of packed red blood cells. This is for 1 resident in the sample with a Hematoma (R8) that required frequent assessment and monitoring. Findings include: R8's Nurses Notes showed, "10/17/10 at 11:00am - Hematoma noted below right knee, inner aspect of lower leg after R8's shower. Extremity elevated and ice pack applied.; 11:15am - Hematoma increasing in size, extends below knee to mid calf. Rolled gauze and elastic wrap applied. Leg remains elevated and ice pack reapplied. Nurse practitioner informed and given condition update. Nursing orders noted and processed." R8's Physician order [REDACTED]. Apply elastic wrap and rolled gauze. Then apply ice for 20 minutes on and 20 minutes off for 2 hours." R8's Nurses Notes showed, "1:00pm - Continue to apply ice packs on 20 minutes and off 20 minutes. leg elevated. Rolled gauze and elastic wrap in place. Hematoma extends from below knee to approximately 2 inches above ankle. R8 complains of intermittent pressure and pain helped with as needed [MEDICATION NAME].; 2:00pm - Went to observe R8's leg with day charge nurse when coming on shift. Removed bandage and gauze to see if swelling had increased. Hematoma extended to about 1.5 inches from inner ankle. leg continued to be elevated at heart level. As beginning to re-wrap leg, skin split with blood oozing out. Wrap with figure eight to apply pressure with rolled guaze and elastic wrap on top.; 6:37pm - R8 noted to have saturated elastic wrap and bedding. When removing saturated bandage skin continued to split further. Quick pressure applied due to increased bleeding. Re-wrapped with new gauze dressing and elastic bandage and ice applied.; 6:45pm - Call out to Nurse Practitioner. New orders to send to the emergency room for evaluation.; 7:00pm - Ambulance here to transport. Transporter went to undo pressure dressing and was informed that dressing was applied because skin will continue to tear unless held in place and asked to keep dressing in place. They mentioned they were worried about circulation. Informed them that R8's ankle has looked blue due to increased pressure in leg...." On 11/1/10 at 3:20pm, E5 (Registered Nurse - RN) stated, "For (R8) and her leg, I would look at the leg. Elevate the leg. Assess for bleeding. Apply pressure if there is any bleeding. Check for pedal pulses and capillary refill. Assess for pain and warmth. See if (R8) can move the extremity." E5 was asked if she would document her assessments/monitoring. E5 stated, "Yes. I would document in the nurses notes and give report on what I saw in shift report." E5 was asked how often would she have monitored R8's leg. E5 replied, "Every 20-40 minutes. Even if we weren't documenting, at least every hour." On 11/1/10 at 3:30pm, E2 (Director of Nursing - DON) was asked how often should R8 have been assessed due to the leg Hematoma. E2 stated, "Every couple of hours." E2 was asked if the monitoring of R8's leg changed once her skin split open. E2 replied, "I don't know how often they monitored." E2 was asked if the documentation of monitoring R8's leg would be in the nurses notes. E2 stated, "Hopefully." E2 was asked what the nurse would document when monitoring R8's leg. E2 replied, "Vital signs, condition of the leg, color of the leg, [MEDICAL CONDITION] to the leg, size of the hematoma, if ice is applied, pedal pulses, measurements of the leg (including circumference), capillary refill and circulation." E2 stated there is no policy and procedure for monitoring or assessment of injuries. The Patient Transfer Form, from the facility to the hospital, dated 10/17/10 for R8 showed, "Right leg hematoma noted after shower this am. About half dollar size. Leg was elevated. Hematoma gradually increased from just below the knee to 2 inches above the ankle with hematoma distended. Wrapped with elastic bandage and ice applied.... Around 2:00pm when nurse went to recheck swelling when unwrapping elastic wrap skin split and began bleeding a small amount. Wrapped with rolled guaze and elastic bandage and ice applied. At around 6:00pm drainage increased and bandage and sheets were noticed to be saturated with blood. When taking off rolled guaze to assess skin split much more oozing blood. Held in place by a gauze dressing to keep skin from further tearing and re-wrapped with rolled gauze and ace bandage and then sent out. Blood pressure within normal limits. Now ankle [MEDICAL CONDITION] present and pedal pulse are more faint. They were strong until last change and check." R8's Discharge Summary (no date) showed, "On 10/18/10 (R8) received a shower. After right leg was dried a hematoma was noted. The hematoma increased in size and split the skin. (R8) transferred to the emergency room for evaluation." The Hospital History and Physical dated 10/17/10 for R8 showed, "Chief Complaint: Right leg pain and swelling.; Present Illness: The patient is a [AGE] year-old white female who was struck over the right lower leg with a towel at the nursing home. R8 states there was bruising to the area which increased rapidly and then split open and she began to bleed. R8 was transported to the emergency room for uncontrolled bleeding, pain and swelling.; Impression: Hematoma right lower extremity status [REDACTED].; Plan: R8 has been admitted to the hospital. R8 was taken to the operating room by the surgeon and is status [REDACTED]." The Hospital Wound Care Note dated 10/20/10 for R8 showed, "Right lower leg with surgical sutured wound and partial open superficial wound 6.5cm by 6.5cm area with trace bleeding. Large area of ecchymosis at lower leg. Right foot very [MEDICAL CONDITION]. Fragile skin. (R8) complained of severe pain with dressing removal." The Hospital Physician order [REDACTED].; Appointment with wound care clinic in 1-2 weeks.; Wound care of right leg: Topical antimicrobial. Apply silver dressing to right leg open wound. Cover with transfer dressing. Dressing to stay in place 3 days. Cover the dressing with thick pad dressing and gauze. Change the thick pad dressing and gauze daily. Re-wrap right foot and lower leg daily with a 6 inch elastic wrap, start at proximal toes wrapping to the knee." The Wound Ostomy Nurse Progress Notes dated 10/25/10 for R8 showed, "Right lower leg continues to be ecchymotic with triangular shaped wound. Beefy wound bed. Right lateral wound oozing clear fluid from blister. Noted 3 sites blistered tissue without fluid on medial right lower leg in ecchymotic area. Dressing adhered to wound bed in spite of saturation with saline causing slight bleeding and very painful to resident. Foot is [MEDICAL CONDITION]. Need to be encouraged to exercise ankle as it is painful to move foot up and down. Discontinue dressing as it is traumatic to wound bed to remove. Cleanse wound to right lower leg with normal saline. Apply silver dressing and cover with foam and wrap with roller gauze and elastic wrap. Wrap foot to reduce swelling. Change foam dressing and gauze wrap daily. Silver dressing every 3 days. Elevate foot to control swelling." R8's History and Physical dated 10/29/10 showed, "Extremities: Right leg - early foot drop, post operative.; Skin: Leg broke down - getting wound care." R8's POS dated 10/29/10 showed, "Physical therapy to evaluate for foot drop brace."