Every finding on record at Thryve of Burbank

Based on observation, interview, and record review, the facility failed to ensure unused isolation gowns were not hanging inside the sorting area of the soiled linen room and failed to ensure contaminated material did not cross over the clean area in the laundry room in an effort to prevent spread of infection. These failures affected 2 (R6 and R7) residents reviewed for infection control and have the potential to affect all the 123 residents at the facility. Findings include:The (04/13/20260 midnight census report documented that there were 123 residents at the facility. On 04/13/2026 at 12:23pm by the Laundry's Soiled Linen room, there were 2 yellow isolation gowns hung by the sorting area. On 04/13/2026 at 12:28pm by the dryers inside the laundry's clean area, there was a paper stuck between the drum and the door of the 2 dryers; one paper contained R6's name and room number, and the other paper contained R7's name and room number. V6 (Laundry Aide) stated she got the paper from the resident soiled linen clothing and stuck them between the drum and the door of the dryer so she knows to whom the clothing belongs to. On 04/13/2026 at 12:44pm, V5 (Housekeeping/Laundry Supervisor) stated he started as Supervisor in March of 2025, and it has been the practice of putting the paper which contained the name and room number of the resident between the door and the drum of the dryer. V5 stated staff does know what is in the resident's clothing and the residents clothing could be contaminated with something that they don't know. V5 stated best practice is to not bring the paper with the resident's name and room number in the clean area of the laundry room.On 04/13/2026 at 1:56pm, V8 (Laundry Aide) stated he has been at the facility for 2 1/2 years and he has been putting the paper with the resident's name and room number back to clean resident's clothing. V8 stated he is now seeing an issue for cross contamination. V8 stated he is now instructed to throw away the contaminated paper and write the name and room number of the resident on a fresh uncontaminated paper which is the smartest thing to do. On 04/14/2026 at 12:05pm inside the soiled linen room, there were 2 yellow disposable isolation gowns hung by the sorting area. V5 stated he did not know how and when the aides used the isolation gowns.On 04/14/2026 at 12:10pm, V6 stated she removes the paper inside the resident soiled clothing plastic bag, puts the resident's clothing in the washer and puts the paper which contained the resident's information on top of the washer so she knows to whom the clothing belongs to and once the resident's clothing are washed, she places the paper between the drum and door of the dryer for the same reason, to know whom the clothing belongs to. On 04/15/2026 at 10:12am, V6 stated she prepared 2 unused isolation gowns by hanging them in the sorting area of the soiled linen room. V6 stated she is the only aide during the morning, and she wanted to save time by hanging the isolation gowns inside the sorting area. V6 stated she would wear one of the isolation gowns, sort the dirty linens and dispose of the isolation gown after. V6 stated she donned the remaining isolation gown if she had to sort soiled linens again and it has been her practice for 38 years. V6 stated she began placing the paper with the resident's information between the door and drum of the dryer when facility no longer provided mesh bag for the resident's dirty clothing. V6 stated she could not recall when, but it was long time ago.On 04/14/2026 at 1:12pm, V2 (Director of Nursing) stated the soiled area in the laundry room is where the washers are located and the clean area is by the dryer where they fold the clean linens. It is not okay for the contaminated paper to cross over the clean area of the laundry room because it cause cross contamination. It has the potential to affect all the residents at the facility. On 04/15/2026 at 10:31am, V2 (Director Of Nursing) stated the expectation is not to prepare the isolation gown and hang them inside the sorting area to save time; it should not be that way because facility did want to contaminate her uniform when she wears the unused isolation gown and then she goes to the clean area of the laundry room which can potentially cross contaminate the clean area of the laundry room. V2 stated for her protection, her family's and the residents' protection, she should not hung the clean isolation gown in the soiled linen room's sorting area. This practice could potentially affect all residents at the facility.On 04/15/2026 at 10:40am, V1 (Administrator) stated in the laundry room, there is a clean area and dirty area. The dirty area should be separated from the clean area. Contaminated materials from the dirty area of the laundry room should not cross over the clean area to prevent cross contamination, for infection control. The paper which contained the resident's information inside the resident's dirty clothing should not cross over the clean area of the laundry room. V1 stated isolation gowns used for sorting dirty linens should not be hung in the sorting area. These isolation gowns are considered dirty. The purpose is to prevent contamination. R6's admission Record documented that R6's diagnoses include but are not limited to encounter for attention to colostomy, acute respiratory failure, and pulmonary nodule. R6's (01/14/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R6's mental status as cognitively intact. R6's (Active Order as Of: 04/13/2026) Order Summary Report documented, in part Enhanced Barrier Precautions. Active: 11/04/2024. R6's (Target Date: 07/02/2026) care plan documented, in part requires Enhanced Barrier Precautions d/t (due to) Colostomy. Enhanced Barrier Precautions will reduce the spread of the infectious agent, minimize the transmission of the infection, and reduce the risk of colonization. Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen. R7's admission Record documented that R7's diagnoses include but are not limited to Type 2 Diabetes Mellitus, ileostomy status, and hypertension. R7's (03/31/2026) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R7's mental status as cognitively intact. R7's (Active Order as Of: 04/13/2026) Order Summary Report documented, in part Enhanced Barrier Precautions. Active: 09/06/2024. R7's (Target Date: 06/26/2026) care plan documented, in part requires Enhanced Barrier Precautions d/t (due to) Colostomy. Enhanced Barrier Precautions will reduce the spread of the infectious agent, minimize the transmission of the infection, and reduce the risk of colonization. Follow facility's Infection Control and Enhanced Barrier Precautions policies/procedures when cleaning/disinfecting room, handling soiled and/or contaminated linen. The (1/2026) Linen/Laundry Handling documented, in part Guidelines: The facility promotes the control of infections through the use of Standard Precautions while handling linen. Procedure: 5. Employees will wear appropriate PPE (personal protective equipment) when handling contaminated linen. (gloves and gowns in the laundry area). The (4/2/2026) Personal Protective Equipment documented, in part This facility promotes appropriate use of personal protective equipment to prevent transmission of pathogens to residents, visitors, and other staff. Definitions: Personal protective equipment, or PPE, refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection (respirators). Policy Explanation and Compliance Guidelines: l. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. 3. Multiple factors determine the appropriate selection of PPE for a particular task: a. The type of exposure anticipated ( e.g., splash/spray versus touch)b. The volume of fluid or tissue to which there is a potential exposure. c. The likelihood of exposure. d. The probable route of exposure (e.g., direct contact versus inhalation). 4. Indications/considerations for PPE use: b. Gowns: 1. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material.The (undated) Laundry Aide Job Description documented, in part Basic Function: To handle and process laundry using proper policies and procedures. Essential Duties: 1. Label laundry per the facility procedures. 3. Sorts, washes, dry, folds and handles laundry using proper procedures. 5. Eliminates crossing of soiled and clean linen.8. Maintains a clean work and storage area. 13. Follows proper infection control practices.

Based on observation, interview, and record review, the facility failed to ensure the daily staffing posting was completed appropriately. This failure has the potential to affect all the 123 residents at the facility.Findings include:The (04/13/20260 midnight census report documented that there were 123 residents at the facility. The (04/01/2026 - 04/13/2026) Daily Staffing posting did not include the daily resident census. On 04/13/2026 at 2:41pm, V9 (Staffing Director) stated, the 'reception' is in charge of filling out the Daily Staffing Posting. V9 stated she provides the daily schedule to receptionist every morning between 6:30am - 8:00am. This surveyor presented to V9 the 04/01/2026 - 04/13/2026 Daily Staffing Posting and inquired what is missing. V9 stated the residents census is not filled out; the regulations stated to include the resident census. V9 stated the purpose of the Daily Staffing Posting is to make everyone, including visitors, aware of the staffing at the facility. The Daily Staffing Posting should be completely filled out daily. The (1/2/2026) Nurse Staffing Posting Information documented, in part Policy: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. Policy Explanation and Compliance Guidelines: l. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name. b. The current date. c. Facility's current resident census. d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses. ii. Licensed Practical Nurses/Licensed Vocational Nurses. iii. Certified Nurse Aides.

Based on observation, interview, and record review, the facility failed to follow their Extreme Weather Temperature Policy by not maintaining indoor temperatures in the range of 71 degrees to 81 degrees Fahrenheit. This failure affected 3 residents (R8, R9, R11) in dialysis and 4 residents (R6, R7, R12, R13) residing on the wing complex.On 1/20/2026 at 11:50AM, during unit rounds, state agency observed residents in the XXX complex unit hallway wearing multiple layers of clothing, hoodies, zipped up jackets. State agency and V3 (Assistant Director of Nursing/ADON) continued walking down the hallway of the XXX complex wing and observed V3 zipping up her blue sweater. V3 stated this hallway is cold. State agency observed multiple staff wearing zipped up sweaters.On 1/20/2026 PM at 12:03PM, V9 (Maintenance Director) stated the complex XXX wing heater system was down and the facility called a company to come and assess the heating system in the end of November. V9 stated after the company came and worked on the heating issue, it resolved the heating issue to the rooms on the left side of the complex XXX wing, the odd room numbers, but we are still having heater issues to the resident rooms in the right side of the complex XXX wing, the even room numbers.On 1/20/2026 at 12:25PM, V10 (Certified Nursing Assistant/CNA) stated the XXX wing is cold, some of the resident's room heaters are not working.On 1/20/2026 at 12:42PM, V11 (Licensed Practical Nurse/LPN) stated the XXX complex unit, some rooms do not have proper heating.Record review of the facilities temperature log sheets provided by V1 (Administrator) document dated 1/7/2026 time 7:00AM reads, location Complex by R14's room temperature was 63.9- degrees Fahrenheit. Temperature log sheet dated 1/8/2026 at 6:00AM documents, location Complex by R6's room, temperature was 62.1-degree Fahrenheit. Temperature log sheets provided by V1 dated 1/13/2026 time 6:00AM documents, location complex by R13's room temperature was 63.2 degrees Fahrenheit. Temperature log sheet dated 1/14/2026 at 6:00AM documents, location Complex near R7 and R12's room, temperature was 60.1-degree Fahrenheit.On 1/20/2026 at 12:53 PM, V9 and state agency were standing in the XXX hallway between R6's room and the room in front of R6's, V9 measured the temperature using the (brand name) thermometer and it read 62.2 degrees Fahrenheit.On 1/20/2026 at 12:53PM, V9 and state agency checked the temperature using a (brand name) thermometer and it read 61.9-degree Fahrenheit inside R6's room. At 12:55 PM checked the temperature in R5's room, V9 and state agency observed that the (brand name) thermometer of R5's room read 62.0-degree Fahrenheit. V9 stated 62.0-degree Fahrenheit in a resident's room is unacceptable and the temperature to the rooms should be 71 to 81 degrees Fahrenheit.On 1/21/2026 at 10:25AM, state agency and V9 went into the dialysis room, in the XXX complex wing. Observed residents receiving dialysis treatment who were wrapped in multiple blankets. V9 measured the temperature in the dialysis room using the (brand name) thermometer and it read 62.2 degrees Fahrenheit.Random interviews were conducted on 1/22/2026, R8, R9, and R11 stated they received dialysis yesterday and it was cold in there. R9 states the cold makes her body hurt and is very uncomfortable. R8 stated it was so cold in there, its uncomfortable, it makes R8 angry. R11 stated the dialysis room is cold, stated she takes two blankets with her and wraps them over her body and head, states there is no heat in the dialysis room.Policy and Procedure titled: Extreme Weather Temperature Policy, effective Date: 1/1/2024.Policy reads: Policy: It is the policy of this facility to maintain indoor temperatures in the range of 71 degrees - 81 degrees Fahrenheit. Interventions will be promptly implemented to protect residents' health and safety when temperatures fluctuate outside the accepted range. Policy Specifications: To assure all departments assist in implementing appropriate interventions to maintain resident comfort during severe exterior temperature changes which may affect interior environment. Standards:Heating and air-conditions system will be inspected, maintained and repaired in accordance with the prevention maintenance schedule. The Maintenance Director will advise administration of any serious malfunctions or need for repairs/replacements beyond the approved budget.3.Repairs of heating and air-conditioning units will be considered a priority during extreme weather or anticipated extreme temperature during winter and summer months.

Based on observation, interview, and record review, the facility failed to follow their Fall Guideline Policy when the admitting nurse failed to complete the Fall Risk Evaluation upon a resident's admission into the facility. This affected 1 (R1) resident of 3 reviewed for accidents.R1 is a [AGE] year-old female admitted to the facility on facility 6/5/2025 at 12:30PM and discharged date on 6/6/2025 at 3:36PM. R1's medical diagnosis are, but are not limited to, Chronic Obstructive Pulmonary Disease with acute exacerbation, acute respiratory failure with hypercapnia, type 2 diabetes mellitus, unspecified asthma with acute exacerbation, epilepsy with status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal electroencephalogram, other supraventricular tachycardia, hypertension.On 1/21/2026 at 11:11 AM, V16 (Restorative Director) stated the fall assessment evaluation for new admitting residents should be done on admission by the admitting nurse. V16 states that I do not see an initial fall risk assessment for the date R1 was admitted to the facility.On 1/21/2025 at 11:57AM, V6 (Licensed Practical Nurse/LPN) stated she was R1's admitting nurse. V6 stated when she got report from the hospital, they stated R1 fell a bunch of times, was a high fall risk, and R1 was not complaint. V6 stated, she does not recall what assessments she did for R1. V6 states for an initial fall risk assessment that should be in place upon admission, a fall risk should be in place to evaluate the resident's fall risk score. V6 stated it is the responsibility of the admission nurse to complete the fall risk evaluation. V6 stated a fall risk evaluation risk assessment should be completed upon admission, after a fall, and quarterly. If a fall risk evaluation assessment is not complete, a resident is at risk of falling.On 1/20/2026 at 1:30PM, V2 (Director of Nursing/DON) stated it is expected for the admitting nurse to complete the initial fall risk assessment the day of admission. I do not see a fall risk score for the admission date.Reviewed R1's fall incident report dated 6/5/2025 at 3:15PM, V6 documents a fall incident description that reads informed by co-nurse the R1 was observed sitting on the floor in room. R1 stated she needed to go to the bathroom, when asked why she didn't use the call light R1 states I forgot a call light because I had to use the bathroom really bad.Reviewed R1's fall incident report dated 6/6/2025 at 1:00PM V14 (LPN) documents a fall incident description that reads R1 as observed on the floor after an unwitnessed fall head to toe assessment performed by V14 and Nurse Practitioner (NP) a knot observed on the left side of the resident's head no active bleeding noted. Resident was observed on the floor after an unwitnessed (fall). Upon assessment R1 stated she was sitting in her wheelchair, and she had reached down in an attempt to grab her phone and subsequently lost her balance.Reviewed R1's Fall Risk Observation, effective Date, 06/06/2025 at 2:56PM documents R1's category as High Risk for falls, score of 13.Reviewed Facilities Fall Guideline Policy provided by V2. Policy revised 8/2024 documents: Purpose: to consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization - wide ownership for fall prevention to: achieve each resident's maximum potential of physical functioning. To prevent or reduce injuries related to falls. To enhance residents dignity and self-worth. To rehabilitate residents to their fullest potential of function. Fall Risk Evaluation: A fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with significant change in condition. Purpose: 1. To consistently identify and evaluate residents who fall and to treat or refer to treatment appropriately. 3. To prevent or reduce injuries related to falls. 6. Individualize interventions for each resident. 1. If the evaluation finds the resident at risk, implement resident specific interventions / precautions.

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance during care in accordance with their assessed needs and care plans. This failure applied to two (R1 and R2) of three residents reviewed for accidents. These failures resulted in falls while being provided care that required emergent hospital transfer. R2 required three staples for the laceration to the left scalp and R2 also had a left shoulder contusion. Findings include: R1 is an [AGE] year-old resident admitted to the facility on [DATE] with the diagnoses, including but not limited to morbid obesity, lack of coordination, chronic obstructive pulmonary disease, dementia, and hypertension. The facility reported incident documents that on [DATE], a resident slid on the floor during care. EMS (Emergency Medical System) was notified. The resident later became unresponsive. CPR (Cardiopulmonary Resuscitation) was initiated. The facility is awaiting the coroner's report. Minimum Data Set (MDS) assessment of 09/15//2025 documents the following:Section C, the BIMS (Brief Interviewed Mental Status) score was 10/15, indicating moderate cognitive impairment.Section GG: R1 is dependent on toileting hygiene, rolling left and right, shower, dressing, and lying to sitting. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On [DATE] Unable to interview V8 (Certified Nursing Assistant) called and left a message. The statement provided by the facility noted that R1 fell during care. V8 written statement noted, on [DATE], approximately 8:26 PM, V8 was providing care to R1. R1 was positioned on her side as part of her routine evening care. V8 stated, while I was finishing. I noticed her leg began to move downward, and R1 started to slide towards the edge of the bed. R1 then slid to the floor into a seated position while holding onto the side rail. R1 did not appear to strike her head or any hard surface. On [DATE] at 10:16 AM, V4(Licensed Practical Nurse/LPN) said, I don't recall a lot from the incident because it was a long time ago, but I went into the room as soon as I was called. R1 was on the floor and was not very responsive, and I told one nursing assistant to call 911 and another to call the supervisor. I did not see any noticeable injury, and I assessed R1 on the floor and after R1 was assisted to the bed by a mechanical lift. R1's vital signs were lower than the initial ones, but R1 was still breathing, and EMS got to the room, and I gave a report to them, and I had to print out her paperwork, and when I came back to the room, the paramedics had started CPR. I think CPR lasted approximately 20 minutes. I called the family after the paramedics told me that R1 had expired. I made all the notifications, and the police were also called. One of the police officers came to talk to me, and another one spoke with the family when they got here. The police recommended that I not talk to the family because of the way they were acting with us. The other police officer was with the family. On [DATE] at 2:30 PM R1's roommate said, R1 fell in the room, and the staff helped her right away, and I do not remember much, because it was a long time ago. On [DATE] at R1's Family member said, he spoke with R1 approximately 7:30 PM, and someone was in the room to assist R1, and disconnected the call. R1's family member said that R1 never complained or said that she was not feeling well, and around 10:30 PM, he received a phone call to come to the facility. The family was not able to see R1 and only touched R1 over the bag and spoke with the police, and did not communicate with staffing on the incident. R1's family member said that R1 fell because only one nursing assistant provided care to her, and she required 2 nursing assistants. R1's family member said I did not get the death certificate yet. I do not know if the death was of a natural cause. I have many questions on how R1 was assessed and when CPR was initiated. Following the fall, R1 became unresponsive, and CPR was initiated by EMS. The facility was awaiting the coroner's report at the time of the survey. The relationship between the fall and the resident's death could not be determined at the time of review. 2. R2 is [AGE] years old resident admitted to the facility on [DATE] with the diagnoses including, but not limited to hypoxic ischemic encephalopathy, respiratory failure on a ventilator/tracheostomy, acute embolism and thrombosis of the femoral vein, thoracic aortic aneurysm, and R2 is incontinent of bowel and bladder and receives enteral nutrition. Facility reported incident documents that on [DATE], R2 was observed lying on his back on the floor beside the bed. A laceration was noted on the left side of the head with active bleeding a scratched noted on the left side of the neck. R2 was sent to a local hospital. Hospital records reviewed, and R2 had a laceration to the left scalp requiring three staples and a left shoulder contusion. Minimum Data Set (MDS) assessment of [DATE] documents the following:Section C 1000(Cognitive skills for daily decision making) score is 3 (indicating severe impaired decision making)Section GG: R1 is dependent on toileting hygiene, rolling left and right, shower, oral care, dressing, and lying to sitting. The helper does all the effort. The resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On [DATE] at 12:22 PM V13 (Certified Nursing Assistant) said, I was doing rounds, and I was giving R2 peri-care by myself. R2 was at the edge, and he fell out of bed towards the door. I turned R2, and he slid out of bed. R2 required two person assist but I could handle him by myself. I could do it myself, and I had been doing that. I was suspended for not having 2 assists. I have received education after. I know that I was supposed to provide care with two, but I did with one. I know now, and I follow the care plan. V12's (Registered Nurse)[DATE] nursing notes stated, I was called into the room by V13, and during patient care, due to the resident having a fall with injury to the left side of his head. The resident left the facility with 911 emergency assistance, going to a local Hospital for evaluation. Upon assessment, the R2 was noted lying on his bedroom floor next to the bed on his back. R2 had a laceration to the back left side of his head with active bleeding. I cleaned the site and wrapped it with a fluff gauze roll and 4x4 to stop the bleeding. R2 also had a scratch on the left side of his neck that was cleaned and bandaged to prevent infection. Pupils not responsive to light, skin was warm to the touch. R2 was alert to self, remains non-verbal. Trach to ventilator stable. Heart rate elevated at 110, blood pressure 128/63, respirations 24. The responsible party was made aware of the condition and transfer. On [DATE] at 2:34 PM, V9 (Restorative Director/Licensed Practical Nurse), said both R1 and R2 fell out of bed while receiving care, and both residents were supposed to have 2 assists instead of one. Both certified nursing assistants provided care alone, resulting in falls. On [DATE] 2:54 PM, V2 (Director of Nursing), I expected the staff follow the care plan and ensure the safety of residents. V2 said, I understand that based on MDS (Minimum data set) assessment, both resident R1 and R2 required 2 assists during care, and one nursing assistant provided care. I provided education to the staff to follow the plan of care. Facility policy titled, Fall Guide (revised on 8/2024), which includes: Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately, and develop an organization-wide ownership for fall prevention to:To achieve each resident's maximum potential of physical functioning.To prevent or reduce injuries related to falls.To enhance residents' dignity and self-worth.To rehabilitate residents to their fullest potential of functionFalling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface. The fall may be witnessed, reported by the resident or an observer, or identified when a resident is found on the floor or ground. Falls include any fall, regardless which setting it may have occurred.The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process:1. Identification of hazards and risksEvaluationImplementationMonitoringAnalysis

Based on observation, interview, and record review, the facility failed to follow their employee handbook on cell phone usage by having a staff member take a personal phone call while providing care to a resident. This failure affected 1 (R1) of 3 residents reviewed for resident rights in a total sample of 6. Findings include:R1 is a [AGE] year-old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: paraplegia, diabetes mellitus type 2, convulsions, hypertension, unspecified injury at unspecified level of cervical spinal cord, and colostomy status. Per the Minimum Data Set (MDS) dated [DATE], reads: Brief Interview for Mental Status score 15/15, cognitively intact.On 9/2/2025 at 11:17 AM, R1 stated an incident occurred on Thursday, 8/28/25 around 4:00 PM. R1 stated during R1's shower on the shower bed by the nurse's station shower room a Certified Nursing Assistant (CNA) was using her cell phone, using face time during R1's shower. R1 cannot provided the name of the CNA. R1 describes the CNA as a skinny African American women. R1 states that the CNA works morning shift, but on August 28, 2025, that CNA stayed until 5:00 PM. R1 states he told his family member about the incident that same evening and did not let management know. R1 stated he did not let management know about the incident because he gets nervous, or his heart begins to race, and he wants to prevent his seizures. R1 stated the incident only occurred 1 time. R1 stated the shower bed is broken. R1 states he does feel safe in the facility. R1 states he has not heard from other residents about cell phone usage during showers in the facility.On 9/2/2025 at 1:28PM, V6 (License Practical Nurse/LPN) stated V6 (LPN) worked day shift on Thursday, 8/28/2025 and was R1's nurse for the day. V6 stated V5 (CNA) was R1's CNA giving R1 a shower on Thursday 8/28/2025. V6 (LPN) stated on 8/28/2025, V6 (LPN) observed V5 (CNA) using V5's (CNA) personal phone and air pods (wireless headphones) while providing patient care to R1. V6 stated she told V5 (CNA) to get off her phone while V5 (CNA) provides patient care. V6 (LPN) reported the incident to the assistant director of nurse on 8/29/2025 day shift. V6 stated she did not observe V5 (CNA) on facetime. V6 stated it is expected for staff not to use their personal phones at while providing patient care.On 9/2/2025 at 2:11 PM V5 (CNA) stated she provided a shower to R1 on 8/28/2025. V5 stated R1 is dependent on staff for lower body related to patient's diagnosis of paraplegia. V5 (CNA) stated she received an emergency personal phone call on 8/28/2025 during R1's shower from V5's family member. V5 (CNA) stated she apologized to R1 for the phone call. V5 stated she was never on facetime. V5 (CNA) said she had her air pods on her ear and when her personal phone rang, it answered the phone call on its own. V5 (CNA) said she had education and had to sign a write up for using air pods/personal cell phone usage. V5 (CNA) states there is no reason why R1 thinks V5 was on facetime during R1s shower on 8/28/2025. V5 (CNA) states she should have not been using the air pods, cell phone during patient care. V5 (CNA) states it is expected for staff not to use their personal cell phone or wear air pod devices during patient care.On 9/2/2025 at 2:52 PM V8 (Director of Nurse/DON) stated she holds a monthly meeting telling staff they are not allowed to use their personal phones in resident areas. V8 stated if she personally sees staff using their personal phones, she advises staff to step out of the resident areas. V8 was informed on 8/29/2025 of the incident with R1 that occurred on 8/28/2025. V8 stated R1 was upset because V5 (CNA) was on her personal cell phone during R1's shower on 8/28/2025. V8 (DON) stated V6 (LPN) told V5 (CNA) to get off her phone. V8 (CNA) is expected to not be on a personal phone call during R1's shower.On 9/2/2025 at 3:03 PM V9 (Administrator) stated he was made aware, today on 9/2/2025 that V5 (CNA) was using her personal phone during R1's shower that occurred on 8/28/2025. V9 (Administrator) was informed of R1's incident by the Assistant Director of Nursing. V9 (Administrator) stated that all staff upon hire and at the monthly meetings, V9 informs staff not to use personal cell phone in resident areas or on the units. V9 (Administrator) stated if staff are seen on their personal phones, he would educate the staff not to use their personal phone in resident areas, write the staff up if seen on a phone call in resident areas. V9 (Administrator) states staff must be off the unit to answer personal phone calls. V9 (Administrator) states they do not have a cell phone policy, documents provided was a page from the handbook stating: Do not use devices during working time that obstruct or restrict your hearing (such as cell phones, MP4 players, (cellular phone brand name), and other similar devices), expect for cell phone use authorized by management.Per the Minimum Data Set (MDS) dated [DATE], MDS section GG reviewed, R1 requires staff assistance with bilateral lower extremity related to medical diagnosis of paraplegia. R1 is dependent on staff with shower/bathe self. The MAR on 8/2025 documents R1 received a shower on 8/28/2025. R1 shower days are on Monday and Thursday day shift. A review of R1 care plan reviews patient has an alteration in musculoskeletal status r/t paraplegia, limited mobility.V5's (CNA) employee disciplinary form dated 9/1/2025 formal warning with supervisors' signature V8 (DON), Rule 25: Unauthorized use of cell phones, or similar devices, telephones or other equipment for personal needs. V5's (CNA) job performance/behavior deficiency: use of electronic devices on unit. V5's (CNA) employee disciplinary form supervisor support: Personal devices like smartphones and tablets are widely used in healthcare for communication, access to clinical information, and patient monitoring, but their use requires strict security policies and professional self-regulation to prevent patient safety issues and ensure HIPAA compliance. While devices offer significant benefits such as improved efficiency, better communication, and expanded access to telehealth services, the also present risks like distraction, data breaches, and a potential for depersonalizing care if not managed properly.Employee handbook: Do not use devices during working time that obstruct or restrict your hearing (such as cell phones, MP4 players, (cellular phone brand name), and other similar devices), except for cell phone use authorized by management.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to maintain the chiller (air conditioner), failed to clean intake vents, failed to document equipment maintenance, and failed to ensure that the chiller was functioning properly. These failures affected 108 residents residing in the facility. Findings include: The (6/17/25) census includes 108 residents. On 6/17/25 at 9:21am, V3 (Maintenance Director) stated right now I'm (V3) having an issue with the chiller, which is brand new, it was installed last year. There's dirt and debris in there so I (V3) was up on the roof trying to flush it out. When there's dirt that builds up, it will throw a low water flow diagnosis so basically if the waters not at a certain flow it will throw that code and shut the unit down. Surveyor inquired if the chiller was currently shut down. V3 replied Right now yes because I was cleaning it. On 6/17/25 at 10:48am, V5 (Maintenance) stated The chiller is having low water flow pressure today so (V3) is working on it as we speak. The system is new it was put in last year, the problem is putting the flow of water back in order. The water goes through a filter, but material goes through the filter and slows up the water, sometimes it will shut the system off if it fills up that filter. It did kick off maybe sometime this morning. On 6/17/25 at 11:26am, V3 stated The chiller is on now I (V3) got up there on the roof and made sure. It's 44 degrees for it to be operating properly. The city water temp is like 70 some degrees right now. It just started back up, it's probably like 72 degrees right now. It did get down to 69.2 before it shut off. Surveyor affirmed that the facility chiller was in fact running however it shut itself off during the inspection. V3 responded I'm gonna shut it off and release the valve again. V3 opened the chiller valve and released the water which was notably brownish-black. V10 (Regional Maintenance Director of Operations) stated See the black stuff? We may have to do this like 3 or 4 times and were gonna clean the strainer. This one should be fine after we clean the strainer. The chiller strainer was soiled with rust colored debris therefore sprayed with water repeatedly. V10 responded Were gonna have to strain this at least 4 or 5 times until it comes out clear, there's a lot of [NAME] in there so we may have to flush it again. We're not gonna leave till it's fixed. Surveyor inquired about the facility intake vents which were completely covered in dust, debris, and cottonwood remnants. V10 inspected the vents and replied, This is dirty, we gotta clean that one too. At 11:57am, the chiller was restarted. V3 stated it's 73.3 degrees that's coming in and 60.2 is actually what's flowing through the building. Once everything gets to flowing good this 73 degrees will drop down even more, we're at 71 degrees now. While V3 and surveyor were checking the numbers the chiller shut off (again). V11 (Regional Maintenance) stated It shut down the pump. V10 responded We should do that bottom one too however the maintenance staff were unable to remove the bottom plate therefore had to purchase additional items to do so. V10 affirmed We started a pre-maintenance program a few months ago to prevent things like this happening. There's a screen that filters the water which will shut down the unit. The heating and cooling guy is coming, we (facility) need a little bit of freon somewhere else too. At 12:54pm, the chiller was restarted (again) V11 stated We got pressure, right now we got 40. It didn't go to 40 last time. V3 and surveyor affirmed that the chiller circuit 1 and circuit 2 were running the water temp was 70.1 and incoming water was 55.3 at that time. The (6/17/25) facility HVAC (Heating Ventilation Air Conditioning) invoices states the chilled water is extremely dirty and chiller bundle has flow restrictions. Cleaned the strainers multiple times once the system was filled, bled, and pump was running. Will quote to clean system up, replace chemical filters and further clean system. On 6/23/25 at 9:29am, portable AC units were still in use at the facility however the temperature was above 80F/Fahrenheit throughout the building (per 6/23/25 temperature logs). Surveyor inquired about the facility chiller V1 stated It was working this weekend but today it went out because of a heat sensor. The (6/23/25) facility HVAC invoice states the system locked out on low flow. Shut down pump, isolated chiller, and cleaned strainer. Removed and replaced white cylinder filters. Restarted chiller. Low flow alarm is nearly immediate. We will isolate the chiller, drain down the heat exchanger and flush with chemical. On 6/23/25 at 3:11pm, V1 affirmed The chiller is up and running. On 6/24/25 at 10:48am, surveyor inquired about the facility chiller maintenance. V5 stated We (Maintenance) change filters and we add chemicals to treat the water that's the regular maintenance that's supposed to be done for that. We're changing the filters weekly, and I think its monthly for the chemicals. On 6/24/25 at 11:27am, surveyor inquired about the facility chiller maintenance. V3 stated Weekly I (V3) change the 4 small filters and monthly add (2) 5 gallons of cleaner. Surveyor requested documentation for the chiller maintenance. V3 responded I don't have any records for that, I'll be honest with you I just don't. The (February 2014) preventive maintenance policy states the preventive maintenance program is maintained by the maintenance department. The maintenance department checks for preventative maintenance program equipment work orders and evaluates/repairs the malfunction described.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to monitor daily atmospheric temperatures, failed to maintain the atmospheric temperaturerange of 71 to 81F (Fahrenheit), and failed to ensure that the temperature was comfortable for one of eight residents (R6) reviewed for safe/comfortable environment. These failures have the potential to affect 108 residents. Findings include: The (6/17/25) census includes 108 residents. On 6/17/25 at 9:15am, the atmospheric temperature was notably warm and humid when surveyor entered the facility. On 6/17/25 at 9:21am, surveyor inquired about the current atmospheric temperature in the facility. V3 (Maintenance Director) stated Right now I'm (V3) having an issue with the chiller, which is brand new, it was installed last year. There's dirt and debris in there so I (V3) was up on the roof trying to flush it out. There was no issue yesterday but today when I came in, the building was warm. The temperature in the building yesterday was around 76 degrees (Fahrenheit), it's supposed to be maintained at no more than 80 degrees. I haven't been able to do my temperatures this morning because I was up on the roof trying to fix it. Surveyor inquired if the chiller was currently shut down. V3 responded Right now yes because I was cleaning it. On 6/17/25 at 10:32am, V3 presented the (May-June 2025) facility atmospheric temperature logs however the temperatures were not documented on 5/3, 5/4, 5/10, 5/11, 5/17, 5/18, 5/24, 5/25, 5/31, 6/1, 6/7, 6/8, 6/14, 6/15 (Saturdays & Sundays). V3 stated The dates that you don't see there, that's on the weekend because I (V3) wasn't here. (Maintenance Staff) were both off on the weekend. Surveyor inquired who's responsible for documenting weekend temperatures in the facility. V3 responded That's a very good question, honestly it should be the person that's managing on duty. Surveyor inquired if the facility policy states to monitor temperatures daily V3 replied Yes ma am. The Friday (6/13/25) 12pm facility atmospheric temperature log (including all the units and dining rooms) was blank therefore surveyor inquired why V3 stated I didn't get a chance to take that one. On 6/17/25 at 10:48am, surveyor inquired about the current atmospheric temperature in the facility. V5 (Maintenance) stated It feels humid right now. On 6/17/25 at 10:58am, surveyor toured the facility with V5 (Maintenance), and the following atmospheric temperature concerns were noted: Joint Hall: 84.1F. Joint Dining Room: 82.2F. Joint room [ROOM NUMBER]: 83.7F. Cardiac room [ROOM NUMBER]: 80.8F. Surveyor inquired about the current cardiac unit temperature V8 (Respiratory) stated For me I am okay, but I think it is too hot. Complex Hall: 81.4F. Complex room [ROOM NUMBER]: 81.6F. On 6/17/25 at 11:08am, V6 (Family) stated When you first come into the facility you don't feel any air. It's warm in the front of the building. On 6/17/25 at 11:26am, V3 stated The chiller is on now I (V3) got up there on the roof and made sure. It's 44 degrees for it to be operating properly. The city water temp is like 70 some degrees right now. It just started back up, it's probably like 72 degrees right now. It did get down to 69.2 before it shut off. Surveyor affirmed that the facility chiller was in fact running however it shut itself off during the inspection. On 6/17/25 at 2:01pm, V1 (Administrator) stated I (V1) got 3 portable AC (Air Conditioning) units so far and affirmed he was working on getting 15 more. On 6/17/25 at 3:00pm, V5 stated the HVAC (Heating Ventilation Air Conditioning) company arrived around 2:15pm and are checking the cooling system with a step-by-step diagnosis. We (facility) had 3 AC's that were delivered this morning; 2 are on cardiac (unit) and 1 is on joint (unit). On 6/17/25 at 3:09pm, surveyor toured the facility (again) with V5 (Maintenance), and the following atmospheric temperature concerns were noted: Joint Hall 84.3F. R6's (Joint) room temperature was 81.9F with a fan running. R6 stated It's hot so I had the window open just for ventilation because it's a slight breeze coming from outside. The Joint Activity Room was filled with residents, a blower and 2 large fans were running however the temperature was 83.2F. The residents participating in the Joint Activity Room were non-interviewable due to cognitive status per V5. North Dining room [ROOM NUMBER].8F. Cardiac Hall: 82.6F. Cardiac room [ROOM NUMBER]: 83.2F. Complex Hall: 83.7F. Complex room [ROOM NUMBER]: 83.8F with 2 fans running. On 6/17/25 at 3:29pm, surveyor inquired about the current facility temperature V12 (Certified Nursing Assistant/CNA) stated, It seems pretty cool right now, just a little bit of hot. On 6/17/25 at 3:31pm, V13 (Licensed Practical Nurse) stated, It was cool this morning, but it got a little warm this afternoon, so I turned some of the lights off. On 6/17/25 at 3:33pm, V14 (CNA) stated It's really really hot while standing at the Joint Unit nurse station. On 6/17/25 at 7:59pm, V1 affirmed the facility received (15) additional portable AC's that are up and running on all the units, aside from the ortho unit (which uses a different chiller). On 6/23/25 at 9:00am, the facility atmospheric temperature was notably warm/humid when surveyor entered the facility and the portable AC units were still in use. On 6/23/25 at 9:29am, surveyor inquired about the facility chiller V1 stated It was working this weekend but today it went out because of a heat sensor and affirmed that the HVAC company was called to repair the chiller today. On 6/23/25 at 2:34pm, V3 presented the (6/23/25) facility temperature logs which affirm temperatures (throughout the entire facility) were above 80F at 2:19pm (including ortho hall 81.7F). V3 affirmed the temperature on the ortho unit was likely elevated due to humidity coming from the other units. V3 stated When I (V3) got here this morning the chiller tripped and went out on low water flow because we (maintenance staff) had to clean it again. It ran for maybe 45 seconds, and it tripped again after that I made a call to (V1) to let him know we had an issue and contacted the HVAC company as well. The HVAC company arrived around 9:30 today, they hooked up a cleaning solution to clean out the heat exchanger. Around 1pm, that was completed but we had to fill the chiller up again with water which takes about 30-45 minutes because it's a big system. We (facility) now have 23 portable AC units running. On 6/23/25 at 3:11pm, V1 stated The chiller is up and running. The summer temperature monitoring guideline (revised 8/5/24) states routine temperature and humidity monitoring of the facility will occur at a minimum one time per day during daylight hours. The accommodation of needs and homelike environment guideline (revised 10/2023) states the resident's environment will be maintained in a homelike manner to ensure comfortable and safe temperatures. Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to risk of hyperthermia and is comfortable for the residents. A determination of homelike should include the resident's opinion of the living environment. The extreme temperature guidelines (revised 4/3/24) states should the temperature index for relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures.

Based on observation, interview, and record review, the facility failed to develop and implement effective safety interventions, including frequent monitoring, for two dependent, immobile, ventilator-dependent residents at high risk for falls to prevent them from falling out of bed. This failure affected two of three residents (R1 and R3) reviewed for accidents and safety. As a result, R1 fell from the bed and sustained a C2 fracture. Findings include: 1.) R1's diagnosis include but are not limited to Anoxic Brain Damage, Respiratory Failure, Tracheostomy, Gastrostomy, Dependence on Respiratory [Ventilator] Status. A new diagnosis of Displaced Fracture of Second Cervical Vertebra dated 3/12/25. R1's cognitive assessment date 2/1/25 identifies she is severely impaired. R1's functional ability assessment dated [DATE] indicates R1 has impaired in range of motion to upper and lower extremities. Additionally, R1 is identified to be dependent on staff for all Activities of Daily Living. Section O identifies R1 has a tracheostomy and a ventilator, requires suctioning and continuous oxygen. On 1/31/25 fall risk observation completed identifies is at high risk for falls. R1 progress note dated 3/8/25 at 1:10PM written by V13 (Respiratory Therapist) states during rounds I heard a vent alarm and went to R1's room. Saw R1 on the floor, notified staff. R1's progress notes written by V7 (Registered Nurse/RN) state on 3/8/25 at 1:08 PM, upon entering the room writer observed resident on the floor laying on her left side. Writer noted resident spitting up intermittent small amounts of tan colored liquid. MDS assessment dated [DATE] section C identifies R1 is unable to answer questions and staff identifies R1 as severely impaired. Section GG identifies R1 is dependent on staff for all cares. R1's care plan identifies she is a nonverbal trach patient. Interventions include dates 3/10/25 and 3/12/25. Interventions dated 10/30/24 anticipate and meet the resident's needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. There are no other interventions until 3/10/25. R1's fall investigation states in part, was likely caused by a combination of forceful coughing and involuntary movements. Despite being immobile and ventilator-debilitated, unexpected muscle activity led to a loss of stability. R1's hospital records dated 3/8/25 documents displaced fracture left lateral mass C2. R1 was transferred to the hospital on 3/8/25 for evaluation following a fall and readmitted to the facility on [DATE]. The facility reported to the state surveying agency on 3/8/25 that R1 sustained an acute displaced fracture of the left C2. On 3/25/25 at 10:33AM an unidentified staff member exited R1's room, bed no longer lowest position, door mostly closed. Position of the door impairs view of resident from nurses' station, the blind on the window was closed, blocking view of R1 from nurses' station. On 3/25/25 at 11:44AM R1's door remains mostly closed to impair view of R1 from nurses' station. On 3/25/25 at 12:07PM V1 (Licensed Practical Nurse/LPN) and V2 (Certified Nursing Assistant/CNA) were providing care to R1. V2 said R1 cannot help at all with her care. V1 said R1's hands, arms, and legs are totally contracted. V1 said she has been like this the whole time she has been here. V1 said R1 is total care dependent on staff. Surveyor observed R1 is on an air mattress during care. On 3/25/25 at 1:26PM V12 (Restorative Nurse) said R1 can't do anything on her own, she is passive for what staff assist her with. V12 said R1 cannot turn and reposition without assistance. V12 said R1 is dependent on staff with everything. V12 said if the resident is at the edge of the bed and coughs, she can fall. On 3/26/25 at 10:30AM V2 (CNA) said R1 was her normal that day. V17 (CNA) and I had just changed her around 12:45PM. V2 said we had left her in the center of the bed. V2 said R1 was in a smaller bed (regular hospital bed) before. V2 said when R1 fell she fell on the left side of the bed, closer to the door. V2 said I have never seen or known R1 fall before. V2 said prior to the day, I have found R1 along the side of her bed, like she moved. V2 said all the residents on this unit will cough and need to be repositioned because they move on the bed. On 3/26/25 at 11:14AM V18 (Case Manager) said when I came to the facility, I asked the nurse how R1 fell . V18 said I see R1 often she does not move, and she doesn't have cognition function. V18 said they really didn't give me an answer. On 3/26/25 at 11:32AM V7 (RN), said I was told that R1 was noted on the floor, on her left side. V7 said I was notified by a Respiratory Therapist. She was the first in the room. V7 said when I assessed R1 I saw a raised area on the left side of her head. V7 said I was sitting at the nurses' station when they told me. V7 said I didn't hear anything at the nurses' station, to alert me that R1 needed help. V7 said R1 is on a ventilator, she was on an air mattress, and had no side rail in use. V7 said for the patients on the unit, their body moves when they cough, I think that is what happened to R1. V7 said when they cough the air mattress makes them move while in bed. V7 said R1 had an air mattress. V7 said I have seen her cough and be moved on the mattress. V7 said R1 was sitting in a regular hospital bed at the time. V7 said the bed was in the lowest position, but not all the way to the floor, and there were no floor mats at the time. V7 said R1 was not able to communicate what happened. V7 said R1 sustained a bump on her head from the floor. V7 said prior, to the fall, nothing was reported, nothing about coughing or increased fidgeting. V7 said I think everyone is a fall risk on that unit. V7 said I think they all should have floor mats and low beds because there are no rails to prevent them from sliding off the beds. V7 said positioning for a patient on a vent includes the head of the bed elevated, and when they cough the body moves. V7 said their position and condition increases the risk for falls. On 3/27/25 at 11:12AM V14 (Nurse Practitioner) said I saw R1 upon return from the hospital, she was nonverbal and at baseline, I had no changes for her. V14 said I was told she fell from maybe a forceful cough because she doesn't move. V14 said R1 had a coughing spell and she slid off the bed. On 3/27/25 at 11:33AM V15 (Respiratory Therapist) said R1 is on a ventilator (vent) and cannot support her own breathing. V15 said R1 has alarms on the vent triggered by high pressure. V15 said high pressure alarms can mean they need suction, coughing, or a disconnect. V15 said respiratory distress will cause an alarm. V15 said a hard forceful cough will probably trigger the alarm to go off for high pressure. V15 said I have been an RT for [AGE] years. V15 said I have never heard of a vent patient falling out of bed because of a hard cough. V15 said coughing can cause the patient to move. On 3/27/25 at 11:49AM V13 (Respiratory Therapist) said I was coming from another room, and I heard the alarm going off. V13 said I saw R1, she was on the floor, and I called the nurse. V13 said R1 remained connected to the ventilator while on the floor. V13 said I had seen R1 earlier that day and R1 was at baseline, there were no changes in her. V13 said R1 usually does not have a lot of secretions. V13 said R1 does cough an average amount. V13 said I have seen R1 cough. V13 said sometimes R1 has a strong cough. V13 said the alarms are loud alarms and can be heard on the unit. There was high pressure, and the alarm goes off, secretions and patient movement will cause the alarm to sound. V13 said there is no way to know how long the alarm was going off. V13 said it was not time to treat R1, I was coming out of the other room and heard the alarm from R1's room. V13 said sometimes R1 coughs strongly. V13 said I have not known a patient to cough so hard to fall out of bed. V13 said if someone on a ventilator is coughing the alarms will go off because it causes a high-pressure alarm. V13 said the nurse was at the desk. V13 said you can hear alarm in the hallway. 2.) R3's diagnosis includes, but are not limited to Respiratory Distress, Acute Respiratory Failure, Anoxic Brain Damage, Hypertension, Tracheostomy and Gastrostomy, and Dysphagia. Incident report dated 3/20/25 R3 was found on the side position on the floor. Incident report dated 3/25/25 notes Incident discussed. R3 experienced a coughing episode that caused a sudden movement and loss of balance. Coughing can trigger involuntary movements, especially in residents who are already physically compromised. Interventions: bed bolsters will be added onto bed. R3's MDS dated [DATE] cognitive assessment identifies R3 is severely impaired. R3 is dependent on staff for all cares. R3 treatments include suctioning and tracheostomy care. R3's care plan interventions were initiated on 11/7/24 include on 11/7/24 anticipate and meet the resident's needs. Educate about safety reminders and what to do if a fall occurs. No other interventions for fall prevention were added until 3/21/25. On 3/26/25 at 10:12AM R4 (R3's roommate) said when R3 fell I was in my bed watching TV. It was in the later evening. I heard a sound and turned to look and R3 was on the floor. R4 said R3 does cough, but I don't recall her coughing before I heard the sound and saw her on the floor. R4 alert and oriented to person, place, and situation. R3 was observed to have visible vibration, as to be coughing, upper body bending upwards from resting position in bed with head of bed elevated. R3 did this three times but remained in the same location of the bed. On 3/26/25 at 11:58AM V9 (CNA) said I had seen R3 around 8:45PM-9:00PM and was in the middle of the bed and positioned correctly, head up, and I left her on her back. V9 said R3 was not coughing more than usual, but her usual amount. V9 said during rounds I heard R4 (R3's roommate) calling for help. V9 said I saw R3 on the floor on the window side of the bed. V9 said we placed bolsters on her bed after the fall. V9 said when R3 was on the floor, the bolsters were not in the bed. V9 said R3 had a regular hospital bed that goes up and down. V9 said R3's bed was not the one that goes to the floor, but she was in the lowest position. V9 said R4 said she heard a noise; she did not describe the noise to me. V9 said R3 had the bolsters (which she described as pads and was not sure of the device name) were still on the bed and they cover the entire length of the mattress on each side. V9 said they look like small wedges and are a separate piece from the mattress. V9 said I have seen when R3 coughs she leans forward. V9 said I was the CNA providing care to R3 on the day she fell . V9 said I was the last to position her before the fall, except it is possible RT (respiratory therapy) provided respiratory care. The surveyor asked how R3 fell despite the use of the bolsters. V9 did not give an answer. On 3/26/25 at 12:39PM V11 (RN) said on 3/20/25 R3 was in the bed, she had been coughing and we called RT earlier. V11 said RT did come right away, and they did not report any concern with R3. V11 said when I spoke to R4 (R3's roommate) she said R3 was jerking and coughing. V11 said I believe that is how R3 fell . V11 said when R3 jerks she lifts up her head and she moves up. V11 said jerks up is what caused R3 to move and fall. V11 said I have not a patient cough hard enough to fall out of bed before. V11 said when on a trach with secretions they cough a lot. V11 said R3 did not have the pads before the fall, the ones like a triangle. V11 said we added the pads (bolster pads) after the fall occurred. V11 said R3 had an air mattress on the bed, and she had a regular size bed. V11 said R3's bed went all the way to the floor. V11 said R3 fell towards the window side of the room (right side) and was on her side when I saw her. V11 said R3 was unable to indicate what had happened. V11 said R3 is nonverbal, she had not fallen before to my knowledge. On 3/26/25 at 2:07PM V6 (Director of Nursing/DON) said R3 had a fall on 3/20/25. V6 said the root cause of R3's fall was a cough. V6 said I spoke to the roommate, myself. V6 said the roommate, R4, said she heard R3 cough, and she heard a noise. V6 said for immobile residents, we have to round on them and keep them positioned in the bed. V6 said no one notified me R3 coughs so hard to move. V6 said we explained to R3's mother that R3 has involuntary movements. V6 said R3 did not have bolsters before the fall, R3 was not care planned for bolsters. V6 said V11 was instructed to add the bolsters and V11 replied I was going to go get them for R3. V6 said both R1 and R3 had air mattress the day they fell . The surveyor asked V6, can an air mattress pose a fall risk on patient who can't move? V6 replied, the air mattress is possible to cause a fall risk, if it is not positioned right, depending on the settings, they are smooth. V6 (DON) said we feel the root cause for both R1 and R2 made her position out of normal, and she can't control her body and caused her to fall. V6 said the staff said R1 had brown stuff coming out of her mouth. V6 said no one had ever said that R1 moves when she cough or has hard coughs. V6 said I have never seen her cough like that, hard to move her. V6 said R1 can't move, she is dependent on staff. V6 said R1 coughed herself out of alignment. V6 said V13 (RT) said they had checked on R1, and she had been fine. V6 said the vent alarmed and V13 responded and saw R1 on the floor. V6 said R1 sustained a C2 fracture, and the hospital doctor said there was nothing needed to treat. V6 said R1 does have a fracture. V6 said based on R1's fall risk assessment she was a high fall risk. On 3/27/25 at 11:12AM V14 (Nurse Practitioner) said I saw R3 after the fall. V14 said I did not notice a change, R3 was still at baseline. V14 said I was told R3 had the same cause of the fall as R1. V14 said R3 has a trach, and she could have coughed. V14 said I was not told that either R1 or R3 were coughing hard. V14 said I have been in nursing (Nurse and NP) almost [AGE] years, I have not seen a patient cough hard to fall out of bed. V14 said these are the first two patients, I have been notified that the coughing contributed to a fall. V14 said I think a vent alarm will trigger when altered breathing, coughing, need suction is needed. V14 said you would think the alarm would sound. V14 said if the alarm is sounding, I would expect they notify respiratory, call me if can't rectify the situation, to finish coughing. I would expect they stay in the room until the patient is stable. V14 I would think, if they stayed with the patient they would keep them safely in the bed. V14 said cough sounds can be different with a trach patient, there can be jerking movement. V14 said if they are on air mattress, they can be slippery. On 3/27/25 at 11:33AM V15 (Respiratory Therapist) said R3 has a tracheostomy on room air with only aerosol, just moisture. V15 said R3 can support her own respirations. V15 said when a person has a tracheostomy and a vent, you will not here them cough because the air does not pass the vocal cords. The facility Fall Guideline dated 8/2024 states the purpose is to consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization wide ownership for fall preventions to To achieve each resident's maximum potential of physical functioning period to prevent or reduce injuries related to falls. The intent of this guideline is to ensure facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: identification of hazards and risks, evaluation, implementation, monitoring, and analysis.

Based on interview and record review the facility failed to implement fall prevention interventions for a resident identified at risk for falls for one (R1) out of three residents reviewed for accidents in a total sample of three residents. Findings include: R1's face sheet documents that R1 is a [AGE] year-old individual with diagnoses not limited to: respiratory failure, dysphagia, oropharyngeal phase, cognitive communication deficit, other reduced mobility, anxiety disorder, unspecified. R1's face sheet documents in part R1 was initially admitted to the facility on [DATE] and discharged from the facility to the hospital on 10/20/2024. On 01/11/2025, at 11:44 AM, V7 (Licensed Practical Nurse) states that nurses work 12-hour shift. V7 states that she cannot recall who was the CNA (certified nursing assistant) working with her the date that R1 fell from her bed. V7 states that she floats. V7 reports that she remembers before leaving off the unit, she did her last round, and V7 states that she saw R1 lying in bed. V7 states about 15 minutes or 20 minutes later, the CNA came to get V7 in the lunchroom and V7 was informed that R1 was on the floor. V7 states that she came to the unit, the respiratory therapist (V7 cannot recall the name) informed her that she found R1 on the floor. V7 states that she conducted a head-to-toe assessment, and her vitals were ok. V7 states R1 did not suffer any visible injuries. V7 continues R1 had a little cut on her leg. V7 reports the provider was notified and ordered for R1 to be set out since the fall was unwitnessed. V7 was asked how was R1 when V7 was working with her that morning. V7 states that R1's vitals were stable, was alert, and is nonverbal. V7 states that she denies helping the CNA provide care to R1. V7 continues to report R1 did not exhibit any behaviors during the shift. On 01/11/2025, at 1:24 PM, V6 (Certified Nursing Assistant) states that she worked 7:00 AM-3:00 PM shift on 10/19/24, and a double shift on 10/20/2024. V6 was asked what happened that day when R1 was found on the floor. V6 states honestly, I was charting in the nurse's station, and then V9 (respiratory therapist) came to me. V6 states she needed assistance because she walked in and saw R1 on the floor. V6 states that R1 barely spoke English and was mainly Spanish speaking. V6 reports that when R1 would need water, or when she needs to be changed, if she needed to get on the bed pan, V6 states R1 would say [NAME] (bathroom) and Agua (water). V6 states that when R1 needed the suction, she used her hand to gesture to point to her trach, and V6 states that she would go get respiratory therapist. V6 reports that R1 was able to move her arms and R1 was not able to move her legs. V6 reports that R1 would turn side to side using her upper body, she would use the side rails to help turn. V6 states when she would talk, it would be very low and in Spanish. V6 states that does not remember R1 having any behaviors. V6 states that she didn't think R1 was a fall risk because R1 came from the hospital and normally they (residents) will have a wristband from the hospital showing that they are fall risk, and if they (residents) are fall risk, they will give us mat to place on the ground. R1 did not have floor mats. V6 states that when she saw R1 on the floor, lying like on her side and she did not see any bleeding, the bed was low. V6 states that she remembers the resident because she worked with the resident for two days and V6 continues to state not noticing any changes during those two days working with R1. Surveyor asked V6 if she needed assistance to provide care to R1. V6 replied no R1 wasn't that big, she turned good, and wasn't hard to turn and provide care to. V6 states I honestly feel like she was reaching for something, and she liked using her bedside table. She used to ask for two boxes of tissue. I always put the table next to her. V6 states that respiratory therapy and nurses go in, and they might not have placed the table next to her. V6 states that R1 was able to use the call light. V6 states that R1's call light was not turned on when the fall happened. V6 reports that R1 was on the vent and V6 thinks she started hearing the beeping, and V9 (Respiratory Therapist) came out of the office and started to see what was beeping about. V6 states that R1 was on her bed when V6 last checked on her 30 minutes prior. V6 reports that the nurse went in to see R1 after V6, she was asking her if she had any pain, checking vitals. V6 reports that R1's bedside table was away from the resident's bed, the call light was on the side next to R1 on the floor. V6 reports V9 was trying to hook R1 back up, and the nurse assisted V6 in putting her back on the bed. V6 states that R1 appeared a little shook up, V6 states R1 said she (R1) was not in a lot of pain, she was alert. V6 states R1 was sent to the hospital. On 01/11/25, at 1:56 PM via telephone V9 (Respiratory Therapist) states that when she heard R1's alarm sound V9 responded right away. V9 states that she found the patient on the floor. V9 states that she does not remember how the area looked because she (V9) was to assess the patient (R1). V9 reports that R1 was older women, small lady. V9 states that she assessed R1, and she (R1) was not in distress. V9 states that she does not remember if R1 had fall floor mats and where R1's bedside table was located. V9 states that as the respiratory therapist she does not use the bedside table because she has all respiratory items on a different table. V9 states that was the first time working with R1 and she did not have any problems that day with R1. V9 states that R1 didn't call her a lot that day, V9 states but she kept close eyes on her, V9 states because she was a little bit confused and R1 had a lot of secretion. She would make eye contact. She reacts when I said something. I think she was Spanish speaking. On 01/11/2025, at 2:27 PM, V4 (Licensed Practical Nurse/Restorative Nurse) states that she is the fall prevention coordinator and the restorative nurse. V4 states that she works Monday through Friday 9:00 AM-5:00 PM. V4 reports that she didn't get to assess R1 yet since R1 was admitted over the weekend. V4 states that upon admission, the admitting nurses initiate the fall risk care plan if a resident is assessed as being a fall risk. V4 states that she then reviews the care plans to make sure they are accurate. V4 states that the higher the score is the higher the risk they are at falling. V4 states that R1's risk score of 16 means R1 is a high fall risk. V4 states that R1's fall risk assessment should have had interventions checked off and there were none checked off. V4 states that standard fall prevention practices include bed in lowest position, make sure they have the right footwear, making sure everything is within the patient's reach, make sure that staff are toileting them when necessary, checking on them every two hours or as needed. V4 states that if the resident does not have items within their reach a fall can occur, because if they are reaching for it, they can roll over and fall out the bed, there is a possibility. R1's care plan reviewed and there is no fall risk related care plan and interventions noted. R1's fall incident report dated 10/20/24, documents in part R1 unable to give description. Predisposing environmental factors noted R1 was seen in the last two hours is checked off and call light within reach is not checked off. Resident (R1) was sent to the hospital will implement fall mats upon return. R1's fall risk assessment dated [DATE], documents in part that R1's fall risk score is 16 and no interventions were checked off. One of the interventions not checked off documents in part resident needs a safe environment with: personal items within reach. R1's hospital records dated 10/18/2024, reviewed and no documentation of R1 having any behaviors or falls in the hospital. R1's respiratory note dated 10/20/2024, 3:01 PM, documents in part find pt. (patient) on the floor face down, suctioned trach and orally /blood-tinged secretions from the trach. R1's progress noted dated 10/20/2024, 4:00 PM, documents in part approximately around 3:30 PM, writer (V7) was informed by respiratory staff that resident was on the floor. Upon coming into resident's room writer noted resident on the floor face down. There were no signs of active bleeding and resident was alert and orient. APN (advanced practice nurse) ordered for resident to be sent to ER (emergency room ). R1's progress note dated 10/21/2024, 11:21 AM, documents in part spoke with hospital ER (emergency room ) staff nurse. Resident admitting DX (diagnosis): hyperkalemia and leukocytosis. Facility document dated 08/2024 titled Falls Guidelines documents in part fall prevention is achieved through an IDT (interdisciplinary team) approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Understanding contributing and predicting factors that present will assist with determining individualized care approaches. Identification of resident risk for accidents on admission: observe resident in environment. Involve interdisciplinary team on development and implementation of interventions to reduce accidents.

Based on observation, interview, and record review the facility failed to implement the written policy and procedure that prohibit and prevent abuse. This deficiency affects all four (R46, R66, R106 and R107) residents in the sample of 23 reviewed for Abuse prevention Program. Findings include: On 8/28/24 at 12:35PM, V9 (Social Service Director/SSD) that they have four identified offender residents in the facility. Review medical records of R46, R66, R106 and R107. Noted that they don't have care plan developed as an identified offender in their charts. V9 said that she does not develop care plan for identified offender residents. She added that she is not aware that she must develop for them. Reviewed facility's identified offender policy with V9 indicates that care plan should incorporate resident who is identified offender including security measures. On 8/28/24 at 2:26PM, Informed V1 (Administrator) of above concern. V1 said that he will talk to V9 (SSD). Review R106's medical records. Unable to locate abuse/neglect screening upon admission. Requested copy of record to V2 (Director of Nursing/DON). On 8/29/24 at 9:40AM, V2 presented copy of R106's admission abuse/neglect screening assessment done on 8/28/24. Informed V2 said that social services do the abuse assessment for all residents upon admission. On 8/29/24 at 1:26PM, V9 (SSD) said that social services do the abuse assessment of resident upon admission. Informed V9 that R106 is admitted on [DATE] and abuse admission assessment was documented and completed in R106's chart on 8/28/24. V9 said that there are only 2 social services in the facility. V9 added that she documented in paper before she documented in resident's chart. Review R46, R66 and R107's admission abuse assessment. No abuse assessment done upon admission. V9 said that she has not completed the assessment in resident's chart. R106 is admitted on [DATE]. R46 is admitted on [DATE]. R66 is admitted on [DATE]. R107 is admitted on [DATE]. All residents are identified offenders. On 8/29/24 at 2:18PM, Informed V1 (Administrator) of concern identified that abuse assessment /screening as part of the abuse prevention program of the facility is not implemented. Facility's policy on Abuse prevention policy indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. IV. Establishing a resident sensitive environment. Resident assessment: As part of the resident's life history on the admission assessment, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary. Facility's policy on Identified offender indicates: Policy statement: It is the policy of this facility to establish a resident sensitive and resident secure environment. In accordance with the provisions of the Nursing Home Act, this facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. Definition: Identified Offender: any person who has been convicted of, found guilty of, adjudicated delinquent for, found not guilty by reason of insanity for, or found unfit to stand trial for, any of the statute citation number listed in the identified offender conviction list or any of the statute citation numbers listed in the sex offenses list of the (state surveying agency) identified offender program attached to this procedure. Care Planning: Upon admission of an identified offender or the decision to retain an identified offender in the facility, in consultation with the medical director and law enforcement shall specifically address the resident's needs in an individualized plan of care. *The facility shall incorporate the identified offender report and recommendations report into the identified offender's plan of care including the security measures listed. * The facility shall evaluate the care plans at least quarterly for identified offenders to make sure the areas related to the identified offence are still appropriate and effective. This review shall be documented, and the care modified as needed. * The facility shall remain responsible for continuously evaluation the identified offender and for making any changes in the care plan that are necessary to ensure the safety of residents.

Based on observation, interview, and record review the facility failed to implement its fall preventive interventions for a resident who is at high risk for falls. The facility failed to implement its policy on investigating and reporting resident's incident. The facility failed to assess accurately a resident who smokes in the facility. This deficiency affects all four (R6, R7, R103 and R106) residents in the sample of 23 reviewed for Resident safety. Findings include: 1. On 8/27/24 at 11:58AM, Observed R7 lying in bed, on semi-Fowlers position. She has oxygen via nasal cannula. Her bed is in high position. She has folded floor mat on side of the wall - one closer to the window side and the other one closer to the bathroom side. V12 (Licensed Practical Nurse/LPN) said, she is not sure if R7 is on fall precaution, but she is sure of R6 (the roommate). On 8/27/24 at 12:05PM, Observed R6 lying in bed with floor mat only on the right side of the bed (by the window side). The bed is on high position. V12 (LPN) took the floor mat on the side of the wall of R7 and placed it on R6's left side of the bed. Noted star sticker placed next to both R7 and R6. V12 said that both residents are on fall precautions. V12 said that star sticker that are placed next to the resident name by the door indicates that they are high risk for falls. V2 (Director of Nursing/DON) came to the room. Showed observation made. V2 said that R6 should have floor mat on both side of the bed and bed should be on the lowest position. V2 took the bed control and placed the bed to the lowest position. On 8/27/24 at 12:30PM, Review R6 and R7 medical records with V12 (LPN). Both residents are at high risk for falls due to history of falls. Both care plan interventions indicated: Bilateral floor mat and bed in the lowest position when resident is in bed. On 8/29/24 at 11:45AM, Review R6 and R7 medical records with V2 (DON). R6 is readmitted on [DATE] with diagnosis listed in part but not limited to Vascular dementia, Muscle wasting and atrophy, Muscle weakness, Anxiety disorder, Gastrostomy. Most recent fall assessment done on 5/8/24 indicated that she is at high risk for fall. Comprehensive care plan indicated that she is at risk for falling related to cognitive and mobility impairment, medication profile and multiple medical comorbidities contributing to risk of fall. Interventions: Bilateral fall mats at bedside. Keep bed in lowest position with brakes locked. Fall incidents: Unwitnessed fall on 4/2/24. R6 was found on lying on the floor. R6 was trying to get out from bed. Witnessed fall on 5/8/24. R6 slide from the bed. R7 is readmitted on [DATE] with admitting diagnosis listed in part but not limited to abnormalities of gait and mobility, Weakness, Delusional disorders, anxiety disorder. No Fall admission assessment was done. Unwitnessed fall incident dated 8/19/24, found lying on the floor. R7 said that she slid from bed. No fall assessment was done after the fall incident. V2 (DON) said that she is at high risk for falls. Comprehensive care plan indicated that she is at risk for fall related to bilateral weakness limitation to bilateral lower extremities, medications, and other disease conditions that increases risk for falls. Interventions: May have bilateral floor mats. Keep bed in the lowest position with brakes locked. Care plan does not indicate that R7 does not want her bed in the lowest position. 2. On 8/27/24 at 12:18PM, Observed R103 sitting in a wheelchair, wearing gown and brief. R103 complained that he cannot sleep because of his room is hot. He said he feels exhausted. Observed left hand thumb is reddened and swollen. R103 said that he caught his hand at the bathroom door 2 weeks ago or last week, he cannot remember. Review R103's medical records. No documentation of incident and investigation of left hand reddened and swollen thumb. On 8/28/24 at 11:22AM, Observed R103 up in wheelchair sitting in the hallway across the nursing station. R103 still with reddened and swollen left thumb. On 8/28/24 at 11:28AM, Interviewed V16 (Registered Nurse/RN), V17 (Certified Nurse Assistant/CNA) and V18 (CNA) who were at the nursing station and were not aware of R103's incident of left thumb. All said that they are not aware that R103 has reddened and swollen left thumb. V3 (Assistant Director of Nursing/ADON) is also not aware of the incident. V16 said, she is the nurse assigned to R103. V16 said that X-ray was done today for R103's right elbow, left thumb and bilateral knees. Surveyor asked for incident report for R103's left thumb. V3 (ADON) and V16 (RN) were not aware if an incident report was made. Both searched R103's e-chart and were unable to locate one. Both said that an incident report of unknown injury form is usually documented under events, but nothing was found in R103's chart except the progress notes. Called V2 (DON). V2 said that she is not aware of R103's reddened and swollen left thumb. V12 (LPN) did not report to her nor made an incident report. V2 said that any incident, regardless of how minor, including injuries of unknown source must be reported to the supervisor and report form must be completed. V2 said that she will initiate the incident report and investigation. R103 is admitted on [DATE] with diagnosis listed in part but not limited to Vascular dementia, Anxiety disorder, Psychosis, Communication deficit, Diabetes Mellitus type 2. 3. On 8/28/24 at 11:20AM, Observed with V3 (ADON) that R106 lying in bed in his room. R106 said that he smokes three times a day and as needed. He keeps his cigarette and lighter with him. Observed cigarettes on top of his bedside drawer. V3 (ADON) said that social service does the smoking assessment to resident who desire to smoke in the facility. R106 is admitted on [DATE] with diagnosis listed in part but not limited to Psychosis. He is an identified offender. Smoking assessment done on 8/17/24 indicated that he does not smoke. On 8/28/24 at 1:30PM, Informed V2 (DON) of above observation and that smoking assessment was not done accurate to R106 who smokes and keeps his cigarette and lighter at bedside. V2 said that smoking assessment should be completed to resident who desires to smoke for safety. Facility's policy on Fall guidelines revised on 8/2024 indicates: Fall prevention is achieved through an IDT approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls. Facility staff across all departments together with resident representatives and residents provide resourceful information with individualizing care and approaches. Fall Management (Determination of risk): *Develop and implement interventions. Facility's policy on Accidents/Incidents/Events- Investigating and Reporting revised August 2008 indicates: Policy statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises must be investigated and reported to the administrator. Policy and interpretation and implementation: 1. Reporting of accidents/incidents: a. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. b. A report form must be completed for all accidents or incidents. d. The Nurse Supervisor/Charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided. 4. Investigative action: a. The nurse supervisor/charge nurse and or the department director or supervisor must conduct an immediate investigation of the accident or incident. b. The following data, as it may apply must be included on the report of incident/accident form: (1) The date and time the accident or incident took place; (2) The nature of the injury/illness (e.g., bruise, fall, nausea, etc.) (3) The circumstances surrounding the accident or incident (4) Where the accident or incident took place (6) The injured person's account of the accident or incident (7) The time the injured person's attending physician was notified (8) The date/time the injured person's family was notified and by whom (9) The condition of the injured person's, to include his or her vital signs (10) Any corrective action taken (12) Follow up information c. A completed report of incident/accident form must be submitted to the Director of Nursing Services no later than 12 hours after the occurrence of the accident of incident. 5. Forwarding completed report of incident/accident forms: 2. Submit the original copy of the report of incident/accident form to the Administrator no later than 24 hours after the occurrence of the accident or incident. Facility's policy on Smoking-residents revised August 2008 indicates: Policy statement: to establish and maintain safe resident smoking practices. Interpretation and implementation: Standards: 2. All residents who desire to smoke will have assessment performed by a qualified member of the social service department to determine if they are safe to smoke independently. The assessments will be reviewed by an interdisciplinary team for determination of appropriate interventions, if needed as well as care plan development. 3. Smoking risk assessment are performed upon admission and quarterly or with any changes which could affect the safety of the resident. These assessments are reviewed by the interdisciplinary team for agreement and planning of interventions.

Based on observation, interview, and record review the facility failed to implement their appropriate extreme high temperature policy and procedures in the facility. This deficiency affects two (R103 and R69) of three residents in the sample of 23 reviewed for Safe and comfortable resident environment. Findings include: 1. On 8/27/24 at 11:54AM, Rounds were made to the 2nd floor unit. Surveyor felt warm air on the unit and noted two electric fans by the nursing station; there was no electric fan by the unit hallway. On 8/27/24 at 12:18PM, Observed R103 sitting in a wheelchair, wearing a gown and a brief. R103 complained that he cannot sleep because his room is hot. He said he feels exhausted. He was observed trying to remove his gown and appears restless. R103 keeps saying the room is hot. The window curtain was observed open with sunlight going through the window and into his room. The air conditioner was located by the window with warm air coming out. Showed observation to both V12 (Licensed Practical Nurse/LPN) and V2 (Director of Nursing/DON), both said that they are not aware of R103's room situation and V8 (Maintenance Director) was called. On 8/27/24 at 12:27PM, V8 (Maintenance Director) informed of R103's room situation. V8 did measure the room temperature using relative humidity temperature meter and his room reading was 84 degrees Fahrenheit (F). V8 said that temperature should be at least 80 degrees Fahrenheit. On 8/27/24 at 12:32PM, Rounds made with V8 (Maintenance Director) on the 2nd floor unit. V8 took the temperature of the hallway and obtained 86.4 degrees (F). V8 took the temperature of the dining room and obtained 86.8 degrees (F). The dining room has 2 electric fans. There were 6 residents in the dining room, sleepy and unable to be interviewed. Observed water station by the nursing station but no staff handling or offering the water to the residents. On 8/29/24 at 10:26AM, Reviewed R103's medical records with V2 (DON). No documentations of R103's being monitored for his intake and output of fluids. No documentation of encouragement of fluid intake. No documentation of R103's signs of discomfort, symptoms of heat stroke and heat exhaustion. V2 said that they don't have any documentation of monitoring indicated in their extreme high temperature guideline. On 8/29/24 at 10:42AM, V8 (Maintenance Director) said that they installed a new air conditioner for R103. V8 said that he usually monitors the temperature daily and in extreme heat every 2 hours, but he said that he did not document it. V8 said that acceptable resident room /environment temperature is below 80 degrees (F). He does not measure and document humidity, only temperatures. Reviewed facility's policy on extreme high temperature with V8. He said that he did not have documentation of monitoring of facility 's room /areas for temperature and humidity every 2 hours from 8am to 10pm and every 4 hours from 10pm to 8am. He does not have documentation of monitoring of ventilation system and air conditioning system. On 8/29/24 at 2:26PM, Informed V1 (Administrator) of above concerns. R103 is admitted on [DATE] with diagnosis listed in part but not limited to Hypertension, Diabetes Mellitus type 2, Vascular dementia, Chronic pulmonary disease, anxiety disorder. Facility's policy on Extreme high temperature guideline revised 4/3/2024 indicates: Purpose: To provide guidance to the facility in times of unseasonable hot weather and or cooling system malfunction. Should the temperature index relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. Should a specific area of the facility rise above 80 degrees, it may be necessary to relocate residents to a cooler section of the facility. If the high temperature procedures do not sufficiently maintain resident safety, the facility shall consult with the Department of Public Health regarding advisability of resident evacuation. Department specific procedures: Nursing: *Monitor residents for intake and output of fluids. Encourage fluids. *Monitor residents closely for signs of discomfort and adverse physical symptoms. *Monitor all residents frequently for symptoms of heat stroke and heat exhaustion. *Offer cool fluids, ice cream, popsicles regularly. Dietary: *Prepare hydration stations for nursing stations and resident areas Maintenance: * Monitor air temperatures at least every 2 hours between 8:00am and 10:00pm in the resident areas and every 4 hours between 10:00pm and 8:00am. Temperatures should be taken at the warmest point identified through baseline monitoring on each floor or wing. Include day rooms, dining rooms, activity rooms and resident rooms. * Monitor all ventilation systems and ensure they are in working condition *Monitor all air conditioning systems. Clear areas around units of vegetation and debris allow better air flow. Clean air conditioning filters. Check all blower motors. Assure water lines to the building are working appropriately. 34069 2. On 8/27/24 at 1:07 PM. surveyor and V8 (Maintenance Director) toured throughout the facility taking random room temperatures. R69's room temp was 80.6 degrees (relative humidity was not relayed at that time and was not documented). On 8/28/24 at 11:30 AM, V23 (Concerned party) said administrator in training is aware of air conditioning issues and said R1's side of the facility has air conditioning issues. Concerned party said this has been an issue since May. Concerned party said air conditioning issues should have been addressed by now. On 8/28/24 at 9:18 AM, R69 said the air conditioner in his room doesn't work thus he was not feeling well. R69 said he was nauseous and had loss of balance. On 8/29/24 at 9:22 AM, V1 (Administrator) said the room temperature should not be higher than 80 degrees. V1 said V8 is responsible for documenting temperatures and relative humidity on extreme heat days. V1 said he did not see relative humidity documented on the temperature log sheet for 8-26-24 and 8-27-24 (Extreme Heat Days). On 8/29/24 at 10:36 AM, V8 (Director of Maintenance) said he did check the relative humidity on Monday and Tuesday (Extreme Heat Days) however V8 did not document relative humidity in the temperature. V8 said the humidity affects extreme heat and will make the environment more stuffy or uncomfortable for the resident. V8 said room temperatures should be below 80 degrees. Extreme High Temperature Guideline (revised 4/3/24) documents: Should the temperature index for relative humidity and temperature in this facility rise above 80 degrees, the facility shall implement the appropriate high temperature procedures. Temperature Log dated August 2024 does not document relative humidity levels for 8/26/24 and 8/27/24 (extreme heat days) as verified by Administrator and Director of Maintenance.

Based on observation, interview, and record review the facility failed to follow the facility's policy for using Low Air loss mattress regarding bed linens for a resident with skin impairment. This deficiency affects one (R7) of three residents in the sample of 23 reviewed for Prevention of Pressure wounds protocol. Findings include: On 8/27/24 at 11:58AM, Observed R7 lying in bed with low air loss (LAL) mattress. V12 (Licensed Practical Nurse/LPN) said that R7 has pressure ulcer and on wound care management. Checked bedding with V12 and V2 (Director of Nursing/DON). Observed multi-layers of linen. R7 has folded linen in quarters used as draw sheet and cloth pad over the LAL mattress. R7 wears disposable adult brief. V2 (DON) said that resident on LAL mattress should only be on a flat sheet over the LAL mattress. V2 instructed V12 (LPN) to inform the CNA (Certified Nursing Assistant) to remove the folded linens and cloth pad underneath R7. On 8/28/24 at 11:38AM, V11 (Wound Care Nurse) said that resident on LAL mattress should only have 2 layers- adult brief and flat sheet, adult brief and cloth pad, or no brief but with flat sheet and cloth pad. V11 said that R7 should only have 2 layers- brief and flat sheet or cloth pad not both. R7 is readmitted on [DATE] with diagnosis listed in part but not limited to Peripheral arterial disease, Bed confinement status, Severe morbid obesity due to excess calories, Venous Insufficiency. Active physician order sheet indicates: Pressure reduction mattress. Comprehensive care plan indicates: R7 has an actual alteration in skin integrity due history of pressure ulcers, decreased mobility. Interventions: Low air loss mattress for pressure reduction while in bed. Facility's policy on Prevention of Wounds effective date: January 2017 indicates: Purpose: to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Interventions and Preventive measures: General Preventive measures: 2. For a person in bed: c. If a special mattress is needed, use one that contains foam, air as indicated. Residents with risk factors-bed fast: 2. Use a special mattress that meets clinical condition. Facility's policy on Low air loss mattress 7/2012 indicates: Purpose: to provide features of a mattress support system that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin. Low air loss mattresses will be utilized for residents with Stage III, IV and unstageable pressure ulcers of the trunk as well as residents with multiple stage II pressure ulcers. Procedure: 5. A single non-fitted sheet may be used on the mattress for assistance with repositioning.

Based on interview and record review, the facility failed to notify the physician of a resident not having any urine output from the urinary catheter for an entire eight-hour shift. This affected one of three residents (R2) reviewed for physician notification in a total sample of six. This failure resulted in R2 retaining 1,450 mL (milliliters) of urine in the bladder (maximum capacity is [PHONE NUMBER] mL) and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. Findings Include: R2 is a [AGE] year-old with the following diagnosis: quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy. A Nursing note dated 5/18/24 documents R2 refused breakfast and lunch. R2 reported not feeling well vital signs were stable. A Nursing note dated 5/19/24 documents a physician was not notified at 12:57 PM that the urinary catheter was leaking and R2 was exhibiting confusion. A Physician note dated 5/19/24 documents the nurse reported vital signs of 85/60, heart rate of 119 after giving medication 30 minutes ago to help raise the blood pressure. Orders were given to send R2 to the hospital via 911. The nurse also reported the urinary catheter was leaking, an order was given to change the catheter. This was not completed before R2 left for the hospital. The Hospital Records dated 5/19/24 document R2 came to the hospital for persistent low blood pressure and tachycardia along with altered mental status. Upon assessment, R2's bladder was palpable at the umbilicus. A comprehensive metabolic panel was drawn and shows the BUN at 71 (normal is 6-20 mg/dL) and creatinine at 1.24 (normal is 0.51-0.95 mg/dL). Both levels are high indicating a kidney injury. A complete blood count was also drawn, and the white blood cells were 20.7 (normal is 4.2-11.0 K/mcL). This is elevated indicating an infection in the body. The urinary catheter was completely dry and had not likely been draining for some time. The catheter was removed and replaced, and urine began pouring from the patient once the catheter was removed. The catheter output in the emergency department is documented as 1450 mL. The urge to urinate for women is when the bladder is about 500 mL full. The maximum bladder capacity can range from [PHONE NUMBER] mL. (These numbers were found on live science.com) The elevated kidney levels (BUN and creatinine) are likely post renal and pre-renal. R2 was admitted to the hospital with a diagnosis of severe sepsis, acute kidney injury, and low sodium levels. The Medication Administration Record (MAR) dated 05/2024 documents changing the urinary catheter for blockage and/or leaking does not have any documentation that it was completed. R2 had the original urinary catheter inserted on 4/17/24. There's also an order to monitor output every shift. On 5/18/24, there is documentation on the dayshift that there was a small amount of output of 400 mL and the night shift documented a small amount of 0 mL. There is no documentation that the catheter was changed, or the physician was notified for the output of 0 mL on 5/18/24. On 5/21/24 at 12:59PM, V4 (Certified Nursing Assistant/CNA) stated V4 was changing R2 around 12PM on 5/19 and noticed at the catheter leaking and told the nurse. On 5/21/24 at 2:23PM, V5 (Nurse) stated V4 notified V5 of R2's catheter leaking when they went to change R2. V5 reported calling the on-call physician and got orders to change the urinary catheter but this was not completed due to R2 needing to leave the facility via 911. V5 stated R2 was admitted to the hospital with sepsis and acute kidney injury. V5 reported a physician should be notified of a change in condition so they can put in orders to help the resident. On 5/21/24 at 3:19PM, V10 (Nurse Practitioner) stated if the catheter is not draining out any urine, V10 would expect staff to flush the catheter with normal saline sterile technique to see if they could get any urine to drain into the bag. V10 reported if that doesn't work, then staff should change the catheter and if that still doesn't work, then the nurse practitioner or physician needs to be notified. V10 stated retaining urine can cause altered mental status in females especially. V10 reported the urine can also back up into the kidneys and cause kidney failure and sepsis. On 5/21/24 at 3:25PM, V2 (Director of Nursing/DON) stated if zero is charted on the MAR for output then the resident had no urine documented. On 5/21/24 at 5:02PM, V12 (Primary Physician) was asked what the expectation of the staff is if there is no urine output for an entire shift. V12 replied V12 would expect the nurse to assess the patient and notify the physician and replace or flush the catheter to see if it is working properly. V12 stated if none of those things work, then there would be an order to send the person to the hospital. On 5/22/24 at 12:21AM, V13 (Nurse) stated if a nurse can't get the urinary catheter to drain then the nurse has to call the doctor. V13 reported V13 didn't call the doctor that night. V13 said, I don't remember needing to because I charted a small output but not the exact amount. V13 was unaware why zero was charted for the urine output. The Physician Order Sheet documents an order to provide catheter care every shift, change the urinary catheter for blockage and/or leaking as needed, and monitor output every shift. These orders were placed on 4/17/24. The Care Plan dated 4/26/24 documents R2 requires an indwelling urinary catheter related to neurogenic bladder. Interventions include to assess the drainage and record the amount, type, color, and odor. Observe for leakage. The policy titled, Notification of Resident Change in Condition, dated 11/2016 documents, Policy: It is the policy of the facility to promptly notify the resident, their legal representative and attending physicians of changes in the resident's health condition .Standards: 1. A licensed nurse shall promptly inform the resident, consult with the resident's physician, and if known, notify the resident legal representative or an interested family member of: . significant change in resident's physical, mental, or psychosocial status, i.e. Mental or psychosocial status in either life-threatening conditions or clinical complication. 2. The licensed nurse is to use professional judgment in determining changes in condition based un assessment and findings or signs and symptoms of change, which could lead to deterioration treated. 3. Clinical change and condition is determined by resident visualization, medical record review, clinical assessment, findings, and care plan review. The policy titled, Catheter Care - Urinary, dated 09/2005 documents, The purpose of this procedure is to prevent infection of the resident's urinary tract . General Guidelines: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to your supervisor.

Based on interview and record review, the facility failed to assess, change, or flush a resident's urinary catheter after the resident did not have any urine output from the catheter for an entire eight-hour shift. This affected one of three residents (R2) reviewed for catheter care in a total sample of six. This failure resulted in R2 retaining 1,450 mL (milliliters) of urine in the bladder (maximum capacity is [PHONE NUMBER] mL) and needing to be treated for a urinary tract infection and an acute kidney injury at the hospital. Findings Include: R2 is a [AGE] year-old with the following diagnosis: quadriplegia, neuromuscular dysfunction of the bladder, dysphagia, and encounter for gastrostomy. A Nursing note dated 5/18/24 documents R2 refused breakfast and lunch. R2 reported not feeling well vital signs were stable. A Nursing note dated 5/19/24 documents a physician was not notified at 12:57 PM that the urinary catheter was leaking and R2 was exhibiting confusion. A Physician note dated 5/19/24 documents the nurse reported vital signs of 85/60, heart rate of 119 after giving medication 30 minutes ago to help raise the blood pressure. Orders were given to send R2 to the hospital via 911. The nurse also reported the urinary catheter was leaking, an order was given to change the catheter. This order was not completed due to R2 leaving the facility via 911. The Hospital Records dated 5/19/24 document R2 came to the hospital for persistent low blood pressure and tachycardia along with altered mental status. On arrival, R2 was febrile to 101.3 F. Upon assessment, R2's bladder was palpable at the umbilicus. A comprehensive metabolic panel was drawn and shows the BUN at 71 (normal is 6-20 mg/dL) and creatinine at 1.24 (normal is 0.51-0.95 mg/dL). Both levels are high indicating a kidney injury. A complete blood count was also drawn, and the white blood cells were 20.7 (normal is 4.2-11.0 K/mcL). This is elevated indicating an infection in the body. The urinary catheter was completely dry and had not likely been draining for some time. The catheter was removed and replaced, and urine began pouring from the patient once the catheter was removed. The catheter output in the emergency department is documented as 1450 mL. The urge to urinate for women is when the bladder is about 500 mL full. The maximum bladder capacity can range from [PHONE NUMBER] mL. (These numbers were found on live science.com) The elevated kidney levels (BUN and creatinine) are likely post renal and pre-renal. R2 was admitted to the hospital with a diagnosis of severe sepsis, acute kidney injury, and low sodium levels. The Medication Administration Record (MAR) dated 05/2024 documents changing the urinary catheter for blockage and/or leaking does not have any documentation that it was completed. R2 had the original urinary catheter inserted on 4/17/24. There's also an order to monitor output every shift. On 5/18/24, there is documentation on the dayshift that there was a small amount of output of 400 mL and the night shift documented a small amount of 0 mL. There is no documentation that the catheter was changed/flushed or that the physician was notified for the output of 0 mL on 5/18/24. On 5/21/24 at 12:59PM, V4 (Certified Nursing Assistant/CNA) stated on 5/19/24 while providing incontinence care around 12PM R2's urinary catheter began leaking so V4 told V5. On 5/21/24 at 2:23PM, V5 (Nurse) stated V4 told V5 that the urinary catheter was leaking while R2 was being changed. V5 reported R2 had a low blood pressure and elevated heart rate so the physician was contacted and notified about the vital signs and leaking catheter. V5 stated V5 did not get a chance to change to urinary catheter before R2 left for the hospital because the doctor wanted R2 sent out via 911. V5 reported calling the hospital after R2 left and R2 was admitted to the hospital with sepsis and acute kidney injury. V5 stated if no urine is coming out of the catheter and collecting in the bag then the catheter should be changed out. V5 denied being told by V13 (Nurse) that R2 had no output in the urinary catheter. On 5/21/24 at 3:19PM, V10 (Nurse Practitioner) stated if the catheter is not draining out any urine, V10 would expect the staff to flush the catheter with normal saline to see if they could get any urine to drain into the bag. V10 reported if that doesn't work, then the staff should change the catheter and if that still doesn't work, then the nurse practitioner or physician needs to be notified. V10 stated the causes of urine not draining into the bag would be dehydration due to a resident not making enough urine or a blockage of the catheter causing them to retain the urine. V10 reported retaining urine can cause altered mental status in the females especially. V10 stated the urine can also back up into the kidneys and cause kidney failure and sepsis. V10 reported R2 has a neurogenic bladder so R2 either needs to be straight catheterized or have a permanent catheter due to the retention. V10 stated signs of retention would be a distended abdomen, pain in the abdomen, or no urine collecting in the back. V10 said, There should not be zero documented for urinary output during a shift. V10 reported a body is constantly in the state of making urine so even if a person is dehydrated, the body should be able to produce some urine as long as there are no problems with retention. On 5/21/24 at 3:25PM, V2 (Director of Nursing/DON) stated R2's urinary catheter was placed on the day R2 was admitted from the hospital (about one month ago). V2 reported R2 was sent to the hospital for elevated heart rate and low blood pressure and was admitted with sepsis and acute kidney injury. V2 stated R2 had an order to change the catheter for a blockage or leaking. V2 reported when zero is charted in the MAR for urine output, it means the resident didn't have any output. V2 stated if a resident doesn't have any output, then the nurse should flush the catheter or change out the catheter to see if the resident has urine in the bladder. V2 reported if the catheter is obstructed then the urine can leak around the catheter. V2 said, If they are retaining urine, they can end up with kidney issues, a bladder rupture, or an infection. On 5/21/24 at 5:02PM, V12 (Primary Physician) stated if someone had no urinary output in an entire shift V12 would assume that there was some kind of blockage in the catheter due to a possible malposition. V12 reported V12 would expect the staff to contact whoever is on call and flush the catheter to see if they get any urine output. V12 stated if the resident still doesn't get any output, then they need to attempt to replace the catheter. V12 said, If urine isn't draining from the bladder into the catheter, it can result in obstructive uropathy and post renal acute kidney injury. V12 reported a kidney injury like this can only be corrected by relieving the obstruction. V12 stated no resident should be retaining urine with a catheter in place. V12 reported V12 would expect the nurse to assess the patient and notify the physician and replace or flush the catheter to see if it is working properly. V12 stated if none of those things work, then there would be an order to send the person to the hospital. On 5/22/24 at 12:21AM, V13 (Nurse) stated V13 was the nurse on night shift on 5/18 for the 11PM to 7AM shift. V13 reported charting small output but was unaware why zero milliliters were also charted. V13 stated if there's output then then staff has to chart it. V13 reported someone not having any output with a urinary catheter in place may have it blocked or that the catheter isn't working anymore. V13 reported the catheter could have something wrong in the tubing so a nurse has to flush it or change it to get urine flowing again. V13 stated if nothing was draining out, that means R2's bladder was probably getting full. The Care Plan dated 4/26/24 documents R2 requires an indwelling urinary catheter related to neurogenic bladder. Interventions include to assess the drainage and record the amount, type, color, and odor. Observe for leakage. The Physician Order Sheet documents an order to provide change the urinary catheter for blockage and/or leaking as needed and monitor output every shift. These orders were placed on 4/17/24. The policy titled, Catheter Care - Urinary, dated 09/2005 documents, The purpose of this procedure is to prevent infection of the resident's urinary tract . General Guidelines: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to your supervisor .7. Maintain an accurate record of the resident's daily output, per facility policy and procedure .12. Empty the collection bag at least every eight hours .14. Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to the supervisor immediately.

Based on interview and record review, the facility failed to identify, assess, and treat a post-surgical wound site for 1 of 3 residents (R1) reviewed for wounds in the sample of 9. This failure resulted in R1's wound site becoming infected, requiring a 10-day course of antibiotics, and at least four weeks of wound care treatment. The findings include: R1's Face Sheet printed 4/26/24 shows she was admitted to the facility on [DATE]. R1's Nurse Practitioner's (NP) Progress Notes dated 2/8/24 at 9:51 AM show R1 is status post tracheostomy and PEG (feeding) tube placement on 1/31/24. R1's Progress Notes show the Wound Care Nurse's, V4, note dated 2/8/24 at 2:16 PM shows R1's admission skin assessment was complete. No wound to R1's right clavicle/neck was documented. On 2/20/24 at 5:28 PM, Respiratory Therapy documentation shows redness was noted on R1's right side next to her stoma (tracheostomy) site with an embedded suture in the skin. Nursing notes dated 2/20/24 at 7:33 PM show R1 has a wound to her right front neck with a scant amount of serous drainage, reddened skin, and no odor. Nursing notes dated 2/21/24 at 1:42 AM show R1 has antibiotic therapy in progress for an infection to her stoma trachea site. On 2/21/24 at 12:03 PM, V4 (Wound Care Nurse) documents that she was informed of an embedded suture to R1's neck under R1's trachea collar. V4 assessed the area and describes some redness to the area with serosanguineous drainage, no odor, and no signs of pain. V4 removed the suture, informed the wound care physician, and initiated a care plan related to the wound. R1's Physician Order Report for 2/7/24 to 4/26/24 shows an antibiotic was ordered on 2/20/24, discontinued on 2/22/24, and reordered on 2/22/24 for a diagnosis of infection to the right clavicle area to be given twice a day from 2/20/24 to 3/1/24. The same order report also show R1 is to receive tracheotomy care every morning from 2/7/24 to 2/27/24. Wound care treatments were ordered to R1's neck/clavicle area beginning on 2/21/24 to 2/27/24 and again from 3/11/24 to 3/27/24. R1's Progress Notes show R1 was sent to the hospital (for unrelated concerns) on 2/27/24 and was readmitted to the facility on [DATE]. R1' Care Plan initiated on 2/21/24 shows R1 has signs and symptoms related to right clavicle area wound infection and is currently on an antibiotic. V14 (Wound Care Physician) documented on 2/23/24 in R1's Wound Evaluation & Management Summary a post-surgical wound to R1's trachea site describing that a suture came out of the trachea site. V14 ordered wound care treatments to the area three times a week for 30 days. V14's Wound Evaluation & Management Summary documentation from 3/29/24 shows R1's post-surgical wound (as described above) was resolved on 3/29/24. R1's NP note dated 2/25/24 at 12:53 PM shows R1's physical exam shows a right clavicle/neck area with embedded suture with wound around site that has mild erythema (redness) and some non-odorous serosanguineous drainage (thin, watery, pink-tinged). The assessment/plan from that note is Infected Wound, initiate antibiotics twice a day for 10 days. On 4/26/24 at 10:44 AM, V5 (Respiratory Therapist/RT) said respiratory does trachea care every day on each resident with a trachea. Trachea care includes changing the gauze, cleaning the stoma and area around it, and suctioning. V5 said sometimes the initial trachea is sutured in place and sutures usually stay in about 14 days. V5 said RT found R1's suture embedded in her skin to the right of her stoma on 2/20/24. V5 said the RT should have been able to see the suture with daily trachea care. V5 said she could have removed the suture, but it was embedded, and she noted some redness and drainage. V5 said she was concerned it could be infected, so she told nursing about it. On 4/26/24 at 12:00 PM, V4 said R1 was admitted with two sutures: one on each side of her trachea plate. V4 said RT asked her to remove the sutures. V4 said R1's right side suture was embedded in her skin and looked puffy, a little red, and had some serosanguinous drainage. V4 said R1 was put on antibiotics to treat it for infection. V4 said RT should have identified the sutures and informed wound care about them. V4 said surgical wounds usually have sutures in place for two weeks. V4 said she does not know how long trachea sutures are left in place, but they should be removed before they become embedded in the skin.

Based on interview and record review the facility failed to ensure a resident was seen by the eye doctor as requested by the resident's Power of Attorney (POA) for 1 of 3 residents (R1) reviewed for vision in the sample of 13. The findings include: R1's Face Sheet shows that she admitted to the facility on [DATE]. R1's Electronic Medical Record shows that she had a Care Plan meeting on 11/3/23 and 3/11/24. On 4/19/24 at 11:39 AM, V14 (Social Service Director) said that R1 has had two care plan meeting since being admitted and the POA has requested for the eye doctor to see her at both meetings. V14 said that she is not sure if R1 has seen the eye doctor yet. On 4/19/24 at 10:55 AM, V2 (Director of Nursing) said that they have an eye doctor that comes to the facility on ce a month to see residents. V2 said that all residents are seen routinely and as requested. V2 said that if a resident or family member wants a resident to see the eye doctor, social services are to make sure that they are put on the list for the doctor to see at their next visit. V2 said that she is not sure why it took so long for R1 to see the eye doctor. R1's Comprehensive Eye Exam dated 3/18/24 shows that R1 saw the eye doctor and was diagnosed with presbyopia and a prescription was given for glasses. On 4/19/24 at 2:50 PM, V2 stated that the facility does not have a policy on vision services, but it is expected that the resident is seen by the eye doctor upon physician's order or as requested by the resident or POA.

Based on interview and record review the facility failed to ensure a resident was seen by the dentist as requested by the resident's Power of Attorney (POA) for 1 of 3 residents (R1) reviewed for dental in the sample of 13. The findings include: R1's Face Sheet shows that she admitted to the facility on [DATE]. R1's Electronic Medical Record shows that she had a Care Plan meeting on 11/3/23 and 3/11/24. On 4/19/24 at 11:39 AM, V14 (Social Service Director) said that R1 has had two care plan meeting since being admitted and the POA has requested for the dentist to see her at both meetings. V14 said that she had seen the dentist by the most recent care plan but was not sure why she was not seen after the first care plan meeting. On 4/19/24 at 10:55 AM, V2 (Director of Nursing) said that they have a dentist that comes to the facility on ce a month to see residents. V2 said that all residents are seen routinely and as requested. V2 said that if a resident or family member wants a resident to see the dentist, social services are to make sure that they are put on the list for the doctor to see at their next visit. V2 said that she is not sure why it took so long for R1 to see the dentist. R1's Dental Consult dated 3/6/24 shows that she had moderate plaque and staining, mildly dry mouth, puffy tissue, and mild thrush. On 4/19/24 at 2:50 PM, V2 (Director of Nursing) said that R1 has only had one dental exam (3/6/24) since being admitted to the facility. The facility's Dental Services Policy revised August, 2008 shows, Oral health services are available to meet the resident's needs .Our facility has a contract with a dentist that comes to the facility and provides dental services .The Director of Nursing Services or his/her designee, is responsible for notifying Social Services of a resident's need for dental services. Social Services personnel will be responsible for assisting the resident/family in making dental appointments.

Based on interview and record review the facility failed to implement interventions to monitor a resident with cognitive deficits and impulsive behaviors and failed to utilize assist of two people for bed mobility and repositioning. This affected 3 of 6 (R9, R10, and R16) residents reviewed for safety and fall prevention. This failure resulted in R16 falling, sustaining a laceration requiring 6 staples and having an acute fracture of left proximal humeral with displacement. R10 slid out of bed and developed an open and raised area on her forehead. The findings include: 1.R16 is [AGE] years old with diagnosis including but not limited to Dementia with Behavioral Disturbances, Major Depressive Disorder, Osteoarthritis, Insomnia, History of Left Arm Humerus Fracture, Palliative Care, Cognitive Communication Deficit, Difficulty in Walking, Need for Assistance with Personal Care, History of Falling, and Weakness. On 11/14/23 at 11:45AM V18 (Licensed Practical Nurse/LPN), said I saw R16 sitting in the edge of the bed folding her clothes. V18 said about 8:00PM I gave R16 her medications and then the Certified Nursing Assistant (CNA) assisted R16 into the bed. V18 said when R16 was in bed, the bed was in the lowest position. V18 said I was at the nurses' station and the CNA was in the hallway. V18 said R16 is a fall risk. V18 said R16 normally gets up unassisted and does stuff. V18 said R16 will constantly get up. V18 said from the nurses' station I heard a noise, and I went to see, then I saw R16 on the floor. V18 said R16's head was on shoes and there was blood on the floor. V18 said R16 was right by the bed. V18 said the bed was not in the lowest position when I went into the room. V18 said R16 can use the bed remote. V18 said R16 needs constant watching. V18 said I don't remember the CNA's name who was working with me. V18 said R16 had a laceration on the scalp, and she was screaming about her left arm. V18 said we do not use symbols on the unit to know who a fall risk is. On 11/14/23 at 12:20PM V21 (CNA) said on first rounds with R16 she was sitting up folding her clothes and I put her to bed. V21 said when I did rounds R16 got back up and I put her back to bed. V21 said I was in another room, then I heard a crash and when I found R16 she was backwards. V21 said when I went in the room R16 was on her back and she had hit her head. V21 said the room she is in now, is not the same room she was in when she fell , she was further down the hallway. V21 said R16 will get up and walk around the room. V21 said R16 did not have floor mats when she fell . V21 said I think R16 just got up and tripped on her shoes. On 11/15/23 at 12:06PM V26 (Medical Doctor) said R16 has behavioral falls. V26 said R16 had an arm fracture a couple years ago. V26 said R16 gets agitated, has delusional thoughts. V26 said R16 is a high fall risk. V26 said floor mats should be in place and the bed remote should not be in her reach. V26 said if the staff don't know the patient, they may have given her the remote. On 11/14/23 at 11:07AM V12 (Assistant Director of Nursing/ADON) said we expect staff to follow the care plan. V12 said the purpose of the fall interventions are to prevent a fall from occurring. V12 said she was the fall coordinator when R16 fell . At 1:49PM V12 said R16 fell out of bed in her room. V12 said R16 fell between 1:00AM and 2:00AM. V12 said R16 had a laceration to her head and her left shoulder was swollen. V12 said R16 received 6 sutures. V12 said the root cause of R16's fall she was disoriented and demented, and she got out of bed unassisted. V12 said at time of the fall R16 had a fall mat and a low bed. V12 said R16's bed goes down to the floor and her bed was in the lowest position on the floor. V12 said R16 was a fall risk and needs supervision. V12 said R16 can't remember she needs assistance and can be impulsive. V12 said frequently means to make rounds as often as needed, there is nothing special about frequently. V12 said the staff should put the resident bed in the lowest position and V16 should not be given the bed remote. V12 said R16 could lift the bed and then it would not be in the lowest position, placing R16 at risk for falls. V12 said when investigating the falls handwritten staff statements are gathered. V12 said she in-serviced the staff on the falling leaves program to identify residents at risk for falls. At 2:44PM V12 presented an undated Inservice Education Report. V18's signature is not included. On 11/14/23 at 2:23PM V24 (CNA) said fall interventions for residents at risk for falls includes putting the bed in the lowest position and placing the bed remote on the side rail, with the buttons facing outward because we don't want the person to move the bed up and down. On 11/15/23 at 2:35PM V32 (Director of Nursing/DON), said if the intervention is to keep the bed in the lowest position, then do not give the resident the bed remote. R16's Fall Risk Observation dated 8/15/23 documents balance problems while standing or walking and a score of 22 level High Risk. R16's care plan dated 11/15/20 documents she is at risk for falls. Interventions include dated 8/26/23 place floor mat on the floor next to bed. Dated 8/25/23 and 8/26/23 Observe frequently and place in supervised area when out of bed. 1/26/22 keep bed in lowest position. Fall Event completed by V18 dated 10/13/23 at 10:40PM documents R16 on the floor in her room. Fall unwitnessed. R16's usual ambulatory status is assist of two with or without a device. Can ambulate has unsteady gait needs supervision. (Floor mat not documented.) Progress Notes dated 10/14/23 at 11:40AM documents R16 observed on the floor in her room next to her bed. On her back with a pair of shoes supporting her head. Laceration to scalp and unable to move left arm and left shoulder swollen and tender. (Floor mat not documented.) Progress Notes dated 10/14/23 at 9:15AM documents R16 has left humeral fracture. Progress Notes dated 10/14/23 at 12:38PM documents R16 returned from emergency room with 6 staples to top of head. Area raised and bruised. R16's hospital records dated 10/14/23 Laceration Repair, scalp, 2cm length x 5cm depth. 6 staples. X-ray left shoulder dated 10/14/23 Impression: Acute fracture of left proximal humeral diametaphysis with mild displacement. 2.R10 is [AGE] years old with diagnosis including but not limited to Respiratory Failure, Cognitive Communication Deficit, Need for Assistance with Personal Care, History of Falling, Dependence on Renal Dialysis, Tracheostomy, Gastrostomy, Dementia with Behavioral Disturbances. On 11/14/23 at 10:07 PM V13 (CNA) said I was working by myself with R10. V13 said I was turning R10 in the bed and she slid onto the floor. V13 said I was changing R10's brief and when I turned her to the right side away from me, she slid. V13 said R10 slid while I was turning her. V13 said R10 was on an air mattress and the air mattresses are slippery. V13 said it is always supposed to be two CNAs on R10's unit. V13 said there was no one to help me that night. At 1:07PM the surveyor asked V13 if the air mattress moved when R10 slid out of bed, and V13 said yes, it's supposed to be clamped, it was not. On 11/14/23 at 2:24PM V23 (CNA) said if a resident needs 2-person assistance I ask someone to help me. V23 said if the person is 2 persons assist, you must go get someone to help to prevent someone from getting hurt. V23 said you can get the nurse, but you cannot do that person's care by yourself, you must get someone else. V23 said if I needed help, I would wait for the help and report to the supervisor that I am waiting for assistance. R10's Fall Risk Observation dated 9/7/23 indicates a score of 20, High Risk. R10's Functional Abilities assessment dated [DATE] is dependent on staff for rolling in bed. R10's care plan dated 7/8/23 identifies R10 at risk for falls related to mobility and cognitive impairment. R10 unable to independently change position while in bed and requires total assistance of two. R10's Progress Notes states nurse notified by CNA that R10 slid over bed while CNA was providing cares. Small open area to left side of forehead with bump. R10's Fall Event report dated 9/27/23 at 5:30AM reports witnessed fall in resident room. During care R10 rolled onto left side and rolled unto floor mat. R10 usually unable to ambulate. 3.R9 is [AGE] year-old with diagnosis including, but not limited to Anoxic Brain Damage, End Stage Renal Disease, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Chronic Respiratory Failure with Hypoxia, Weakness, Need for Assistance with Personal Care, Dependence on Respiratory Ventilator Status, Dependence on Renal Dialysis, and Gastrostomy Status. On 11/9/23 at 1:17PM V14 (Licensed Practical Nurse) said I was in R9's room flushing her feeding tube between 10:30 and 11:00AM. V14 said R9 was in the bed and connected to the ventilator. V14 said she had not seen R9 move her arms and legs. V14 said R9 was on an air mattress, and it was inflated regular. V14 said I then left R9's room. V14 said the treatment nurse then entered R9's room after V14 left. V14 said while in the other room with the CNA, she heard commotion. V14 said when I came out of the room, I saw R9 on the floor. V14 said she was assigned to R9 and there was one agency CNA, who's name V14 does not know. V14 said when she got to R9's room she saw the Respiratory Therapist, an agency nurse, and 2 other staff she did not know by name. V14 said R9 had a hematoma on the side of her head. V14 said R9 had not been restless or fidgety before the fall. On 11/9/23 at 1:46PM V15 (Nurse Supervisor) said she was called to the unit regarding R9's fall. V15 said I was not there when R9 fell . V15 said I spoke to R9's son and he said his mother does not move. V15 said R9 does not normally move. On 11/9/23 at 2:03PM V7 (Respiratory Therapist) said I heard a ventilator disconnect alarm going off. V7 said when I saw R9 she was in the right side of her bed on the floor, laying on her right side. The surveyor asked how R9 could have fallen, V7 said a cough and a slide and that R9 could reach for things. V7 said no one saw the fall. V7 said the ventilator alarm had sounded because the ventilator tubing had come off. V7 said I don't remember how the mattress was when R9 was on the floor. On 11/9/23 at 2:12PM V5 (Infection Preventionist) said I heard an overhead page and when I got to the room I saw R9 on the floor on the right side of the bed, closest to the window. V5 said V14 was the assigned nurse working with R9 and an agency CNA was assigned. V5 said no one was in the room when R9 fell . V5 said R9 was on an air mattress and they seem slippery to me. V5 said R9's baseline is that she can't move. The surveyor asked V5 how R9 could have fallen, V5 said R9 coughed and with the air lifting she plopped over. V5 said R9 had a lump on her head. V5 said it was real shocking to me that R9 had fallen. V5 said we had a few falls with people on air mattress. V5 mentioned the air mattress again and said, I think they can be slippery. On 11/9/23 at 2:27PM V19 (LPN) said I covered for wound care team on 9/2/23. V19 said about 45 minutes to an hour before R9 fell I had applied cream to her buttocks. V19 said the agency CNA had assisted her in turning R9 to apply the cream to her buttocks. V19 said after completing the treatment R9 was left on her back in the bed. V19 said I can't remember how the pillows were used to position R9. V19 said R9 was on a low air loss mattress. The surveyor asked V19 about the settings on R9's air mattress pump. V19 said I glanced at them but could not report what the settings were. The surveyor asked R9 what safety interventions were in place when she left R9's room and V19 said she may have had floor mats, but I can't remember. V19 said the CNA stayed in the room when I left. On 11/9/23 at 11:49AM V20 (CNA) was contacted for interview. The facility provided V20's name and phone number as the assigned agency CNA for R9 on 9/2/23. V20 said no one fell when I was working at the facility. V20 said I did not assist in getting anyone off the floor. V20 said I don't know who R9 is. On 11/14/23 at 11:07AM V12 (ADON) said according to staff after R9's son left her room she became upset. V12 said R9's son left around 11:00AM. V12 said the CNA was walking past R9's room and saw R9 on the floor. V12 said it was an agency CNA, I am not sure of her name. V12 said R9 had a raised area to the right eye. V12 said she investigated R9's fall. V12 said I spoke to V16 (Wound Nurse) about the fall. V12 said I don't have the root cause of R9's fall documented. 11/16/23 at 12:51PM V16 said I was not working the day R9 fell . V16 said I did not respond to R9's fall or see R9 on the floor. On 11/15/23 at 2:35PM V32 (DON) said regarding R9 the nurse wrote R9 tried to get up and that something happened. V32 said we have had reports that people have been falling out of the bed because the air mattress are going up and doing it. V32 said with R9 we questioned if the air mattress was the cause of her fall. The facility provided a typed, witness statement denotes V18's statement regarding R9's fall. Statement denotes V18 was notified that R9 fell out of bed. The statement is unsigned. There were no other witness statements provided for R9's fall. (On 11/16/23 a new, typed, unsigned, witness statement was provided on 11/16/23 with V14's name.) On 11/15/23 at 3:40PM V18 (LPN) said I did not see R9 on the floor. V18 said I was not the nurse for R9 on 9/2/23. V18 said if I was the nurse assigned, I would have documented in the record. (No documentation was found written by V18.) Review of R9's orders dated 9/1/23 includes pressure reducing mattress. R9's Functional Abilities assessment dated [DATE] documents R9 is dependent on staff for dressing and rolling in bed. R9 is unable to sit up or walk. R9's care plan dated 9/1/23 stated R9 requires 2 staff assistance for turning and repositioning. R9 is prescribed anticoagulant therapy. R9's care includes floor mats, but intervention is dated 9/2/23. R9's Fall Risk Observation and fall event both dated 9/2/23 documents she had an unwitnessed fall. R9 Communication Form notes she was transferred to the hospital on 9/2/23 with a raised bump to the right side of her head. The Facility Incident Report dated 9/2/23 indicated R9 observed on the floor next to the bed. Noted with swelling to right side of the bed. R9's hospital records dated 9/2/23 R9 was found face down on the ground. R9 had a large hematoma to the right side of her head. R9s hospital diagnosis include Fall and Blunt Head Trauma.

A. Based on interview and record review, the facility failed to acknowledge and transcribe hospice orders that were provided for one resident (R299) at the start of hospice care. This failure affected one out of four residents reviewed for receiving hospice care in the facility and led to R299 receiving a hemodialysis treatment after the order for hemodialysis was discontinued; placing R299 at increased risk of hemodynamic instability. This failure led to R299 expiring during hemodialysis treatment. Findings include: R299 was a [AGE] year old female who was admitted to the facility [DATE] with diagnoses that included Hypertensive heart and End Stage Renal disease. On [DATE] at 12:57PM, V46 Family member said, [R299] came in [to the facility] for a minor stroke and was getting therapy. We (the family) realized she was declining and unable to tolerate the dialysis. They kept trying to dialyze her and she didn't have any fluid to take away, she was so small. We discontinued dialysis and put her on hospice on a Friday. The nurse came in next day on Saturday morning while we were visiting and said she was scheduled for Dialysis. We informed her that we signed a DNR (Do Not Resuscitate) and hospice papers and that dialysis was discontinued. The nurse told us that she did not receive that in report and that she (R299) had to go anyway. When they took her back, I think she was on the machine for under an hour and she died while they were giving dialysis on [DATE]. Dialysis Services were observed to be given on-site in the facility through a Contracted Provider. Hemodialysis note dated [DATE] indicated that R299 was received for 12:00PM scheduled appointment which was ordered to last three hours. The Dialysis Note documented that R299 was received cooperative and disoriented, with diminished lung sounds and no edema (swelling) identified. Received patient with minimal response to verbal stimuli patient hypotensive instructed tech to bolus 500 [milliliters] ns (normal saline) at start of treatment. BP (blood pressure) improved. No respiratory distress noted no S/S (signs/symptoms) of pain will continue to monitor. Blood Pressure taken prior to treatment start at 11:54AM was ,d+[DATE]mmHg (millimeters of mercury). Treatment was initiated at 11:58AM- bp was ,d+[DATE]mmHg and it was noted Treatment started. BP low, RN (Registered Nurse) aware. During treatment at 12:01PM, bp was ,d+[DATE]mmHg. At 12:02PM bp was ,d+[DATE]mmHg and noted bp low, 500 milliliters of saline given per RN, [patient] is resting, quiet, bp will be retaken. 12:07PM bp ,d+[DATE]mmHg- Noted blood pressure improving. 12:37PM BP ,d+[DATE]mmHg- Noted Bp dropping RN aware. 1:07PM bp ,d+[DATE]mmHg- Noted Bp in the 80's patient given another 200 milliliters of normal saline bolus. 1:37PM- Noted unable to obtain BP tried to bolus patient with [Normal Saline] unable to. Both art (arterial) and venous needles clotted. Noted patient with no RR (respirations) listen for heart tone unable to detect. No carotid pulse present. Treatment terminated. [Patient] is [Do Not Resuscitate] will call NH (nursing home) RN (registered nurse). On [DATE] at 11:40AM V44 Hospice Clinical Director said, R299 was admitted to hospice services on [DATE] and the hospice nurse provided orders to the facility nursing staff. There was an order to stop dialysis when R299 was admitted . Once the contract was signed by the facility, the hospice company assumed or took over care and management for R299 with a hospice physician in place, however, the facility nursing staff is expected to provide direct care and assessments. It was the facility's responsibility to transcribe orders and communicate any changes with R299 to the Hospice nurses or Hospice Physician. On [DATE] at 12:00PM V2 Director of Nursing said, we provided a document that authorized start of hospice services for R299. According to this, services were initiated on [DATE]. The process is that the hospice nurse writes the orders, gives them to the nurse on duty and discusses the plan of care with the facility nurse. The orders should be placed immediately in the electronic record by the facility nurse because it reflects whether the resident will be receiving restrictive or comfort care measures. If there was an order to discontinue dialysis care, that order should have been implemented immediately. Furthermore, looking at the dialysis notes and seeing that R299 was unable to tolerate dialysis twice that same week, I would not have sent her again, and would expect the nurses to question the primary or the dialysis nurse to contact the nephrologist for further orders prior to starting another treatment. On [DATE] at 12:51PM V39 Dialysis Supervisor said, I provided the facility with the dialysis notes for R299 and reviewed them. Based on these notes on [DATE] I see prior to the treatment, R299 was minimally responsive and blood pressure was low. She was given a bolus of fluid to increase the blood pressure. The blood pressure increased, and treatment was initiated. During the treatment, the blood pressure went down to high 80s and was dropping. At that time and they weren't removing any fluid. R299's heart stopped, and the access lines clotted. They called the facility nurse to the dialysis room, and she was taken off of the machine and was turned over to the facility. In the event a patient is received in dialysis with a change in status, we expect the nurses to monitor and when they become unstable, reach out to the nursing home for guidance and be in communication with the nephrologist. The notes do not indicate that the dialysis nurse called the nephrologist. The notes do not indicate that R299 was on hospice. Because we are contracted with the facility, anytime there is a change in patient status, the facility would tell us if they were stopping dialysis treatments or if the patient is going on hospice. We have access to the facility's Electronic Medical Record, and they have access to ours as part of our collaboration of care. On [DATE] at 6:44PM V47 Nephrologist said, I work with the company administering dialysis at the facility. The dialysis nurses are in constant contact with the nephrologist whenever they are providing treatments. If a patient is unstable, such as not being able to tolerate the treatment, or having to cut the treatment short, they should call the nephrologist to let them know. We usually recommend holding dialysis until the resident is stable because the fluid changes that occur during the dialysis treatment has the potential to cause more harm than good. Unstable is not the way to go. If the patient is not tolerating, they may show signs of hypotension (low blood pressure), becoming unconscious or showing mental status change. Treatment usually causes a routine drop in blood pressure, which is why it is constantly being monitored. These vitals presented in [R299's] case indicate chronic hypotension. To give treatment would not be contraindicated, but if the patient has been physically declining and not able to tolerate treatments prior to this one on [DATE], I would question the benefit. I get involved when sometimes patients are placed on hospice and request dialysis treatments to continue but it is very rare. If I was the physician at the time, I would not have allowed [R299] to continue dialysis treatments due to previous intolerance and starting hospice care. The facility presented a Hospice care agreement which was signed by R299's POA (Power of Attorney) and a hospice liaison. Physician Order Sheet dated [DATE] was reviewed and did not contain any orders that were initiated by hospice, and an order for dialysis services given three times weekly remained in place. Care Plan at the time of discharge did not indicate hospice services were in place. Nursing progress notes were reviewed from admission to discharge and did not indicate hospice orders were received on [DATE]. On [DATE] at 2:00PM nurse wrote Dialysis nurse made writer aware resident was unresponsive. Upon assessment writer observed no rise or fall in chest. Unable to obtain vital, no apical pulse noted. Resident pronounced at 1:31pm by [Hospice Nurse]. Daughter made aware, no postmortem arrangements at this time. Hospice admission orders dated [DATE] were reviewed and included an order to Stop Dialysis. B. Based on interviews and record reviews, the facility failed to follow a physician's order related to a medication that had been discontinued for one (R90) of one resident reviewed for physician's orders and quality of care. Findings include: R90 is a [AGE] year-old, female, admitted in the facility on [DATE] with diagnoses of Anxiety Disorder, Unspecified. MDS (Minimum Data Set) dated [DATE] indicated that her BIMS (Brief Interview for Mental Status) score was 15 which means intact cognition. On [DATE] at 10:55 AM during checking of R90's narcotic sheet, it was documented that she still takes Alprazolam tablet 0.5 mg (milligrams) PRN (when needed). V13 (Registered Nurse, RN) stated that she administered Alparazolam to R90 at 9:00 AM. According to POS (Physician Order Sheet) dated [DATE], R90 has an order of Alprazolam - Schedule IV tablet 0.5mg., gastric tube every 8 hours PRN for Anxiety. The order also stated that Alprazolam was discontinued on [DATE]. On [DATE] at 11:00 AM, R90 was interviewed regarding medications. R90 speaks a foreign language and needed an interpreter. V26 (Director of Rehab) acted as interpreter. R90 stated, I do not know specific medications that I have been taking. I know that I am taking medications for blood pressure and for anxiety. I don't know if my medications were changed, no one told me anything. On [DATE] at 11:17 AM, V27 (Licensed Practical Nurse, LPN) was asked if there is an order to continue Alprazolam. V27 replied, There is no order for Alprazolam, I just checked the orders. She has not expressed any depression or anxiety. I am a PRN (when needed) nurse and for two days I have been with her, she had not expressed any anxiety. On [DATE] at 11:40 AM, V2 (Director of Nursing) was asked regarding discontinued medications. V2 stated, Doctor's orders need to be followed and note any changes in the order. During medpass, the record should be reflected in the MAR and narcotic sheet. If the narcotic sheet and the order do not coincide, the nurse has to check the order and follow the doctor's order. On R90, the Alprazolam was changed to another medication at a lesser dose. Facility's policy titled Medication Administration dated [DATE], stated in part but not limited to the following: Policy- Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Procedures- B. Administration. 2) Medications are administered in accordance with written orders of the prescriber. 44570

Based on observations, interviews, and record reviews the facility failed to follow their policy and procedures to prevent falls by not ensuring fall risk assessments were performed quarterly to reassess residents fall intervention needs, failed to not ensure a resident was adequately supervised; failed to not ensure a quadriplegic resident with a history of falling out of bed with two staff providing care received two person assistance when receiving incontinence care; and failed to ensure safety practices were applied for this resident when beginning to fall out of bed. These failures resulted in R28 experiencing a fall and sustaining a head injury and resulted in R58 falling out of bed and sustaining a right leg fracture. The facility failed to provide a resident with needed assistance and the resident subsequently had two falls within an hour time period. This failure applied to one (R45) of one resident reviewed for falls. Findings include: R28 is a [AGE] year-old female with a diagnoses history of Displaced Fracture of Right Leg, Subsequent Encounter for Closed Fracture, Functional Quadriplegia, Dementia, and Weakness who was admitted to the facility 08/31/2018. R28's Functional Ability assessment dated [DATE] documents she is Dependent, and helper does all of the effort, resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity for rolling left and right or the ability to roll from lying on back to left and right side and return to lying back on the bed. R28's Quarterly Minimum Data Set assessment dated [DATE] for Functional Abilities and Goals documents she is dependent on staff for rolling left and right from lying on back. R28's Current care plan documents she is at risk for falling related to impaired mobility, incontinence and antidepressant medication use with interventions including 2 Person assist with cares. Staff in serviced (initiated 06/23/2023). Fall Report from 01/01/23 - 06/27/23 documents R28 had a change in plane while in her bedroom on 06/22/23 at 9:00 PM with location marked as resident bathroom. R28's progress note dated 06/06/2023 06:07 PM documents: upon doing rounds with the Certified Nursing Assistant (CNA), both writer and CNA provided care. While giving care to patient, both writer and CNA turned patient underestimating patient's weight, patient then shifted all the way to the right of the bed with legs hanging off. Writer and CNA caught patient before patient could fall and held onto patient for safety. Patient then repositioned back all the way in bed by writer and CNA. Redness noted to face and right side of body due to patient being up against side rails. Nurse Practitioner made aware with new orders for neuro checks and right-side x-ray for precaution. R28's progress note dated 06/23/2023 12:14AM documents: Patient is a [AGE] year-old bed bound patient with dementia and functional quadriplegia just returned from hospital after feeding tube was reinserted had 5 small emesis of dark brown emesis. As aide was cleaning patient she slid out of the bed and was helped gradually to the floor.; at 12:14 AM Resident noted on 6/22/2023 @9pm by Certified Nursing Assistant (CNA) then Nurse coughing with vomiting of dark brown watery liquid around 5 episodes; while resident was having emesis with CNA present, resident started sliding out of bed, CNA broke resident fall by gradually lowering resident to the floor and called for Nurse. R28's progress note dated 06/24/2023 01:20 PM documents: Resident remains an extensive with one person assistance with activities of daily living; at 07:17 PM During rounds Certified Nursing Assistant (CNA) stated that resident had bowel movement. CNA also noted that resident had some edema to right lower leg, ankle, and foot. When writer assessed, slight discoloration and edema was noted to lower right leg, ankle, and foot. Physician was made aware of edema to foot, right lower leg, and ankle post fall 6/23/23. Orders were given to get x-ray to right lower leg, ankle, and foot. R28's x-rays dated 06/25/23 documents she sustained an acute fracture of her right leg. R28's hospital record dated 06/26/2023 documents she apparently fell from bed at nursing home. Unclear how this happened as she has functional quadriplegia and is not able to move. She apparently fell from bed and sustained a leg fracture. On 06/27/23 at 01:21 PM V34 (Certified Nursing Assistant) stated R28 had just been brought back from the hospital on 06/22/23 because of her tube feeding. V34 stated when residents come back from the hospital, they have a lot of linen with them. V34 stated she was removing stickers from R28 and observed a little poop on her then initiated changing her and removing her linens. V34 stated R28 was turned towards her while she was standing next to R28's bed. V34 stated R28's diaper and linens were tucked in back of her to prevent the diaper from scratching her skin. V34 stated R28 began coughing badly and she asked her if she was ok. V34 stated she noticed R28 began vomiting. V34 stated she reached for a towel that she placed on R28's headboard to place it under R28 to catch the vomit. V34 stated as she grabbed for the towel R28 was sliding down towards her with the bottom half of her body sliding first. V34 stated she was standing near R28's head. V34 stated she grabbed the top of R28's body and fell with her trying to break her fall. V34 stated she fell on her knees and R28's knees and legs landed on the floor with the top of R28's body including arms, shoulder, and head landing in her arms. V34 stated normally there is one Certified Nursing Assistant (CNA) present when changing or reposition R28 on the evening shift. V34 stated sometimes two CNA' may need to assist with providing care to R28 depending on the comfort level of the staff. V34 stated we do need two people because sometimes R28 starts coughing and will begin jerking. V34 stated sometimes within 30 minutes to an hour R28 would slide down in her bed from coughing or jerking. V34 stated sometimes R28 has spasms and begins jerking. R58 is an [AGE] year old female with a diagnoses history of Dementia with Behavioral Disturbance, History of Falling, and Need for Assistance with Personal Care who was admitted to the facility 05/21/2020. R58's progress note dated 04/06/2023 12:30 PM documents: writer was summoned to resident's room by a loud noise from resident's room, where resident was lying supine and touching the back of her head, her wheelchair by the side of her head and her walker upside down, upon assessment, resident stated that she wants to pick up a bag with her clothes inside. Resident complained of headache on a scale of 3/10, a raise bump noted to the back of her head, resident was assisted to her wheelchair by two staff, Nurse Practitioner was made aware of resident's status, order to send resident to hospital for further evaluation post fall; at 01:08 PM resident with unwitnessed fall today, states she did hit her head and admits to headache. Resident is currently on a blood thinner; at 7:24 PM Writer spoke with hospital emergency room nurse; resident being admitted for fall observation. R58's Current care plan documents she is at risk for injury related to dementia; at risk for falling related to dementia, unsteadiness on feet, weakness with interventions including Observe frequently and place in supervised area when out of bed (effective 04/06/23); Keep personal items and frequently used items within reach (effective 11/15/2020). Facility Incident/Accident Report from 01/28/23 - 06/28/23 documents R58 had an unwitnessed fall while self-ambulating without staff assistance; Intervention included being sent to the hospital emergency room for evaluation, upon return to facility care plan updated to observe frequently when out of bed. Fall Report from 01/01/23 - 06/27/23 documents R58 had an unwitnessed fall 04/06/23 at 11:45 AM. R58's Admission Fall Risk assessment dated [DATE] documents she was a high risk for falls with fall risks including a history of one or two falls in the past 3 months, requiring assistance to ambulate, confinement to wheelchair, disorientation x3. R58's Fall Risk assessment dated [DATE] documents she was a high risk for falls with fall risks including a history of three or more falls in the past 3 months, requiring assistance to ambulate, confinement to wheelchair, use of antidepressants and anti-hypertensives. R58's Fall Risk assessment dated [DATE] documents she was a high risk for falls with fall risks including a decrease in muscular coordination, use of three or more medications such as diuretics and hypoglycemics in the past 7 days, requiring assistance to ambulate, confinement to wheelchair, use of antidepressants and anti-hypertensives, declined in neuromuscular function, and decline in cognitive/psychiatric function. R58's Fall Risk assessment dated [DATE] documents she was a high risk for falls with fall risks including intermittent confusion, use of one or two high risk medications in the past 7 days, history of one or two falls in the past 3 months. R58's Fall Risk assessment dated [DATE] documents she was a high risk for falls with fall risks including intermittent confusion, requiring assistance to ambulate, confinement to wheelchair, use of three or more medications such as antidepressants, anti-hypertensives, anxiolytics, cardiovascular dysrhythmia, and decline in cognitive/psychiatric function. On 06/28/23 at 12:53 PM V2 (Director of Nursing) stated fall risk evaluations are done on admission. V2 stated when providing care, the first priority is keeping the resident safe. If V34 (Certified Nursing Assistant) was unable to get a towel while keeping R28 safe then the priority should have been to keep her in a stable position and keep her safe. On 06/28/23 at 03:14 PM V14 (Restorative/Fall Nurse) stated from what staff tells her R58 attempts to be very independent at times and could be a bit of a handful. V14 stated based on this information and personal observation, R58 requires limited to moderate assistance with some activities of daily living such as toileting and dressing. V14 stated R58 requires one person assistance with transferring from her wheelchair to another surface. V14 stated R58's room being right across from the nurses station allows sufficient supervision. V14 could not answer when asked how was R58 able to have an unwitnessed fall when in a room across from the nurses station if her room location allows adequate supervision. V14 stated fall risk assessments are performed on admission, quarterly, and as needed. V14 stated quarterly fall risk assessments are done to determine if there are any changes in a resident's condition, to see if their needs have changed, and if they've had falls within their quarterly assessment time frames. V14 stated any changes identified during fall risk assessments may have an impact on resident's fall interventions. V14 stated R58 requires a mechanical lift for transfers. 46344 R45 is a [AGE] year old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R45 has multiple diagnoses including but not limited to spinal stenosis, spinal fusion, dysphagia, need for assistance with personal care, history of falling, difficulty in walking, cognitive communication deficit, HTN, hyperlipidemia, GERD, CAD, CKD III, and CHF. On 6/26/23 at 12:05PM, R45 was interviewed regarding the fall incident on 5/30/23. R45 said when I admitted here, I needed assistance with care but now I am independent and can transfer myself to the bathroom on my own. However, when I did need assistance, I had to wait a long time for care. I had a fall incident (5/30/23) where I put my call light on for assistance and the CNA (Certified Nursing Assistant) refused to take me to the bathroom. I went to the bathroom earlier that shift, but I had to go again, and she would not take me. She was not happy with me about how much I was using my call light. On 6/28/23 at 10:03AM, V24 (Registered Nurse) was interviewed regarding R45's fall incident on 5/30/23. V24 said I was the nurse on duty this night. V25 (agency CNA) was going to bring R45 to the bathroom. She told me that she was unaware that he could not walk. V25 said he attempted to stand up and fell in his room. I asked her what she was doing when he was transferring himself and she said she was just standing there. R45 told me he thought V25 was going to help him transfer but she just stood there. V25 said she attempted to break his fall and lowered him to the ground. I assessed him at this time and found him to have some scratches on one of his arms and legs but no major injuries. He said he wasn't in any pain. V24 said a couple minutes later, V25 was calling for help because R45 was on the ground again. V25 said she saw him crawling on the floor and said he had to go to the bathroom. I told him the CNA was just in here to take you to the bathroom. V25 told me when she took him to the bathroom he did not urinate or defecate so she took him back to bed. At this time, R45 was assessed again. He did say that V25 lowered the bed on his feet or legs. I assessed him and did not note any injuries. He was then put back to bed. I got a statement from V25 who said she was attempting to get him up off the floor by herself, but the bed was too high. She said she lowered the bed but there was no incident, and we were able to transfer him back to his bed. It is to be noted that V25 was attempted to be interviewed via phone with no answer. On 6/28/23 at 12:30PM, V2 (Director of Nursing) was interviewed regarding fall incident on 5/30/23. From my understanding during the investigation, R45 attempted to get up on his own and bring himself to the bathroom. R45 said he put his call light on, but no one would come and assist him. He said V25 came in when he was transferring and just stood there and watched him fall. However, V25 told me that she entered the room and saw R45 attempting to go to the bathroom. She caught him and lowered him to the ground. V2 said agency CNA's should be aware of the level of care a resident needs because they should be getting report from the nurse or previous CNA, and we also have care cards in the rooms. I am not sure exactly what happened because at the time I did not have an Assistant director of Nursing, Infection Preventionist, or Restorative Nurse and I was actively filling all these roles by myself. My expectation would be that the CNA's answer call lights immediately. If they are busy, they need to let the resident know and come back as soon as they can. He was using the call light excessively when he was first admitted . Facility progress note dated 5/30/23 at 4:45AM states in part but not limited to the following: R45 was being assisted to the bathroom by the CNA but was lowered to the floor. Writer completed full body assessment and noted resident had a scratch on his right arm and right leg. No complaints of pain. Facility progress note dated 5/30/23 at 4:55AM states in part but not limited to the following: R45 attempted to get out of bed by himself and was found crawling on the floor mat next to his bed. Facility progress note dated 5/30/23 at 1:58PM states in part but not limited to the following: Social Service Director and Administrator went to meet with R45 regarding an issue that occurred early this morning. R45 reports that he was mistreated by the overnight staff. Says he pushed his call light to get some help so that he can transfer from his bed to his wheelchair to go to the bathroom. R45 reports that he was ignored by the nursing staff then he heard them talking about him outside of his room door. Resident care plan titled: Falls with start date of 5/22/23 states in part but not limited to the following: Problem: Resident at risk for falling r/t impaired mobility and impulsiveness; Goal: Resident will remain free from injury; Approach: Observe frequently and place in supervised area when out of bed; place resident in a fall prevention program. Facility policy titled Falls and Fall Risk, Managing dated 2001 states in part but not limited to the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to follow physician orders for warfarin and PT/INR blood draws for a resident with a history of atrial fibrillation. This affected 1 of 3 residents (R1) review for following physician orders. This failure resulted in R1's INR levels being subtherapeutic which resulted in a stroke. Findings include: R1 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, difficulty walking, anemia, hyperparathyroidism, calcium metabolism disorder, hypertension, atrial fibrillation, and non-pressure sores of bilateral lower legs. R1's admission orders dated 2/24/23 documents: Warfarin 2.5 mg daily. R1's physician order report dated 3/23/23 documents warfarin 2.5mg Monday thru Saturday. R1's medication administration record for 2.5mg warfarin dated 3/23/23 documents: not administered: drug/item not available. No warfarin was administered on 3/26/23. On 5/11/23 at 11:49AM, V3 (Director of Nursing/DON) said nurses should follow admission orders unless changed by the physician. V3 was unsure if there had been any changes to R1 admission orders. On 5/10/23 at 1:48PM, V21 (Medical Doctor/MD) said he will usually follow the admission order from the hospital and does not recall making any changes to R1's coumadin orders. V21 said he does not recall changing Coumadin to Monday thru Saturday and unable to provide rationale for why medication would have been changed on admission. V21 said he would expect his orders to be followed by staff and would expect to be notified if medication was not given. R1's admission orders dated 2/24/23 documents: warfarin reminder: INR 2-3. Check PT/INR every Monday, Wednesday, and Friday. R1's physician order report dated 3/22/23 documents: PT/INR once a day on Monday, Wednesday, and Friday. R1's medical record does not document any PT/INR result was drawn on 3/27/23 (Monday). On 5/9/23 at 12:21, V16 (Lab personal) said she was unable to see any PT/INR draws on 3/27/23 for R1. On 5/10/23 at 1:48PM, V21 (MD) said he would expect his orders to be followed by staff and would expect to be notified if lab was not drawn. R1's laboratory results collected 3/23/23 at 05:15am for prothrombin time, PT 20.8 and International normalized ratio, INR 1.6: For patients stabilized on long term anticoagulation therapy, the following target ranges are usually recommended: standard therapy: 2.0 -3.0 (myocardial infarction, atrial fibrillation, venous thrombosis, pulmonary embolism). Final reported 3/25/23 at 16:09. On 5/10/23 at 1:48PM, V21 (MD) said he was aware of results drawn on 3/23/23 and would not have ordered any changes to coumadin based on results because resident was a new admit and obtaining a baseline PT/INR. R1's laboratory results collected 3/24/23 at 09:00am for prothrombin time, PT 18.7 and International normalized ratio, INR 1.4: For patients stabilized on long term anticoagulation therapy, the following target ranges are usually recommended: standard therapy: 2.0 -3.0 (myocardial infarction, atrial fibrillation, venous thrombosis, pulmonary embolism). Final reported 3/27/23 at 11:51. On 5/10/23 at 1:15PM, V20 (Nurse Practitioner/NP) said an INR below 2 is not therapeutic and would need a medication change. A patient who is being treated with warfarin for atrial fibrillation who is not within a therapeutic INR level is at greater risk for blood clots. Blood clots can cause stroke Coumadin helps to make the blood thinner, so clots do not develop. R1's progress note dated 3/28/23 documents: during medication pass, resident wasn't able to stay attentive and kept dozing off. Resident would not answer to his name or simple commands. Vital Signs: 166/91 Blood Pressure, 102 Heart Rate, 97.2 Temperature, 99% room air, 120 Blood Sugar. resident had bilateral weakness to both upper extremities. Normal baseline is alert/oriented x4. MD via (Brand) facility software system was contacted and was ordered to send the resident out to the hospital. R1's hospital record dated 3/28/23 documents: R1 activated code stroke with history of Atrial Fibrillation on Coumadin . presenting with acute right-sided hemiparesis, awake but nonverbal. Baseline is alert and oriented x4 with no prior neuro deficits. CT obtained revealing inferior M2 occlusion. R1's hospital neurology note dated 3/28/23 documents under assessment: Stroke etiology likely from atrial fibrillation with subtherapeutic INR. Facility healthcare NEXSYS (Automated medication dispensary onsite) medication lists documents: warfarin 1mg, 2.5mg and 5mg available for use. Stroke assessment inconclusive. Facility policy titled orders for anticoagulants policy dated 2/2014 documents: To ensure anticoagulants are only prescribed when proper clinical and laboratory monitoring is in place. Anticoagulant therapy orders will be administered as ordered by the attending physician.

Based on interview and record review, the laboratory failed to timely report one resident's (R1) PT/INR results. This affected 1 of 3 residents (R1) reviewed for lab services. This failure resulted in a delay in relaying subtherapeutic INR levels to the physician which led to R1 being hospitalized for a stroke for one of three reviewed for lab services. Findings include: R1 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, difficulty walking, anemia, hyperparathyroidism, calcium metabolism disorder, hypertension, atrial fibrillation, and non-pressure sores of bilateral lower legs. R1's laboratory results collected 3/23/23 at 05:15am for prothrombin time, PT 20.8 and International Normalized Ratio, INR 1.6: For patients stabilized on long term anticoagulation therapy, the following target ranges are usually recommended: standard therapy: 2.0 -3.0 (myocardial infarction, atrial fibrillation, venous thrombosis, pulmonary embolism). Final reported 3/25/23 at 16:09. R1's laboratory results collected 3/24/23 at 09:00am for prothrombin time, PT 18.7 and International Normalized Ratio, INR 1.4: For patients stabilized on long term anticoagulation therapy, the following target ranges are usually recommended: standard therapy: 2.0 -3.0 (myocardial infarction, atrial fibrillation, venous thrombosis, pulmonary embolism). Final reported 3/27/23 at 11:51. On 5/10/23 at 1:15PM, V20 (Nurse Practitioner/NP) said an INR below 2 is not therapeutic and would need a medication change. A patient who is being treated with warfarin for atrial fibrillation who is not within a therapeutic INR level is at greater risk for blood clots. Blood clots can cause strokes. Coumadin helps to make the blood thinner, so clots do not develop. On 5/11/23 at 11:49AM, V3 (Director of Nursing/DON) said residents PT/INR results are expected to be reported same day. On 5/11/23 at 10:20AM, V24 (Lab) said residents PT/INR results are expected to be reported same day unless there is something unexpected that happens. R1's medical record does not document any changes to warfarin orders until 3/27/23. R1's physician order dated 3/27/23 documents: 3 mg warfarin daily. Recheck in one week. R1's hospital neurology note dated 3/28/23 documents under assessment: Stroke etiology likely from atrial fibrillation with subtherapeutic INR. Facility policy titled Orders for Anticoagulants Policy dated 2/2014 documents: To ensure anticoagulants are only prescribed when proper clinical and laboratory monitoring is in place. Anticoagulant therapy orders will be administered as ordered by the attending physician.

Based on observation, interview, and record review, the facility failed to ensure that residents with pain had their prescribed pain medication available for 2 of 9 residents (R1, R3) reviewed for pain management. This failure resulted in R3 experiencing bilateral knee pain and generalized pain at an 8, on a scale from 1-10. The findings include: 1. On 2/26/23 at 9:46 AM, R3 was lying in an air bed with the head of the bed elevated. V5 (Licensed Practical Nurse/LPN) entered R3's room to obtain vital signs before preparing her morning medications. V5 asked R3 if she was having any pain. R3 replied, Oh yes, I have pain especially in my knees. But I'm sore everywhere. I would like my pain pill. R3 rated her pain at an 8 (on a 1-10 scale, with 10 being the worst pain you have ever felt). V5 checked the narcotic box for R3's pain medication (Norco 10 mg - 325 mg tablets), but it was not there. V5 stated, She don't have none, I'll have to check and see what she's talking about. Let me check one more time. (V5 was unable to find Norco for R3). She's out of Norco. I'll have to find out what's going on with that. V5 entered R3's room and administered a cup for of medications. V5 did not have Norco. R3 looked in the cup and asked V5, What's this? V5 replied, These are your morning mediations. R3 asked where her pain medication was. V5 replied, I have to find out where your pain medicine is. R3 stated, I ain't supposed to run out of Norco. At 1:20 PM, R3 was in bed, grimacing and complaining of bilateral knee pain. R3 stated, I still haven't got any pain medication. I'm not sure what is happening with that. And I'm still having pain at an 8. I used to go get steroid injections in my knees, but I haven't been able to do that in a while. So, I need the Norco for my pain. This isn't a new pain, I've been having it for a while. At 1:29 PM, V5 (LPN) said R3's Norco will be delivered in the next shipment from pharmacy. A nurse should re-order a resident's medications when they get to the last 4-5 tablets. R3 should not have run out of Norco. The pharmacy said that we did not need a new prescription and they will send another 30 tablets. R3's undated Face Sheet showed diagnoses to include, but not limited to heart failure, dysphagia, anxiety, dementia, morbid obesity, bilateral osteoarthritis of the knee, weakness, and need for assistance with personal care. R3's facility assessment dated [DATE] showed she had moderate cognitive impairment; and required extensive staff assistance for bed mobility, dressing, and personal hygiene. R3's Care Plan initiated 12/13/21 showed, Resident at risk for pain and discomfort r/t (related to) osteoarthritis, BLE (Bilateral Lower Extremity) edema, and impaired mobility . Approach: Encourage resident to request pain medication before pain becomes unbearable . Administer medications as ordered . R3's Physician Order Report dated 2/26/23 showed an order for Norco 10-325 mg tablet orally BID (twice a day) PRN. R3's February 2023 Medication Administration Record showed R3 had not received Norco since 2/24/23 at 6:37 PM. On 2/26/23 at 1:50 PM, V6 (Pharmacist) said the nurses should re-order medications when the resident has three days of medication remaining. R3 should not have run out of Norco. She could experience unnecessary pain if there is a delay in her receiving her pain medication. The nurse should re-order medications through the EMR or via telephone/fax. R3 had a refill ordered today, but this was the first time the pharmacy was contacted for a Norco refill since the last supply was sent out on 2/6/23. The pharmacy dispenses 30 tablets of Norco at a time for R3, so the order lasts about 15 days. The facility's Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy Policy dated 10/25/14 showed, Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt . Procedures: A. Ordering Medications . 3. Sending refills via an electronic reorder request through an electronic medical records program and ordered. 5. Reordering of medications is done in accordance with the order and delivery schedule developed by the pharmacy provider . Reorder medications four (4) days in advance of need . to assure an adequate supply is on hand . 2. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include palliative care, atrial fibrillation, protein-calorie malnutrition, hypertension, constipation, major depressive disorder, pain in left hip, and rheumatoid arthritis. R1's facility assessment dated [DATE] showed she has no cognitive impairment and requires extensive assistance from staff for all care. R1's care plan started on 5/26/22 showed, Resident is admitted to hospice care due to overall decline in health . Resident will experience death with dignity and continued pain management daily through next review . Administer pain medications as ordered . Communicate with hospice team any changes in resident condition . R1's care plan started 7/30/20 showed, . R1 is at risk for alteration in comfort/pain related to generalized weakness and diagnosis of rheumatoid arthritis and other disease process . R1 will have relief of pain with each reported/observed pain episode . Administer medications as needed as ordered . R1's current physician order sheet showed an order dated 7/13/22 for Hydrocodone-acetaminophen 5-325 mg . three times a day; 6:00 AM, 2:00 PM, 10:00 PM. R1's February 2023 eMAR (Electronic Medication Administration record) showed R1's Hydrocodone-acetaminophen 5-325 mg was Not Administered: Drug/Item Unavailable on 2/6/23 at 10:00PM, 2/7/23 at 6:00 AM, 2/9/23 at 2:00 PM, 2/24/23 at 6:00 AM, and 2/24/23 at 2:00 PM. R1's 2/24/23 nursing progress note showed, Resident in bed, HOB (head of bed) elevated, no distress noted, respiration even and non-labored. Resident complains of being tired, mild-moderate pain generalized, last Norco (Hydrocodone-acetaminophen) administered last evening. Author to contact hospice for Norco refills . On 2/26/23 at 3:00 PM, V3 (Assistant Director of Nursing/ADON) said the residents should not run out of their pain medications because the facility has 2 nurse practitioners and a physician that are in the facility nearly every day of the week between the 3 of them. V3 said if the nurses notice they are running out of a medication they should let the Nurse Practitioner, or the Physician know so they can complete a new prescription if that is what is needed. V3 said the facility also has a convenience supply of medications that include Hydrocodone-acetaminophen which is accessible to the nurses if they contact the physician and let them know the resident is out of medication. V3 said she would have expected the nurses to notify the physician and to substitute pain medications until the new supply of Hydrocodone arrived.

Based on interview and record review, the facility failed to supervise a cognitively impaired resident who was identified as a fall risk and develop and implement a plan with effective interventions to prevent or reduce the risk of future falls. This affected 2 of 3 residents (R1, R11) reviewed for fall prevention. The failure resulted in (R1) having multiple unwitnessed falls, sustaining left lateral rib fractures and scalp swelling. Findings include: 1. R1 has diagnoses of Dementia, weakness, abnormalities of gait/ mobility, lack of coordination, abnormal posture, unsteadiness on feet, repeated falls, other symptoms/signs involving cognitive functions and awareness. R1's brief interview for mental status dated 10/4/22 documents a score of six which indicate severe impairment. Section G (functional status) documents: R1 requires limited assistance with one-person physical assist for walking in room and transfers. Balance during transitions and walking, moving from a seated to standing position, walking, moving on and off toilet and surface transfer between bed, chair and or wheelchair documents: Not steady, only able to stabilize with staff assistance. Fall observation dated 2/26/22 documents: high risk. (8/17/22 fall) On 12/22/22 at 10:47am, V5 (Restorative Director) said that R1 had an unwitnessed fall in the bathroom which resulted in fracture ribs. No interventions were documented. Nursing note dated 08/17/2022 documents: Resident (R1) had an unwitnessed fall while in the bathroom. R1 complained of left hip/rips pain. All safety measures implemented, will continue with plan of care. Event report dated 8/17/22 documents: R1's location prior to the fall- unknown, mental status-confused and respond to name/pain. Left rib 2 view x-ray dated 8/18/22 documents: Acute left lateral rib fractures. Care plan dated 8/19/2020 documents: Resident (R1) has a history of falling related to dementia, abnormal posture and unsteadiness on feet -No interventions documented for R1's fall on 8/17/22. (11/11/22 fall) On 12/22/22 at 10:47am, V5 (Restorative Director) said, R1 had an unwitnessed fall while attempting to get into the wheelchair from the bed. R1's wheelchair was unlocked. R1 slipped. Physical therapy was consulted for strength training, toning, gait training and mobility device. R1 attempts to self-transfer frequently. R1 knows she needs to notify staff, but she doesn't. Education was not an effective intervention related to R1's diagnosis of Dementia and cognitive impairment. R1 should have been given a (Brand type) mattress for attempting to transfer from the bed. Nursing note dated 11/11/2022 (6:20am) documents: Writer notified that patient (R1) was on the floor at bedside. Patient (R1) stated the chair got away from me. Wheelchair noted with wheels unlocked. Nursing note dated 11/11/2022 (12:51pm) documents: R1 observed attempting to transfer self from bed to wheelchair, educated on safety, encourage to pull call light for assist. Progress note dated 11/11/2022 (1:48pm) documents: R1 reported she slipped out of bed while attempting to transfer to the wheelchair. Maximum education to R1 regarding wheelchair safety with correct height of bed when transferring. Maximum education for R1 to reach out for help via call light when transferring. R1 reported, Well, this old bird is just going to keep on going. Event report dated 11/11/22 documents: R1 had an unwitnessed fall. R1 was found on the floor. Fall from bed. Care plan dated 8/19/2020 documents: Resident (R1) has a history of falling related to dementia, abnormal posture and unsteadiness on feet. (start date 11/14/22) -Provide max education regarding w/c (wheelchair) safety including w/c brake lockage, safety with transfers and safety with correct height of bed when transferring. Reiterate to resident to reach out for help with call light when transferring. (12/01/22 fall) On 12/22/22 at 10:47am, V5 (Restorative Director) said, R1 had an unwitnessed fall on 12/1/22 around 6am. R1 was walking from the bathroom, while dripping urine and slipped in the urine. R1 sustained a lump on the head. R1's intervention was to provide toileting assistance after meals and before bed. The intervention should have been to provide assistance on toileting upon waking. Physician note dated 12/01/22 (6:24am) document: Patient (R1) fell from the wheelchair to the floor. R1 sustained a swelling on the scalp. Nursing note dated 12/01/2022 (6:53am) documents: Upon rounds R1 was noted on floor in supine position. During assessment writer noted a lump on R (right) side of head. R1 stated she was trying to transport to restroom. Event report dated 12/01/22 documents: R1 had an unwitnessed fall. Functional status evaluation compared to baseline documents: need more assistance with ADL care. Fall precaution, low bed, frequent rounding in place. R1 refuses to comply despite understanding. Care plan dated 8/19/2020 documents: Resident (R1) has a history of falling related to dementia, abnormal posture and unsteadiness on feet -No interventions documented for R1's fall on 12/1/22. Nursing noted dated 12/04/22 documents: R1 noted up walking around without wheelchair. R1 needs reinforcement. (12/8/22 fall) On 12/22/22 at 10:47am, V5 (Restorative Director) said that R1 had a witnessed fall on 12/8/22. R1 slid of out the wheelchair. The witness was not able to get to R1 in time to prevent the fall. R1 verbalized she hit her head. Intervention was to provide toilet assistance before bed and upon waking. The intervention should have been anti-skid pad (Brand) for R1's wheelchair. Nursing note dated 12/08/2022 documents: R1 was observed sitting upright on bedroom floor at approximately 9:00am. R1 verbalized that she hit the back of her head. R1's roommate verbalized she witnessed patient (R1) sliding out of the chair. Event report dated 12/08/22 documents: Functional status evaluation compared to baseline documents: need more assistance with ADL care, fall (one or more) and generalized weakness. Pain evaluation documents; new, sharp, 3/10. Care plan dated 8/19/2020 documents: Resident (R1) has a history of falling related to dementia, abnormal posture and unsteadiness on feet -No interventions documented for R1's fall on 12/8/22. Hospital paperwork dated 12/8/22 documents: R1 was (AOx1) alert and oriented times one. R1 said, I was eating and slipped onto the ground. R1's roommate called the nurse. Facility staff said, R1 tries to get up unassisted. R1 fell next to her bed. (12/10/22 fall) On 12/22/22 at 10:47am, V5 (Restorative Director) said that R1 had a fall on 12/10/22. R1 was observed sitting in front of unlock wheelchair. R1 slid off the chair while trying to sit down. Intervention was to ensure floor free of glare, liquids and foreign objects. This was not an effective intervention. R1 would not have been able to lock the wheelchair due to cognitive impairment. The IDT comes up with interventions after a fall. I am responsible for putting those intervention in place, and making sure they are effective, and educating staff. If the interventions put in place don't work/prevent a future fall, we come up with new intervention. Nursing note dated 12/10/2022 documents: R1 was observed sitting upright in front of her unlocked W/C (wheelchair) on her bathroom floor. The patient (R1) stated, I slide off the chair while trying to sit down. Event report dated 12/10/22 documents: was fall witnessed-no. Care plan dated 8/19/2020 documents: Resident (R1) has a history of falling related to dementia, abnormal posture and unsteadiness on feet -No interventions documented for R1's fall on 12/10/22. Fall policy revised 8/2008 (Treatment/Management) documents: based on the proceeding assessment, the staff and physician will identify pertinent intervention to try to prevent subsequent falls. 2. R11 was admitted with diagnoses of difficulty in walking, cognitive communication deficit and weakness. Fall risk observation dated 12/22/22 documents: R11 is a high fall risk related to visual impairments, balance problems while standing. Care plan dated 12/23/22 documents: R11 at risk for falling related to decreased mobility, glaucoma and weakness: keep bed in lowest position with brake locks, keep call light in reach at all times, keep personal items and frequently used items within reach. Minimal data set section G (functional status) dated 12/27/22 documents: R11 requires extensive assistance with one-person physical assist with transfers and walking in the room. Balance with walking and turning around: not steady, only able to stabilize with staff assistance. Fall event dated 12/25/22 at 1:30am documents: R11 had unwitnessed fall in room. R11 was noted lying on his side on the floor in front of his bed. R11 was help to the washroom and back to bed via walker. Fall event dated 12/26/22 at 10:05am documents: R11 had an unwitnessed fall. R11 had intermittent confusion. Care plan dated 12/26/22 documents: Give R11 verbal reminders not to ambulate/transfer without assistance. Keep call light in reach at all times. Obtain physical therapy consult for strength training, toning, positioning, transfers, gait training, mobility devise. Place R11 in restorative programs, provide proper, well-maintained footwear, provide transfer assistance from bed to wheelchair. On 12/30/22 at 3:39pm, V5 (Restorative Nurse), R11 was a fall risk related to balance. R11 had an unwitnessed fall on 12/25/22. R11 was self-ambulating. R11 reported falling while trying to go the washroom. The interventions put in place was not effective. On 2/3/23 at 11:29am, V5 said, R11's had a fall on 12/26/23, R11 rolled out of bed. Fall policy revised 8/2008 (Treatment/Management) documents: based on the proceeding assessment, the staff and physician will identify pertinent intervention to try to prevent subsequent falls.

Based on interview and record review, the facility failed to follow hospital discharge orders by not ordering and administering pain medication [MEDICATION(S)] (Opiate Narcotic Analgesic) 5mg every 8 hours for pain for 1 of 3 residents reviewed for pain. This failure resulted in R1 complaining of pain for 5 days without medication or relief. Findings include: R1 was admitted on [DATE] due to a motor vehicle accident (MVA) with a semi-truck. R1 was admitted for acute pain, left rib fracture (5-12), left (3-8) anterior lateral rib fracture, right (1-2) rib fracture, right inferior and superior pubic rami fracture, left anterior acetabular fracture, left pubic bone fracture and left sacral alar fracture. R1 had multiple orthopedic surgeries. R1 is total assist due to pain. Nursing note dated 5/3/22 documents: R1 present with a lot of pain during her therapy session but was able to sit up in the wheelchair. On 6/22/22 at 1:24 pm, R1 who was assessed to be alert and orient to person, place and time stated, I was in a MVA and sustained multiple fractures. I didn't have my pain medication when I got here. Staff wanted to send me back to the hospital. I refused to be transferred related to the pain with movement. I asked for two acetaminophen and a Benadryl. On 6/22/22 at 1:48 pm, V9 (R1's family member) stated, we were informed that R1 did not have any pain medication on file. On 6/23/22 at 3:1 5pm, V11 (Physical Therapy director) stated, R1 complained of pain related to pelvis/multiple fractures. On 6/24/22 at 1:14 pm, V19 (Nurse) stated, R1 complained of extreme pain in the beginning. On 6/29/22 at 2:30 pm, V2 (DON/Director of Nursing) stated, R1 did not receive any medication out of our convenience box/machine. On 6/30/22 at 11:18 pm, V3 (ADON/Assistant Director of Nursing) stated, R1 was receiving acetaminophen for pain. R1 did not have the [MEDICATION(S)] between 5/3/22 -5/9/22 because R1 needed a new script. Hospital paperwork dated 4/28/22 documents: [MEDICATION(S)] 5mg take one tablet by mouth every 8 hours as needed for pain start 4/28/22. Quality- ten. Refill- zero. Controlled drug receipt dated 4/28/22 received 4/29/22 documents: [MEDICATION(S)] 5mg tablet take 1 tablet by mouth every 8 hours as needed for pain. Quantity dispensed 10. Medication was signed out on 4/29/22 -5/3/22 ten tablets given. Controlled drug receipt dated 5/8/22 received 5/9/22 documents: [MEDICATION(S)] 5mg tablet take 1 tablet by mouth every 8 hours as needed for pain. Quantity dispensed. Quantity dispensed 30. Medication was out on 5/9/22 - 5/25/22. Nursing note dated 5/8/22 documents: R1 was given acetaminophen and Benadryl. R1 was reassessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 refused. Nursing note dated 5/9/22 documents: R1 was assessed for pain, reports no pain, educated on the delivery of [MEDICATION(S)]. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain - Clinical Protocol Revised August 2008 Treatment/Management #2. The physician will order appropriate non-pharmacologic and medication interventions to address the individual ' s pain.

Based on interviews, and records reviewed, the facility failed to conduct a comprehensive assessment for pain, treat pain post fall incident, failed to report complaints of pain to the attending physician and nurse for 1 of 3 residents (R2) reviewed for pain. This failure resulted in R2 in pain crying with tears for over 4 hours. Findings include: R2 is [AGE] year old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's cognition was assessed to be intact. R2 was transferred to the hospital on 1/14/22 and did not return to the facility. On 1/21/22 at 2:50PM V23, Wound Care Coordinator, said on 1/14/22 she was called by V1. Administrator, and notified R2 was having pain on his left side and if I could go see R2 and assist in getting R2 transferred to the hospital. V23 said R2 did not say anything to her when she went to see him. On 1/25/22 at 10:02AM V25, R2's family, said on 1/14/22 she called the facility to check on R2 and she was told Physical Therapy was with R2 and he seemed upset. V25 said she arrived to visit R2 around 4:30PM and R2 was completely upset, V25 said I noticed it immediately. V25 said she spoke with a nurse who didn't know anything about R2. V25 said she spoke with V1 and requested R2 be transferred to the hospital. On 1/25/22 at 10:18AM V12, Certified Nursing Assistant (CNA), said she found R2 on the floor on 1/14/22 around 4:30AM. R2 said I understand some Spanish and R2 said he was in pain, he was crying he was in pain. V12 said R2 indicated he had pain on his left side from his left foot to his left shoulder. V12 said she saw R2 was red on his left side from pressure of the fall. V12 said the bed was not in the lowest position and there was not a floor mat under R2, but it was on the other side of the bed. V12 said R2 rubbed his skin on the floor when he fell and his arm was bleeding. On 1/25/22 at 11:25AM V1, Administrator, said an agency nurse was assigned to R2 on 1/14/22 and he had no information about R2. V1 said he went to see R2 and he pointed to his shoulder, R2's daughter said R2 has discomfort to his shoulder. V1 said R2's daughter requested R2 be transferred to the hospital. [Agency nurse phone number not provided to surveyor.] On 1/25/22 at 11:45AM V13, Therapy Director, said she worked with R2 and he usually had pain in his legs. V13 said R2 was able to perform upper body exercises. On 1/25/22 at 12:01PM V14, Physical Therapist, said on 1/14/22 R2 was her first patient she saw him around 3:00PM. She was made aware at the nurses' desk that R2 had fallen. V14 said she saw R2 in his room and he was crying, had tears on his face. V14 said normally R2 does not cry with tears. V14 said normally R2 has pain in his legs. V14 said she did not report to anyone R2 was in pain. V14 said about an hour later someone told me R2 was going to the hospital. On 1/25/22 at 1:33PM V2, Director of Nursing, said after a resident has a fall we do post fall assessments and we continue to monitor the resident for changes, and pain. V2 said she did not see R2 at all on 1/14/22. On 1/25/22 at 3:34PM V16, Licensed Practical Nurse (LPN), said on 1/14/22 I saw R2 on the floor and he was moaning. V17 said he did not asses R2. V17 said when V24, R2's Nurse, arrived to the room V17 left the unit. On 1/25/22 at 4:35PM V17, Registered Nurse, said he saw R2 on the floor and he was moaning. V17 said when V24 arrived to the room he left the unit. On 1/25/22 at 10:10AM V19, Medical Director, said he expects the nursing staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/25/22 at 11:42AM V17, CNA, said she was assigned to R2 routinely. V17 said R2 had periods of confusion and often requested pain medication for his legs. V17 said she would report R2's request to his nurse. V17 said she never saw R2 crying with tears. On 1/26/22 at 12:36PM V23, Wound Care, said on 1/14/22 she did not provide wound care to R2 because his treatment is ordered Sunday, Tuesday, and Thursdays. [1/14/22 was a Friday.] The surveyor was unsuccessful in contacting V24, LPN, who was assigned to R2 on 1/14/22 when he fell . Calls and messages were left on 1/21/22 at 3:28PM additional calls were made on 1/25/22 at 9:57AM, 9:58AM and 12:45PM on 2 phone numbers provided by the facility. R2's Event Report dated 1/14/22 notes: Initial Observation complains of shoulder pain. Pain Observations bracing, grimacing, massaging a body part of area, rubbing is check marked. Analgesic given is documented on Event Report. However, documentation was made on the Medication Administration History for 1/14/22 or R2's Controlled Drug Form until 9:00AM. Pain was documented at 5:10AM by V24. V24 did not return surveyors calls to be interviewed. Review of R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's Controlled Drug Form dated 1/14/22 at 9:00AM notes [MEDICATION(S)]-Acetaminophen tablet administered. Pain scale evaluation performed on 1/14/22 notes R2 has a pain rating of 7 on 0-10 pain scale. No follow up note or documentation was found to address the effectiveness of the medication. Review of R2's Medication Administration History for 1/14/22 [MEDICATION(S)] tablet as needed every 12 hours is not signed off as given since 1/13/22 at 5:50PM. [MEDICATION(S)] is not signed on R2's Controlled Drug Form dated 1/14/22. Review of R2's Progress Notes dated 1/14/22 at 5:02AM notes R2 complained of left arm pain. Medication was offered but declined at this time. Order for STAT left arm X-ray given. The next nurse written Progress Note is at 5:38PM noting R2 complained of pain to left chest and arm. Doctor notified and order to transfer to the hospital carried out. [This note is 12 hours after the initial complaint of left arm pain. No progress note was found after the fall until 1/14/21 at 5:01PM noting R2 was being sent to the hospital for complaints of pain.] R2's Risk for pain and discomfort related to wound to right lower extremity initiated 11/12/21 includes: administer medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Adjust if ineffective, monitor and record any non verbal signs of pain (crying, moaning). The facility Pain - Clinical Protocol revised August 2008 notes as follows: Identify individuals who have pain or who are at risk for having pain. Such assessments should occur whenever anytime pain is suspected. Identify the nature and severity of pain. Evaluate non-verbal individuals for nonspecific signs and symptoms that could reflect pain; for example grimacing. The physician will order appropriate non-pharmacological and medication interventions to address the individual's pain. Staff will reassess the individual's pain and consequences of pain at regular intervals. The staff will discuss significant change in levels of comfort with the Attending Physician. Resident's Physician and resident's family/responsible party should be notified of significant changes pertaining to resident's pain level.

Based on interview and record review, the facility failed to ensure a resident received physician-ordered hemodialysis for one (R2) of three residents (R2, R3, R4) reviewed for [CONDITION(S)] in the sample of 5. This failure resulted in R2 developing pulmonary congestion and fluid overload, resulting in hospitalization . Findings include: R2's Face Sheet (obtained 4/20/21) states R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Progress Note, dated 3/27/21 at 7:19 PM, states R2 was admitted to the facility. R2 is a [CONDITION(S)] patient with a [CONDITION(S)] schedule of Tuesday, Thursday and Saturday. R2 has medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's diet is renal diet, regular texture, with thin liquids. All medications verified via telehealth. All orders carried out. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication Administration History for March 2021 and April 2021 indicate staff signed/initialed that R2 received [CONDITION(S)] on Tuesday 3/30/21, Thursday 4/1/21, and Saturday 4/3/21; had vital signs checked after [CONDITION(S)] on Tuesday 3/30/21, Thursday 4/1/21, and Saturday 4/3/21; and had his access site right AVF checked for redness, bleeding and swelling from 3/29/21 - 4/3/21. There was no documentation in R2's Progress Notes from 3/27/21- 4/3/21 stating R2 had completed hemodialysis. Physician's Progress Note dated 4/3/21 at 4:25 PM states R2's Nurse reports [CONDITION(S)] (could see pitting [CONDITION(S)] in video). Nurse having difficulty obtaining vitals, she reports. Nurse said R2 is on 2 liters of oxygen. R2 is on hemodialysis but not clear the hemodialysis schedule (R2 is not on [CONDITION(S)] schedule so nurses are not sure if/when R2 had her hemodialysis). R2 is lethargic and not very interactive on video call, which appears to be a change. Assessment/Plan: send to hospital STAT due to lethargy and fluid overload status, let family know of situation. Progress Note dated 4/3/21 at 7:36 PM states R2 was observed with labored breathing and pitting [CONDITION(S)] (+4) to bilateral upper extremities. R2 is very lethargic. Unable to obtain vital signs. Physician contacted and made aware of residents change in condition. Received order to send resident to emergency room STAT via 911. Order carried out. R2 remained in stable condition until departure to hospital accompanied by paramedics. Hospital Records, obtained 4/21/21, stated R2 was admitted to the hospital emergency roiagnom on [DATE] at 5:14 PM, presenting with weakness and apparent missed hemodialysis. Emergency Department Resident Physician Note, dated 4/3/21, stated on arrival to the emergency department, R2 was mildly tachypenic, however otherwise stable vital signs. Physical exam reveals an edematous uncomfortable appearing woman with signs of volume overload. Concern at this time for pulmonary congestion and volume overload secondary to missed hemodialysis, also concern for electrolyte abnormality, such as [CONDITION(S)], also considering heart failure exacerbation, other electrolyte abnormality. Admission and nephrology consult anticipated. R2 was admitted to the hospital. Hospital Records state R2 was hospitalized from 4/3/21 - 4/15/21. R2's chest X-ray completed on 4/3/21 shows moderate cardiomegaly with suggestion of pulmonary vascular congestion and moderate bilateral pleural effusion with underlying atelectasis or consolidation. Comprehensive Metabolic Panel, completed 4/3/21, indicates low sodium (126, normal range 135-145 millimoles per litre-mmol/L), elevated potassium (5.8, normal range 3.1-5.1 mmol/L), low chloride (93, normal range 98-107 mmol/L), and elevated creatinine (6.17, normal range 0.51-0.95 milligrams per decilitre-mg/dl). Complete Blood Count (CBC) completed 4/3/21 indicated low hematocrit (29.8, normal range 36-46.5 %). On 4/20/21 at 2:30 PM, V3 (Director of Nurses) stated an approval request was sent to the facility's inhouse [CONDITION(S)] company regarding R2 receiving [CONDITION(S)] services as a new admission. V3 stated that R2 was never put on a [CONDITION(S)] list. V3 stated R2 missed [CONDITION(S)] on Tuesday 3/30/21 and Thursday 4/1/21. V3 stated the facility was not aware R2 did not have her [CONDITION(S)] treatments until R2 began showing symptoms (pitting [CONDITION(S)], shortness of breath) on Saturday 4/3/21. V3 stated R2 was sent to the emergency roiagnom on [DATE] for [CONDITION(S)]. The undated [CONDITION(S)] policy states the facility is responsible to pre-screen all potential [CONDITION(S)] residents prior to admission. The [CONDITION(S)] company will notify the facility that the resident has been accepted. The facility will then notify the [CONDITION(S)] company when the resident has been admitted to the facility. The [CONDITION(S)] company will then place the resident on the schedule. The facility must request the patient be scheduled for [CONDITION(S)] by speaking to or emailing with a member of the [CONDITION(S)] unit. The [CONDITION(S)] company will email a schedule to the Administration daily. The [CONDITION(S)] schedule includes any pending residents, hospitalization s, and current 'in house' residents. Facility Administration will reconcile new admissions and the schedule to ensure any new admission or readmission has a scheduled 'chair time' for [CONDITION(S)].

Based on interview and record review, the facility failed to follow their abuse policy by not immediately reporting to a supervisor that a resident (R1) had the appearance of swelling and redness to right arm. This failure resulted in a 2-day delay before initiating an abuse investigation and before R1 was assessed for injury and identified to have sustained a severely displaced [MEDICAL CONDITION] humeral neck (right arm) with soft tissue swelling. Findings include: During interview with V6 (Certified Nurse Assistant/CNA) on 8/18/19 V6 stated, I didn't get a chance to report it to the nurse; not at that time. There wasn't a nurse there. Her right arm was red and appeared to be swollen. One of the nurses called off so I didn't get a chance to report it. I had been off for 3 days, so I didn't know if that was her usual or not. She just made a sound when I moved her. She didn't say she was in pain. She does that when she is turned. I moved her as carefully as possible. It was that Friday night that I worked. During interview with V2 (Director of Nursing) on 8/18/20 regarding R1's bruise, V2 stated, No, the first time I heard anything V1 (Administrator) told me about it. I didn't hear anything from the staff. During interview with V6 on 8/19/20 regarding patient care on R1, V6 stated, I changed her incontinence brief twice on my shift. I didn't notice anything on her at first. Then when I changed her both times, I noticed redness to her arm. When asked about reporting any changes with a resident, V6 stated, If I have a patient and I changed them the first time and then see something I would report that. If I see anything that causes me alarm, I would report that to the nurse as soon as I see it. There was no nurse on the unit at the time. I only had R1 that night. I would have asked the nurse how long the resident had that; but I didn't know what was going on. I would have gone off the unit to tell someone. By the time I got through finishing up my rounds the nurse was not there. I worked 11pm-7am shift; that was Saturday morning. During interview with V2 on 8/19/20 regarding staff report of any change in resident condition, V2 stated, They should report any abnormalities, bruises, skin tears, falls; they should report it to the nurse immediately, as soon as they notice something is wrong. The nurses should chart every shift on the residents. A progress note should be charted. I can't tell you why the nurses did not chart anything; I don't know why no one charted; there is no excuse for that. During interview on 8/20/20, V1 stated nothing was reported by V6 on Friday (7/31/20). When questioned about policy on bruises of unknown origin, V1 stated, To report to the nurse and then investigate. When asked about an abuse investigation being started for R1 Friday (7/31/20) V1 stated, The investigation started on 8/3/20 at 11:55 am when the nurse was aware of the situation. At 9:54 AM, V14 (Physician) was interviewed. V14 stated, The facility has the third eye when caring for the residents and I was notified on Monday (August 3rd). I get contacted when there is any change of status. During interview at 10:20 AM, V2 was aked if V6 reported R1's redness to her right arm to any staff on Friday 7/31/20 11-7 shift; V2 stated, No she didn't. V2 was asked if an abuse investigation was started for R1 on Friday (7/31/20); V2 stated, No we didn't know anything on Friday the 31st. Nothing was started until Monday when the nurse found out. During record review noted from 7/24/20 7am-7pm shift - 8/2/20 7am-7pm shift there are no assessments documented from nursing staff on R1. Record review documents: On 8/2/20 at 8:15pm V9 (Licensed Practical Nurse) documented R1 had a bruise to the right arm and x-ray ordered. At 3:03 AM V9 documented R1 had a severely displaced fracture on the right arm per x-ray. MD notified; to see primary MD in am. On review of R1's progress notes, on 8/3/20 V14's note states R1 x-ray showing fracture; unknown if she had a fall. Nothing documented at this point. R1's 8/2/20 Radiograph of the Right Humerus states: humeral neck with severely displaced fracture. Soft tissue swelling identified. V6's General Orientation Checklist For All New Employees affirms completion of Abuse and Neglect Policy on 12/21/17. The Abuse Prevention Policy dated February 2017 states: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [REDACTED]. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. - orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation and misappropriation of property; - identifying occurrences and patterns of potential mistreatment; - immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; - implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; - filing accurate and timely investigative reports. Procedures: V. Internal Reporting Requirements and Identification of Allegations Employees are to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who had been designated to act in the administrator's absence. Reports will be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicions of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration or pain. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property.

Based on interview and record review, the facility failed to provide care and services according to accepted standards of practice by not immediately investigating suspicious redness and swelling to resident's (R1) right arm. This failure resulted in a delay in treatment of [REDACTED]. Findings include: During interview with V6 (Certified Nurse Assistant/CNA) on 8/18/19 V6 stated, I didn't get a chance to report it to the nurse; not at that time. There wasn't a nurse there. Her right arm was red and appeared to be swollen. One of the nurses called off so I didn't get a chance to report it. I had been off for 3 days, so I didn't know if that was her usual or not. She just made a sound when I moved her; she didn't say she was in pain. She does that when she is turned. I moved her as carefully as possible. It was that Friday night that I worked. During interview with V2 (Director of Nursing) on 8/18/20 regarding R1's bruise, V2 stated, No, the first time I heard anything, V1 (Administrator) told me about it. I didn't hear anything from the staff. During interview with V6 on 8/19/20 regarding patient care on R1, V6 stated, I changed her diaper twice on my shift. I didn't notice anything on her at first. Then when I changed her both times, I noticed redness to her arm. When asked about reporting any changes with a resident, V6 stated, If I have a patient and I changed them the first time and then see something, I would report that. If I see anything that causes me alarm, I would report that to the nurse as soon as I see it. There was no nurse on the unit at the time. I only had R1 that night. I would have asked the nurse how long the resident had that; but I didn't know what was going on. I would have gone off the unit to tell someone. By the time I got through finishing up my rounds, the nurse was not there. I worked 11pm-7am shift; that was Saturday morning. During interview with V2 on 8/19/20 regarding staff report of any change in resident condition, V2 stated, They should report any abnormalities, bruises, skin tears, falls; they should report it to the nurse immediately, as soon as they notice something is wrong. The nurses should chart every shift on the residents. A progress note should be charted. I can't tell you why the nurses did not chart anything. I don't know why no one charted; there is no excuse for that. During interview on 8/20/20 V1 stated nothing was reported by V6 on Friday (7/31/20). When V1 was asked about facility policy on bruises of unknown origin, V1 stated, To report to the nurse and then investigate. When V1 was asked about when the abuse investigation started for R1, V1 stated, The investigation started on 8/3/20 at 11:55 am when the nurse was aware of the situation. During interview at 9:54 AM, V14 (Physician) stated, The facility has the third eye when caring for the residents and I was notified on Monday (August 3rd). I get contacted when there is any change of status. During interview at 10:20 AM, V2 was asked if V6 reported R1's redness to her right arm to any staff on Friday (7/31/20 11-7 shift); V2 stated, No she didn't. V2 was asked if an abuse investigation was started for R1 on Friday (7/31/20); V2 stated, No we didn't know anything on Friday the 31st. Nothing was started until Monday when the nurse found out. Record review did not show an incident report documented for R1 for 7/31/20. During record review from 7/24/20 7am-7pm shift - 8/2/20 7am-7pm shift, there are no assessments documented from nursing staff on R1. Record review indicates: On 8/2/20 at 8:15pm V9 (Licensed Practical Nurse) documented R1 had a bruise to the right arm and x-ray ordered. At 3:03 AM V9 documented R1 had a severely displaced fracture on the right arm per x-ray. MD notified; to see primary MD in am. On review of R1's progress notes, on 8/3/20 V14's note states R1 x-ray showing fracture; unknown if she had a fall. Nothing documented at this point. R1's 8/2/20 Radiograph of the Right Humerus states: humeral neck with severely displaced fracture. Soft tissue swelling identified. V6's General Orientation Checklist For All New Employees affirms completion of Abuse and Neglect Policy on 12/21/17. The Certified Nurse Assistant Job Description states: Job Summary: The purpose of this position is to assist the nurses in the providing of resident care primarily in the area of the daily living routine. Job Requirements: 5. Knowledge of JACHO, OBRA, IDPH, and HFS regulations as related to duties. Main duties: H. Report any changes in resident's condition - e.g. eating habits, behavior, temperature, etc. to the charge nurse of the unit. L. Complete assignment report to charge nurse at the end of every shift. P. Detect and report situations that have a high probability of causing accidents or injuries to residents and/or staff. V6's Job Description Acknowledgement, signed on 8/14/17, states: Administrative functions: Report all changes in the resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical. The Charge Nurse Job Description states: Organize and assign all jobs to be done on his/her shift so that the work load is evenly divided among his/her employees on the basis of staff size and qualifications, pass medications at the appropriate times, and care for the clinical nursing needs on residents on his/her wing. Job Requirements: 7. Knowledge of JACHO, OBRA, IDPH, and HFS regulations related duties and responsibilities Main duties: O. Direct charting in his/her shift and make monthly detailed evaluation of all resident charting so that charts reflect progress and condition of residents in the EMR system. Q. Make rounds and observe individual residents who are experiencing episodes of acute illness, deterioration in health status, recent injury, recovering from surgery, etc. so as to be acquainted with the resident's status, both physically and emotionally and to ascertain that the staff is rendering proper care. U. Prepare incident/accident reports, events and observations using the EMR system. W. Detect and correct situations that have a high probability of causing accidents or injuries to residents and/or staff. The Abuse Prevention Policy date February 2017 states: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [REDACTED]. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [REDACTED]. - orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation and misappropriation of property; - identifying occurrences and patterns of potential mistreatment; - immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; - implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; - filing accurate and timely investigative reports. Procedures: V. Internal Reporting Requirements and Identification of Allegations Employees are to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or to a compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who had been designated to act in the administrator's absence. Reports will be documented, and a record kept of the documentation. Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicions of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health immediately, but not more than two hours of the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. The nursing staff is responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is discovered. The report is to be documented on a facility incident report and provided to the nursing supervisor, administrator or designated individual. Following the discovery of any suspicious bruises, lacerations or other abnormalities of an unknown origin, the nurse shall complete a full assessment of the resident for other bruises, laceration or pain. The resident's physician and representative, if necessary, shall be notified of any incident or allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property.

Based on record review and interview the facility failed to follow physician orders [REDACTED]. These failures resulted in R5 sustaining a pain level of 10 and hospital transfer. Findings include: The (4/14) change in condition physician notification guidelines state: the nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgment requires immediate medical intervention. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received. R5's POS (Physician order [REDACTED]. [MEDICATION NAME] 500mg (milligrams) 2 tablets every 8 hours as needed for pain (start date: 8/25/19); [MEDICATION NAME] 10/325mg every 6 hours as needed for pain (start date: 8/25/19); [MEDICATION NAME] 5mg every 8 hours for spasm (start date: 8/25/19); [MEDICATION NAME] 300mg every 8 hours for pain (start date: 8/26/19). R5's progress notes include: (8/25/19) 5:41pm, new admit. Post-surgical patient from (Hospital Name). Last pain medication given at 3:00pm per nurse on duty at (Hospital Name). (8/26/19) documented at 7:33am. At approximately 8:30pm, writer was called in patient room. Patient was screaming on the phone to her daughter stating she was in pain. Patient asked if she could have a strong pain pill. Writer tried to explain that her medication is not here yet and that from her just getting here it will take a while for the medication to come from pharmacy. Writer (Nurse) told patient that I would see if there is anything I can give for pain now until medication arrives. Patient was given Tylenol 1,000mg at 10pm. At approximately 3am, patient was complaining of pain and asked if her medication came. Writer explained to patient that some medication came in but not the pain medication nor the [MEDICATION NAME]. Patient began screaming stating she's calling her daughter and wants to leave the facility. Patient then asked for more Tylenol; writer told patient that she only can get it every 8 hours. Patient began to scream and holler. (8/26/19) 12:08pm, resident noted crying and agitated complained of pain and numbness. 12:45pm, Order obtained from physician to send resident to hospital per family request. On 8/28/19 at 3:07pm, V2 (Director of Nursing) stated, (R5) was complaining of not being able to get her pain medication. The night nurse told me she was given Tylenol. Her [MEDICATION NAME] and [MEDICATION NAME] did not arrive until the morning. Surveyor inquired if R5's doctor was notified that she endured pain because her prescribed medications were unavailable. V2 responded, That was not done. V2 affirmed that the facility has an emergency box of medications and stated, If the medication is in there, they are able to get medications from there. The (undated) facility (emergency box) inventory list includes [MEDICATION NAME] 300mg. On 8/29/19 at 11:45am, V12 (Licensed Practical Nurse) stated, On 8/25/19 (7pm-7am shift) R5 was real aggressive and agitated. She wasn't happy with anything I did. I explained to her that the only medication I could give her was Tylenol because she was a new admission the medications were not here. I would say her pain was probably like a 7, a 6 or 7 maybe. After I gave her the Tylenol she told me she was ok. Around 4am the CNA (Certified Nursing Assistant) went in to change her and she started to curse me out. Surveyor inquired if [MEDICATION NAME], and/or [MEDICATION NAME] were available for administration. V12 stated, They didn't come yet. When you do an admission, you put medications in. It takes the pharmacy time to bring them. While I was there the meds didn't come. All I was able to give her was the Tylenol. Surveyor inquired if [MEDICATION NAME] and/or [MEDICATION NAME] were in the emergency box. V12 responded, I'm not even sure of that. I never had an emergency that I had to go to the emergency box. Like I said, I had given her the Tylenol. Surveyor inquired if the physician was notified on 8/25/19 and/or 8/26/19 of R5's pain and unavailable medications. V12 responded, No, I didn't call the doctor. On 8/29/19 at 12:54pm V13 (Medical Director) stated, (R5) does have chronic pai[DIAGNOSES REDACTED] and chronic low back pain. She was status [REDACTED]. Surveyor inquired about the potential harm to R5 if the prescribed medications were not administered as ordered.V13 stated, The patient was not on any life threatening medications if it was missed. Mainly pain control if she was not on the medication. R5's (August 2019) MAR (Medication Administration Record) affirms that [MEDICATION NAME] is not documented as administered. [MEDICATION NAME] was scheduled for midnight and 8am administration; neither dose is documented. On 8/25/19, R5's pain assessment is not documented. On 8/26/19, R5's pain level was documented 10 at 10:16am. [MEDICATION NAME] and [MEDICATION NAME] were not administered until that time. The (2/14) Medication Administration Policy states: medications must be administered in accordance with a physician's orders [REDACTED].

Based on observation, record view and interview the facility failed to have a pressure ulcer prevention and treatment program for monitoring the beginning development of pressure ulcer, for possible treatment and changes in care plan interventions; failed to have pressure relieving low air loss mattress inflated while in use for treatment or prevention of pressure ulcers; failed to investigate and revise a resident's plan of care for the prevention and treatment of [REDACTED]. ulcer. This applies 2 of 2 sampled residents (R1, R5) and 4 supplemental residents (R8, R9, R10, R15) with pressure ulcers or at high risk for pressure ulcer. As a result, R5 developed two facility aquired stage II pressure ulcers. Findings include: 1. According to R5's face sheet the resident was last re-admitted to the facility on [DATE]. R5's [DIAGNOSES REDACTED]. On 1-16-18 at 3:30pm, R5 was in supine position. A tube feeding was running at the time. The tube feeding formula was running at 50cc per hour. The label on the tube feeding formula of Norvosource - Renal had a written date of 1-16 -2018, 50 cc times 20 hours and was up at 1pm. According to the minimum data set ((MDS) dated [DATE] and 12-21-17 R5 requires two people to physically assistance him for transferring, dressing, hygiene and bathing. R5 had two pressure ulcer (sore) risk assessments completed on 1/11/2018 and 1/16/2018; both assessments had a score for his risk. R5 had a physician order [REDACTED]. On 1-16-2018 at 2:30PM, V15 (wound doctor) stated she visits the facility once a week. V15 reported R5 had two facility acquired pressure ulcers, one on each buttock. V15 stated she would expect the nursing staff to inform the resident's primary doctor of any new pressure ulcer in her absence. On 1-16-2018 at 4:33pm V6 (treatment nurse) reported she could not remember how she came to know about R5's first pressure ulcer on 1-11-2018. She believed it may have been his wife, since she is always here. Initially she believed it was two pressure ulcers on the right buttock. However, the wound doctor assessed it as one pressure ulcer. V6 stated the second pressure ulcer was found on the examination by the wound doctor today. R5's skin observation tool dated 1-10-2018 08:49 had the following information: Site 23) coccyx and Notes Resident noted with pink open area on buttocks. Area was cleansed, covered with antibiotic ointment. Wife, doctor and wound care nurse made aware. No other assessment of the wound found in the documentation. In R5's progress notes, a Skin/Wound note dated 1-11-2018 10:07 had the following information: Area observed on right superior buttocks (stage II) 2.2 X 2.4 (no depth measured); Right inferior buttocks (stage II) 2.0 X 2.0. (no depth measured), MD aware, TX (treatment) implemented, wife and daughter at bedside, No pain or discomfort noted at this time. PRN (as needed) pain Meds given as needed, Wound consult needed. In R5's progress notes, a Skin/Wound note dated 1-16-2018 13:30 Area observed on left buttocks (Stage II) 2.5 X (no other measurement noted), MD aware, TX implemented, wife and daughter at bedside and is aware, no pain or discomfort noted at this time, PRN pain meds given as needed. In R5's progress notes, there were two Orders-Administration Notes both dated 1-16-2018 13:15, Note text: right superior buttocks cleanse with NSS (normal saline solution)/wound cleanser skin prep peri-wound apply [MEDICATION NAME] dressing every 72 hours/ PRN. Right inferior buttocks: cleanse with NSS/wound cleanse skin. Cleanser skin prep peri-wound apply [MEDICATION NAME] dressing every 72 hours/PRN. R5's care plan had an identified problem of a history of pressure ulcer resolved 10/19/2017. The care plan also indicated 1/11/18 right superior and inferior buttocks and 1/16/2018 left buttock. The care plan was initiated on 10/12/2017, revision on 01/05/2018. There were no changes in the interventions since 10/12/2017. The intervention for checking R5 who was identified as high for skin breakdown was once weekly according to the care plan. Based on the above information, R5's two right buttock pressure ulcers were first identified on 1/10/2018 (according to skin observation tool). A nursing assessment was completed on 1/11/2018 for the two pressure ulcer. The treatment for [REDACTED]. On 1-16-2018 V2 (acting director of nursing) was questioned about the facility's planned program for treatment and prevention of pressure ulcer. V2 indicated the survey team was provided with the facility's planned program. V2 was asked to provide any evidence of the facility's investigation to determine the reason why R1 developed the facility acquired pressure ulcers. No investigation was provided to the survey team. 2. R1's [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE] and a pressure sore risk assessment was done 1/13/2018. The assessment noted R1 was at high risk for development of a pressure ulcer (sore). R1's MDS assessment (5-day Medicare) with an assessment date of ARD, in section G noted: R1 depended on staff for bathing need and needed physical assessment with hygiene and bed mobility. R1 had no diet order. Had a physician order [REDACTED]. V14 (dietitian) stated she was new to the facility and had not completed the assessment. R1's care plan with an admission date of [DATE] indicated R1 had a tube feeding and a potential for pressure ulcer development. The intervention included but not limited to: a referral to RD (registered dietitian) as indicated, follow facility policies/protocols for the prevention and treatment of [REDACTED]. R1's care plan was not individualized to meet the resident's need. R1 has no diet order. R1's progress notes contained a Skin/Wound note dated 1/12/2018 16:27 had the following information: Full body assessment completed upon admission,[MEDICAL CONDITION] intact, [DEVICE] (gastric tube) intact, sacral area noted reddened, skin barrier applied, no pain or discomfort noted at this time, PRN (as needed) pain meds given as needed. On 1-15-2018 at 8:26 AM, R1 was in bed. R1 had [MEDICAL CONDITION] to a ventilator, a tube feeding running and had hand mitts applied to both of her hands. No call light cord was visible at the time. R1 was able to respond to yes or no questions. The surveyor asked R1 if she needed something. R1 gestured to the surveyor indicating she wanted to be repositioned. The surveyor asked R1 if she could call a nurse. R1 gestured indicating No with her head. R1's call light required a button to be pushed. The surveyor asked R1's roommate to activate her call light. The surveyor noted five minutes after the call light was on, V8 (certified nurse aide/ CNA) to respond to the call light. As V8 repositioned R1 up in bed, the surveyor observed R1 had a pillow under her feet. However, there was no pillow (or any other device) keeping the bony prominence of R1's legs from coming together. Also, R1 began to sink back down into the air mattress. On examination of the mattress, the surveyor observed the middle of the mattress was not inflated. V8 stated she did not know how long R1 was in this position, because she did not check the resident when she came on duty. The surveyor was able to feel the metal frame of the bed while pressing down on the mattress. The control of the bed's air mattress had blinking light indicating something was wrong. V2 (acting DON) came in the room after 15 minutes to check the mattress and confirmed something was wrong with R1's mattress. On 1-19-2018 the facility provided the survey team with a nutritional assessment for R1. According to the assessment lock dated 01/16/2018 at 19:32 (hour), R1 was NPO (nothing by mouth) receiving a tube feeding with a [MEDICATION NAME] 1.5 formula to run 40 ml (milliliter) per hour with 200 ml flush every 6 hours. This feeding provided R1 with 1320 calories, 56 gram protein and 1468 ml fluid. R1's assessed needs were 1350-1532 calories, 54-65 grams protein and 1350-1500 ml fluid per day. The abnormal skin integrity as documented in the progress 1/12/2018 was noted as a factor in R1's nutritional assessment. The nutritional recommendation was suggest change of formula to Glucerna 1.5 45 ml/ hour and 200 ml flush every 6 hours. 3. On 01-16-2018 at 1:45pm, R15's wife complained about not having staff to turn R15 during the night. It was reported to the surveyor, family members have been present in the facility 24 hour a day since R15 was admitted to the facility. On 1-16-2018 after informing V1 (administrator) of R15's wife concerns, V1 reported he took the complaint regarding R15 and talked with the family. The plan was to add additional staff during the night shift. R15 had recorded weight of 241.8 pounds and a height of 6 feet. According to R15's medical record, the resident was admitted to the facility on [DATE]. The Admission note written 1/10/2018 12:38 by V9 (charge nurse) included the following information: Received am accompanied by wife and sister. Small open area to L (left) inner buttock. Skin tears to b (bilateral) upper ext. (extremity). The skin observation tool dated 1/10/2018 at 14:35 had the following information: Site 32 - left buttock, open area. No other description or measurement was documented at the time it was identified and assessed. The pressure sore (ulcer) risk assessment dated [DATE] 13:56 had a score indicating R15 was at high risk for development of a pressure ulcer. R15 had an order for [REDACTED]. Nursing documentation from 1/10/2018 to 1/15/2018 had no documentation of doctor notification of R15's skin condition or treatments implemented. On 1/12/2018 at 14:36 R15's nursing note contained: Family request to (have) bariatric bed. On 1/16/2018. On review of R15's electric record and record requested, there was no wound care notes available prior to V15's (wound care doctor) visit of 1/16/2018. V15 was observed talking to family member just before entering R15's room for assessment and treatment. V15's assessment and plan of care recommendation were documented 1/16/2018 as follows: Unstageable DTI of the left buttock - initial evaluation - Continue: [MEDICATION NAME] every three days and Add: Collagen dressing - every three days. Recommendation: reposition per facility protocol, off load wound, low air loss mattress, every(Q) 2 hours repositioning, off loading wedge. On 1-16-2018 at 3pm, the surveyor noted R15 was positioned laying down in an over sized bed. It was a bariatric bed but no specialty mattress cover was noted. It did not appear to be a air mattress. The surveyor asked V9 (charge nurse) if R15 had a low air lost mattress. V9 then asked V10 (nurse aide) if R15 had a low air loss mattress. V10 replied, No. 4. R8 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. At the time of admission, R8 presented with a Stage 4 sacral wound. During observation of wound care treatment on 1/15/18 at 1:08pm, R8 was laying in bed with low air loss mattress in place. Settings on mattress were programmed to maximum weight (350 lbs.). Mattress was covered with a fitted sheet, there was a fabric incontinence pad under R8 and he was also wearing a disposable adult incontinence pad. R8's MDS (minimum data set) dated 1/8/18 lists R8 as always incontinent of bowel and bladder as well as requiring extensive assistance/one person physical assist (3/2) for bed mobility. Interview with V6 (Wound Treatment Nurse) 1/15/18 at 1:10pm stated, (R8) has too much going on, on this mattress; that's why I took everything off. It should be just the incontinence pad or a draw sheet, not both. The fitted sheet defeats the purpose of having the low air loss mattress. It's (low air loss mattress) set to max weight. I need to check his weight to set it according to his weight. Review of R8's medical record documents his most recent weight as 137 lbs. on 1/7/18. Continued observation on 1/15/18 at 1:08pm of resident during wound care treatment, noted that resident was flinching when V6 rinsed the wound and his toes were curling. Surveyor asked V6 if R8 was pre-medicated prior to receiving treatment and she stated that she watches for non-verbal signs of pain in R8 because he is not verbal; V6 stated that he is normally calm and does look like he is in pain so he is not pre-medicated. Surveyor continued to ask if it appeared that R8 was currently in pain since he was flinching. V6 then asked R8 if he was in pain and he motioned yes with his head; V6 then asked R8 where his pain was and he pointed to his sacrum. Care plan for R8 with initiation date of 12/28/17, focus of Stage IV pressure ulcer sacrum related to immobility includes interventions: follow facility policies/protocols for the prevention/treatment of [REDACTED]. to ensure the resident's comfort. Facility's Skin Management Guidelines with revised date of (YEAR)-03 includes: all residents assessed to be at risk for breakdown should be placed on a pressure redistribution mattress or wheel cushion. Facility provided manufacturer user manual for low air loss mattress system; user manual states that the Pressure-Adjust Knob is adjustable by patient's weight with pressure level set by using the weight scale as a guide. Weight scale on knob goes from 80 (soft) to 350 (firm) lbs. Physician orders [REDACTED]. Review of R8's Medication Administration Record [REDACTED]. Weekly wound documentation provided describes R8's sacral wound as the following: 12/23/17 - 12/31/17: measurement is 4.0 x 3.0 with undermining AA o'clock 3.5; 1/1/18 - 1/7/18: measurement is 4.0 x 3.0 with undermining AA o'clock 3.5. V6 measured R8's sacral wound during treatment observation and wound had increased in size from the previous measurement; size of the wound as measured on 1/15/18 measured 4.5 x 3.5 x 2 with undermining between 12 and 1 o'clock at 3.5. 5. R10 is a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During observation of wound care treatment on 1/15/18 at 12:30pm, R10 was laying in bed. Mattress was covered with a fitted sheet, there was a fabric incontinence pad under R8 and he was also wearing a disposable adult incontinence pad. While V6 was rinsing wound with saline solution as ordered, R10 was flinching and said, Ouch. R10 continued to state that it felt as if alcohol was being put on an open cut. V6 did not offer to provide R10 with any pain relief. R10 has a physician order [REDACTED]. MAR (Medication Administration Record) for R10 has 12pm dose of [MEDICATION NAME] HCL coded as 1 (1 = away from facility with meds). R10 was not medicated prior to wound treatment. V6 (Wound Treatment Nurse) 1/15/18 at 12:40pm stated that since R10 is verbal, she determines if he needs to be pre-medicated with pain medication based on his reaction to treatment. V6 stated all residents with a Stage II pressure sore or higher are put on a low air loss mattress. Surveyor asked V6 if R10 should be on a low air loss mattress and she stated, Yes, he should be; actually he is on a low air loss mattress. Surveyor then pointed out that R10 was not on a low air loss mattress and that he was on a regular mattress. V6 then went back in the room to check the mattress and came back out and stated, You are right, I missed that; he should be on a low air loss mattress. Care plan for R10 with initiation dates of 01/04/2018 and 01/10/2018, focus related to pressure ulcer and wounds include interventions: treat pain as per orders prior to treatment/turning, etc. to ensure the resident's comfort and anticipate the resident's need for pain relief and respond immediately to any complain of pain. 6. R9 was reviewed for use of low air loss mattress. On 01/15/18 at 8:05am, R9 was lying in bed with low air loss mattress in place. R9 stated that she is in pain because there was something in the mattress stabbing her back. Settings on mattress were programmed to maximum weight (350 lbs.) for comfort and the low pressure indicator and normal pressure lights were blinking. R9 was bottoming out (sinking in to the middle) on the mattress. Observation of R9 on 01/15/18 at 10:42am, R9 was lying in bed with low air loss mattress in place. Low pressure and normal pressure indicator lights were blinking. R9 was still bottoming out on the mattress and stated, It's hurting my back and my hips. Observation of R9 on 01/15/18 at 12pm, R9 was sitting in the chair in her room while V16 (Guest Services) was working on R9's mattress. At this time, V16 stated that he just finished checking the mattress because the pressure was low and he saw the lights were blinking. V16 stated that it was probably one of the hoses that was not connected properly and he was just notified that it had to be checked. According to manufacturer recommendation: Low air loss mattresses use a blower pump to remove excess moisture, while at the same time immersing the patient into the mattress. This treatment is primarily concerned with moisture control, a crucial component of managing severe and chronic wounds. As the patient lays on the mattress, moisture is dissipated between the mattress and the cover. Low air loss mattresses are constructed from special fabric which is permeable to vapor. The moisture from the patient transfers through this fabric cover to interact with the air blowing up from the mattress. By utilizing this barrier, the patient can be cool and dry without having direct air blown onto their skin. Aside from regulating and managing moisture levels, there is another primary aim of low air loss mattresses for wound therapy. Perhaps even more importantly than the management of moisture, these mattresses immerse the patient into the surface to a much higher degree than a conventional bed. By maximizing the contact area and carefully regulating pressure levels and contact, blood flow to the area affected by the wound or injury is promoted. Blood flow is the most important factor in determining healing timeframe, so this can be enormously beneficial when patients are looking to see rapid healing in order to return to their normal daily routine. The facility's Skin Management Guidelines with revised date 2013-03 included the following for pressure ulcer reduction and prevention strategies: Systematic skin Evaluation, An integral part of any skin care program and through these inspections early skin problems can be detected and interventions started. The inspections start on admission and daily skin inspection. Evaluations must continue on a daily basis for all residents that are at risk for skin breakdown. Staff should evaluate skin condition for color, moisture, temperature, integrity and turgor. It can be done by a licensed nurse or CNA (certified nurse assistance). Ensure Adequate Nutrition and hydration: poor diet intake can play a role in pressure ulcer development and delay healing. A nutritional evaluation should be completed on all residents in order to maintain skin integrity and prevent pressure ulcer development. Accurate documentation: The plan of care should address efforts to stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions and modify the the intervention as appropriately. The care plan should specifically address risk factors, pressure points, under nutrition and hydration deficits and moisture and its impact. Pain management: monitor the resident for pain and put protocol in place to assist in pain management. Pain management should include administration of medication prior to dressing changes and around the clock if needed. Positioning devices: Positioning devices should be used to keep bony prominences from direct contact with each other. These devices may be in the form of pillows or foam wedges. Pressure Redistribution mattresses and Devices: All residents assessed to be at risk for breakdown should be placed on a pressure redistribution mattress or wheel chair cushion. The important thing to check for when using a pressure reducing overlay or mattress is bottoming out . Pressure Ulcer Development: When a new pressure ulcer or skin issue has been identified the licensed nurse will document findings, wound characteristics, stage (if applicable), wound measurements in centimeters (cm) wound characteristics, pain associated with wound on weekly wound documentation form. Initiates and/or updates care plan and CNA care directive with interventions. These procedures listed above were not all followed for the care and treatment for [REDACTED].

Based on interview and record review, the facility failed to ensure that residents receive medication as order to avoid a significant medication error. This applies to two of three residents (R3, R7) reviewed for medications, in the sample of 16. This failure resulted in R3, who is not a diabetic, receiving nine doses of [MEDICATION NAME], resulting in [DIAGNOSES REDACTED] requiring hospitalization . Findings include: According to the facility's QAPI (Quality Assurance and Performance Improvement) Action Plan dated 08/08/2017 (voluntarily provided to this writer by E2, DON-Director of Nursing), an investigation revealed that E4 (LPN-Licensed Practical Nurse) had entered a new order for [MEDICATION NAME] on 08/02/2017. Prior to discharge on 08/05/2017, E5 (Registered Nurse Case Manager) reconciled R3's discharge medications including the [MEDICATION NAME]. Neither nurse detected that R3 was not diabetic, but had an order for [REDACTED].>E4 was interviewed on 08/08/2017. During the interview, E4 said she had just realized after going through her documentation that Z3 (Physician) had given her two orders on that day for two different residents, R3 and R7. E4 however entered the wrong medication, [MEDICATION NAME], on R3 instead of entering it for R7. This led to R3 getting a wrong medication and R7 missing some doses of the [MEDICATION NAME]. E5 was interviewed on 08/08/2017 and said she did not reconcile the discharge medications with their correlating diagnoses. E4 (08/22/2017 at 2:58 PM) said, she put in an order for [REDACTED]. R3's MAR (Medication Administration Record [REDACTED]. R7's MAR (08/2017) notes that R7 did not receive [MEDICATION NAME] until 08/08/2017 and missed ten doses of [MEDICATION NAME]. The facility's Concern Forms notes R3's daughter reported, on 08/08/2017, that R3 had been hospitalized due to [DIAGNOSES REDACTED]. R3's ambulance run sheet dated 08/07/2017 notes the following: per family pt (patient) not responding like normal this morning. Pt (patient's) blood sugar level, was 39 percent. Crew gave 1 (one) tube oral glucose w/ (with) no change. Pt (patient) became alert and oriented x3 after one amp D/50. The report describes R3 as disoriented, verbally inappropriate and slow to respond. Impression: [DIAGNOSES REDACTED]. R3's hospital record (emergency room Progress Note-08/07/2017) notes the following: R3 from home with daughter to evaluate her for having drops in her blood sugar. States today at 8:00 AM they had to call 911 for her because she was not acting right., her blood sugar was 39, EMS (paramedics) gave her something to fix it. Patient is coming to Emergency Department with three episodes of [DIAGNOSES REDACTED] in the last two days. Today it was down to 30 and patient was very lethargic. EMS gave her glucose and it improved. Patient is not a Diabetic, she is not on any insulin or oral Diabetic medications. Will admit. Z3, physician (08/22/2017 at 2:29 PM) said, that he never ordered [MEDICATION NAME] for R3, who is not a diabetic. Z3 said he was notified by the facility that R3 had become hypoglycemic. Z3 said if someone who is not a diabetic receives [MEDICATION NAME] could become hypoglycemic.

Based on observations, interviews and record reviews, the facility failed to identify, assess, monitor and treat pressure sores as ordered by the physician and failed to provide preventative measures for 5 of 6 residents reviewed for pressure sores. These failures resulted in residents experiencing the development of new pressure sores and/or deterioration of opened wounds. This applies to to 5 of the 6 residents (R1, R2, R3, R6 and R10) reviewed for pressure sores inside the sample of 17 resident. The findings include: 1) Per R1's Minimum data Set ((MDS) dated [DATE], R1 has multiple medical [DIAGNOSES REDACTED]. R1 is on a ventilator via [MEDICAL CONDITION]. R1 needs extensive assistance with ADLs (Activities of Daily Living). On 7/28/15 at 2:50 PM, E4 (Nurse) provided wound care to R1. R1 has 3 dime size open areas or pressure sores in the right sacral area. E4 was unable to identify what stages the wounds were and was unable to describe the characteristics of these wounds. E4 stated she's not a wound care nurse. E4 cleansed the wounds with normal saline solution (NSS) and covered the wounds with bordered gauze. The bordered gauze covered only 2 of R1's pressure sores and left the 3rd, which was R1's bottom wound, uncovered/exposed. R1's Physician order [REDACTED]. On 7/29/15 at 10:10 AM, E6 (Wound Care Nurse) stated R1 had two stage 2 pressure ulcers on the right sacrum which were acquired in the facility. E6 said R1's top one (wound) measured as 1 centimeter (cm) in diameter and the 2nd one was measured as 0.5 cm in diameter. E6 stated R1 needs Duoderm treatment which would help with the healing process of R1's wounds. E6 said a bordered gauze dressing is not an acceptable treatment for [REDACTED]. On 7/29/15 at 1:10 PM, E6 rendered wound care assessment and treatment to R1. R1's middle and bottom dime size pressure sore merged together creating one larger wound. E6 described the top open wound as unstageable due to presence of slough in the wound bed and measured as (L) Length 1cm x (W) Width 2 cm. The larger wound that merged together was described as stage 3 pressure sore and measured as (L) 4 cm x (W) 2.5 cm, with 10% yellow slough and 90% red tissue. R1's Physician order [REDACTED]. However, R1 was observed not receiving pressure sore treatment as ordered by his primary physician and required by his condition. Progress Notes dated 7/16/15 indicates: Open areas to sacrum were found. Wound care and unit manager notified. There was no evidence in R1's Progress Notes, Nursing Notes, or TAR (Treatment Administration Record) of weekly skin and wound assessments being done consistently for R1 . There was no evidence that the wound physician had seen or assessed R1's pressure sore. R1's only Braden Score dated 7/10/15, identified R1 as a moderate risk for pressure sores. There is no evidence to show preventative measures were put in place (eg. pressure relieving mattress or low air loss mattress) for pressure sore prevention prior to R1's breakdown. 2) Per R6's MDS (Minimum Data Set) dated 7/9/15, R6 has multiple medical [DIAGNOSES REDACTED]. R6 needs extensive assistance with ADLs. On 7/28/15 at 1:30 PM E4 rendered wound care to R6. E4 was unable to identify and describe R6's wound characteristics. E4 stated, I am not a wound care nurse. E4 cleansed with NSS the surrounding area (skin) of R6's stage 4 pressure sore, but not inside the wound. E4 proceeded to apply Santyl ointment to the surrounding area of the wound but did not apply any Santyl ointment into R6's wound. R6's POS dated 7/3/15 indicates: Santyl to left upper back wound every shift and as needed. R6's Wound care specialist notes dated 7/8/15 indicates: Left mid-back stage 4 pressure sore. Treatment: Hydrogel. R6's wound in the left back is due to kyphosis and poor ability to reposition. R6 needs padding to the back of wheelchair. Follow/support nutrition and hydration. R6's Wound care specialist notes dated 7/15/15 indicates: Stage 4 pressure ulcer. Treatment: Hydrogel. Monitor nutrition. Keep bacterial load low and keep appropriate moisture with wound. Decrease pressure on the back due to scoliosis. From 7/28/15 through 7/30/15 between 9:30 AM though 1:00 PM, R6 was observed sitting up in her wheelchair with no back padding. R6's only Braden Scale dated 7/2/15, identified R6 as a moderate risk for skin breakdown. Wound specialist recommended back padding on R6's wheelchair to alleviate pressure on her back. On 7/29/15 at 10:15 AM E6 stated the following for R6's wound: Clean the wound bed, dab the wound bed with NSS in a gauze, clean the wound from inner to outer area. Then apply Santyl ointment to the wound bed and cover with dry dressing. Santyl ointment is not supposed to be applied to the surrounding area or outside area of the wound. On 7/29/15 at 1:45 PM E6 (Wound Care Nurse) stated, We do comprehensive skin assessments on admission. We notify physician and family if there's a skin breakdown. We (wound care) do our assessments and treatment recommendations, then we do weekly skin and wound assessments. 7/30/16 at 9:55 AM E6 stated that Santyl ointment and Hydrogel are two different medications with different purposes. Santyl ointment is a [MEDICATION NAME] agent while Hydrogel is to keep the wound moist. Whoever carried out the order for R6 should have clarified the order with the wound doctor. E6 added that she just changed the order as of today to Hydrogel as originally ordered/recommended by the wound physician. On 7/31/15 at 12:25 PM Z6 (R1's and R2's primary physician) stated that all wounds or skin breakdown must be referred to wound care specialist. Z6 stated he did not know what the facility did in the absence of the wound care doctor, and someone should cover when the wound doctor is not available. Z6 also stated he couldn't remember if the facility had notified him with regards to R1's and R6's skin breakdown. The facility's Policy and Procedure for Skin Management showed the following instructions for the nursing staff: Overview: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes.Practice Guidelines: .Following admission, the Braden Scale For Predicting Pressure Sore Risk will be completed weekly for additional 3 weeks (for a total of 4 weeks including admission), quarterly, annually and with a significant change of status for their risk for development of pressure ulcer. Facility was unable to provide evidence of accurate wound report or wound tracking upon request until the third day. 3). R3's Face Sheet shows R3 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Braden Scale dated 7/8/2015 states, Very high risk for pressure sore development. Progress Note dated 7/17/2015 states, Patient noted with open area to coccyx area, area was cleaned with Normal Saline and duoderm was applied. R3 acquired the pressure sore in the facility. Physician order [REDACTED]. The Treatment Administration Record dated 7/17/2015 through 7/27/2015 did not contain signatures for the wound treatments. There is no evidence that the treatments were implemented. R3's Care Plan for skin breakdown dated 7/17/2015 states, complete a full body check weekly and document. Reposition in bed/adult recliner frequently for comfort and pressure reduction. However, R3's clinical record contained no weekly skin notes, no wounds notes and there was no description of R3's wound. On 7/28/2015 starting at 10:00 AM with tour guide E13 (Activity Director), R3 was laying on a standard bed. R3 was on a ventilator and had a tube feeding infusing. On 7/28/2015 at 10:30 AM, E11 (Nurse) was assigned to care for R3. E11 said she did not know who had wounds on the unit. E11 stated the wound care nurse would know and said go ask the certified nursing assistants on the unit. On 7/28/2015 at 10:30 AM, E12 (Certified Nursing Assistant) was assigned to care for R3. E12 did not identify R3 as having a pressure sore. On 7/28/2015 at 1:35 PM, E12 (CNA) and E27 (Restorative Aide) were observed placing a low air loss mattress on R3's bed. E27 (Restorative Aide) said R3 is just now receiving a low air loss mattress because R3's family was complaining about R3 not being on one (low air loss mattress). On 7/29/2015 at 8:55 AM, E15 (Nurse) said R3's dressings were changed by the treatment nurse (E16). On 7/29/2015 at 8:56 AM, R3 was laying in bed with two large duoderm dated 7/29/2015 on the buttock area. The right buttock area duoderm did not cover the entire wound. R3 began to have episodes of incontinence which leaked out over the uncovered wound area. E12 (CNA) and E27 (Restorative Aide) provided incontinent care for R3. On 7/29/2015 at 11:30 AM, E6 (Wound Care Nurse) said she was not familiar with R3's wounds and had just returned from a leave of absence. E6 said E16 (another Wound Care Nurse) did the treatment for [REDACTED]. E6 said she would re-do R3's treatment today because she (E6) was informed the dressing did not cover all the areas of R3's wound. E6 (Wound Care Nurse) said R3 should have been placed on a low air loss mattress since admission because of R3's high risk for the development of pressure sores. E6 was asked if R3 had weekly skin and wound assessments. E6 said there should be weekly documentation of wounds and weekly skin assessments for residents. E6 (Wound Care Nurse) stated again she was on leave for a few months and E16 (Wound Care Nurse) was responsible for the wound care program while she was gone. On 7/29/2015 at 11:36 AM, E16 (Wound Care Nurse) said R3 had a small opening on the sacral area. E16 (Wound Care Nurse) said the unit nurse was responsible for doing resident's wounds treatments. E16 said residents who have wounds should be turned every two hours and have a low air loss mattress as part of their pressure sore prevention plan. On 7/29/2015 at 1:55 PM, E6 (Wound Care Nurse) and E17 (CNA) did the treatment for [REDACTED]. R3 had two stage 2 pressure sores, one located on the left buttocks (measuring 0 .5 cm in length by 0.5 cm in width) and one on the right buttocks (measuring 0.4 cm in length by 0.5 cm in width). The pressure sore on the right buttock area was not all covered by the duoderm. E6 confirmed R3's dressing should cover R3's entire wound. E6 (Wound Care Nurse) said E16 did R3's dressing change but E16 did not notify the doctor of R3's additional wounds. On 7/30/2015 at 1:25 PM, E15 (Nurse) said she noted R3's skin breakdown on 7/17/2015. E15 (Nurse) said it was just a little redness at the beginning of R3's breakdown. E15 (Nurse) said she did not know how to describe the wound and just documented an open area. E15 could not answer when the wound deteriorated or if treatment was given/changed to prevent R3's wound from further deterioration. On 7/30/2015 at 12:48 PM, R3 was laying in bed. Z3 (R3's family member) said no one has turned R3 in 4 hours. Z3 stated someone from R3's family has been with R3 all morning, but no staff has repositioned R3. Z3 said this is not the first time this has occurred. Z3 said staff could have done more to prevent R3's pressure sores from happening. Z3 stated R3 should have had an air mattress in the beginning, but the facility would not provide one. Z3 said R3 came in without a pressure sore and now R3 has bed sores. On 7/30/2015 at 11:53 AM, E6 (Wound Care Nurse) said there is no tracking or monitoring of R3's wounds. E6 could not answer how the wound deteriorated but states again that she was on leave of absence and it should have been done. On 7/31/2015 at 12 PM, Z7 (Physician) for R3 refused an interview. 4. R2 has numerous medical [DIAGNOSES REDACTED]. On 7/28/15 at 11:20 am, E8 (RN) stated that R2 is dependent on staff for all care. On 7/29/15 at 9:35 AM R2 was observed laying in bed on his back. E9 turned R2 to do a bodycheck and a small open area was discovered on R2's right buttock. E9 stated that she was not aware of this open area and that she would notify the wound care team. When questioned as to who does skin checks on residents, E9 stated that the wound care team did the skin checks, as well as nursing staff. E9 stated that it appeared to be a Stage 2 wound. E9 could not say when R2's last skin check was done. physician's orders [REDACTED]. On 7/28/15 at 11:20 AM E9 stated R2 had been on her unit for several weeks, and she had never seen R2 out of bed. E9 could not say why R2 did not get up, other than stating that R2 was a fall risk. R9 was observed 3 times during the day shift on 7/28/15 (9:55 AM, 12:30 PM, 1:45 PM) and 4 times on 7/29/15 (8:40 AM, 9:35 AM, 10:30 AM, 1:30 PM), to be in bed for all those observations. R2 was never observed out of bed on 7/28/15, 7/29/15 or 7/30/15 (9:00 AM, 11:45 AM). At 10:00 AM on 7/29/15, E8 (CNA) stated that she was caring for R2 that day and had cared for him in the past, but not for a week or so. She stated she was not aware of the open area just discovered on R2 as she had not given R2 his bath yet and had only repositioned him that morning. She hadn't observed his buttock area that day. E8 stated R2 had gotten out of bed in the past but she was unable to say when. She stated she could not recall when she had gotten R2 up and stated that it had been a while. R2's Weekly Pressure Ulcer Record dated 7/29/15 indicates the site assessed was the right buttock. This was documented as a new wound which was facility acquired. This was described as pressure-type wound and staged as a Stage one, despite the area being open. The measurements were 1.5 cm in length by .5 cm wide, with no depth. Description of site documents, open red area to right side of buttocks. R2's Braden Scale for Predicting Pressure Sore Risk dated 6/27/15 scores R2 as a 15, which is at risk for pressure sore development. This document describes R2 as bedfast, with slightly limited mobility. On 7/30/15 at 10:35 AM, E6 (Wound Care Nurse) stated that R2 had no other skin assessments prior to the one done 7/29/15 after his right buttock open area was discovered. E6 stated that typically a skin assessment would be done on admission and then weekly. 5. On 7/28/2015 at 1:17 PM, R10 was observed incontinent of stool. R10's dressing in her sacral area had come off due to her incontinence. The certified nurses aide (E28) caring for R10 was interviewed. E28 stated she last changed R10 at 10 AM, which was approximately 3 hours ago. R10's opened wound was observed to have a large amount of slough with necrotic areas. E29 was R10's nurse. E29 said she did not usually change resident's dressing because there was a treatment nurse. E29, after taking a long time to locate supplies, changed R10's dressing. R10's nurse (E29) cleaned R10's sacral wound with normal saline and applied a [MEDICATION NAME] dressing. R10 also had necrotic wounds on her right and left heels which were covered with foam dressing. E29 stated R10's dressing changes were being done every 72 hours. E6 was interviewed on 7/29/2015 at 9:45 AM. E6 stated R10 was admitted to the facility with a sacral wound on 6/26/2015. E6 said R10 was seen by the wound care physician on 7/08/2015 and 7/15/2015 and assessed R10 to have an unstageable pressure sore with slough measuring 18 cm x 12 cm in the sacrum/left buttock areas. E6 said the physician also assessed R10 to have developed a new unstageable wound on the right and left heels in the facility, one on 7/08/2015 and the second one on 7/15/2015. E6 said the wound care specialist ordered R10's sacral wound be treated with an ointment dressing. E6 said she was on leave when the wound care specialist wrote R10's order, but R10's wound care specialist order should have been followed. E6 could not explain why the nursing staff had not followed up to ensure the wound care specialist order had been implemented in the care of R10's wound. E6 said that the nurses were responsible for ensuring that the residents received the treatment ordered by the wound care specialist in her absence. E6 stated she had no record/documentation done by the facility's nursing staff to show as evidence that weekly skin assessments continued to be done as required after 7/15/2015. E6 said skin checks should be done weekly or every 7 days, but R3 had none done. E6 provided documentation of R10's POS and TAR (Treatment Record Sheet) which showed R10 was treated with a [MEDICATION NAME] dressing from date of admission on 6/26/2015 till 7/28/2015 every third day. E6 said this was not the treatment recommendation by the wound care specialist. E6 stated R10's were reassessed when she returned to duty on 7/29/2015 which was approximately 13 days since R3's last assessment. E6 said she measured R10's wound on the sacrum and observed R10's wound had increased in size and was 8.5 cm x 12.5 cm with a depth of 0.2 cm. E6 said R10's heel wounds were Deep Tissue Injuries, which also increased in size. E6 said in the absence of the wound care specialist, she called R10's primary physician, Z5. E6 said Z5 ordered daily Santyl dressing changes on 7/30/2015 because R10's sacral wound had the presence of a lot of slough. After signs of deterioration of R10's wound, the wound care specialist orders were implemented. E6 did not have evidence of a comprehensive wound assessment being done for R10. R10's primary physician (Z5) was interviewed on 7/31/2015 at 12 PM. Z5 is also the facility's medical director. Z5 said the wound care team was responsible for directing the care of resident's wounds, and the floor nurses should follow up to ensure the treatment and orders given by this team are followed. Z5 said the wound care specialist recently became unavailable and the nursing staff should contact the primary physician for wound care orders. Z5 stated resident's should have skin check/assessments done weekly. Z5 was asked about R10's care needs. Z5 described R10 as a resident who was unresponsive and in poor medical condition. Z5 said R10 was at risk for her skin to break down quickly and she required weekly skin assessments to ensure treatment of [REDACTED]. Review of R10's Face Sheet showed R10 is a [AGE] year old female with [DIAGNOSES REDACTED]. Review of R10's care plan dated 7/08/2015 showed, R10 was at risk for skin break down because of her incontinence and immobility. This plan of care identified R10 having a Stage 2 Coccyx wound. R10's plan of care did not show it was updated to address her unstageable wounds in her sacral/left buttocks area or heels. The treatments for R10's heels were not included. Staff failed to show evidence of monitoring R10 for incontinence every 2 hours, changing her promptly and consistently monitoring for changes in R10's wound as her plan of care directed. During the Daily Status Meeting with administrative staff (E1/administrator and E2/director of nursing) on 7/30/2015 and 7/31/2015, the facility's pressure sore program for residents was discussed. E2 confirmed that she identified 27 residents having pressure sore on the 671 (Resident Census and Condition) form when the survey team entered the facility on 7/28/2015, and by 7/30/2015 the number increased to a total of 35 residents (who were identified as having pressure sores at more than a stage I). E2 nor E1 could explain why the facility's system for monitoring, assessing and treating pressure sores had failed. E1 and E2 identified one treatment nurse to take care of approximately 27 to 30 residents but could show no evidence this one nurse could manage so many medically complex residents. E1 said the facility was working on increasing the number of knowledgeable nurses to work on the wound care team. E1 and E2 identified E16 as being the treatment nurse during E6's absence from the building, but could not explain why E16 did not complete all the tasks needed to prevent such poor outcomes in the residents' care. E2 said the floor nurses were there to provide wound care with the treatment nurses, but E2 said a lot of the nurses did not know how to stage or identify the type of pressure sores residents could develop. When asked to provide the training schedule, E1 nor E2 presented any evidence to show that the facility provided the nursing staff with any training/inservice needed to function as a treatment nurse or part of the treatment team.

Based on record review and interview, the facility neglected to maintain a safe environment to prevent the occurrance of a fall, neglected to conduct a comprehensive post fall assessment to detect presence of a [MEDICAL CONDITION], provided physical therapy exercises in the presence of right hip pain with movement, neglected to maintain R25's lower extremities in good alignment following complaints of right hip pain and neglected to immediately notify physician of findings of a right [MEDICAL CONDITION] for 1 of 3 residents(R25) reviewed for abuse. These failures resulted in a [MEDICAL CONDITION], a delayment of treatment and acute medical services and uncontrolled pain. Findings include: Nursing admission assessment dated [DATE] shows R25 is a [AGE] year old resident admitted to the facility on [DATE] for rehabilitation treatment for [REDACTED].#7 resulting from a fall at home. R25 has a [DIAGNOSES REDACTED]. R25 is alert, confused and with impaired hearing. R25 requires 2 persons assist for transfer and bed mobility. Fall risk assessment dated [DATE] shows R25 at high risk for falls. R25 enjoys tearing papers into small pieces and putting the pieces in cups. Fall investigation report dated 3/25/14 states R25 had been observed sitting up on the side of the bed and reaching over on the floor to pick up fallen pieces of paper. Undated Nurses notes signed by E19 (Nurse) states " Staff heard a loud noise coming from patient ' s (R25) room. " R25 was found on the floor in her room. Incident Report shows this fall occurred on 3/24/14 at 10:15am. Fall investigation was conducted by E21 (Nurse Manager). Investigation documentation states Z10 (family member) had previously expressed concerns about R25 ' s fall risk because R25 will try to get out of bed and needs to be closely monitored. Z10 stated on 4/3/14 at 9:30am that he was very concerned about R25 experiencing another fall and asked facility staff to monitor R25 closely. E19 stated during an interview on 4/2/14 at approximately 2:10pm that she found R25 sitting on the floor with back against the night stand. According to E19, R25 showed no signs of discomfort. Range of motion exercises was performed to assess for injuries and R25 had no injuries. R25 was unable to state what happened due to non-verbal status. R25 ' s chair alarm was not attached to R25 and did not sound. According to E19, R25 was picked up off the floor by 2 staff members, each supporting R25 by underarms and each holding onto R25 ' s pants and lifted R25 onto the wheelchair. E22 (Certified Nurses Aid) stated on 4/3/14 at 10:45am, that E19 informed her that R25 had fallen. E22 was assisting another resident at the time and within 5 minutes went to R25 ' s room and noted R25 " sitting in the wheel chair in her room while E19 was performing passive range of motion (PROM) to R25 ' s extremities. " E22 further stated that at the beginning of her shift (7-3pm) R25 was in her room, sitting in the wheel chair with several cups of shredded paper and there was shredded paper on the floor and R25 could have been trying to pick paper off the floor when she fell in her room. Immediately following the fall, R25 was placed near the nurses ' station. E20 (Physical Therapist) wheeled R25 (time unknown but after the fall) to the therapy department and conducted range of motion exercises to R25's extremeties. E20 stated on 4/2/14 at approximately 12 noon that she was not informed that R25 had sustained a fall. According to E20, R25 exhibited signs of pain during right knee exercise; " R25 exhibited facial grimacing and placed her hand on mine, wanting me to stop. " E20 said she stopped the exercise for a few minutes and, with a more gentle approach, attempted to resume PROM to right knee. E20 stated that R25 exhibited no further signs of pain. E20 proceeded to perform PROM to right hip by raising R25 ' s right thigh at which time R25 motioned that she was in pain. E20 stated that, based on R25 ' s reaction, she (E20)rated pain at a 9 or 10 on a 0-10 pain scale which was triggered with movement of the right thigh. E20 discontinued therapy to the right side and focused the exercises to the left side. R25 was transported back to the unit 2 times during therapy for E19 to perform neurological checks on R25. According to E20, when she informed E19 of R25 ' s pain in right hip (at 11am), E19 gave R25 prescribed [MEDICATION NAME] and instructed her (E20) to continue therapy, avoiding weight bearing and exercises to right side. E21(Nurse Manager) conducted a second interview with involved staff on 4/3/14 and provided more detailed account of what transpired after R25 ' s fall. According to E21, Z9 (Attending Physician) was paged by E19 at 11am and Z9 responded to page at 11:45am at which time Z9 ordered stat X-ray. Portable X-rays were done in the facility at 12:30pm. E22 stated that she was present with R25 during X-ray procedure. E22 supported R25 ' s shoulder and buttocks and rolled R25 to right and left sides for X-rays to be done. According to E22, R25 exhibited no signs of pain or discomfort during the procedure. E22 stated she elevated the head of R25 ' d bed and placed R25 in a sitting position by moving both legs off the bed. E22 stated she held R25 by the arms and manually lifted R25 from bed to chair. According to E22, during this transfer R25 ' s feet were touching the floor but there was no weight bearing. R25 showed no signs of pain nor discomfort. Once in the wheel chair, R25 ' s feet were placed on the foot rest and R25 remained up in wheel chair near nurses station after X-rays completed. At 1:15pm a phone report of X-rays was given to E19, with findings of right [MEDICAL CONDITION]. The written report was to follow. The written report was received by facsimile at 2:28pm. E21 stated that E19 waited for the written report before notifying Z9 of the results. Z9 was paged at 2:35pm and responded to page at 3pm. Z9 ordered R25 be sent out to the hospital. Private ambulance service was called at 3:10pm, arrived at the facility at 3:29pm to transport R25 to the hospital. Z9 stated on 4/3/14 at approximately 1:10pm that he would prefer to have been called immediately when phone report was received but he (Z9) is not familiar with facility ' s policy for relaying verbal reports. Z9 stated that R25 would have received emergency treatment earlier if he was aware of the [MEDICAL CONDITION] earlier. There was a 2 hour delay in sending R25 to the hospital after [MEDICAL CONDITION] was identified. E2 (Director of Nursing) completed an incident report for the State Agency. Both initial and final reports are dated 3/24/14, 10:15am. The initial report states R25 got up out of her wheelchair to stand and fell . The final report states R25 was reaching from her wheel chair and slipped out. The report does not address the root cause of R25's fall. R25 's functional assessment dated [DATE] shows R25 requires 2 person physical assist with bed mobility and transfer. E22 stated during surveyor interview that she turned R25 in bed without seond person assist and she manually lifted R25 from bed to chair without a second person assist. There was no gait belt used by staff during transfers of R25. E2 stated on 4/3/14 at approximately 4pm that it is not a policy of the facility to use gait belt during transfer. emergency room records dated 3/24/14 states R25 sustained a closed Right Femur Subthrocanteric Fracture, closed, non-displaced. R25 underwent closed reduction surgery.

Based on observation, record review and interview, the facility failed to implement fall prevention interventions for 5 residents (R18, R19, R24, R25, R28) residents assessed at high risk for falls. R18 and R25 sustained serious injuries as a result of fall. Findings include: 1. Nursing admission documentation dated 3/3/14 states R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R18 is assessed as alert X 2-3 with periods of confusion and unsteady gait. R18 is confined to a wheel chair. R18 requires 2 persons assist with transfer, ambulation and toileting. Fall risk assessment dated [DATE] shows R18 is at high risk for falls and describes R18 as "very impulsive". Fall prevention interventions include " tab alarms, low bed and floor mat. " Incident Report dated 3/3/14 states R18 was found on the floor by a visitor at approximately 8:30pm, calling out for help. R18 was in a lying position with head raised off the floor. R18 was assessed, found to have no injuries then transferred to bed. R18 was then transferred back to the wheel chair and placed at the nurses ' station for monitoring. Post fall interventions included " low bed, floor mat, up at nurses ' s station, frequent checks when available. " Incident Report dated 3/4/14 at approximately 8:30am states R18 was again noted on the floor in her room, lying on her left side near the bathroom door. According to the report, the tab alarm was attached and sounding and R18 stated she was trying to go the the bathroom. R18 sustained a skin tear and hematoma. R18 complained of headache and dizziness. First aid measures were rendered to injured sites. R18 was sent out to the hospital. emergency room records dared 3/4/14 shows R18 was admitted to the emergency room at 9:53am. R18 was diagnosed with [REDACTED]. Z11 (Family Member) stated on 3/20/14 at approximately 10:30am that the facility staff contacted her regarding first fall and she requested that an alarm be attached to the bed. Z11 further stated she was very concerned about R18 and was denied 24 hour visitation to keep an eye on R18. E9 Nurse) stated on 3/8/14 at approximately 3:30pm that, after R18's first fall, she was placed at the nurses' station for close observation. R18 was noted to remove her chair alarm. E8 (nurse) stated on 3/18/14 at approximately 2:15pm that R18 was placed at the nurses's station on the morning of 3/4/14 for close monitoring. E9 stated that a physical therapist took R18 back to her room and R18 fell while unsupervised in her room. E9 further stated that she does not remember if there was a falling star posted outside R18's door which would have alerted staff to R18's high fall risk. E10 (Physical Therapist) stated on 3/19/14 at approximately 1:35pm that R18 was sitting in her wheel chair on the morning of 3/4/14 when she arrived on the unit. E10 stated she took R18 to her room to complete an initial evaluation. After introducing herself to R18, the breakfast tray was brought into the room and she (E10) ensured the chair alarm was attached to R18 and she left the room. E10 stated that she was not aware that R18 had fallen the previous night and if she aware, she would not have left R18 unattended. E10 also stated that there was no falling star sign on R18's door and if there were, this would have alerted her to R18's fall risk status. 2. R19 was admitted to the facility on [DATE]. Initial fall risk assessment dated [DATE] shows R19 at risk for falls. Intervention put in place was " encourage use of call light. " There is no evidence to show that fall risk care plan was initiated. Incident Investigation dated 3/3/14 states R19 was found on the floor in her room. During the investigation R19 stated she was trying to remove wet bed linens from underneath her. Post fall intervention includes " encourage to use call light, bed to remain in lowest position, remove wet linen during hygiene care, falling star program. " Care plan initiated 3/6/14 states R19 is at risk for falls related to " new to the facility, Depression, weakness and abnormal gait. " Interventions include placement on fall precaution. " Care plan also states R19 has self care deficit, needing assist with activities of daily living. On 3/19/14 at approximately 9am, R19 was observed in her room with privacy curtain closed. R19 was in bed with bed at high position with no upper clothing on. There was a washbasin on the over bed table within R19 ' s reach. R19 stated that she was trying to perform self hygiene. There were no staff present in the room. R19 ' s bed alarm was not in place. There was no fall mat on the floor. 3. On 4/1/14 at approximately 10:45am, R24 was observed in bed, with bed in high position. E3 (Assistant Director of Nursing) was present and stated she will lower the bed. There was no falling star on the door, no mats on the floor and no tab alarm in place. E3 stated R24 is non-verbal and alert to self only. Fall risk assessment dated [DATE] shows R24 is at high risk for falls. Documented intervention includes " call light within reach " and " Bed in lowest position. " Care plan originated 11/22/13 states R24 is at risk for falls related to " opens eyes only, unable to stand, assumed poor vision, unable to use call light and [DIAGNOSES REDACTED]. 4. Nursing admission assessment dated [DATE] shows R25 is a [AGE] year old resident admitted to the facility on [DATE] for rehabilitation treatment for [REDACTED]. R25 has a [DIAGNOSES REDACTED]. R25 is noted to continuously remove Oxygen tubing and enjoys tearing paper into small pieces and placing them in cups. R25 is incontinent of bowel and bladder with poor balance. R25 requires 2 persons assist for transfer and bed mobility. Fall risk assessment dated [DATE] shows R25 at high risk for falls. Fall prevention interventions include " bed in lowest position; tabs alarm; floor mat in place. " Fall investigation report dated 3/25/14 states R25 had been observed sitting up on the side of the bed and reaching over on the floor. R25 ' s bed was switched to a low bed. Further documentation states R25 was tearing up papers and attempted to pick up scraps of paper on the floor. Undated Nurses notes signed by E19 (Nurse) states " Staff heard a loud noise coming from patient ' s (R25) room. " R25 was found on the floor in her room. Incident Report shows this fall occurred on 3/24/14 at 10:15am. Fall investigation was conducted by E21 (Nurse Manager). Investigation documentation states Z10 (family member) had previously expressed concerns about R25 ' s fall risk because R25 will try to get out of bed and needs to be closely monitored. Z10 stated on 4/3/14 at 9:30am that he was very concerned about R25 experiencing another fall and asked facility staff to monitor R25 closely. E19 stated during an interview on 4/2/14 at approximately 2:10pm that she found R25 sitting on the floor with back against the night stand. According to E19, R25 showed no signs of discomfort. Range of motion exercises was performed to assess for injuries and R25 had no injuries. R25 was found to be alert but not able to state what happened due to non-verbal status. R25 ' s chair alarm was not attached to R25 and did not sound. According to E19, R25 was picked up off the floor by 2 staff members, each supporting R25 by underarms and each holding onto R25 ' s pants and lifted R25 onto the wheelchair. E22 (Certified Nurses Aid) stated on 4/3/14 at 10:45am, that E19 informed her that R25 had fallen. E22 was assisting another resident at the time and within 5 minutes went to R25 ' s room and noted R25 " sitting in the wheel chair in her room while E19 was performing passive range of motion (PROM) to R25 ' s extremities. " E22 further stated that at the beginning of her shift (7-3pm) R25 was in her room, sitting in the wheel chair with several cups of shredded paper and there was shredded paper on the floor at the time of R25's fall. According to E20 (Physical Therapist), R25 exhibited signs of pain during right knee exercise. R25's physician ordered portable X-ray which showed right hip fracture. emergency room records dated 3/24/14 states R25 sustained a closed Right Femur Subthrocanteric Fracture, closed, non-displaced. R25 underwent closed reduction surgery. 4. R28 was admitted to the facility on [DATE]. Initial fall risk assessment dated ,[DATE] shows R28 at high risk for falls with intervention for " call light within reach. " Care plan initiated 12/14/13 states R28 is placed on fall precaution. Care plan was updated on 3/4/14 due to R28 having a fall in the facility ' s parking lot after R28 ' s daughter transferred R28 from car to wheelchair. Nursing documentation dated 3/13/14 states R28 " attempts unsupervised ambulation at times. " New interventions dated 3/17/14 states " apply tabs monitor. " On 4/1/14 at approximately 10:40am, R28 was observed in bed with bed not in it's lowest position, no bed alarm in place, no mats on floor. E3 (Assistant Director of Nursing) was present and stated that R28 does not try to get out of bed. Nursing documentation of updated fall prevention intervention dated 3/29/14 states " discontinue tab alarm. Patient does not attempt to ambulate without supervision, uses call light. " Facility ' s Fall Management policy dated 10/2011 does not address fall prevention interventions for residents assessed as high risk for falls. E9 (Nurse) stated on 3/18/14 at approximately 3:30pm that the facility ' s protocol for residents who are admitted with high fall risk includes posting a falling star outside residents door, low bed, fall mat, chair and bed alarm. E1 (Administrator) and E2 (Director of Nursing) stated on 4/2/14 at approximately 4:15pm that the only standard intervention for residents assessed at high risk for falls is the posting of the falling star outside the resident's room. All other interventions are individualized based on the resident's condition.