Every finding on record at Timbercreek Rehab and Health Care Center

Based on observation, interview and record review, the facility failed to provide continuous observation for two of two residents (R4, R8) that are at high risk for falls and require continuous monitoring, in a sample of 10. These failures resulted in R4 having an unwitnessed fall which required R4 to be transferred to the hospital emergency room for evaluation and was diagnosed with Acute Cystitis with Hematuria, Urinary Tract Infection, Post Traumatic Contusion, Edema of Left Frontal Scalp (Hematoma) and Left Hip Pain. The following days, R4 was reported to be lethargic, had slurred speech, was leaning left, hallucinating, required more assistance with activities of daily living and went on hospice on 7/17/26, 6 days post fall. Findings include:The Skilled Fall Policy dated 5/25 documents the purpose of the Fall Program is to develop, implement, observe and evaluate an interdisciplinary approach and manage strategies and interventions that foster resident independence and quality of life. Each resident in the community who experiences a fall will be treated and assed to adequately treat any current injuries and comprehensively assessed to determine causal effects of the fall to develop intervention to prevent further falls. After each fall, an occurrence report will be completed, root cause will be determined and interventions will be implemented. The Resident Monitoring- One to One form documents staff must maintain residents in line of sight, keep residents close enough so residents can't be out of sight and must not leave the residents. Relief of staff members must take place while residents are still in view. Document using codes at least hourly. 1. R4 was admitted on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety Disorder, Vascular Dementia, Peripheral Vascular Disease, Persistent Mood Disorder and Cerebral Ataxia. R4's Minimum Data Set, dated [DATE] section C Brief Interview for Mental Status documents a score of 4, severely cognitively impaired. R4's Fall Risk dated 6/16/26 was scored at a 30 (high risk for falls) and on 7/11/26 a 34 (high risk for falls). R4's Care Plan documents on 5/26/26, R4 was moved closer to the nurse's station and one-to-one observation was initiated. R4's Resident Monitoring One-to-One tracking forms dated 7/1/26 through 7/26/26 lacked hourly monitoring 9 of 26 days. The monitoring form dated 7/11/26 noted R4 was checked by V12 (Certified Nurse Aide from a sister facility) at 1:00 AM. R4's Progress Notes documents R4 had multiple falls (1/22/26, 2/4/26, 4/20/26, 5/25/26 x2 (fracture of orbital socket with laceration) and 7/11/26). R4 has combative and aggressive behaviors such as hitting staff and threatening to kill others. R4 sustained a fall on 7/11/26 at 2:30 AM and was found bleeding on her bathroom floor. R4 was transported to the hospital for evaluation and treatment and returned to the facility on 7/11/26 at 6:33 AM. The Progress Notes document R4 sustained multiple traumatic injuries following the fall (7/11/26) including forehead laceration, forehead bruising, skin tears to right upper arm, left anterior leg and right lateral lower leg, left arm pain and left hip pain with tenderness to palpation, as well as treated for a Urinary Tract Infection with Hematuria (blood in urine) from Cystitis. R4's Power of Attorney declined further workup and on 7/17/26 elected hospice benefits. R4's Hospital Emergency Department record dated 7/11/26 documents R4 sustained a left forehead hematoma, contusion and edema of left frontal scalp, and was diagnosed and treated for Acute Cystitis with Hematuria and Urinary Tract Infection. The Interdisciplinary Team meeting note dated 7/13/26 documents V9 (Certified Nurse Aide) who was providing one-to-one cares with R4, left R4's room to go get V8 (Registered Nurse) because she needed to do rounds on her hallway. V9 asked V11 (Certified Nurse Aide) to go to R4's room to do one-to-one observation, V11 found R4 on bathroom floor with blood coming from her forehead.V8's (Registered Nurse) witness statement dated 7/12/26 at 12:03 PM documents on 7/10/26 at approximately 11:00 PM, V8 (Registered Nurse) observed R4 up walking around in her room without supervision. V8 then went to find V9 (Certified Nurse Aide), leaving R4 unsupervised walking around her room. On 7/28/26 at 1:00 PM, V8 (Registered Nurse) confirmed her witness statement and that R4 was seen walking around her room unsupervised and V8 left R4 alone to find V9 on 7/10/26 at 11:00 PM. On 7/29/26 at 9:14 AM, V9 (Certified Nurse Aide) stated she was the CNA assigned to R4 when R4 fell on 7/11/26. V9 stated the nurse was supposed to relieve V9 but never came back. V9 asked V11 (Certified Nurse Aide) to watch R4 while V9 went to find the nurse but V11 was finishing with another resident's cares. On 7/29/26 at 12:43 PM, V11 (Certified Nurse Aide) stated that just within minutes of V9 exiting R4's room, V11 went into R4's room and found R4 on the bathroom floor bleeding from her head. R4's record lacked documentation of post fall monitoring/assessments including pain, neurological checks and vital signs or monitoring for signs and symptoms of sepsis related to diagnosed Urinary Tract Infection. As of 7/14/26, the last pulse was taken on 7/7/26, respiratory rate and temperature on 5/11/26. On 7/29/26 at 2:00 PM, V1 (Administrator) and V2 (Director of Nursing) stated the facility did not have a post fall (witnessed/unwitnessed fall, if injury was sustained or if resident hit their head) monitoring policy. When asked what the protocol was and what the nurses were expected/taught to do post fall, V2 was unable to answer the question. V1 and V2 were unable to provide any educational materials which were utilized to teach/guide staff post fall protocols. V2 agreed one-to-one observations were not documented hourly between 7/1/26 and 7/26/26. V1 and V2 agreed R4 was left alone twice during the shift, once by V8 (Registered Nurse) on 7/10/26 at 11:00 PM and again by V9 (Certified Nurse Aide) on 7/11/26 approximately between 2:20 PM and 2:30 PM. 2. R8 was admitted on [DATE] with diagnoses of Psychotic Disorder with Delusions, Schizoaffective Disorder, depression, Fracture of Vertebrae, Dementia, Anxiety Disorder and Cerebral Ataxia. R8's Fall Risk dated 3/25/26 was scored at a 30 (high risk for falls). R8's Care Plan dated 7/6/26 documents R8 requires one-to-one observation due to behavioral problems and aggression towards others, as well as fall risks. R8's Progress Note dated 7/15/26 documents R8 has been on one-to-one observations since 6/21/26. Due to R8 not getting out of bed at night, one-to-one is discontinued at night and will continue during the day. R8's Resident Monitoring One-to-One tracking forms dated 7/7/26 through 7/14/26 lacked hourly monitoring 6 of 8 days. It was unable to be determined what time of the day the night one-to-to observations were to be stopped. Between 7/15/26 and 7/20/26, one-to-one observations were stopped at various times, the earliest being 4:00 PM and the latest at 7:00 PM.The Daily Assignment Sheets dated 7/15/26 through 7/20/26 and 7/22/26 through 7/27/26 have a Certified Nurse Aide assigned to be the one-to-one sitter during the 6:00 PM to 6:00 AM shift.On 7/29/26 at 2:00 PM, V2 (Director of Nursing) stated she didn't know when R8 required one-to-one observations but agrees the tracking forms demonstrated gaps in the observations.

Based on interview and record review the facility failed to document a discharge summary and/or a recapitulation of stay for one resident (R1) of three residents reviewed for discharge. R1's Medical Record documents that he was admitted to the facility with diagnosis to include but not limited to Anemia post hemorrhage, Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. R1's Medical Record contain a Release of Responsibility form dated 6/26/26 and signed by R1. The form documents R1 was educated to wait to see the doctor for discharge orders and R1 did not want to. R1's Medical Record does not contain any other documentation regarding R1's discharge against medical advice. On 7/28/26 R1 stated that no one discussed discharge instructions, safety or any other information before he left the facility. (V7/Social Services Director) had me sign a piece of paper so they (facility) wasn't responsible for me leaving and then I left. I didn't get any medications or supplies or instructions of any kind. On 7/28/26 V1 (Administrator) confirmed R1's Medical Record did not contain documentation regarding his condition upon discharge. All discharged charts should follow the Discharge Policy, whether it is AMA or not. The Facility's Discharge Summary and Plan policy dated 8/2025 documents The Discharge Plan, Instructions and Summary provides a recapitulation or summary of the resident's stay. Discharge, Plan, Instructions, and Summary: a. Social Services Director or Social Service Designee will open the Discharge Plan, Instructions and Recapitulation of Stay at the time the discharge is scheduled. b. The IDT (Interdisciplinary Team) will be notified when the assessment is open and incomplete sections will be discussed in the morning meeting. c. Social Service Director or Designee will complete sections A, B, D, H. d. Nursing will complete sections C and E; Wound nurse will ensure skin and treatments are recorded. e. Dietary will complete section F. f. Activities will complete section G. g. Social Services Director of Social Services Designee will ensure all sections are complete and the document is signed and locked. The Facility's Discharge Summary and Plan policy dated 8/2025 documents Discharge Education: a. Nurse will review discharge instructions and mediations with resident/resident representative. Copy of Disposition of Medication form will be given to resident/resident representative and a copy scanned into the record. b. Social Services Director or designee will include the Discharge Plan, Instructions, and summary in the Discharge Packet. Nurse will document discharge note in the progress notes section of the resident record. Discharge note will include-skin assessment, who they discharge with, where they are discharging to, what belongings were sent with them and other pertinent information.

Based on observation, interview, and record review, the facility failed to ensure physician-ordered rehabilitation services were implemented and monitored for one (R1) of three residents reviewed for rehabilitation services in the sample list of five. This failure resulted in R1 not receiving ordered rehabilitation services from admission through the time of survey, placing R1 at risk for avoidable functional decline and causing R1 to express fear, anxiety and depression. Findings include:R1's census record documents R1 admitted to the facility on [DATE].R1's Medical Diagnosis list documents R1 was admitted to the facility following a left lower extremity fracture requiring surgery and has diagnoses including Cellulitis of the left lower limb, Type 2 Diabetes Mellitus, Morbid Obesity, Chronic Venous Insufficiency, Chronic Diastolic Heart failure, Osteoporosis, Muscle Disorder, and Complex Regional Pain Syndrome of the left lower extremity.R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires extensive assistance/dependence with toileting, showering, and transfers.On 7/20/26 at 11:15 AM, R1 was seated in a motorized wheelchair with blankets positioned around the chair. Five undated occlusive dressings were observed on R1's left lower extremity.On 7/20/26 at 11:20 AM, R1 stated she was admitted to the facility for physical therapy following surgery for a fractured left leg but has never received therapy since admission. R1 stated she continued to experience weakness and recurrent infections in R1's left leg. R1 stated she had expected to receive therapy to improve her strength and mobility but had not been evaluated or treated. R1 stated she remained dependent upon staff for transfers and mobility. R1 further stated she feels fearful of possibly losing her leg and anxiety and depression about not regaining function in her leg and being able to return home because she is not getting the therapy she needs to improve. On 7/20/26 at 1:00 PM, V15 (Therapy Director) stated R1 had not received therapy services since admission. V15 stated an occupational therapy evaluation had been completed on 4/28/26 and a request for payor authorization was emailed to V16 (Business Office Manager), and a subsequent request for prior insurance authorization for therapy for R1 was submitted on 6/8/26 because R1 would benefit from physical and occupational therapy. V15 stated no authorization had been received and no additional communication regarding the request had occurred. R1's electronic medical record revealed no evidence physical or occupational therapy services had been initiated. R1's record also contained no documentation of a restorative nursing program or other interventions implemented to maintain or improve R1's functional abilities while awaiting therapy authorization.On 7/21/26 at 9:30AM, V1 (Administrator) and V16 (Business Office Manager) stated a prior authorization request had been sent to the corporate office at the end of June; however, no response had been received. Both V1 and V6 acknowledged the facility had not followed up regarding the authorization request. V1 confirmed this request should have been followed up on.On 7/21/26 at 11:00 AM, V11 (R1's Physician) stated he wrote admission orders for Physical and Occupational Therapy because R1 was alert, oriented, and capable of participating in rehabilitation to improve strength, prevent decline in activities of daily living, and promote healing of R1's left leg wounds. V11 stated he was unaware therapy services had not been initiated and reported the facility requested therapy orders again on the day of survey.The facility's Therapy Services Agreement, dated 8/2/24, documents the facility operates a licensed skilled nursing facility that furnishes nursing care to residents requiring therapy services and contracts with a therapy provider to furnish Physical Therapy, Occupational, and Speech Therapy services in accordance with federal and state regulations and facility policies. The agreement further required therapists to participate in interdisciplinary conferences, coordinate resident care, and outlined the facility's responsibility to provide payer source information and obtain required authorizations to facilitate timely initiation of therapy services.

Based on observation, interview, and record review, the facility failed to ensure a resident with impaired skin integrity received ongoing wound assessment, physician oversight, implementation of ordered treatment, and care planning for one (R5) of three residents reviewed for skin integrity in the sample list of five.Findings include:R5's Medical Diagnosis List documents R5 has diagnoses including Lymphedema, not elsewhere classified, Irritant contact dermatitis due to friction or contact with other specified body fluids, Obesity, unspecified, Cellulitis of left lower limb, Complete paraplegia, Neuromuscular dysfunction of bladder, Neurogenic bowel, not elsewhere classified, and Colostomy complication, unspecified.R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact and dependent on staff for all activities of daily living.R5's Physician orders dated 6/29/26 documents for staff to cleanse the posterior scrotum and left hip with wound cleanser, apply collagen particles mixed with zinc oxide, cover with an absorbent (ABD) dressing every night shift and as needed.R5's Braden assessment dated [DATE] documents R5 is at Moderate Risk for Skin Impairment.R5's care plan documents R5 has impaired skin integrity related to Hoyer transfers, catheter and ostomy devices, and documents irritant contact dermatitis to the posterior scrotum. R5's care plan had not been comprehensively revised to reflect R5's current wound status, progression, and treatment needs.On 7/21/26 at 9:50 AM, V6, V7, and V8 (Certified Nursing Assistant/CNA) transferred R5 from his motorized wheelchair to bed. Observation revealed a suprapubic catheter with brown drainage noted on the gauze surrounding the insertion site. No dressing was present over the scrotal/coccyx area despite physician orders requiring absorbent (ABD) dressing. Two new open areas, each approximately the size of a quarter, were observed between R5's legs. After being notified, V14 (Registered Nurse) assessed the wounds and stated there were definitely two open areas and that the current treatment was not going to help. V14 stated she would notify the physician for new orders. During care, R6 stated the dressing changes had been moved to night shift and that many of the nurses were not completing the dressing changes.On 7/21/26 at 9:30 AM, V2 (Director of Nursing) stated the facility had experienced problems with its wound program and confirmed R5 should have been receiving weekly skin assessments with documented wound measurements. V2 stated she is not surprised treatments are not being completed daily. R5's Skin Issues Progress Notes documents a Progress Note dated 6/29/26 identified a house-acquired moisture-associated skin damage (MASD) to R5's scrotum, with the wound site documented as the right/left thigh. R5's wound measurements were documented as length 0.85 centimeters (cm), width 0.78 cm, depth 0 cm, with an area of 0.56 cm^2. R5's Treatment orders included collagen particles, zinc, and an ABD dressing to be applied daily.R5's Skin Issues Progress Note dated 7/7/26 documents an increase in wound size, with measurements of length 1.48 cm, width 1.57 cm, depth 0 cm, and an area of 1.99 cm^2. The assessment also documented heavy saturation of the dressing; however, the same treatment regimen was continued. There is no documentation of physician notification of the wound changes.R5's Skin Issues Progress Notes dated 7/13/26 and 7/17/26 did not include wound measurements or a description of the wound status.On 7/21/26 at 11:30 AM, V13 (Nurse Practitioner) for V11 (R5's Physician), stated V11's office had not received any communication from the facility regarding the R5's thigh or scrotal wound from 6/29/26 through 7/21/26. V13 further stated that R5 was evaluated by the nurse practitioner on 7/1/26, but the facility did not report any skin concerns during that visit. Additionally, V13 stated that the wound treatment order entered by the facility on 6/29/26 was not issued by the physician or nurse practitioner.The facility's Skin Identification, Evaluation, and Monitoring Policy dated 2/2026 documents This policy establishes guidelines for the assessment, treatment, documentation, and monitoring of wounds and skin alterations to ensure residents receive timely and appropriate care. Nursing staff are responsible for completing wound assessments, documenting wound appearance and measurements when applicable, evaluating dressings, completing weekly re-evaluations, following health care provider treatment orders, and updating care plans with appropriate interventions. When a new wound is identified, staff will initiate protective measures, notify the provider, resident/resident representative, wound care nurse, and Director of Nursing as appropriate, while ensuring all findings, treatments, notifications, and education are documented in the medical record. The facility will provide ongoing oversight through education, audits, and QAPI monitoring to promote compliance and support wound healing and prevention.

Based on interview and record review the facility failed to respond to resident call lights in a timely manner for five of ten residents (R4, R5, R8, R9 and R10) reviewed for call light response in a sample of 13.Findings include: R4's current Care Plan documents, R4 requires assistance from one member of staff for activities of daily living.R5's current Care Plan documents, R5 requires assistance from one member of staff for activities of daily living.R9's current Care Plan documents R9 is a Right Above the Knee Amputation requiring assistance from one member of staff for activities of daily living and R9 is a fall risk requiring the call light to be positioned for easy access when in room.R10's current Care Plan documents, R10 requires assistance from one member of staff for activities of daily living and R10 is a fall risk requiring the call light be positioned for easy access when in room.On 7/7/26 at 11:37 am, R4 (alert and oriented) stated, They do not do great answering call lights. Yesterday, it took them well over half an hour to help me. I had eye surgery a few days ago, and every time I get anesthesia it takes me a few days to feel normal. I rang my bell yesterday because I needed them to push me in the wheelchair to get to the dining room, because it is so far away, and it took forever for them to get to me.On 7/726 at 11:19 am, R5 (alert and oriented) stated, The staff do the best they can, but they just do not have enough. It usually takes them within a half an hour to answer my light, unless it is mealtime, then it takes way longer than a half an hour.On 7/7/26 at 1:42 pm, R9 (alert and oriented) stated, I have been here for about a month, and I do not even have a working call light to call for help, and it has not worked since I got here. I have told people about it also and no one has ever looked at it.On 7/7/26 at 1:24 pm, R10 (alert and oriented) stated, After I ring my bell, sometimes it takes them quite some time to get to me and it takes a long time.On 7/7/26 at 1:48 pm, V19 (Certified Nursing Assistant/CNA) stated, I do not think (R9) ever uses his call light, he gets up on his own.On 7/8/26 at 8:36 am, V16 (Ombudsman) stated, The last Resident Council meeting was held on 6/24/26, lasted two and a half hours, and they still complained about call lights taking too long. It is an ongoing issue.On 7/7/26 at 1:53 pm, V2 (Director of Nursing) entered R9's room and pressed the button to activate R9's call light. R9's call light was lying on the floor and would not sound or light up. V2 stated, I am going to get (V18/Maintenance Director) to look at it. I expect the call lights to be answered promptly.On 7/7/26 at 2:06 pm, V18 (Maintenance Director) stated, There was a split call light button, with two cords on it. I fixed (R9's) call light and it is working now.The Facility Call Light Policy and Procedure, dated 7/2025, documents: promote resident safety in the community; call lights will be answered in a timely and efficient manner once engaged by a Resident; and call lights shall be left within Resident reach when the Resident is in their room.The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: facility must treat you with dignity and respect and must care for you in a manner promotes your quality of life; and must not be abused or neglected (physically, verbally or mentally); and must provide services to keep your physical and mental health at their highest practical levels.The Facility Certified Nursing Assistant Job Description, undated, documents: answers call light promptly; and answering Resident call lights and requests.The Facility Resident Council Minutes (4/23/26) document issues with call lights. The Facility Resident Council Minutes (6/24/26) document issues with call lights.

Based on observation, interview and record review the facility failed to provide hydration services (fresh water) for three of ten residents (R5, R9 and R10) reviewed for hydration in a sample of 13.Findings include: The Facility Resident Council Minutes (4/23/26) document issues with ice water. The Facility Resident Council Minutes (5/27/26) document issues with ice water not passed at times and only certain staff will do it. The Facility Resident Council Minutes (6/24/26) document issues with ice water continues to be a problem.The Facility Grievance Form, dated 5/25/26, documents, ice water is only passed by certain (Certified Nursing Assistants) and that staff was educated on passing of ice water and frequently passing water.The Facility Grievance Form, dated 5/27/26, documents, water stations are not getting fresh water in them daily and the Facility is to assess the water stations.R5's current Care Plan documents that R5 is at risk for complications with hydration and R5 should be allowed to drink as desired/accepted/tolerated.R9's current Care Plan documents R9 is at risk for complications with hydration and that R9 should be allowed to drink as desired/accepted/tolerated.R10's current Care Plan documents R10 is at risk for complications with impaired skin integrity and hydration, and that R10 should be allowed to drink as desired/accepted/tolerated.On 7/726 at 11:19 am, R5 (alert and oriented) did not have water in R5's water pitcher (that was sitting on R5's) bedside table. R5 stated, The staff do the best they can, but they just do not have enough. I have not gotten any fresh water today. On 7/8/26 at 9:23 am R5's water pitcher was approximately a fourth full (with no ice) and R5 stated, I still have the same water as yesterday, they have not gotten to me yet.On 7/7/26 at 1:42 pm, R9 (alert and oriented) did not have fresh water at bedside. R9 stated, They do not do a very good job getting me fresh water, it is hit and miss. I have not gotten any fresh water today yet. I do not even have a working call light to call for help. On 7/8/26 at 10:03 am, R9, had no ice water at bedside and stated, They have not brought me any ice water yet today.On 7/7/26 at 1:24 pm, R10 (alert and oriented) did not have any water at bedside and stated, I do not get fresh ice water every day.On 7/8/26 at 10:50 am, V13 (Certified Nursing Assistant/CNA) stated, We are supposed to pass fresh water every shift and extra if someone requests more. We usually pass it in our slow time, like after morning get-ups/breakfast time and lunch. Some CNA's have different routines, and I am not sure if it always gets done.On 7/8/26 at 8:36 am, V16 (Ombudsman) stated, The last Resident Council meeting that was held on 6/24/26, lasted two and a half hours. The Residents has so many complaints that hydration stations were taken away, and I did not see any when I was there either. They had so many complaints about not getting fresh water. They also complained that between mealtimes, they cannot even get iced tea or juice.The Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; and must not be abused or neglected (physically, verbally or mentally); and must provide services to keep your physical and mental health at their highest practical levels.The Facility Certified Nursing Assistant Job Description, undated, documents to provide hydration to all residents.

Based on observation, interview, and record review the facility failed to ensure the facility maintained an effective pest control program. This has the potential to affect all 89 residents.Findings include:The facility's Pest Control Policy, dated 2019, documents Policy: The facility maintains an effective pest control program to remain free of pests and rodents. Facility-wide pest-control strategies are developed emphasizing kitchens, cafeterias, laundry, central sterile supply areas, loading docks, construction activities, and other regions prone to pest infestation. 1. On-going measures are taken to prevent, contain, and eradicate common household pests such as roaches, ants, mosquitoes, flies, mice, and rats. 2. General measures to decrease pests include the elimination of cracks and crevices, proper lighting and ventilation, use of screens on windows and doors, and use of self-closing doors. 4. All food stored in the dietary area is kept in a designated area in securely covered containers, is off the floor, and away from the walls.The Illinois Long-Term Care Ombudsman Program Booklet, dated 11/2018, documents Your rights to safety: Your facility must be safe, clean, comfortable and homelike.The facility's Pest Control Service Report, dated 3/27/26 and signed by V24/Pest Solutions Technician, documents, Inspected and treated the interior for German cockroaches. In the kitchen I did an inspection only. Checked the activity on the glue boards. The most activity seems to be around the sinks and heated cabinets. Please encourage the kitchen staff to keep things as tidy as possible.The facility's Pest Control Service Report, dated 6/1/26 and signed by V23/Pest Service Technician, documents, Visit Notes: Joggers completed in the kitchen. Do not allow access until every service for food prep is thoroughly cleaned. Allow full night for fogging to work. Pest Summary: Location: Kitchen- German cockroach.The facility's Pest Control Service Report, dated 6/12/26 and signed by V23/ Pest Service Technician, documents, Today (V23/Pest Service Technician) treated the kitchen and several indoor areas for roaches and ants. I also placed insect monitors inside the kitchen to gauge the activity level. Staff stated they hadn't seen any activity for 48 hours when (V23) arrived today. I treated the exterior of the building for ants, checked rodent stations, and replaced bait as needed. Pest Summary: Location- Interior. Activity: German Cockroach.R6's Grievance Form, dated 5/27/26, documents, Issue: Cleanliness of Community: Description- Bugs in the dining room and other areas.On 6/18/26 at 9:55 AM a tour was conducted in the kitchen with V12/Dietary Manager. Several insect monitors were observed around the base boards of the kitchen area- full of dead roaches. V12 verified at this time that roaches have been a problem in the kitchen for a long time and that pest control has been trying to treat the issue. The kitchen floor was dirty, grimy, and had loose food debris scattered. Beneath the three-compartment sink in the kitchen had a large area of thick, black, grimy debris. V12 stated at this time they were unable to pull out the compartment sink to get back there and clean. A large visible sticky liquid was observed under the kitchen stand up refrigerator with dirty cups observed. V12 opened the stove, and a large cockroach was observed scattering off. V12 verified it was a roach. The other double oven was observed. The outside of the double oven was dirty, grimy, with thick food debris covering the oven. The double stove had thick black debris underneath. Baseboard coving was observed either off the wall or peeling off the wall in several spots around the kitchen. V12 stated they do not have a cleaning schedule and can't clean everything because at times there just isn't enough staff to do everything. V12 stated, There typically should be three dietary staff on days each day, and today it's only me and one other dietary staff.On 6/18/26 at 10:33 AM V9/CNA (Certified Nursing Assistant) stated she witnessed roaches in the doorway of the kitchen and dining room.On 6/18/26 at 10:57 AM V11/CNA stated, I have seen roaches. I saw one crawling on the wall this morning. I have seen them all over the building.On 6/18/26 at 11:14 AM V13/CNA stated, Roaches have been a problem for a long time. I see them everywhere, including the kitchen and in the ice chest.On 6/18/26 at 11:55 AM V5/LPN (Licensed Practical Nurse stated) she witnessed roaches mainly in the kitchen area.On 6/18/26 at 1:42 PM V4/CNA stated she had witnessed roaches in the halls and coming out of the dining room doors.On 6/18/26 at 1:09 PM V1/Administrator in Training stated, We (the facility) have had issues with roaches since I have started, and it's been ongoing. I started at this facility in October 2025. We have upped our Pest Control to come in weekly as of now.The facility's Midnight Census Report, dated 6/17/26, documents 89 residents reside within the facility.

Based on observation, interview and record review the facility failed to maintain adequate laundry services due to department staffing shortages, resulting in delayed clothing returns and a lack of available personal clothing for residents. This failure has the potential to affect all 89 residents residing within the facility. Findings include: The facility's Environmental Services Account Manager Job Description, undated, documents Position Summary: Manages and supervises the environmental services staff at a single site according to policies and procedures, and federal/state requirements. Provides leadership, support, coordination, and guidance to ensure that quality standards, inventory levels, safety guidelines, and customer services expectations are met. This same Job Description documents The manager is also responsible for coordinating and insuring the satisfactory and timely completion of project and program work done in the building on various shifts. The facility's Laundry Worker Job Description, undated, documents Position Summary: Laundry Workers perform a variety of tasks on varying shirts, including collecting and sorting soiled linen, loading, and unloading machines, and folding clean linen. Operates computer-operated washers and dryers. Responsibilities include counting and recording the linen processed each day, making proper deliveries to units, and cleaning and sanitizing the work area including machines, worktables, and sorting area. Performs laundry activities within well established guidelines to ensure that quality standards, safety guidelines and customer service expectations are met. Delivers personal clothing to the appropriate resident. The facility's Laundry Handling and Processing Policy, dated 2/1/2025, documents, Delivery: Delivery times should meet the needs or residents (before showers, before bed changes, or during meal service). The facility's Personal Laundry Handling and Processing Policy, dated 2/1/25, Policy: Providing clean personal clothing is critical for resident care and dignity. The Illinois Long-Term Care Ombudsman Program Booklet, dated 11/2018, documents Your personal property rights: You have the right to keep and wear your own clothing. The facility's Housekeeping/Laundry Schedules dated 5/3/26 through 6/20/26 document one laundry aide working each day. Resident Council Minutes, dated 3/25/26, documents, Old business: Laundry not being delivered back in timely manner or putting clothes in the wrong closets. New Business-Housekeeping/Laundry: Laundry not getting back on a timely manner or delivered to wrong resident. R4's Grievance Form, dated 3/12/26, documents, Issue: Missing Clothing/Item. Description: not getting clothes back from laundry. Resident Council Minutes, dated 4/23/26, Housekeeping/Laundry: Lost Clothing/Clothes in wrong closet, taking too long to deliver clothes back. R5's Grievance Form, dated 5/19/26, documents, Issue: Laundry Issue. Description: (R5's) clothes didn't come back from laundry. Wearing same socks for week/same clothes on in two days. Family will now do her laundry. R6's Grievance Form, dated 5/27/26, documents, Description: (R6) not getting her dresses back/underwear/pants. R7's Grievance Form, dated 5/27/26, documents, Issue: Laundry Issue: Description: Not getting (R7's) socks back from laundry and (R7's) clothes. R9's Grievance Form, dated 5/27/26, documents, Description: Not getting his socks/clothes/boxers back from laundry. Resident Council Minutes, dated 5/27/26, Housekeeping/Laundry: Clothes/Socks etcetera, not coming back from laundry. On 6/18/26 at 10:36 AM, R2 was observed up in her wheelchair in her room. R2 had on a clean shirt but was wearing no pants. R2 stated, It always takes laundry so long to get my clothes back to me. I have no pants to wear today because laundry hasn't got them back to me. On 6/18/26 at 10:41 AM, R2's closet was observed with very little clothing and no pants. On 6/18/26 at 11:30 AM, a tour was conducted with V1/Administrator in Training of the facility's laundry room. The laundry room was observed with a large four wheeled bin full of clean clothing in one room, and several barrels of dirty linen in another room. V1/Administrator in Training stated, We have had issues with laundry getting distributed timely. We (the facility) switched to an outsourced laundry agency on 4/20/26, to try and help the situation. Laundry typically only works with one laundry aide throughout the day, and they can't keep up. The department heads and I sometimes go back to help get caught up. We (facility) would like another laundry aide on second shift, but we have had a hard time getting someone. We are trying to hire one now. On 6/18/26 at 9:37 AM V3/Ombudsman stated, I was at the facility on 6/11/26. Residents were complaining about missing clothing or not getting their clothing back from laundry. I went and checked with (V15/Laundry Supervisor). The laundry room was beyond backed up with clean clothing and dirty clothing. (V15) told me they are short staffed, and a lot of clean clothing just needed folded and delivered to the resident's rooms. On 6/18/26 at 10:45 AM R3 stated sometimes laundry does not get R3's clothes back to R3's room timely, so R3 does not have clean clothes to wear sometimes. R3 stated, It happens quite often that laundry does not deliver our clothes back to us for weeks sometimes. On 6/18/26 at 10:57 AM V11/CNA (Certified Nursing Assistant) stated, They (residents) don't get clean clothes back in a timely matter. Some missing clothes for about a month.On 6/18/26 at 11:55 AM V5/LPN (Licensed Practical Nurse) stated, There has been an issue that residents don't get their clothing back timely or they go to the wrong resident. On 6/18/26 at 12:11 PM V16/CNA stated, Residents are hoarding their dirty clothes because they don't get them back from laundry. We (staff) go back and forth to the laundry room daily to try to find clothes. It is not getting any better. Been going on for a couple of months.On 6/18/26 at 1:02 PM V15/Housekeeping Supervisor stated, I just started working for the company around one month ago. When I first started at this facility, we (staff) were having issues getting the staff linen out timely and the residents' clothing out timely. Just last week some of the facility employees came back to help us. I think we need more staffing with laundry. We only have one laundry aide doing laundry today on day shift. We should have two, one for first shift and one for second shift. They just added a position for second shift. In the mornings, laundry is completely overwhelming due to only having one laundry aide. We have never had a second shift laundry aide since I started. We can't get all the laundry done in one shift washed and put away. On 6/20/26 at 11:05 AM, V14/R5's POA (Power of Attorney) stated that when R5 was admitted to the facility on [DATE] the family purchased several new clothes for R5. More clothes had to be bought for R5 because R5's clothes were not returned from the laundry. About a month ago the family started doing R5's laundry so R5 would not lose anymore clothes.On 6/20/26 at 11:26 AM R9 stated, The laundry still s**ks. It still takes laundry one to two weeks to get me back my things. I still have missing items. They will look for the missing items and bring them back slowly one by one. The laundry is horrible here. On 6/20/26 at 11:32 AM R7 stated, A lot of time laundry doesn't get us back our socks timely, so we must go without socks. They just went through and got us a lot of our socks back around a week ago, but I noticed we are starting to not get them back once again. On 6/20/26 at 11:37 AM R4 stated, The laundry is terrible here. I am constantly missing my underwear and socks, and laundry won't get it back to me for sometimes weeks. I have gone several times natural because I have had no underwear or socks.

Based on interview record review and observation the facility failed to provide appetizing or appealing-appearing food and appropriate condiments for residents of the facility. This failure has the potential to affect all 94 residents currently residing in the facility.Findings include: The facility was unable to provide a Dietary policy.The Resident Roster provided by the Administrator on 5/5/26 documented 94 residents resided in the facility.On 5/6/26 at 12:20pm R1 and R3 stated meals served by the facility are not appealing and often inedible. On 5/6/26 at 12:30pm R4, R5, and R6 were eating lunch in the dining room. The posted lunch menu listed the lunch meal was: Chicken Fried [NAME] and Zucchini. The fried rice was brown with very small pieces of diced chicken, and the zucchini slices were limp and sitting in watery fluid. On 5/8/26 during the lunch meal service the menu posted in the Dining Room was dated Wednesday 5/6/26 and listed the Fried [NAME] and Zucchini meal served on Wednesday. The lunch menu for 5/8/26 lunch meal was documented as Ravioli and roasted yellow squash on the facility's weekly menu provided to this surveyor by V17 Dietary Manager.Upon touring the Dining Room at approximately 12:40pm this surveyor noted many uneaten ravioli edges remaining on plates, and noted residents were attempting to cut off the edges around the meat-filled ravioli and only eating the middle portion of the ravioli pasta.On 5/8/26 at 12:15pm R9, R10 and R11 stated they find the food served at the facility is often bad in general and is not something they would serve to anyone as it is so poorly prepared and presented on the plate. R1 stated the eggs served for breakfast were burnt, and often the eggs served looked burnt. R9 also stated the egg dish served at breakfast looked burnt and was not edible. R11 stated the hot cereal served at breakfast was mostly water with a few grains of (hot cereal) in it. On 5/8/26 at approximately 12:20pm, during the lunch meal in the Dining Room R1, R4, R5, R9, R10 and R11 stated the ravioli served for lunch was hard to eat, and the edges of the ravioli were hard and difficult to cut. R5 stated she couldn't eat the egg dish at breakfast because It was burnt. On 5/8/26 at approximately 2:00pm V1 Administrator stated the facility was aware of the issues with the food and preparation in Dietary and made changes in staff in the department including hiring a new Dietary Manager and are in the process of interviewing and hiring additional Dietary personnel.

Based on interview, observation and record review the facility failed to provide assistance with personal hygiene cares for one resident (R1) of 4 residents reviewed for Activities of Daily Living in the sample of 11. Findings include:R1 is a [AGE] year-old resident of the facility admitted on [DATE] with diagnoses including Scoliosis, Sciatica, COPD/Chronic Obstructive Pulmonary Disease; CHF/Congestive Heart Failure; Lymphedema; Obesity and Type 2 Diabetes Mellitus.R1's current Care Plan documents the following: (R1) has an ADL (Activities of Daily Living) Self Care Performance Deficit. PERSONAL HYGIENE/ORAL CARE: The resident requires X1 Extensive staff assist with personal hygiene and oral care.On 5/5/26 at 2:10pm V5 CNA/Certified Nursing Assistant stated R1 requires set-up for morning and HS personal hygiene cares in her room. On 5/5/26 at 2:20 pm, R1 was sitting in a bariatric wheelchair in her room, awake, alert and oriented. R1 stated she is never given a face cloth, towel, soap or a basin of water for personal hygiene/washing up in the morning or at bedtime, nor has she been provided with items for oral care such as toothbrush, toothpaste or mouthwash. R1 stated she is unable to maneuver her wheelchair around in her bathroom due to tight quarters and cannot utilize the sink for any personal hygiene. R1 stated, I don't even get to wash my face in the morning before breakfast.On 5/5/26 at 2:20 pm there was no wash basin, no washcloth or towel, and no oral care items in R1's room or bathroom.On 5/6/26 at 10:00 am there was no wash basin or personal hygiene items in R1's room or bathroom. R1 stated there was no set-up or assistance provided by staff last evening or this morning to enable R1 to perform morning personal hygiene.On 5/6/25 at approximately 3:00 pm V2 DON/Director of Nursing stated R1 should be provided the set-up and any assistance she may need to freshen up in the morning and before bedtime.

Based on record review, interview and observation the facility failed to provide physician-ordered medication for one resident (R1) of six residents reviewed for medication administration in the sample of 11.Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including obesity; CHF/Congestive Heart Failure, Scoliosis, Sciatica, Lymphedema, Hypertension and Type 2 Diabetes.The facility's Medication Availability policy documents the following: Nursing administration to compare the orders to the medications in the med cart to ensure medications are available. Refills ordered timely through the EHR (pharmacy's electronic medication re-ordering system) .Night shift responsible for reordering insulins, inhalers, eye drops, controlled drugs every Monday and Thursday night, and If medication not available, staff to check (back-up medication) for med, staff to call the pharmacy if med not in (backup medication system), notify DON/Director of Nursing, notify practitioner.R1's medical record includes a Physicians Order by V20/R1's Physician, dated 03/19/2026 as follows: Hydrocodone-Acetaminophen oral tablet 5-325mg. Give 1 tablet by mouth every 4 hours as needed for Low Back Pain/R side Sciatica.R1's current Care Plan documents the following Focus: Chronic Pain related to Scoliosis, the Goal listed for this pain Care Plan is as follows: Resident will Report Satisfactory Pain Control, and Interventions include: Administer pain medication per order. R1's Care Plan also includes the following: Focus: (R1) has pain at times. and Interventions include The resident's pain is alleviated/relieved by: Norco (Hydrocodone-APAP 5-325)R1's May eMAR/Medication Administration Record documents the last time R1 received a dose of Norco for pain the night of 5/3/26. There are no doses of Norco signed off on R1's eMAR indicating any doses of Norco were administered on 5/4/26 or 5/5/26.On 5/5/26 at approximately 2:30 pm R1 stated she had been out of pain medication (Norco/hydrocodone 5mg/milligrams/Acetaminophen 325mg for a few days. R1 stated she only asks for pain medication at bedtime and in the night in order to sleep comfortably. R1 stated she cannot sleep comfortably on the bed in her room and prefers to sleep in the recliner in her room.On 5/5/26 at approximately 3:20 pm V5 LPN/Licensed Practical Nurse stated she had ordered a refill for R1's Norco on Friday of last week, but the prescription wasn't signed by the doctor yet and the pharmacy will not approve use of the emergency back-up medication system to provide (R1) with the medication, which is available in the automated medication backup appliance in the medication room. V5 stated there were no refills available at the pharmacy for R1's Norco and therefore the pharmacy cannot approve administration of the drug until the prescription refill is signed by the Physician and submitted to the pharmacy. V5 stated she was aware there was just one dose of R1's Norco left on Sunday 5/03/25 and R1 would be out Norco after it was administered.On 5/6/26 at approximately 2:00 pm V5 stated V20 returned the prescription for Norco to the facility without signing it for refill, asking for a better diagnosis for the pain medication. V5 verified R1's pain medication has not been refilled and is not available to R1 as of 5/6/26 at 3:20pm.On 5/6/26 at approximately 4:05 pm V2 DON/Director of Nursing verified Nursing staff had not notified her of R1's need for Norco and stated R1 should never have run out of Norco and the medication should have been noted far enough in advance and refilled prior to running out of the medication. V2 stated R1's Physician should have been notified by Nursing of the pressing need for the refill before R1 ran out of the medication.

Based on observation, interview, and record review the facility failed to ensure baseboard heaters were maintained in a safe manner and failed to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. These deficient practices resulted in R1 becoming entrapped between the bed and a baseboard heater, sustaining painful partial-thickness burns with blistering to the left upper arm, left forearm, and left hand that required emergency room treatment. These deficient practices had the potential to affect all 87 residents residing in the facility.These failures resulted in Immediate Jeopardy.While the immediacy was removed on 3/25/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.These requirements were not met as evidenced by:Based on observation, interview, and record review the facility failed to ensure baseboard heaters were maintained in a safe manner and failed to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. These deficient practices resulted in R1 becoming entrapped between the bed and a baseboard heater, sustaining painful partial-thickness burns with blistering to the left upper arm, left forearm, and left hand that required emergency room treatment. These deficient practices had the potential to affect all 87 residents residing in the facility.These failures resulted in Immediate Jeopardy.While the immediacy was removed on 3/25/26, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Midnight Census Report dated 3/24/26 document 87 residents reside within the facility.The facility's Maintenance Director's Job Description, undated, documents, Position Description: Responsible for supervising and coordinating the activities of the maintenance department to ensure environmental center compliance in accordance of Federal, State, and Local ordinances, regulations and building codes. Ensures center is maintained in a sanitary, attractive, and orderly condition, in good repair, free from hazards such as those caused by electrical, plumbing, ventilation, heating, and cooling systems.On 3/24/25 from 4:08 PM to 5:00 PM a facility tour was conducted in the presence of V8 (Maintenance Director). During the tour, V8 utilized an infrared thermometer to measure the surface temperatures of baseboard heaters located in resident rooms. It was observed that all resident rooms were equipped with six-foot baseboard heaters installed beneath the windows. In rooms occupied by R6 and R7, the baseboard heater surface temperature measured 172 F. A stuffed animal pillow was observed resting directly on top of the heater in R6 and R7's room, and a bag was positioned immediately adjacent to the heater. In rooms occupied by R4 and R5, the baseboard heater surface temperature measured 168 F. A window curtain was observed hanging down and draping on top of the heater. In rooms occupied by R2 and R3, the baseboard heater surface temperature measured 163 F. The thermostat was missing from the unit. At the time of observation, R2 was lying in bed with the right side of the bed positioned directly against the heater. R2, who is hard of hearing, had their right hand and arm within reach of the heater and stated, The heater gets very hot. In rooms occupied by R1 and R8, both residents were observed lying in bed. The baseboard heaters in these rooms were also missing thermostats. In the room occupied by R9, the resident was lying in bed. The baseboard heater surface temperature measured 160 F. The surveyor attempted to touch the surface of the heater and determined it was too hot to safely touch.R2's MDS dated [DATE] documents R2 is moderately cognitively impairedR2's current Care Plan does not include measures to keep R2 at a safe distance from the baseboard heating element or to protect R2 from burns.On 3/24/26 at 5:00 PM V8 confirmed that the facility did not maintain the manufacturer's operating and preventative maintenance instructions for the baseboard heaters. This included the parts list with component descriptions and the air-balance report. A complete set of these documents was not available on-site.On 3/24/26 at 5:00 PM V8 stated he had not previously monitored or documented the surface temperatures of baseboard heaters or heater covers and was not aware of any established process for doing so. V8 further stated that following an incident in which R1 sustained a burn on 3/21/26 from a baseboard heater, he conducted a visual inspection of all heaters on 3/22/26 to identify units requiring repair or replacement. However, V8 reported that he had only measured the surface temperature of four heaters since that time and confirmed that no formal process has been implemented for routine temperature monitoring.On 3/24/26 at 5:15 PM V1 (Administrator-In-Training) verified all curtains and personal items, and all residents should be positioned within a safe distance of approximately 12 inches from the baseboard heaters to prevent burns and fire hazards. V1 also verified the facility does not have the manufacturer's operating and preventative maintenance instructions for the baseboard heaters.R1's admission Record documents R1 is a [AGE] year-old admitted to the facility on [DATE] with diagnoses of Hemiplegia, Convulsions, Respiratory Failure, Type II Diabetes Mellitus with Diabetic Hemiplegia, Chronic Kidney Disease Stage III, Depression, and Dementia with Anxiety.R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is cognitively severely impaired and is dependent or requires extensive assistance of staff for all ADLs (Activities of Daily Living).R1's Progress Notes dated 3/16/26 at 11:54 AM through 3/20/26 4:55 PM documents R1 receives hospice care, had no signs and symptoms of pain, and received morphine as needed to control pain.R1's Progress Notes dated 3/21/26 at 2:57 AM document and signed by V3 (LPN/Licensed Practical Nurse) document, This writer was notified by (V6/Certified Nursing Assistant/CNA) that (R1) had a burn to his arm. Both nurses went to assess immediately. (R1) was in his bed and the bed was pulled away from the wall where it had been before the burn was noticed. (R1) noted to have red blistered areas to his left lateral pinky up to his wrist and large red area that appears to have blistered and popped to his forearm, from wrist to his elbow. 911 called immediately by this writer. The other nurse administered PRN (as needed) pain medication at this time that 911 was called.R1's Hospital emergency room Notes dated 3/21/26 documents, Chief Complaint: Burn. (R1) arrives from (the facility) via AMT (Advanced Medical Transport). (R1) rolled over in bed and was found with his left arm on a baseboard heater. Significant burnt to left forearm. Caught hand and arm on radiator at nursing home prior to visit. Developed two areas of partial thickness burns with blistering left upper arm and left forearm and ulnar aspect of the hand with blistering present. Burn specialist states to debride thin blisters, if we can leave tense thick blisters intact, bacitracin, and xeroform gauze with kerlix (rolled gauze) overlying the wound. Follow-up Tuesday afternoon at the burn clinic.R1's Progress Notes dated 3/21/26 at 8:44 AM document R1 returned to the facility with wound care orders.R1's Progress Notes dated 3/22/26 at 2:48 AM and signed by V3 documents, (R1) given PRN pain mediation before starting treatment. (R1) did not tolerate the treatment well. (R1) was pulling his arm away from us and crying out in pain. The wound starts at the distal part of (R1's) pinky finger and goes up his arm and stops right below (R1's) shoulder. There are no signs and symptoms of infection at this time. Temp (Temperature) 98.8 (F/Fahrenheit). Pain medications given after treatment was done. No measurements obtained with this dressing change due to (R1's) pain level and not able to cooperate.R1's Progress Note dated 3/24/26 and signed by V6 (Nurse Practitioner) documents, Reason for visit: New skin and wound consult on (R1). (R1) seen today for reports of a burn to (R1's) left arm. Upon exam, (R1) has new second degree burns to his left arm extending from his left lateral hand to behind his left upper arm. Per staff reports, (R1) was in his wheelchair and parked by a heater and obtained the burns. The burn on the lateral side of (R1's) hand is presenting as a large, fluid-filled blister. Remining burns up to the back side of his left upper arm are partial thickness wounds with dermal tissue expose. Wound Assessment: Location left arm. Etiology burn-second degree. Partial Thickness. Size 30 cm (centimeters) by 10 cm by 0.1 cm. Calculated area is 300 sq. (square) cm. Exudate (drainage) light amount of serosanguineous (pale red). Wound pain at rest FLACC (Face, Legs, Activity, Cry, Consolably) Scale four (indicating moderate pain.) Treatment cleanse with wound cleanser, apply xeroform (petrolatum based dressing) to base of wound, secure with kerlix (rolled gauze), and change three times per week and as needed (PRN).R1's emergency room Photographs taken on 3/21/26 show R1's left arm had large partial thickness burns from the top of the outer aspect of the left arm, extending down to the lower outer aspect of the left arm and left hand/fingers. This photographs show a fluid filled golf-ball sized blister to R1's top outer arm.On 3/24/26 at 4:45 PM R1 was lying in a low bed, sleeping. R1 could not be aroused at this time. R1's left arm was wrapped in rolled gauze from the top of his arm down to the tip of his fingers. On 3/24/26 at 4:00 PM V7 (Coroner) stated, I got a call from hospice that (R1) was receiving hospice services, actively dying, and did not have money or a power of attorney to take care of R1's body after R1 passes away. The hospice worker informed me that (R1) was sent to the emergency room for severe burns to his left arm that was caused by the facility's baseboard heater. I went to the emergency room to see (R1) and spoke to a burn pathologist about the burns. Since (R1) was hospice and actively dying, the hospital chose to send (R1) back to the facility with treatments for the burns. (R1) is non-verbal and could not have yelled for help when being burned. That is neglectful of the facility to have allowed (R1) to get burned to that extreme.On 3/24/26 at 6:00 PM V6 (CNA) stated, Around 12:00 AM on 3/21/26 I went into change (R1). I could not get (R1) turned because his arm was stuck between the bed and the baseboard heater. I moved (R1's) bed out and when I did, I saw (R1) had a huge burn up and down his left arm. I immediately got the nurse (V3). I am not sure how long (R1) was lying with his arm trapped between the bed and heater.On 3/24/26 at 6:30 PM V3 (LPN) stated, (V6) had come and got me right after 12:00 AM on 3/21/26 and told me (R1's) arm was burned by the baseboard heater. I immediately went in to assess (R1) and sent (R1) to the emergency room. I have had to do (R1's) treatment to the burns on his left arm since he has returned from the hospital. (R1) yells out and cries in pain whenever I do the treatments. I feel awful for (R1).The Immediate Jeopardy started on 3/21/26 when the facility failed to ensure baseboard heaters were maintained in a safe manner and failed to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks and R1 became entrapped between the bed and a baseboard heater, sustaining painful partial-thickness burns with blistering to the left upper arm, left forearm, and left hand that required emergency room treatment.On 3/25/26 at 2:10 PM V1 (Administrator-In-Training), V9 (Vice President of Operations), and V10 (Regional Reimbursement Specialist) were notified of the Immediate Jeopardy.On 3/27/26 this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. During tour of the facility on 3/27/26 from 9:30 AM through 10:45 AM all residents and their beds were positioned at a safe distance from the baseboard heaters.2. On 3/25/26 V11 (MDS Coordinator) and V12 (MDS Coordinator) obtained surface temperatures of all baseboard heaters in all resident rooms. All baseboard heaters were verified to be at operating temperatures below 140 degrees F.3. On 3/25/26 V1 and V8 obtained manufacturer guidelines for baseboard heaters to ensure safe operation and compliance with recommended safety standards.4. On 3/25/26 V1 educated V8 to ensure baseboard heaters do not exceed a temperature of 140 degrees F or above and was directed to routinely monitor and document temperatures to ensure ongoing compliance. 5. On 3/25/26 V1 educated all department heads to ensure resident beds were never lowered or pushed against baseboard heaters when in use and a visual guide was implemented and posted to demonstrate the appropriate safe distance between beds and heaters to ensure consistent compliance.6. On 3/25/26 V13 (Assistant Director of Nursing) educated all licensed nurses to ensure resident beds were never lowered or pushed against baseboard heaters when in use. 7. On 3/25/26 V14 (CNA Supervisor) and V15 (CNA Supervisor) educated all CNAs and unlicensed staff to ensure resident beds were never lowered or pushed against baseboard heaters when in use.8.On 3/25/26 V1 implemented a process to ensure all room assignments were appropriate for the number of residents in each room, to allow for safe placement away from environmental hazards, including baseboard heaters.9.On 3/25/26 V1, V2, V13, V14, and V15 conducted a facility-wide audit to identify any additional risks related to heater placement and bed positioning and all concerns were immediately corrected and resident care plans were updated accordingly.10. On 3/25/26, through 3/27/26 V1 and V8 have conducted twice daily environmental temperature rounds to ensure baseboard heater temperatures are 140 degrees F or below. These daily temperatures will continue twice daily for five days a week, and then weekly for four weeks.Completion Date: 3/25/26

Based on record review and interview the facility failed to provide QAPI (Quality Assurance and Performance Improvement) training to all employees. This failure has the potential to affect all 87 residents residing within the facility.Findings include:The facility's Midnight Census Report dated 3/24/26 document 87 residents reside within the facility.The facility's Annual In-Service Schedule does not include in-servicing regarding QAPI.The facility's Staff In-Services and Computer Based Training dated 3/1/25 through 3/28/26 were reviewed and did not include QAPI training.On 3/28/26 at 9:50 AM V1 (Administrator In Training) verified facility staff have not received QAPI training.

Based on interview and record review, the facility failed to perform pressure ulcer care and skin checks as ordered for one of three residents (R1) reviewed for pressure ulcer care in a sample of four. The facility's Pressure Injury Assessment and Treatment policy, dated 12/2024, documents to document in the resident electronic medical record when the treatment is completed. On 12/4/25, R1 stated that his wound care varies as to when it is completed. R1 stated that the wound care is done at least daily. R1's Treatment Administration Record, dated 11/12/25 through 12/4/25, documents to cleanse R1's left heel with soap and water. Apply Dakins (antiseptic) soaked gauze to the wound bed and cover with an abdominal pad, and cover with a gauze wrap and apply heel boots every day shift. This treatment is not signed out as being completed 11/12/25, 11/18/25, 1/19/25, 11/22/25 through 11/26/25, 12/1/25, and 12/2/25. This form also documents to perform daily skin checks. R1's daily skin checks were not signed out as being completed on 11/12/25, 11/19/25, 11/22/25 through 11/26/25, and 12/1/25 through 12/3/25. On 12/6/25 at 1:00pm, V4, Infection Preventionist/Treatment Nurse, stated that if the treatments are not signed out, then they were not completed as ordered. V4 stated the treatment is to be signed out when completing the care, and if the resident refuses, it should be documented in the progress notes.

Based on interview and record review the facility failed to perform nephrostomy care, urinary catheter care, and document urinary output as ordered for one of two residents (R1) reviewed for bowel and bladder in a sample of four. Findings include: The facility's Catheter Care, Urinary policy, dated 12/2024, documents to maintain accurate record of the residents' daily output every shift. This form documents to empty the collection bag at least every eight hours. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. On 12/4/25 at 9:30am, R1 stated he thinks his catheter care and nephrostomy care are done at least daily but does not know for sure. R1's Treatment Administration Record, dated 11/12/26 through 12/4/25, documents to flush R1's urinary catheter with 30 milliliters of normal saline every day and night shift. This form documents R1's normal saline flush was only done once on 11/13/25 and 11/14/25, 11/22/25 through 11/26/25. R1's urinary catheter output monitor and record output every day and night shift were not done on 11/13/25, and only once on 11/14/25. 11/16/15. 11/18/25, 11/19/25, 11/22/25 through 11/16/26, 11/30/25, 12/1/25 through 12/3/25. R1's Urinary Catheter care and Nephrostomy tube is to be completed every day and night shift.This care was only completed one time daily on 11/14/24, 11/18/25, 11/19/25, 11/22/25 through 11/16/25, 12/1/25 through 12/3/24. On 12/6/25 at 1:00pm, V4, Infection Preventionist/Treatment Nurse, stated if urinary catheter and nephrostomy care are not signed out, then they were not completed as ordered. V4 stated the treatment is to be signed out when completing the care, and if the resident refuses, it should be documented in the progress notes.

Based on Interview and Record review, the facility failed to notify a resident's physician of new onset, unilateral extremity pain for a resident with severe cognitive impairment for one of three residents (R1) reviewed for injury in the sample of four. This failure resulted in R1 waiting over 24 hours to receive emergency care/ imaging for a fracture of R1's right tibia and fibula.Findings include: R1's current Care Plan, dated 8/11/25, documents R1 has diagnoses including but not limited to Alzheimer's Disease, Anxiety, Senile Degeneration, and Severe Dementia with Psychotic disturbance. This care plan documents Resident has a behavior problem of increased confusion with anxiety related to: Alzheimer's or related dementia.R1's electronic progress note, dated 8/5/2025 at 1:26 PM and signed by V4 (Licensed Practical Nurse), documents, Late entry: 8/3/25 (R1) was observed in hallway acting per normal. Propelling herself while whimpering she wants to go home repeatedly. While in the dining room, this nurse attempted to administer medications and PRN (as need) ABH (Ativan, Benadryl, Haldol, anti-anxiety/ antipsychotic medicated cream) and (R1) became extremely upset and refused medications. A later reattempt to apply ABH cream with CNA (Certified Nursing Assistant) and successful. A little while later same CNA (V15) said she thought she knew what was wrong with (R1) and palpated right hip area in which (R1) winced and attempted to pull away. PRN morphine (narcotic pain medication) administered with some difficulty, however then resident rested in wheelchair at the nurse's desk for a while. Later another resident needed to use phone at the desk so when staff went to move (R1) back in her chair (R1) grabbed (her) leg at the right knee and brought towards her chest. No reported incidents to explain her pain as resident is primarily nonverbal with limited communication. Continued to monitor.On 8/22/25 at 2:45 PM, V4 (Licensed Practical Nurse) confirmed she was the nurse for R1 on 8/3/25 and stated, I took care of (R1). On Sunday morning (8/3/25), she was tooling around and acting normal. She did not want her morning meds, sometimes she does that though. (V15 CNA) brought (R1) to the nurse's station and said I think she is in pain and when (V15) went to touch (R1's) right hip area, she winced from that. (R1) later grabbed her right knee and brought it to her center, almost like a guarding motion. Those were her only signs she displayed of pain. Neither was a normal behavior for her. I was afraid to order an X-Ray because she'd be non-compliant, she would need held and not handle that well. All of this happened just after breakfast on 8/3/25. I know (R1) was later taken to lunch and I don't think anything else was ever said. I didn't notify the DON (V2, Director of Nursing) or the MD (V7, R1's Physician).On 8/22/25 at 3:05 PM, V15 (CNA) stated, On 8/3/25, I was taking care of (R1) and I told the nurse (V4) when I touched (R1) on the right hip she acted like she was in pain and hurting. I know she drew her knee up at one point later too when she was in front of the nurse's station. She was displaying pain on the side. She was confused often and that day she couldn't be calmed down with music or other interventions. I could tell (R1) was more anxious and not acting her normal self. On 8/23/25 at 9:20 AM, V14 (Registered Nurse) confirmed she was R1's nurse on the evening of 8/3/25 until the morning of 8/4/25. V14 stated, I was told in report the day before (8/3/25) that (R1) was having some pain. The next morning (8/4/25) the CNA (V16) called me in the room, and we couldn't really tell what was wrong. (R1) was grabbing towards her right knee. We decided not to get her up or move her and that when dayshift comes in, they can order an x-ray. This was all before 6 AM, before we were going to change shifts. (R1) kind of guarded her right knee. That morning with (V16), she had been more resistive to care. V14 confirmed she did not notify R1's Physician (V7) or (V20, R1's Guardian).R1's nursing progress notes, dated 8/4/2025 at 11:03 AM and signed by V6 (Licensed Practical Nurse), documents R1 was refusing all pain medications and was sent to the emergency department for evaluation and imaging. On 8/23/25 at 10:33 AM, V6 (Licensed Practical Nurse) stated, I took report on 8/4/25 (morning) and it was stated to me that (R1) was acting strange towards the end of the night shift. I assessed (R1) and when trying to assist her she recoiled and seemed fearful. I thought it could be her leg bothering her, but I wasn't sure. It was strange that (R1) wasn't allowing staff to help her. That was new behavior for her. I was not aware of anyone notifying the (V7, R1's Physician), (V20, R1's Guardian), or (V2, Director of Nursing) prior to myself, that morning. R1's Emergency Department notes, dated 8/4/25 at 2:34 PM and signed by V21 (emergency room doctor), documents R1 was brought to the emergency room for right ankle swelling and later admitted to the hospital with a right closed Tibia-Fibula fracture and Dementia.On 8/23/25 at 12:10 PM, V2 (Director of Nursing) confirmed he was notified of the situation with R1 on the date she was sent out to the hospital (8/4/25). V2 stated he was unaware she was having symptoms of pain the day prior (8/3/25). V2 confirmed when R1 was sent to the emergency room it was discovered she had a lower right leg fracture of both bones and that V7 (R1's Physician) and V20 (R1's Guardian) was not notified of the change in R1's condition until 8/4/25. The facility's Significant Condition Change and Notification policy, dated 12/2024, documents To ensure the resident's family and or representative and medical practitioner are notified of resident changes such as: A significant change in the resident's physical, mental or psychological status; Abnormal or unusual or new complaints of pain. This policy also documents When any of the situation exist, the licensed nurse will contact the resident's representative and their medical practitioner. The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If the medical practitioner cannot be reached, the director of nursing or the charge nurse can make arrangements for transportation to the emergency department. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. All significant changes will be recorded on the (facility's electronic record program) communication board in the resident record. Charting will include an assessment of the resident's current status as it relates to the change in condition.

Based on Observation, Interview and Record Review, the facility failed to ensure that direct resident care staffing was adequate to meet the needs of residents in the facility. This failure has the potential to affect all 83 residents residing in the facility.Findings include:The facility's Resident Roster dated 8/22/25 and provided by V1 (Administrator), documents there are 83 residents residing in the facility.The facility's (undated) Resident Acuity spreadsheet provided by V1 (Administrator) on 8/25/25, documents the facility has 75 residents who require some level of staff assistance with Activities of Daily Living. Of those 75 residents, 27 of them require moderate assistance and 36 require total dependence on staff. This spreadsheet also documents 40 residents have behavioral mental health needs, 14 of which display aggression.R3's Grievance/ Complaint form, dated 8/4/25 and signed by V1 (Administrator), documents, This resident came to the SSD (Social Services Director, V5) to talk about the staffing. The resident is happy with staff but is unhappy with the cuts/ shortages. (R3) is worried about prolonged waits to be helped and get medications.R3's current Care Plan, dated 10/11/24, documents R1 has diagnoses including but not limited to Congestive Heart Failure, Chronic Kidney Disease, and Restless Legs Syndrome. This care plan documents R1 has a plan of Actual / At Risk and/or Potential for complications with deficits with ADL's (Activities of Daily Living) related to current medical/physical status. Has medications and diagnoses that can/may affect ADL's. This same plan of care documents R3 requires limited assistance of one staff member for transferring, toileting, locomotion, and dressing.On 8/22/25 at 2:05 PM, R3 was sitting in a recliner chair in her room. R3 stated she does not feel like the facility has enough staff to care for the residents. R3 stated, This morning, they had an emergency, and my morning medications did not get to me until lunchtime. I know it is because the nurses are just busy, and they have a lot to do. The CNAs (Certified Nursing Assistants) are busy too. I wait a long time when I do push my call light. If I need help to the use the restroom, I may wait 30-45 minutes before someone comes in to help. They just don't have enough staff working to get to everyone. R3 confirmed she requires a wheelchair to get around the facility and she has a history of falling.R4's current Care Plan, dated 8/5/24, documents R4 has diagnoses including but not limited to Heart Failure, Hemiplegia affecting right side, Epilepsy, Spastic Hemiplegia affecting left side, Chronic Kidney Disease, Joint Stiffness, Muscle Weakness, Difficulty Walking, Chronic Pain, Lack of Coordination and Abnormal Posture. This care plan documents R4 has a plan of (R4) is at risk for falls related to a history of falls, spastic hemiplegia affecting left side, decrease muscle coordination, use of assistive device, dependent on staff to stand. This care plan documents R4 requires extensive assistance of two staff for transfers and bed mobility.On 8/22/25 at 1:30 PM, R4 was sitting in the hallway outside of his room in a wheelchair. At this time R4 stated he has been waiting 45 minutes to get into bed and use the urinal. R4 stated, Staff are busy, they are not just sitting around. I know it's the end of lunch time, but I can't use the toilet because I require a (mechanical lift) to transfer so I need to get to bed and use a urinal. They need two staff to transfer me and so I must wait too long because there isn't enough of them.On 8/22/25 at 1:40 PM, V12 (Licensed Practical Nurse) stated staffing has been a challenge at times. V12 stated I am a nurse for 32 residents today in my area. I have several residents who require (mechanical lifts), two residents on dialysis and so they have decreased strength levels on several day of the week, I have another resident with a gastrostomy tube. We are not staffed based on the needs of these residents. I believe we have around 19 residents who have CHF (Congestive Heart Failure) and they need daily weights. It's a lot for two nursing assistants to keep up with.On 8/22/25 at 3:05 PM, V15 (Certified Nursing Assistant) stated, Staffing depends on the day. We have a resident (R1) on 15-minute watch right now. I have around 22 residents in my hall. Of those I have five to six (mechanical lifts) and that requires two staff members for every transfer. It can be very difficult to keep up with everything. On 8/23/25 at 10:33 AM, V6 (Licensed Practical Nurse) stated, We did just have some staffing cuts which makes it difficult at times to get things accomplished. Treatments and charting are things that often can't be caught up on. Especially charting. For example, that day (8/4/25) I had two residents transfer out to the hospital and it put me behind on everything else. It's hard to give safe resident care when you don't have enough staff in the building. The residents will often complain of longer wait times and that staff morale has decreased.On 8/22/25 at 3:20 PM, V2 (Director of Nursing) confirmed the facility is hearing more resident complaints on not having enough staff. V2 stated, Residents have complained to me about the staffing cuts that were made. We also have increased our census so we are getting more residents and more behaviors/care needs and we are scaling back on staff. It is noticeable to residents and of course staff feel it too.The facility's Facility Assessment, dated 7/13/25, does not include numerical staffing requirements necessary of nurses and nursing assistants for each shift, to meet the needs of the residents based on the resident population and census. This same assessment documents, The facility's plan to ensure sufficient staff to meet the needs of the residents at any given time is based on the (state minimum) staffing calculator, which takes into consideration the facility census and acuity levels impacting staffing needs.The facility's (undated) Activities of Daily Living policy, documents, This facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff will ensure that each resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical condition demonstrate that the decline was unavoidable, including bathing, dressing, grooming, transferring, locomotion, ambulation, toileting, eating, communication including using speech, language or other functional communication systems specific to the needs of the individual resident.

Based on interview and record review, the facility failed to assess and document a resident's pain and administer pain medication to a resident with severe cognitive impairment, who was later diagnosed with right lower leg fractures for one of three residents (R1) reviewed for accidents in the sample of four. Findings include:R1's current Care Plan, dated 8/11/25, documents R1 has diagnoses including but not limited to Alzheimer's Disease, Anxiety, Senile Degeneration, and Severe Dementia with Psychotic disturbance. This care plan documents Resident has a behavior problem of increased confusion with anxiety related to: Alzheimer's or related dementia.R1's Treatment Administration Record (TAR), dated 8/1/25-8/22/25, documents R1 has an order for Pain monitoring every shift, every day and night shift. Start Date, 3/10/2025. This record does not document dayshift pain monitoring was assessed on 8/2/25 or 8/3/25. This same TAR documents on the evening of 8/3/25, R1's pain was assessed to be a 7/10, severe pain.R1's Medication Administration Record (MAR), dated 8/1/25-8/22/25, documents R1 has an order for Morphine Sulfate (Concentrate) Oral Solution 20 Milligrams/Milliliter (ml) (Liquid Narcotic pain medication). Give 0.25 ml by mouth every two hours as needed for Pain or Air Hunger. Start Date, 3/06/2025. This same MAR does not document any other medications for pain were in place on 8/3/25 and does not document any pain medication was administered to R1 on 8/3/25.On 8/22/25 at 2:45 PM, V4 (Licensed Practical Nurse) confirmed being R1's nurse on the dayshift of 8/3/25. V4 stated, V15 (Certified Nursing Assistant, CNA) brought (R1) to the nurse's station (on 8/3/25) and said, I think she is in pain and when the CNA went to touch (R1's) right hip area, she winced from that. (R1) later grabbed her right knee and brought it to her center, almost like a guarding motion. Those were her only signs she displayed of pain. Neither was a normal behavior for her. I maybe charted Morphine administration in the progress notes; I am not sure if it was charted in the MAR or not. All of this happened just after breakfast on 8/3/25.On 8/23/25 at 9:20 AM, V14 (Registered Nurse) confirmed she was R1's nurse on the evening of 8/3/25 until the morning of 8/4/25. V14 stated, I was told in report the day before (8/3/25) that R1 was having some pain. The next morning the CNA (V16) called me in (R1's room) and we couldn't really tell what was wrong. (R1) was grabbing towards her knee. We decided not to get her up or move her and when dayshift comes in, they can order an x-ray when the place opens. This was before 6 am, just before we were going to change shifts. She kind of guarded her right knee. That morning with (V16), she had been more resistive to care. I think I was able to squirt some Morphine in her mouth for pain. I am not sure if it was charted on the MAR. Sometimes we chart on the MAR or chart in the narcotic sign out book.R1's Nursing Progress notes do not contain any pain assessments, progress notes or pain medication administrations for R1 on 8/3/25. R1's Emergency Department notes, dated 8/4/25 at 2:34 PM and signed by V21 (emergency room doctor), documents R1 was brought to the emergency room for right ankle swelling and later admitted to the hospital with a right closed Tibia-Fibula fracture and Dementia.On 8/23/25 at 12:10 PM, V2 (Director of Nursing) confirmed he was notified of the situation with R1 on the date she was sent out to the hospital (8/4/25). V2 stated he was unaware she was having symptoms of pain the day prior (8/3/25). V2 confirmed when R1 was sent to the emergency room it was discovered she had a lower right leg fracture of both bones. V2 stated if the Morphine was being administered it should be charted on the Medication Administration Record to show it was given.On 8/25/25 at 2:00 PM, V1 (Administrator) stated that V1 and V2 have searched for the Morphine sign out sheet for R1's narcotic pain medication from 8/1/25-8/22/25 and they are not able to find it. V1 confirmed there is no way to determine if R1 was properly assessed and given pain medication on 8/3/25 because it is not charted in R1's medical record.The facility's Pain Management policy, dated 2/2025, documents Effective pain management can remove the adverse psychological and physiological effects of unrelieved pain. Optimal management of the resident experiencing pain enhances the healing and promotes both physical and psychological wellness. It is the responsibility of all clinical staff to assess and periodically reassess the resident for pain and relief from pain. Expressions of pain may be verbal or nonverbal and are subjective to the resident including but not limited to: negative verbalizations and vocalizations (groaning, crying, whimpering, screaming), behavior such as resisting care, distressed pacing, irritability, depressed mood or decreased participation in usual physical and/or social activities. If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the resident's care providers. Pain control mechanisms include but are not limited to: Medications administered for the control or relief of pain, Medications administered for the control or relief of anxiety, Repositioning of the resident. Management of the resident's pain is an interdisciplinary process, and it is to be included on the resident's interdisciplinary care plan.The facility's Controlled Substance policy, dated 12/2024, documents Controlled substances are subject to special handling, storage, disposal, and record-keeping requirements. The facility will maintain compliance with these special provisions. The licensed nurse or CMT (Certified Medication Technician) where applicable will sign the medication out on the Controlled Substance Proof of use form immediately and will document the medication on the Medication Administration record immediately after administering the drug. The Controlled Substance Proof of use record is to be kept in the Controlled Medication Book. When completed, these records are to be placed in the resident's permanent record.

Based on interview and record review, the facility failed to protect a resident (R2) from physical abuse by another resident (R1), reviewed for abuse, in a sample of seven.Based on interview and record review, the facility failed to protect a resident (R2) from physical abuse by another resident (R1), reviewed for abuse, in a sample of seven.FINDINGS INCLUDE:The facility policy, Abuse, Prevention and Prohibition Policy, dated 03/2025 directs staff, Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.R1's facility form admission Record, documents that R1 was admitted to the facility on [DATE] with the following diagnoses, Schizophrenia, Mood Disorder, Anxiety, Depression, Schizoaffective Disorder and Mild Intellectual Disabilities. R1's current Care Plan, dated 3/12/24 includes the following Focus Areas, (R1) has the potential to be physically aggressive related to Mood Disorder, Schizophrenia; (R1) has the potential to be verbally aggressive related to Mood Disorder, Schizophrenia.The facility form, Allegation of Abuse, dated 5/30/25 at 2:30 P.M. and completed by V2/Director of Nurses documents, (R1) was in the hallway near the front lobby screaming at another resident (R2). (R1) struck (R2) with a closed fist to the face. Both residents separated and brought to separate rooms to discuss the incident. Neither resident was injured during this incident. (R1) quickly apologized. POA (Power of Attorney) and DR (Doctor) notified. Both residents separated and debriefed on incident. (V1) notified to complete investigation. (R1) was informed that he would have to be referred to other facilities if he is unable to keep his hands to himself or stop calling staff and residents vulgar names. (R1) apologized and apologized to (R2) and staff. (R1) was given ideas for better outlets of frustration.On 7/15/25 at 10:30 A.M., V2/Director of Nurse verified he was present when (R1) hit (R2) with a closed fist to (R2)'s face. At that time V2 stated that R1 has a history of being verbally and physically aggressive to staff and residents.

4.) On 06/09/25 at 11:18 AM R7 and R68's window had no blinds, and the curtain was hanging halfway off the bracket and unable to be closed. R7 and R68's six-foot-long baseboard heater was lying on the floor, not attached to the wall. R7 and R68's bathroom floor had a thick brown stain surrounding the base boards and the toilet. On 06/11/25 at 11:33 AM V3 (LPN/Licensed Practical Nurse) verified R7 and R68's window had no blinds or curtains that were able to be closed. On 06/11/25 at 11:36 AM V18 (Housekeeper) stated, (R7 and R68's) bathroom floor has always been stained and (R7 and R68's) window has never had a working blind or curtains. I do not know how long the heater has been lying on the floor. Based on observation, interview, and record review the facility failed to ensure resident rooms were clean and free of urine odor, resident room windows had privacy blinds or curtains in good repair, resident heating units were properly attached to the wall, and failed to ensure all resident rooms had adequate cooling for five of 18 residents (R4, R7, R9, R38 and R68) reviewed for homelike environment in the sample list of 40. Findings include: The facility's Resident Rights policy dated 12/2024 documents it is the responsibility of the staff in the facility to provide services to the residents, and advocate for Resident Rights. 1.) 06/10/25 10:36 AM 06/09/25 11:17 AM R4 had two cardboard boxes taped to the window covering the windows with silver tape. On 6/10/25 at 12:10 PM, V20 (Certified Nursing Assistant) stated there are cardboard boxes that cover windows because the windows let in hot/cold air. 06/09/25 11:00 AM, V5 (Maintenance Director) stated the blinds do not block out the sun, so residents will often ask to have boxes over the windows. V5 further stated the facility plans to fix the issues in the facility, but they have not been given the funding to do so yet. 2.) 06/09/25 02:07 PM R9's room had a very strong smell of urine. On top of R9's bedside table was a full urinal of amber colored urine. R9's bed had no fitted sheet and R9 was laying on top of the mattress. R9's floor was sticky with dirt and debris. R9's Current Medical Diagnosis List documents R9 has a mental illness of Schizophrenia. R9's current care plan documents R9 needs assistance with activities of daily living (ADLs). This same care plan documents R9 does not keep up with personal hygiene related to R9's mental illness and requires staff assistance. On 6/11/25 at 2:00 PM, V2 (Director of Nursing) stated resident rooms should be clean and in good working order. 3.) On 6/10/25 at 1100 AM, R38's room did not contain an air conditioning unit. An electronic temperature reader revealed R38's room temperature was 76 degrees. R38's Nurse Progress notes dated 6/5/25 documents R38 was sent to the local hospital for a planned surgery. 06/10/25 11:22 AM, V5 (Maintenance Director) stated V5 is not doing temperature checks in the facility. V5 stated R38's room does not have a window air conditioning unit at this time, but the facility will be installing one in R38's room. V5 confirms R38's room does not have central air conditioning. V5 stated the unit was removed from that room awhile back. On 6/10/25 at 12:10 PM, V20 (Certified Nursing Assistant) and V21 (Certified Nursing Assistant) stated R38 has always wanted R38's room to be very cold. V20 further stated R38 would often complain that R38's room was too hot. On 6/10/25 at 1:00 PM, V2 (Director of Nursing) stated R38 has been moved several times to different rooms because it's been hard to find a roommate that likes the room as cool as R38 does. V2 stated V2 is aware that R38s room does not have an air conditioning unit and the facility is working to install a new unit. R38's electronic medical record documents under the census line that R38 was moved into R38's room on 5/1/25.

Based on observation, interview, and record review the facility failed to ensure resident safety during van transportation for one (R1) of three residents reviewed for accidents in a sample of five. This failure resulted in R1 sustaining a fall and suffering from pain and fractured ribs. Findings include: The facility's Fleet Safety Program, undated, documents, Safety Policy: (Named facility) has implemented a fleet management program to establish minimum safety requirements for the operation of vehicles used for company business. We are committed to providing and maintaining a safe working environment for our employees and protecting our residents and citizens of the community from injury and property loss. Your commitment to these policies and procedures are vital to building a safe driving culture within (named facility) and ensuring your own safety, the safety of others and the success of the business. This document continues to state Employee/Driver: Comply with the requirements of this program .Follow all safe driving rules, traffic regulations, and ensure driver(s) and all passengers are wearing appropriate securement device (e.g., seat belt and shoulder harness, wheelchair securement straps.) The consent form included in this Fleet Safety Program includes As a driver of a company vehicle or a private vehicle on company business I understand that it is my responsibility to operate the vehicle in a safe manner and follow to drive defensively to prevent injuries and property damage. R1's Quality Care Reporting Form, dated 11/12/24, documents R1 had a fall in the parking lot resulting in a small discoloration and pain to R1's chin. R1 was sent to the hospital for evaluation and treatment. Summary of event and any actions taken: Transport staff to be educated on safety and proper transportation safety. R1's hospital Emergency Provider Notes, dated 11/15/24, documents, HPI (History of Present Illness): Patient reportedly fell on [DATE]. She was reportedly in a handicap van and was being unloaded, however the lift was not up, and her wheelchair was rolled/dropped out of the van. She fell to the ground and struck her face/head and landed on her left side. She was evaluated at (named facility) who did a CT (Computed Tomography) of her head and neck but did not do imaging of her back/ribs. R1's hospital CT Chest without Contrast, dated 11/15/24, documents, Impression: 1. T8-T9 left rib fractures with associated small hemothorax. On 12/11/24, at 11:43am, R1 sat in a wheelchair in a lounge area. R1 stated the following: I was in the back of the van, and she (V7 Transportation driver) pushed me up (to the rear of the van). I guess she (V7) thought the lift was up, but it wasn't. I went down, fell on the ground, and broke two ribs. They sent me out to the hospital and the hospital said I had two broken ribs. I had pain when moving, but not now. There was one other resident in the van. They let him off the lift first then they never brought the lift back up. (V7) was in front of me and I was going backwards. It made me feel unsafe. They are supposed to take care of you and not you taking care of them. It scared me when I fell . My side hurt from falling on it, but I didn't know right away that I had two broken ribs until the hospital told me. R1 stated that the pain was 10/10 in the beginning and then for about two days. On 12/11/24, at 10:30am V5 Transportation Scheduler stated the following: (R1) was in the hospital and was picked up by (V7 Transportation Driver). I was with another resident (R5) at his appointment then we all returned together. The incident happened upon return. We got back here with both residents. (V5) was unloaded first as I lowered the ramp with (V5) on it. (V5) couldn't propel through the parking lot so I wheeled (V5) to the more even sidewalk and he was in a safe place. As I came back around to the back of the van to help with (R1) I saw (V7 Transportation Driver) wheeling (R1) to put (R1) on the ramp which was still on the ground. I tried to run to try to catch (R1) but it happened so fast. Not sure how I could have stopped it from happening. (R1) went down chair and all. (V7) was in front of (R1's) wheelchair pushing her out backwards. The wheelchair tipped and landed on its backside. (R1) was sent back to the hospital for evaluation. (R1) had redness on her shoulder blade and back, but not on her face or head. (V7) could have looked to see if the lift was up or double checked to make sure and not assume things were done. I am not sure if (V7) heard me say that I was taking (R5) further up to the sidewalk. I should have verified (V7) heard me and double checked the ramp was in proper place for the next resident. On 12/11/24, at 2:07pm, V7 Transportation Driver stated the following: We had two residents on the van, (R1 and R5) and (V5) was helping me. (R1) was in the front part of the back end of the van and (R5) was at the back. (V5) unloaded (R5) out the back using the lift. I had unhooked (R5's) wheelchair and (V5) lowered (R5) down. As (V5) lowered (R5) I went to unhook (R1) and rolled (R1) to the back. I thought (V5) had put the lift up and (V5) had not. I pushed (R1) back and was holding onto the wheelchair when I realized the lift wasn't up. That's when (R1) hit the ground hitting her head. V7 continued to state that usually the first person who lowers the lift for one resident is the one who brings it back up for the next resident because they are the one who has the controls. (R1) had said her chin hurt. (R1) was sent out to hospital. I should have checked to make sure the lift was up without assuming. V7's current Personnel file includes but is not limited to includes Supervisor Report of Counsel with a date of occurrence as 11/11/24 (error - should state 11/12/24). Description of Occurrence: Resident being transported in facility van. Upon arriving at Facility, staff member went to unload resident from van and did not use proper lift equipment. V7's file also includes Term History, Termination Date: 11/22/24. Reason: Safety Violations; Notes: Violated van safety protocols. On 12/12/24, at 2:00pm, V1 Administrator stated the following: (V8 Regional Director) and I discussed (R1's incident) and decided we should terminate (V7) and not let that happen again. It was lack of awareness. All safety protocols were in place. Human error. I was not a witness. The investigation did notate that the lift was on the ground when (R1) was wheeled out of the van. Better awareness of surroundings may have prevented the incident.

Based on interview and record review, the facility failed to assess a wound and promptly initiate treatment upon identification of pressure ulcer for one of three residents (R2) reviewed for pressure ulcer wound treatment in the sample of eleven. This failure resulted in R2's pressure ulcer worsening to Unstageable. Findings include: Facility's Decubitus Care/Pressure Area Policy Revised 1/2018 documents: 2. The pressure area will be assessed and documented on the Treatment Administration Record/TAR or the Wound Documentation Record. 3. Complete all areas of the Treatment Administration Record or Wound Documentation Record. I) Document size, stage, depth, drainage, color, odor, and treatment (upon obtaining from the physician); 4) Notify the physician for treatment orders. R2's Face Sheet documents R2's diagnoses include: Cerebral infarction, aphasia, weakness, metabolic encephalopathy, myocardial infarction type, atherosclerotic heart disease, essential hypertension, hyperlipidemia, type 2 diabetes mellitus. R2's current Care Plan documents: (R2) is at risk for impaired skin integrity including skin tears, bruising and/or pressure related to very limited mobility, inadequate nutrition, and problems with friction and shearing of skin due to needing maximum assistance for moving and changing position. R2's Braden Scale for Predicting Pressure Ulcer Risk Dated 6/22/24 documents a score of 13 (16 and less = High Risk for developing pressure ulcers). R2's Progress Note Dated 8/8/24 documents: Quality Assurance/QA team reviewed (R2's) new pressure ulcer to coccyx. Nurse reported new open pressure ulcer to coccyx on 8/4/24. On 10/2/24 at 9:10am, V7 Licensed Practical Nurse/LPN stated she was the nurse for R2 on 8/4/24 and noted R2's coccyx wound. R2's Physician Orders Dated 8/2024 has no documentation of a physician ordered treatment obtained upon identification of R2's wound on 8/4/24. R2's Treatment Administration Record/TAR did not contain documentation that wound treatments were performed on 8/4/24 or 8/5/24. On 10/2/24 at 9:30am, V14 Certified Nursing Assistant/CNA stated she was R2's Caregiver on 8/5/24. V14 stated that during R2's bed bath, she observed an open area on R2's coccyx. V14 stated, It was tiny, less than 0.5 cm/centimeters like a pin drop. It was open with a little redness around it. It was tiny. R2's initial Wound Assessment and Plan signed and dated 8/6/24 by V13 Wound Physician documents R2's pressure ulcer to her coccyx had an onset date of 8/4/24. The assessment documents R2's pressure ulcer was unstageable, measures 3cm x 2cm, and the wound bed contains 70 percent slough (yellow tissue). On 10/2/24 at 11:10am, V13 stated, I saw (R2's) coccyx wound on 8/6/24 when the treatment was started. The staff did not reach out to me prior to 8/6/24. V13 stated with no treatment in place, R2's pressure ulcer could worsen overnight.

Based on observation, interview and record review, the facility failed to prevent a resident with known wandering and exit seeking behaviors from leaving the facility without staff supervision for one of four residents (R1) reviewed for elopement in a sample of four. R1 was last seen by staff in the facility on 7/13/24 at 6:00 pm and was located three days later (7/16/24) on a local park bench, approximately two and a half miles from the facility, in 90-degree Fahrenheit temperature. This failure resulted in R1 requiring transportation to the local hospital for evaluation and treatment. This failure has the potential to affect all Elopement Risk Residents residing in the facility. Findings include: This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 7/24/24, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their In-service training and Quality Assessment oversight. Accu-weather documents: low temperature on 7/13/24 was 72 degrees Fahrenheit/F and a high of 91 degrees F; low temperature on 7/14/24 was 73 degrees F and a high of 90 degrees F; low temperature on 7/15/24 was 68 degrees F and a high of 93 degrees F; and low temperature on 7/16/24 was 70 degrees F and a high of 82 degrees F. Google Maps documents the facility is approximately two and a half miles from the address where R1 was located on a park bench. Facility Elopement Prevention Policy, revised 10/2006, documents: It is the Facility Policy to provide a safe and secure environment for all Residents; to ensure this process, the staff will assess all Residents for potential elopement; determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk of elopement; at the time of screening and/or upon admission, ask the Resident/Representative/Family/Past Care Givers if the Resident has a history of wandering or elopement; a licensed nurse will complete the Elopement Risk Assessment upon and/or within eight hours of admission to the Facility; an interim plan of care for minimizing the risk for elopement will be initiated upon high risk determination; staff will take a photograph of the Resident and photograph will be placed in the Medication Administration Record and the Resident will have their photograph and basic identifying information placed in a special folder/binder to be maintained at the Nurse's Station; Department Supervisors will be provided with a listing of Residents at high risk for elopement and will disclose this information to their employees as necessary; the Interdisciplinary Team/IDT will initiate a plan of care for any Resident determined high risk for elopement and specific measures will be included in each high risk Resident's plan of care to minimize risk factors and communication of these interventions will be made to direct care staff through exposure to the Resident's plan of care and periodic review and disclosure of the contents' of Elopement File/Binder; any high risk Resident will be promptly and courteously escorted back to the appropriate nursing unit, activity room, dining area or Resident room when noted to be near an Exit door; revision of the Elopement Risk Assessment will be completed quarterly and after an isolated elopement attempt, monthly for Residents who attempt elopement more than five times a week and upon significant change in condition and as needed; the plan of care for minimizing elopement risks will be reviewed each time the Risk Assessment is completed with initials and dating of the care plan by any member of the IDT present for review; and any employee will be educated within a reasonable time frame of hire and throughout the year with elopement education on the location of the elopement file/binder and Elopement Prevention Policy. Facility Missing Resident Policy, revised 8/13/24, documents: It is the Facility policy reasonable precautions are taken to minimize the risks of Resident elopement attempts; reasonable precautions include, but are not limited to door alarms, staff intervention, staff education regarding door alarms and individual resident intervention; is the policy of the Facility to demand immediate response to elopement attempts, door alarm activation and participation in search attempts in the even a Resident is deemed missing; a Resident is deemed missing when an initial reasonable search of the Facility interior and immediate grounds has not rendered physical evidence of the Resident's person, there exists no evidence of the Resident's whereabouts upon examination of documents including but not limited to the medical record, calendar of events and sign out books/sheets and after questioning of Facility staff and residents evidence of whereabouts remains uncertain; when a Resident fails to return from community outing within a reasonable time frame of estimated time of return or within reasonable time frame of known and established past habits/patterns; it is the staff responsibility to immediately notify the Charge Nurse; report to the Charge Nurse for assignment; conduct a search of the Facility interior including under beds, closets, bathrooms, storage areas, laundry/maintenance areas and to conduct a sweep of areas with staff members working together to sweep each consecutive room to avoid the possibility of Resident moving to adjacent rooms undetected and to interview people of unimpaired cognitive ability for possible sightings; conduct a search of the Facility grounds including outdoor buildings/sheds/garages, parked cars, ditches and interview people on the grounds; expand the search to the neighborhood streets and yards within four to five blocks of the Facility if unable to locate on Facility premises; continue to expand the search until the Resident is located and returned to the Facility; the Charge Nurse/Director of Nursing/DON responsibility is to determine when and where the Resident was last seen, notify the Administrator, DON, Department Supervisors, auxiliary staff, off duty staff to assist in the search; notify the Responsible Party/Guardian/Family and notify the attending Physician; Administrator responsibility is to notify the Regional Director of Operations and/or Director of Clinical Operations upon designation of Resident missing, notify Law Enforcement officials and request assistance if the Resident is not located on the premises or surrounding immediate neighborhood and facilitate/coordinate staff assistance in investigation/search under the direction of Law Enforcement; after return to the Facility conduct a complete assessment, initiate Emergency Care Policy, notify personnel involved in the search the Resident has been located (Responsible Party, Administrator, DON, Department Supervisors, Attending Physician and Law Enforcement); complete a Quality Care Reporting Form, document all observations, assessments, interventions and Resident response in the medical record; conduct a thorough Investigation Report of Missing Resident and report the findings to the Quality Assurance/QA Committee with a timeline of occurrences, interventions and responses and prepare a report of staff performance; report as required by State and Federal regulation to the appropriate regulatory agencies; and review of the occurrence in the morning QA meeting to establish a Facility specific strategy to prevent further occurrence. Facility Assessment Tool, dated 8/18/2017, documents: The purpose of the assessment is to determine what resources are necessary to care for Residents competently during day-to-day operations and emergencies, to provide care allows Residents to maintain/attain their highest practicable physical, mental and psychosocial well-being; Appendix PP provides survey guidance through interpretive Guidelines in the State Operations Manual if systemic care concerns are identified are related to the Facility's planning, review of Assessment to determine if these concerns are considered part of the Assessment process; other medical diagnoses or conditions may be considered for admission and the QA team will meet and identify any new needs or resources needed to provide care and support for the person; the Resident's care is based on their individual needs (i.e., enteral tube feeding, preferences and routines, provide culturally competent care, identify hazards and risks for Resident; and develop, implement and maintain an effective training program for staff; ensure providing competent care to Residents every day and during emergencies. Facility Resident Rights, dated 11/2018, documents: The Facility must provide equal access to quality care regardless of diagnosis, condition or payment source; must provide services to keep your physical and mental health at highest practicable levels; be safe; develop a person-centered Care Plan including personal and cultural choices and must make reasonable arrangements to meet your needs and choices; you have the right to move out of your Facility after you give the Administrator, Nurse or Doctor written notice you plan to move and your discharge plan and steps to achieve the goal should be included in your Care Plan; and before your Facility can transfer or discharge you it must prepare you to be sure your discharge is safe and appropriate. On 7/18/24, the Facility Elopement Risk Binder did not document a Resident Information Sheet/Picture for R1 but contained a handwritten note R1 is an identified Elopement Risk. R2, R3, and R4 are documented as Elopement Risk Residents and have a Resident Information Sheet/Picture. R1's Hospital Discharge History and Physical, dated 5/13/24, documents R1 requires: 24-hour care and physical assistance and supervision due to decreased cognition, command following, decreased Upper Extremity Range of Motion, dependence on Activities of Daily Living; and requires Speech Therapy and Occupational Therapy. R1's Physician Order Sheet/POS, dated 5/17/24 through 7/13/24, documents R1 admitted to the facility on [DATE] and V14 (R1's Physician) has read and approves the Plan of Care. R1's POS documents diagnoses including Acute Respiratory Failure with Hypoxia and Hypercapnia, Closed Fracture of the Occipital Bone and Occipital Condyle, Intraparenchymal Hemorrhage of the Brain, Traumatic Subdural Hematoma, Subarachnoid Hemorrhage status post internal Hemorrhoid Ligation, Alcohol and Cocaine Abuse, Hyponatremia, Back Injury, history of Lumbar Disc Herniation, Anemia, Acute Encephalopathy, history of Falls and Altered Mental Status R1's Physician Order Sheets do not document a Discharge Order for R1. R1's New Admission Information Sheet, undated, documents R1 admitted to the facility on [DATE] and R1's Emergency contact person is V11 (R1's Sister) and V12 (R1's Brother-n-Law). R1's Interdisciplinary Discharge Summary for Resident, dated 5/17/24, documents R1 requires staff assistance with Activities of Daily Living/ADLs, needs medication assistance, is not oriented to time and place, meal preparation service is necessary and requires a wheelchair. R1's Facility Admission Screening Form notes (handwritten on untitled blank paper), dated 5/17/24, documents: R1 admitted to the Facility a mechanical lift for transfers; had a Cervical Collar (C-Collar) to stay on at all times for one month, and the Facility to schedule a follow-up Computed Tomography laboratory test (CT Scan) in one month for removal of the C-Collar; talks but is confused; has a Gastrostomy Tube (G-tube) being used for medications; and speaks Spanish. R1's Medication Administration Record/MAR, dated 7/1/24 through 7/14/24, documents R1 was out (of facility) for R1's 7/13/24 8:00 pm medications. All medications on 7/14/24 document R1 was out of facility. R1's Nursing Notes, dated 5/17/24 through 7/13/24, do not document on 7/13/24. R1 exited the building and was not able to be located. On 7/18/24 and 7/19/24, the facility could not provide or locate documentation of R1's Nursing Notes from the dates of 5/29/24 through 7/14/24 at 6:00 am. On 7/19/24 at 10:28 am, after multiple requests, V1 (Administrator) stated, We do not have any Nursing Note documentation for (R1) for the time period of 5/29/24 through 7/14/24 at 6:00 am. I cannot provide any Nurse's Notes about the events of (R1) getting out of the building. On 7/18/24 at 12:08 pm, V2 (Director of Nursing/DON) stated, We do not have any Nursing documentation for (R1) for the time period of 5/29/24 through 7/14/24 at 6:00 am. On 7/19/24 V2 stated, I still cannot find any of (R1's) Nursing documentation for the time period of 5/29/24 through 7/14/24 at 6:00 am, we just do not have any. I also do not see anyone charted the events surrounding when (R1) went missing or anyone notified (V14/R1's Doctor) (R1) was missing. R1's Minimum Data Set/MDS, dated [DATE], documents R1 requires setup with Activities of Daily Living. R1's A.I.M. for Wellness Assessments (used to notify the Physician), dated 5/17/24 through 7/13/24, do not document a 7/13/24 entry for R1 exiting/eloping the building. R1's Elopement Evaluation, dated 5/17/24, documents an entry R1 had physical impairments requiring assistance outside of the building and R1 had severe Mental Illness/CVA (Cerebrovascular Accident)/Brain Injury/Traumatic Brain Injury/Alzheimer's or Dementia. No evaluation updates were documented on R1's Elopement Evaluation. R1's Social Service Progress Notes, dated 5/17/24, documents R1 admitted to the Facility and uses a wheelchair to move around. The Progress Note also documents R1 will be a rehabilitation to home so the Social Service Director will contact the appropriate agencies before discharge. R1's Prescreen of Risk for Violence, dated 5/17/24, documents R1 has been the victim of physical or sexual abuse, has poor impulse control, risk taking or reckless behavior, currently use of alcohol/recreational drugs, had a recent relapse of substance abuse and was physically able to harm others. R1's Prescreening/Screening Assessment for Harmful Behaviors, dated 5/17/24, documents: R1's history of talking about/threatening harm/aggressive behaviors towards others; talking about/threatening self-harm, suicide or engage in self-destructive behaviors; maintains considerable anger and hostility/strong dislikes towards others; and has a history of addictive substances and recognizes chemical addition as self-destructive behavior. R1's current Care Plan, undated, documents: incontinence complications with bowel/bladder; risk for falls related to history of Hypoxia and Respiratory Failure and do not leave unattended in the bathroom; arrange for discharge as needed, discuss feelings/goals for placement, share concerns, involve family/friends, obtain Physician order for discharge, set up services for durable medical equipment as needed for safe discharge and Social Services to intervene as needed. R1's Fall Risk Assessment, dated 5/17/24, documents R1 is a high Fall Risk. R1's Bowel and Bladder Assessment, dated 5/17/24, documents R1 will begin therapy. R1's Quality Assurance/QAT Progress Notes, dated 5/12/24 through 7/13/24, do not document R1's exit from the building or exit seeking behaviors. R1's Release of Responsibility for Discharge Against Medical Advice, dated 7/16/24, is incomplete and does not document implications of discharge against medical advice, following alternatives or R1 assuming responsibility of care. On 7/18/24 at 1:10 pm, V1 (AIT) verified the Release was filled out three days after R1 exited the building and is incomplete. The Police Department Event Report (24-110644) dated 7/14/24, documents the Police arrived at the Facility on 7/14/24 at 12:47 am for a Missing Person complaint and documents (R1) followed a visitor out of the front doors and (V1/AIT) still did not want to report (R1) as missing at this time. R1's Hospital History and Physical/H&P, date of service 7/16/24, documents R1 presents with leg swelling and per chart review, patient eloped from Skilled Nursing Facility (SNF) a few days ago and was found on a park bench today with swollen legs and was transferred to (a nearby local Hospital) after seeing abnormal findings on a head Computed Tomography (CT). The H&P also documents: R1 was asleep, and R1 stated R1 was sleepy because R1 had been walking a lot for the past few days and R1 could not recall how R1 got to the Hospital and does not remember if R1 was in the park earlier today; R1 was unsure if R1 had a fall over the past few days, but R1 did recall R1 fell into dumpster's a few months ago, which led him to the Hospital a couple months ago; R1 endorses bilateral leg swelling, tenderness and erythema; R1 stated R1 had blisters on the soles of bilateral feet, with suspected onset a few days ago; R1 used a C-collar (cervical collar) but took it off three days ago; R1 currently states neck pain with chronic headache on the back of the head; imaging test results document an Acute Left Frontal Convexity Subdural Hematoma and Encephalomalacia in the Anterior Frontal Lobes new since prior CT; positive for dizziness, light-headedness, numbness in bilateral fingers and headaches; and PEG (percutaneous endoscopic gastrostomy) tube in place. The H&P documents R1 assessment and active Hospital Problem as Acute on Chronic intracranial subdural hematoma and leg swelling (Stasis Dermatitis versus/vs. Cellulitis vs. new onset Congestive Heart Failure vs. Deep Vein Thrombosis vs. Lymphedema vs. Peripheral Vascular Disease). The Facility Admission/Discharge Report, dated 6/1/24 through 7/18/24, documents on 7/13/24, R1 was discharged to other. The Report does not document R1's discharge to home, another Facility or a Hospital. On 7/18/24 at 12:17 pm, V3 (Maintenance Director) stated, I heard (R1) got out of the building and we all showed up to look for (R1), but we could not find (R1). Then I heard (V5) went and picked (R1) up from a park bench and took him to the Hospital. On 7/18/24 at 11:40 am, V5 (Housekeeping Supervisor) stated, I got called to the Facility very late on Saturday, 7/13/24, because (R1) went missing. Everyone was looking for (R1), we had people look all over the Facility, outside on the property and I even volunteered to go into the woods behind the Facility and I searched for him and called his name out for well over an hour and could never find him. Then we started looking in the nearby neighborhoods and still could not find him. We were all here until the early hours, on 7/14/24, looking for him. We even had off duty Certified Nursing Assistant/CNAs) looking for him and staff over the next couple of days. Then, my wife called me, she was going to a doctor's appointment, on 7/16/24 around 9:30 am, and she saw him sleeping on a park bench near the Medical Center here in town. So, I immediately called (V1/AIT) and went over and picked (R1) up and took (R1) to the hospital. (R1) told me (R1) had been walking so much, (R1's) feet to knees hurt so bad. I asked (R1) if (R1) was hungry and (R1) did say (R1) had just eaten a cheeseburger. (R1) was gone from the night of 7/13/24 through 7/16/24 and (R1) looked pretty rough and (R1's) legs were so swollen. I saw (R1) setting off the door alarms multiple times. (R1) was always setting off the door alarms. Just a few weeks ago, (R1) got out of the B Hall door and I caught up with him, and just walked with him around the entire building, to let him get some exercise. On 7/22/24 at 7:58 am, V10 (R1's Brother-n-Law) stated, (R1) left and they took him to the hospital. On 7/23/24 at 2:49 pm, V16 (Care Plan Nurse/Licensed Practical Nurse/LPN) stated, I was never informed (R1) was exit seeking. The staff should be telling me, so I can get it on R1's Care Plan. On 7/23/24 at 5:49 am, V12 (Police Officer) and V13 (Police Officer) jointly stated, On 7/14/24 around 12:30 or 12:45 am, (V12 and V13) both responded to a call from the Facility, for a missing person. When we asked (V1/AIT) about (R1's) status and medical condition, they told us (V12 and V13) (R1) was not an endangered person and did not want us to report (R1) as missing. (V1) said when (V1) checked the camera's it looked like (R1) walked right out of the front door, earlier night around 7:30 pm, and a lot of staff had already tried to locate (R1) but were unsuccessful. We were not aware (R1) had a feeding tube and needed medical assistance, because they did not tell us any of. We searched the surrounding areas for (R1) and were unable to locate (R1). Then a couple days later we received a phone call a staff member's family (Spouse) found (R1) on a park bench and they took (R1) to the hospital, so we no longer needed to search for (R1). On 7/18/24 at 3:53 pm, V6 (Registered Nurse/RN) stated, July 13, 2024, was my first day back and I had not been at facility for a long time. My shift started at 6:00 pm, I got report and started my medication pass. Around 8:30 pm, (V7/Certified Nursing Assistant/CNA) came and told me when (V7) checked on (R1), (V7) could not find (R1). I never even saw (R1) the entire time, and do not even really know (R1). Some of the staff did say (R1) was known to walk around and get lost in the Facility a lot and was even known to attempt to go outside, and they would have to redirect (R1). I was busy passing my medication and getting report, so I had not seen (R1) either at this point. We notified V2 (Director of Nursing/DON), then made sure to check every room and the building looking for (R1). The last time anyone saw (R1) was determined to be at dinner, which would have been around 6:00 pm. They did end up looking at video surveillance and found (R1) left the building around 7:30 pm. All management staff and the Police were called, and search began for (R1). I am a 6:00 pm to 6:00 am night shift nurse, and (R1) had still not been located by the time I had left on 7/14/24 at 6:00 am. There is an Elopement binder at the Nurse's Station name people elope, but I never had time to look at it. On 7/19/24 at 1:22 pm, V7 (Certified Nursing Assistant/CNA) stated, I was scheduled on the 6:00 pm to 6:00 am shift the night of 7/13/24. I noticed (R1) was gone and this was not unusual for (R1) because (R1) tries to get out quite often, but I would always find him. I have a good relationship with (R1), and we bonded, and (R1) would tell me (R1) would not try and get out if I was taking care of (R1) over there (B Hall). That night, I was by myself, and it was hard to keep eyes on everyone. On 7/13/24, around 8:30 pm, I noticed (R1) was missing. I had just thought to myself I had not seem him yet. I had to answer three call lights first, then I went to look for (R1) and could not find him. I went and reported him missing. There were previous times I would find (R1) over on the other wing sleeping in another bed, so I then started checking every single bedroom, every closet, bathroom and every room I could possibly think of, but I could not find him. We called (V2/DON) to notify (V2), then the next thing, every manager came in. The Police were called to help to search for him, but we never found him. About three weeks ago, I personally wrote (R1's) name in the Elopement Binder at the B Hall Nursing Station, because of (R1) attempting to exit the building and getting lost in the building so much. Also, about 2 weeks ago, I noticed (R1) was going downhill a little bit more than usual and getting more confused. (R1) would take (R1's self) to the bathroom, but I would have to help clean (R1) up afterwards. (R1) also had a feeding tube they were caring for. I personally did not ever see (R1) get out of the building alone, if we saw (R1) getting out we did not let (R1) go out alone, a staff would always follow him. (R1) would attempt to get out of the building a lot and would always set the door alarms off. The whole time I ever took care of (R1), (R1) never said anything to me about leaving Against Medical Advice or eloping from the facility. On 7/18/24 at 2:50 pm, V4 (Corporate/Clinical and Regulatory Compliance) stated, I advised (V1/AIT) this was not an incident needed reported or investigated, because I instructed (V1) to treat it as an unplanned discharge Against Medical Advice/AMA. The Police were called, and all managers came in to search for (R1), but (R1) was never found until three days later on 7/16/24. The Facility does not normally call the local Police Department or Management staff in for a resident chooses to go AMA. On 7/18/24 at 12:08 pm, V2 (Director of Nursing/DON) stated, I got a phone call on 7/13/24 around 9:00 pm or 10:00 pm, (R1) could not be found. They had last seen (R1) around 6:00 pm. Since I got the phone call first, I came in immediately and we looked at the security camera and found out how (R1) got out. Around 7:30 pm, it showed a family member walking in the front door and (R1) walking out right at the same time. (R1) looked like a 'regular' person, so they probably did not even question (R1) leaving. We called the Police and filed a report and called in the nursing team and department heads and did a local search for (R1) and did not find (R1). We could not get a hold of (V11/R1's Sister) because none of the telephone numbers work. (R1) was semi-homeless, an immigrant and spoke mostly Spanish, but was able to understand English. The search for (R1) was stopped around 3:00 am/4:00 am on 7/14/24. On 7/16/24, when (R1) was located a few miles away, on a park bench at a Medical Complex, (V5/Housekeeping Supervisor) went and picked (R1) up and transported (R1) to the Hospital. At time, we asked (R1) to sign Against Medical Advice/AMA form. I never completed an investigation, and I cannot locate any nursing notes or anything in (R1's) medical record about (R1) leaving the building. On 7/18/24 at 1:10 pm, V1 (Administrator in Training/AIT) stated, Here is my timeline of events from 7/13/24, I have it on a post-it note. On 7/13/24 at 11:45 pm, (V2/Director of Nursing/DON) contact me about (R1) not being in the building. On 7/14/24 at 12:13 am, my team and I were enroute to the Facility. On 7/14/24 at 12:49 am, I notified the local Police Department (R1) was missing. My entire staff searched the grounds/surrounding areas on 7/14/24 from at least midnight 7/14/24 at 3:00 am. I reviewed the cameras and noticed (R1) left out the front door at 7:38 pm, when a family member was coming in, (R1) went out. When we attempted to contact the family; we could not leave a message or voicemail. We considered Against Medical Advice (AMA) when (R1) left the faciity on [DATE]. I did not do an investigation or notify Public Health of (R1) eloping, because as I said, we considered (R1) leaving AMA. (R1) did have a feeding tube, and we did not do any discharge planning or anything for (R1). I did notify the Police and we did do a search of the facility and through town for (R1) though, we do not normally call the Police or do a search for people would leave AMA. We have not offered any services such as Therapy, or screening of (R1's) Assessments and known behaviors. We cannot find any Behavior Tracking Sheets for (R1). (R1) used to come and go out of the facility on his own but would always stay close. We usually require all residents sign in and out at the front desk when leaving the facility but (R1's) is blank. On 7/18/24 at 1:10 pm, V1 (Administrator in Training/AIT stated, On 7/16/24, we sent (V5/Housekeeping Supervisor) to pick up (R1) from the bench and transport (R1) to the Hospital and asked (R1) sign a Release of Responsibility for Discharge Against Medical Advice. V1 (AIT) verified the Release is incomplete and was dated three days after (R1's) exit from the building. On 7/18/24 at 1:10 pm, V1 (AIT) stated, On 7/13/24, I got a phone call to come to the facility because (R1) was missing. I immediately tried to call (V4/Corporate/Clinical and Regulatory Compliance). I tried calling her about twenty times and could not get a hold of her. I then came into the facility and was here until around 3:00 am-3:30 am, searching for (R1). I called the Police when I got here and they came and searched for (R1) also, but no one could locate (R1). I do not normally call the local Police Department or ask Management staff to search for a Resident just goes AMA. A few days later, (R1) was located on a nearby park bench and transported to the hospital. (V4) finally called me back on 7/14/24 around 11:50 am, and (V4) advised me to handle it as an unplanned discharge (Against Medical Advice), so I did not think I needed to investigate it or report it to Public Health. We do not have any investigation or any documentation to provide on (R1's) exit from the building or Unplanned Discharge. V1 verified no documentation in R1's medical record was available regarding (R1) exiting the building. On 7/19/24 at 10:10 am, V1 (AIT) stated, (R1) used to come and go out of the facility on his own but would always stay close. We usually require all Residents sign in and out at the front desk when leaving the facility but (R1's) Sign Out/Acceptance of Responsibility for Leave of Absence sheet is blank. On 7/25/24 at 11:00 AM, (V1/AIT) stated, Come to find out, (R1) was exit seeking and had also attempted to get out of the facility earlier same day (7/13/24). I just found out through my investigation. The Immediate Jeopardy began on 7/13/24 at 7:30 pm, when R1 who had known wandering and exit seeking behaviors exited the facility through an alarmed entrance door without staff supervision. R1 was found on a local park bench, approximately two and a half miles from the facility, in 90-degree Fahrenheit temperature. V1 (Administrator in Training) was notified of the Immediate Jeopardy on 7/23/24 at 1:44 pm. On 7/25/24 at 10:30 am, the surveyor confirmed through interview, observation and record review the facility took the following actions to remove the Immediate Jeopardy: R1's, R2's, R3's and R4's Elopement Assessment and Care Plans were reviewed and updated accordingly. All Resident's Elopement Assessments were reviewed and updated, and Residents at Risk Plan of Cares were reviewed and updated. All Staff were in-serviced on Elopement Policy and Abatement Plan, dated 7/24/24 reviewed. (Door Alarm Policy and Elopement Prevention Policy) Weekly Door Alarm Testing was initiated on 7/13/24. Quarterly QA Meeting, dated 7/24/24, reviewed (notified Medical Director of Immediate Jeopardy/Abatement Plan, Survey Compliance, Safety issues, Personnel). Notification of the Allegation of Immediate Jeopardy to the Medical Director was completed on 07/24/2024. On 7/25/24, the Elopement Binder was reviewed. Elopement Prevention Policy, Missing Resident Policy, Door Alarm Policy, Investigate Report of Missing Resident Form and Emergency Codes were reviewed. Continue to monitor R2, R3 and R4 and other high-risk for elopement residents. Monitor Residents with potential to be affected by the alleged deficient practice: All residents who have the ability to exit a door without assistance have the potential to be affected by this alleged deficient practice. The Facility (V15//Social Services and V16/Care Plan/Minimum Data Set/MDS) will review immediate actions and changes to Facility systems and review/update all elopement assessments on all residents. (Completed on 7/13/2024) V2 (DON) and V16 (Care Plan/MDS) will review and update all Care Plans for elopement related to supervision and monitoring. (Completed on 7/24/2024) V3 (Maintenance Director) will check door alarm functionality and review all doors and alarms. (Completed on 6/7/2024) and ongoing weekly by V3. V15 (Social Service Director) will review/update the Facility elopement books. (Completed on 7/15/2024) V2 (DON) to complete training/educate staff with Staff on the Elopement Policy, monitor the door alarms, and identify Residents at risk for elopement. (Completed for scheduled staff: 7/24/2024) All staff will complete in-service prior to working the floor to work. QA/QAPI (Quality Assurance/ Quality Assurance and [TRUNCATED]

Based on interview and record review the Facility failed to prevent accidents/falls with injury for one of three residents (R1) reviewed for accidents. This failure resulted in R1 requiring hospital evaluation and treatment for injuries and a decline in Activities of Daily Living (R1). Findings include: Facility Fall Prevention Policy, revised 1/10/18, documents: to provide for Resident safety and to minimize injuries related to falls, decrease falls and still honor each Resident's wishes/desires for maximum independence and mobility; all staff observe residents for safety; final risk score will be determined by the Interdisciplinary Team/IDT based on fall risk score, history of falls, medical condition which directly impacts on equilibrium and/or ambulation; unit nurse will immediately assess the Resident and provide care or treatment if needed and a fall huddle will be conducted with staff on duty to help identify circumstances of the even and appropriate interventions; unit nurse will place documentation of the circumstances of the event and appropriate interventions; report all falls during the morning Quality Assurance/QA meeting; transfer with proper number of assist and gait belt; and remind staff to allow residents to proceed at their own pace. Facility Mechanical Lift Policy, revised 10/30/18, documents the mechanical lift may be used to lift and move a resident with limited ability during transfer while providing safety and security for residents and nursing personnel; move resident to chair and lower resident, the guidance strap may be used to guide the resident in to a proper position while resident is being lowered; and provide resident any assistance needed prior to leaving the area. Facility Patient Lifts Safety Guide, undated documents: check patient's condition before using a patient lift; check patient's physical capabilities; check to see if patient can assist with transfer; check patient's weight and physical condition; use manufacturer's guidelines to make sure lift is appropriate; determine how many caregivers are required to safely lift the patient; determine number of caregivers needed; most lifts require two or more caregivers to safely operate lift and handle patient. Facility Resident Council Minutes, dated 3/27/24, document Residents do not like we have too many Agency staff here. On 4/25/24 at 2:00 pm, the Facility was unable to provide V4's (Agency Certified Nursing Assistant/CNA) in-servicing on the Facility mechanical lifts. 1. R1's Physician Order Sheet/POS, dated 4/1/24 through 4/30/24, documents R1's diagnoses including a History of Falls, Hypertension, Congestive Heart Failure, Neuropathy, Osteoarthritis, Hyperlipidemia, Diabetes, Left Hip pain and Dependent Edema. R1's POS documents an order for pain medication (Norco one tablet every six hours), dated 4/3/24. R1's Skilled Progress Note, dated 3/25/24, documents R1's transfer status as a stand-up lift transfer. R1's Bowel and Bladder Assessment, dated 3/12/24, documents R1's functional assessment for help with mobility and help with toilet transfer as limited assistance. R1's Fall Risk Assessment, dated 3/12/24, documents R1 requires assistance to stand and is a high fall risk, ten points or more is a high fall risk (score of 18). R1's Minimum Data Set/MDS, dated [DATE], documents R1's Brief Mental Status (11/15) and R1 requiring partial/moderate assistance with Toileting and Chair to Bed Transfer and Toilet Transfer as dependent with the assistance two or more staff. R1's Care Plan, dated 12/13/23, documents R1 as a sit to stand transfer. R1's current Care Plan, documents on 4/17/24, R1's Activity of Daily Living/ADL's and Transfer status is a full mechanical lift (Hoyer) and requires two staff members. R1's Grievance/Complaint Report, dated 3/28/24, document concerns with not enough sit to stands. R1's Grievance/Complaint Report, dated 4/24/24, document concerns with CNA's (Certified Nursing Assistants) will not take people to the bathroom during meals they them they have to wait until after lunch. No method of correction was documented. R1's Grievance/Complaint Report, dated 4/24/24, document concerns with Second and Third Shift do not do peri-care after using the bedpan. No method of correction was documented. R1's Grievance/Complaint Report, dated 4/24/24, document concerns with R1 waiting thirty minutes to be taken to the bathroom, by the time they came she had gone. R1's local Hospital Emergency Department After Visit Summary documents R1's reason for visit as Fall and the medics state, (R1) was in the bathroom and was on a sit to stand. They were moving (R1) back to the recliner when they were not close enough to the chair. (R1) lost (R1's) footing and slipped down to the ground in what she explained as a pretzel. (R1) states (R1) did not hit head or loss of consciousness. States it was a witnessed fall. (R1) complains of back pain and leg pain. The Summary also documents R1 has pain in both knees and bilateral low back pain. The Summary reports family at bedside states (R1) was on the edge of the chair, when the seat on the sit-to-stand (lift) was released, causing (R1) to slide off the chair onto the floor with (R1's) knees tucked towards (R1's) chest. The Summary documents Radiology tests (Lumbar Spine, Right Knee, and Left Knee) were performed. Pain medication as needed for pain control and may apply ice and heat to lower back and bilateral knees for pain control. R1's Nursing Progress Note, dated 4/15/24, documents an incident with a transfer from a mechanical lift to a recliner. (V4/Certified Nursing Assistant/CNA) was performing a one-person mechanical lift transfer. V4 misjudged the seat of the recliner and R1 was dangling in the (mechanical lift) sling causing R1 to slip towards the floor. R1 complained of pain and was sent to the local Hospital for evaluation and treatment. R1's Nursing Progress Note, dated 4/15/24 at 6:30 pm, documents a CNA requested (V11/Licensed Practical Nurse/LPN) to assist with getting R1 into the recliner. R1 was dangling in the sling and V11 was able to seat R1 on the edge of the chair. R1's Nursing Progress Note, dated 4/15/24 at 7:00 pm, documents V6 (R1's Daughter) asked V11 (LPN) about R1's fall. V6 stated R1 told V6 R1 fell and had to be picked up off the floor. V6 stated R1 was in excruciating pain to hips and thighs, legs, knees, feet and lower back and R1 wanted to go to the hospital. R1 told V11 (LPN) R1 fell when V4 (CNA) dropped me out of the machine. V11 stated R1 was still hooked up to the sit to stand and it was not on the floor. R1 stated, it happened before V11 entered the room. R1's Nursing Progress Note, dated 4/15/24 at 7:05 am, documents R1's transfer to the local Hospital Emergency Department. R1's Nursing Progress Note, dated 4/16/24 at 1:00 am, documents R1 returned to the Facility. Pain medication administered. R1's Nursing Notes, dated 4/15/24 through 4/16/24, do not document an assessment of R1 for injuries or pain. V8's (Registered Nurse) written statement, dated 4/15/24 at 6:30 pm, documents when V8 was leaving for the day, V4 (CNA) asked for help with a transfer for R1. When V8 arrived to R1's room, R1 was sitting in a sling in the sit to stand close to the floor. V4's (CNA's) written statement, dated 4/15/23, documents on 4/15/24 at 6:30 pm, R1 needed to use the bathroom and then get in to R1's chair. V4 got the sit to stand and took R1 to the bathroom and as V4 was taking R1 to the chair, R1 dropped down and said R1's legs gave out. V4 immediately went and got help. The whole time R1 was still strapped in the sit to stand and R1's butt was a couple inches from the ground. The Nurse (V11) helped me get R1 in to the chair. V4's written statement does not document the assistance of two staff performing the transfer. On 4/25/24 at 2:00 pm, V12 (Staffing Agency) stated, We do not normally in-service our staff on mechanical lift for the Facility's, we just do basic training. On 4/25/24 at 2:10 pm, V2 stated, We normally leave it to the Staffing Agencies to provide training to their staff on things like mechanical lifts and transferring. On 4/25/24, at V12 and V2 could not provide in-service documentation for V4 (CNA) on the Facility mechanical lift usage. On 4/25/24 at 10:45 am V9 (CNA) stated, We got new sit to stands when the new company bought this place, but we have not been in-serviced on them yet. On 4/25/24 at 10:45 am, V10 (Agency CNA) stated, I have not been in-serviced on the mechanical lifts. The facility got new ones and we actually like the old lifts better. On 4/25/24 at 4:20 pm, V7 (R1's Daughter/Power of Attorney) stated, On the night of 4/15/24, my mom (R1) called me and was very, very upset and crying. She told me she got dropped while in the sit to stand coming back from the bathroom being put into her recliner. (V4/CNA) missed the recliner chair and mom slid out. So, I called my sister (V6) because she lives close to the Facility and is a Nurse Practitioner. She was there within ten minutes. My mom was in excruciating pain and wanted to go the hospital but at first, they would not send her because they (V11) said she did not even fall. My mom told me just one Aide was doing the sit to stand, and there actually should be two. I am worried about my mom because she does not have a tailbone and her midback is compressed, so when she said her back hurt, I was concerned more damage was done. My mom does have chronic pain, but now she has been complaining of even more pain since this happened. I asked V2 (Director of Nursing/DON) for a report and I have never gotten one. We even had a Care Plan meeting, and no one would answer my questions about what happened with transfer. On 4/25/24 at 4:49 pm, V6 (R1's Daughter) stated, My Sister (V7) called me to tell me Mom had called her and was in terrible pain from a fall, so I live five to ten minutes from the Facility, and I went immediately there. Mom was in horrible pain. On 4/25/24 at 9:40 am, R4 (R1's Roommate) stated, I was sitting right here in my recliner, and I saw everything. Little Aide (V4) did not know what she was doing. She kept messing with the buttons on the lift. (V4) did not lift (R1) up high enough to reach the seat of the recliner and (R1) went down and slid all the way to the floor and (R1's) feet were still on the sit to stand. Little girl (V4) went running out of the room yelling, Oh my gosh, help, help! Then the nurse (V11) came in and helped get (R1) back into the recliner. They were scrambling around to get her off the floor. They were saying (R1) was not on the floor but (R1) was. I could see if right from here (pointing to area straight in front of R4's recliner). R1 was screaming and crying and was in pain. Then they did not want to send her to the hospital because they were saying she was not hurt and did not actually touch the floor. (R1) was definitely hurt because you could tell she was so scared and was crying. (R1) then called her daughter (V7) and (V7) sent the other daughter (V6) up. (V6) had to ask them to send (R1) out to the hospital to be looked at. Half of the time the slings do not even work either, just a few days ago we found a bunch of pieces of the strap laying on the floor, we picked them up and they were in shreds. On 4/25/24 at 9:30 am, R1 stated, I was dropped on the floor during a transfer back from the bathroom. By the way, (V4/Agency Certified Nursing Assistant/CNA) was doing my transfer by herself, and there usually are two Aides helping. I was using a sit-to-stand lift and (V4) took me to the bathroom. When we got back to put me in my recliner, (V4) did not have me high enough to go onto the seat of the recliner and my butt dropped and I slid to the ground. My legs were still up on the sit to stand, and I was dangling, and my legs were bent so far up against my chest, I was like a pretzel. My Roommate (R4) was yelling really loud for the nurse to come and help me. (V4) starting yelling for help too and left the room to get help but (V4) left me dangling in the sit to stand by myself. Then (V8/Registered Nurse) came to my doorway and yelled 'Oh my God, oh my God she is on the floor' and then left and did not even offer to help me. (V8) told me was the change of shift and (V8) was leaving. So then (V11/Licensed Practical Nurse) and (V4/CNA) came and helped me into the chair. I called my daughter (V7), and she called my other Daughter (V6) who is a Nurse Practitioner and lives close, and (V6) came immediately here to help me. I was in lots of pain and hurting all over, they kept telling me they were not going to send me to the hospital because they said 'my butt did not hit the floor' so I did not need to go to the emergency room . I wanted to go to make sure nothing was hurt, so (V6) made them call 911, because they were not going to call. I got X-Rays at the hospital. Now because of this, I have been downgraded and made to be a (full mechanical lift), instead of a sit-to-stand, all because (V4) did not know how to use the sit-to-stand. They tell me the (full mechanical lift) will not fit into the bathrooms, so know I have I have to use a bedpan, and it takes them forever to get to me because I am a full lift now and they need two people. I normally have pain anyway but now my pain has been way worse because of this. They changed my pain medicine to 'Norco' but then they were out of 'Norco' and I had to go without it for an entire day, and I have been in a lot of pain because of this. They did not even offer me anything else to get rid of my pain. No one has ever talked to me about what happened or even looked at my body, so I have no idea if I have any bruising or anything. On 4/25/24 at 10:57 am, V8 (Registered Nurse) stated, I was the day shift nurse day and was giving report to V11 (Licensed Practical Nurse). V4 (CNA) was transferring R1 in a sit to stand back from the bathroom and missed R1's recliner, so R1 slid down towards the floor. R1 did not have another staff member with R1 to help, and us two nurses (V8 and V11) were giving report. I walked down to R1's room after V4 came down yelling for help. I did walk down to R1's room after but I did not help get her up, because my shift was over. If I were being honest, I did not see another CNA helping and I honestly cannot say if R1 did land on the floor, because I was not in there. I do know when I went to the doorway of the room, R1 was still hanging in the sit to stand sling and her bottom was just a few inches off the floor. On 4/25/24 at 5:04 pm, V11 (Licensed Practical Nurse) stated, I was getting shift change report from (V8/RN) and (V4 CNA) came yelling down the hallway (V4) was having problems getting (R1) in to the recliner during a sit to stand transfer after the bathroom. (V4) and I were the only two on whole side (100 Hall, 300 Hall and 400 Hall) and (V4) was my only CNA night and there was no one else to help her. When I got to (R1's) room to help, (R1) was kind of dangling from the sit to stand lift with (R1's) feet raised up high in the sit to stand. We then helped get (R1) back into the recliner by pulling on the sling and (R1's) pants and were finally able to get (R1) into the recliner. When I went in to (R1)'s room, (R1) was about three or four inches off the floor. Now (R1) is a (full mechanical lift) and uses a bed pan. Our Hoyer's do not fit in our bathrooms, so everyone is a (full mechanical lift) has to use a bed pan. We sent (R1) out to the hospital to be evaluated, per (V6's / R1's Daughter) request. I was still there when (R1) returned, but I missed the hospital orders for ice and heat or Ibuprofen to be given for pain. On 4/25/24 at 9:30 am, V2 (Director of Nursing/DON) stated, We did not technically consider (R1) fell , so I never looked into the fall to investigate it. From what I understand, was (V4/CNA) was transferring (R1) by herself and (V4) missed the recliner. I will say (V4) should not have been transferring with a mechanical lift by herself, we usually like two people to do together. We did send (R1) out the hospital and she was sent back a few hours later with no fractures. I do know she has been in a lot of pain, but she does get a scheduled pain [NAME] (Norco).

Based on observation, interview and record review the Facility failed to supply Physician ordered pain medication and manage pain for one Resident (R1) of three reviewed for pain in a sample of three. This failure resulted in R1's increased level of pain and decline in Activity of Daily Living. Findings include: Facility Pain Prevention and Treatment Policy, revised 12/7/17, documents: it is the Facility policy to assess for, reduce the incidence of and the severity of pain in an effort to minimize further health problems, maximize Activity of Daily Living functioning and enhance the quality of life; assessment of pain and if appropriate, treatment in order to assure the needs of the resident who experience problems with pain are met; intervention implemented to reduce pain which may include the use of medication, medical devices or treatments, but are not limited to heat or cold or massages; and a plan based on information gathered during a resident pain assessment that identifies the resident's needs and specifies appropriate interventions to alleviate pain to the extent feasible and medically appropriate. Facility Conformance with Physician Medication Orders, reviewed 9/27/17, documents all medications shall be given only upon written order of a Physician; and shall be given as prescribed by the Physician and at the designated time. R1's Physician Order Sheet/POS, dated 4/1/24 through 4/30/24, documents R1's diagnoses including a History of Falls, Hypertension, Congestive Heart Failure, Neuropathy, Osteoarthritis, Hyperlipidemia, Diabetes, Left Hip pain and Dependent Edema. R1's POS documents an order for pain medication (Norco one tablet every six hours), dated 4/3/24. R1's local Hospital Emergency Department After Visit Summary documents R1's reason for visit as Fall and the medics state, (R1) was in the bathroom and was on a sit to stand. They were moving (R1) back to the recliner when they were not close enough to the chair. (R1) lost (R1's) footing and slipped down to the ground in what she explained as a pretzel. (R1) states (R1) did not hit head or loss of consciousness. States it was a witnessed fall. (R1) complains of back pain and leg pain. The Summary also documents R1 has pain in both knees and bilateral low back pain. The Summary reports family at bedside states (R1) was on the edge of the chair, when the seat on the sit-to-stand (lift) was released, causing (R1) to slide off the chair onto the floor with (R1's) knees tucked towards (R1's) chest. The Summary documents Radiology tests (Lumbar Spine, Right Knee, and Left Knee) were performed. Pain medication as needed for pain control and may apply ice and heat to lower back and bilateral knees for pain control. R1's Medication Administration Record/MAR, dated 4/1/24 through 4/25/24, documents pain medication Norco 5/325 milligram/mg one tab every six hours. The MAR does not document administration of pain medication (Norco) on 4/19/24, at 11:00 am, 5:00 pm or 11:00 pm. The MAR documents a note ordered again. The MAR does not document pain medication administration (Norco) for the 4/19/24 scheduled doses from 5:00 am through 11:40 pm. R1's Medication Administration Record and Treatment Administration Record, dated 4/1/24 through 4/25/24, does not document any additional pain management for R1 and does not document the hospital order for pain control and may apply ice and heat to lower back and bilateral knees for pain control. R1's Grievance/Complaint Report, dated 4/24/24, documents, Ran out of (R1's) pain medications and missed days because pharmacy did not deliver them. R1's Pain Assessment, dated 3/12/24, documents R1's pain presence, occasional pain frequency and effect on function and rarely over the last five days has pain limited daily activities. R1's current Care Plan documents: has chronic pain; anticipate the Resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions, dosing schedules and resident satisfaction with results; monitor/report to nurse any signs or symptoms of non-verbal pain; and notify Physician if interventions are unsuccessful or if current complaint is significant from Resident's experience with pain. On 4/25/24 at 4:20 pm, V7 (R1's Daughter/Power of Attorney) stated, On the night of 4/15/24, my mom (R1) called me and was very, very upset and crying. She told me that she got dropped while in the sit to stand coming back from the bathroom being put into her recliner. (V4/CNA) missed the recliner chair and Mom slid out. My mom was in excruciating pain. I am worried about my mom because she does not have a tailbone and her midback is compressed, so when she said her back hurt, I was concerned that more damage was done. My Mom does have chronic pain, but now she has been complaining of even more pain since this happened. They ran out of pain medication for her and since this fall, she has now been changed to a (brand name) lift instead of a sit to stand. They told her that she now has to use a bed pan because the lift will not fit into the bathrooms. This pain has caused (R1) to have a decline in comfort. On 4/25/24 at 4:49 pm, V6 (R1's Daughter) stated, My Sister (V7) called me to tell me that Mom had called her right after Mom was dropped in a mechanical lift and was in terrible pain l, so I live five to ten minutes from the facility, and I went immediately there. Mom was in horrible pain. Then apparently they did not have her medication available a day or so after she came back from the hospital, so she was in terrible pain then, I am not even sure if they even offered her anything then. On 4/25/24 at 9:40 am, R4 (R1's Roommate) stated, I was sitting right here in my recliner, and I saw everything. Little Aide (V4) did not know what she was doing. She kept messing with the buttons on the lift. (V4) did not lift (R1) up high enough to reach the seat of the recliner and (R1) went down and slid all the way to the floor and (R1's) feet were still on the sit to stand. Little girl (V4) went running out of the room yelling, Oh my gosh, help, help! Then the nurse (V11) came in and helped get (R1) back into the recliner. They were scrambling around to get her off of the floor. They were saying that (R1) was not on the floor but (R1) was. I could see if right from here (pointing to area straight in front of R4's recliner). R1 was screaming and crying and was in pain. Then they did not want to send her to the hospital because they were saying that she was not hurt and did not actually touch the floor. (R1) was definitely hurt because you could tell that she was so scared and was crying. Ever since that fall, she has been complaining of being in more pain in her back and legs, and because of that, they now have to use that machine (mechanical lift) to move her and now she has to use a bedpan, and that hurts her butt. On 4/25/24 at 9:30 am, R1 stated, I was dropped on the floor by my recliner during a transfer on a sit to stand, coming back from the bathroom. When we got back to put me in my recliner, (V4) did not have me high enough to go onto the seat of the recliner and my butt dropped and I slid to the ground. My legs were still up on the sit-to-stand lift and I was dangling, and my legs were bent so far up against my chest, I was like a pretzel. My Roommate (R4) was yelling really loud for the nurse to come and help me. (V4) starting yelling for help too and left the room to get help but (V4) left me dangling in the sit to stand by myself. I called my daughter (V7), and she called my other Daughter (V6) who is a Nurse Practitioner and lives close, and (V6) came immediately here to help me. I was in lots of pain and hurting all over. I normally have pain anyway, but now my back and leg pain has been way worse because of this. They changed my pain medicine (Norco) but then they were out of it, so I had to go without it for an entire day, and I have been in a lot and lot of pain because of this. They did not even offer me anything else to get rid of my pain. On 4/25/24 at 11:15 am, R1 stated, I was so upset that day that I could not get any pain medication, I had to go all day without it, and I am not sure that they even tried to do anything to help me. On 4/25/24 at 5:03 pm, V11 (Licensed Practical Nurse) stated, I was the nurse that was on duty when (R1) went to the hospital and came back. I did not see the orders from the Hospital for ice and heat, so I did not transcribe them onto the orders. On 4/25/24 at 1:05 pm, V2 (Director of Nursing) stated, (R1) did experience an incident on 4/15/24 and went to the Hospital. When (R1) came back from the Hospital, (R1) had been complaining of more pain. R1's MAR and TAR (Medication or Treatment Administration Record) does not document to ice or heat for pain relief for 4/16/24 through 4/24/24, I do not think that got transcribed from the Hospital records. It does look like (R1) did not get any scheduled pain medication (Norco) either, on 4/19/24 after the 5:00 am dose and I do not see that anything else was offered. We should have offered (R1) an alternative or to at least ice/heat it when the Norco was not available. I also do not see that we notified the Physician that the medication was not here, to be able to have given something as an alternative.

Based on observation, record review and interview the facility failed to prevent a resident fall with injury for one of four residents (R3) reviewed for falls in a sample of four. This failure resulted in R3 sustaining a large hematoma to right forehead and R3 having pain. On 1/2/2023 at R3 was observed sitting in the main dining room in a reclining chair. R3 had a noticeable hematoma to right forehead with a yellowish color around the hematoma and down R3's right lateral face. R3's Nurses Notes, dated 12/202/2023, documents, (R3) was noted on the floor in her room. (R3's) face was down to right side of bed with head towards door and feet to window. (R3) was rolled over onto back and noted a large bump to right forehead. (R3) was sent to the local hospital for evaluation. On 1/3/2024 at 10:45AM V4/LPN (Licensed Practical Nurses) stated, When I entered R3's room the wheel was broken off R3's wheelchair and on the floor. R3 was laying on the floor face down. R3's Quality Care Reporting Form, dated 12/20/2023 at 3PM, documents, (R3) sent to local hospital for an evaluation after alleged fall. (R3) complained of pain to right forehead. (R3) sustained injury to right forehead. R3's Investigation Report for Falls, dated 12/20/2023, documents the following: (R3) was reaching forward and fell face down, beside bed facing toward the doorway of the room. (R3's) wheelchair was used and device was not in good working repair. Left wheel to wheelchair was broke. R3's Emergency Notes, dated 12/20/2023, documents, Fall from wheelchair and Injury of Head large. Hematoma in the right frontal scalp. R3's Hospitalist History and Physical, dated 12/20/2023, documents the following: Chief Complaint: Fall (R3) present to the emergency room from the long-term care facility following an unwitnessed fall from (R3's) wheelchair. (R3) presents with a large hematoma to her right forehead. R3's CT Brain scan, dated 12/202/2023, documents, (R3) has a large hematoma to right frontal scalp. On 1/2/2024 at 2:14PM V1/Administrator stated, (R3) fell out of the wheelchair. (R3) did get a bump to her forehead. (R3) was not sent out because (R3) fell . On 1/3/2024 at 1:34PM V2/Director of Nurses stated, I do believe that (R3) sustained an injury that warranted a trip to the emergency room , to get evaluated. The wheelchair that (R3) was using is out in the garage. Someone tried to solder the wheelchair wheel back on.

Based on interview and record review, the facility failed to prevent a fall for one (R4) of three residents reviewed for accidents in a sample of three. This failure resulted in R4 being transferred to the Emergency Department/ED with injuries to face, sustaining a hematoma and an uncontrolled nose bleed. Findings include: The facility's Fall Prevention Policy, dated 11/10/18, documents: Policy: To provide for resident safety and to minimize injuries related to falls; decreases falls and still honor each resident's wishes/desires for maximum independence and mobility. 2. Identify, on admission, the resident's risk for falls. 5. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. R4's diagnoses included: Adult Failure to thrive, Iron deficiency anemia, hypertension, osteoarthritis, major depressive disorder, obstructive sleep apnea, syncope, chronic subdural hematoma, diabetes mellitus, encephalopathy, unsteady gait, recurrent falls. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has a BIMS (Brief Interview of Mental Status) score of 6. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R4's Progress Note dated 11/3/23 documents: Patient sent to (Local Hospital emergency room /ER) due to unwitnessed fall to her face down prone position. R4's November Incident/Accident Log documents: 11/3/23 R4 fell at 10:00am by rolling out of bed and sustaining a hematoma to head. Interventions bariatric bed. R4's Facility Incident Log report to (State) Department of Public Health, dated 11/6/23, documents: Final Report: Intervention put into place to contact hospice company and request a bariatric bed to give her more room to reposition herself while laying down. R4's Hospital documentation dated 11/3/23 documents: Diagnosis of ground-level fall; contusion of face. Chief Complaint: Fall. Laceration on the inside of her upper lip. (Facility Staff) reported that they found (R4) face down on the floor this morning. Both rails were down on her bed and it appeared that (R4) had rolled out of bed. (R4's) nose had been bleeding and swelling was noted to the left side of her face. R4's current Care Plan documents: Self-care deficit-needs supervision and/or assist to complete quality care and/or poorly motivated to complete Activities of Daily Living Skills/ADLS. (Full Mechanical Lift); transfer; problem/need inability to transfer safely without assistance related to musculoskeletal impairment, physical deconditioning due to history of falls, osteoarthritis, unsteady gait, fatigue/weakness. Patient does not understand mobility limits due to cognitive limitations. Resident has been known to attempt to get out of bed unattended. On 11/15/23 at 2:20pm, V11 Registered Nurse/RN/Hospice stated R4 fell on [DATE] and was sent to (local Hospital emergency room /ER) for evaluation. V11 stated, (The facility) couldn't get the nose bleeding to stop. At this same time, V11 stated that prior to R4's fall on 11/3/23, R4 was on a standard sized bed and demonstrated increased movement while in bed. V11 stated, The facility staff called and we discussed providing (R4) with a larger mattress, a bariatric bed and mattress, and fall mats. On 11/15/23 at 12:00pm, V2 Director of Nursing/DON stated R4 was on hospice because of having a decline; stated R4 would get restless in bed and somehow had rolled herself out of bed on 11/3/23. On 11/15/23 at 12:00pm, V2 DON stated, (R4) moves more in the bed and slings her legs over the sides of the bed. When I worked on the floor, I noticed her hovering close to the side of her bed, I'd get her an extra blanket and reposition her to the middle of bed. When (R4) fell , she burst her lips and then a bruise around her nose developed a couple of days later.

Based on interview and record review the facility failed to follow physician orders for one resident (R64) of 19 residents reviewed for physician orders in the sample of 39. This failure resulted in R64 experiencing unresolved back and shoulder pain. Findings include: Facility Fall Prevention Policy, revised 11/10/18, documents: to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility; immediately after any resident fall the Unit Nurse will assess the resident and provide any care or treatment needed for the resident; a fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions; the Unit Nurse will place documentation of the circumstances of a fall in the Nurses Notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. 1. R64's Physician Telephone Order, dated 8/16/23, documents an order for a Magnetic Resonance Imaging laboratory test/MRI to R64's Right Shoulder for complains of pain. R64's Laboratory Patient Report (X-ray of Right and Left Shoulder), dated 7/6/23, documents an impression result of Osteoarthritis of the Right Shoulder and joint space. The Left Shoulder impression result of Humeral Neck Sclerosis suspicious of fracture, age indeterminate. R64's Laboratory Patient Report (X-ray of Right Shoulder), dated 7/28/23, documents a Right Shoulder impression result of possible Subtle Fracture involving the Medial Humeral Neck, new since prior (7/6/23 X-ray). The Lab Result documents V13's (R64's Physician) order for an Orthopedic consult. R64's Nursing Note, dated 8/16/23, documents a Physician's Order to increase R64's pain medication (Gabapentin) and schedule a Magnetic Resonance Imaging laboratory test (MRI) for R64's bilateral shoulders. R64's Medical Record, dated 8/16/23 through 9/21/23, does not document a result for the MRI or an Orthopedic consult. On 9/21/23 at 7:45 am, R64 stated, I fell out of bed a couple of weeks ago, and fell into the garbage can, and banged my arm up, and they found me on the floor. They really have not done anything for me. I was also supposed to get an X-Ray weeks ago too and an 'MRI' but nothing has been done. I have not been seen by an orthopedic doctor yet either. My shoulder and back are still killing me and I do not have any answers. I just have to take a lot of pain medication and it never really helps it, so I sit here in pain all the time. On 9/19/23 at 12:30 pm, V4 (Care Plan Nurse) stated, I just looked at (R64's) Physician Telephone Orders and it looks like (R64) was supposed to have an MRI and Orthopedic follow up, but I do not see that any of that was ever done. Our Transportation Driver schedules all of our appointments and transports the residents, said that she never scheduled the appointments either. On 9/21/23 at 8:59 am, V2 (Director of Nursing/DON) stated, I am the one that wrote the telephone order on 8/16/23, when I was doing rounds with (V13/R64's Physician), for the MRI and we never scheduled that. I also do not see that an Orthopedic appointment was ever scheduled. R64's medical chart does not have any Orthopedic appointment notes or MRI results either. We also cannot find any documentation that (R64) was ever transported for an MRI or Orthopedic appointment. I did not schedule the MRI appointment or tell anyone to schedule the MRI after I took the order. On 9/21/23 at 9:05 am, V1 (Administrator in Training) stated, I checked in to the transportation schedule and it looks like (R64) was never transported to an MRI or Orthopedic appointment.

Based on observation, interview, and record review, the facility failed to evaluate each residents fall, failed to conduct root cause analysis and failed to implement interventions to reduce the risk of future falls for one of three residents (R38) reviewed for falls in the sample of 33. This failure resulted in R38 falling on 7/19/22 and receiving a trimalleolar fracture of the right ankle. Findings include: The facility's Fall Prevention policy, dated 11/10/18, documents, Policy: to provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurses notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA (Certified Nursing Assistant) assignment worksheet. Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. On 10/02/22 at 09:59 AM, R38 was alert sitting up in bed. R38 stated she was on a motorized wheel chair and stood in the bathroom by herself when she lost her balance and slid down the wall. R38 stated she wasn't supposed to transfer herself but no staff were available. R38 uncovered her right leg to show she had a splint from her foot up to the top of her calf that was covered with an ace bandage. R38 stated she ended up breaking her ankle when she fell . R38's Nurses' notes, dated 5/31/22 at 4:20 p.m., documents, (R38) noted on floor in room sitting up on buttocks. She was between end of bed, wheelchair, and tv stand. 2 skin tears noted to left arm near wrist (1.5 cm (centimeters) and 0.7 cm) and left forearm near elbow (2 cm and 5.5 cm) wounds cleaned and dressed with island dressings. R38's Hospitalist History and Physical, dated 7/4/22, documents, Chief complaint: Patient presents with fall. R38's current medical record has no documentation of a fall investigation being completed for R38's falls on 5/31/22 and 7/4/22 nor the implementation of new interventions to prevent future falls. R38's Hospital notes, dated 7/19/22, document, R38 presents today for fall and right ankle pain. R38 is a resident from the facility and was trying to get from her wheelchair when she came down the wall onto her knee and felt a 'pop' from her right knee and ankle. She states her pain is a 10/10 and continuous like someone is 'beating it with a hammer. R38's Hospital Right Ankle X-Ray, dated 7/19/22, documents, Impression: Acute right trimalleolar ankle fracture and mild posterior subluxation of the tibiotalar joint. R38's State Agency Notification, dated 7/21/22, documents, Upon investigation, R38 was trying to transfer independently from her motorized wheel chair to the toilet without assist and fell on [DATE]. R38 sent to ER (emergency room ) for evaluation and treatment due to complaints of right ankle pain. X-ray completed at hospital showing a trimalleolar fracture of the right ankle. Orthopedic follow up appointment scheduled. Physician and family notified. Interventions put in place were to exchange motorized wheel chair for standard wheel chair for safety with transfers and to educate resident on using call light/asking for assist with all transfers. R38's Nurses' notes, dated 7/19/22 at 11:40 p.m., documents, R38 returned from ER via AMT (Advanced Medical Transport) wheel chair van at 11:30 p.m. with new orders to follow up with orthopedic center in one day related to right ankle fracture. NWB (non-weight bearing) to RLE (right lower extremity). R38's Physician order, dated 7/19/22, documents, New order to follow up with orthopedic center in one day (7/20/22) related to trimalleolar closed fracture of right ankle. NWB to RLE. Keep splint CDI (Clean Dry and Intact), keep RLE elevated. Monitor for decreased capillary refill numbness and tingling to RLE and if present return to ER. R38's Care plan, dated 6/16/22, documents, Alteration in transfer ability. Unable to transfer independently related to diagnosis of [CONDITION(S)] ([CONDITION(S)]) with oxygen dependence, CHF (Congestive Heart Failure), fatigue, weakness evidenced by history of falls. R38's care plan has no documentation of new interventions being implemented following R38's falls on 5/31/22, 7/4/22, and 7/19/22. On 10/04/22 at 12:05 PM, V1 (Administrator) stated, (R38) had a fall in July while she was out on a home visit. The family took her to the emergency room and then she was discharged from there back to the facility. We did not do a fall investigation because she wasn't in the facility when the fall happened. On 10/04/22 at 01:41 PM, V2 (Director of Nursing) stated, I cannot find a fall investigation for (R38's) fall on 5/31/22. On 10/04/22 at 2:55 PM, V4 (Care Plan Coordinator) stated that R38's care plan was not updated following R38's falls on 5/31/22, 7/4/22, nor 7/19/22.

Based on observation, interview and record review, the facility failed to develop and implement interventions to successfully protect a vulnerable resident (R1) from multiple inappropriate sexual advances by R2 and R3. The facility also failed to prevent two male residents (R2 and R3) with a history of sexual abuse from having continued access to R1 and all other residents on the same wing. These failures have the potential to affect five of five residents (R1-R5) reviewed for Abuse in a sample of fourteen. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 1/13/20 at 3:15 PM, the facility remains out of compliance at a Severity Level 2 while the facility continues to monitor and adjust the implemented procedures. Findings include: The document titled Abuse Prevention Program dated 11/28/16, states, This facility affirms the right of our residents to be free from abuse and neglect. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of neglect or abuse of our residents. This is done by: establishing an environment that promotes resident sensitivity, resident security and prevention of neglect and abuse of the resident; Identifying occurrences and patterns of potential neglect and abuse of residents; Dementia management and resident abuse prevention; Immediately protecting residents involved in identified reports of possible abuse; Implementing systems to investigate all reports and allegations of mistreatment, promptly and aggressively, and making the necessary changes to prevent future occurrences. This facility is committed to protecting our residents from abuse by anyone including other residents. The definition of abuse is instances of all residents, irrespective of any mental or physical condition, cause harm, pain or mental anguish including sexual abuse. Sexual abuse is non-consensual sexual contact of any type with a resident. Neglect is the failure of the facility to provide services to a resident that are necessary to avoid physical harm, mental anguish or emotional distress. Staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of neglect and abuse of these residents. Staff will continue to monitor the goals and approaches on a regular basis. The document given to residents when admitted to the facility, titled Resident's Rights for People in Long Term Care, from the Illinois Department of Aging dated 6/09, states, You must not be abused by anyone - physically, mentally or sexually. The Facility Assessment, dated 12/11/20, states, Part 1: Resident Profile Diseases/Conditions, Physical and Cognitive Disabilities (residents that are admitted to the facility) Psychiatric/Mood Disorders: [MEDICAL CONDITION] (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, [MEDICAL CONDITION], Behavior that Needs Interventions. Part 2: Services and Care We Offer Based on our Residents' Needs. Resident support/care needs: The facility provided various services for the residents we care for. The residents care is based on their individual needs and preferences and are reflected in the individuals care plan. The care and services provided are broken down by category. Mental Health and Behavior: Implement interventionist help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, other psychiatric diagnosis. Provide Person-Centered/Directed Care: Prevent abuse and Neglect; Identify hazards and risks for residents. Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies: Staff type: Mental Health Social Worker; Behavior and Mental Health Providers; Psychiatric Services and Mental Health Providers. General training topics: Abuse, Neglect; Activities that constitute abuse, neglect; Care/management for persons with dementia and resident abuse prevention; Dementia and Behavior de-escalations/redirecting techniques. Attachment 1 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities (10/04/16) Rules and Regulations; Behavior Health Services - The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Final (Five Day) Incident Report, dated 12/31/20, signed by V1 (Administrator) sent to the Illinois Department of Public Health, Long Term Care, stated, (R1) is a female, (who has a) BIMS (Brief Interview for Mental Status) score of 99 (unable to complete the interview) and with a [DIAGNOSES REDACTED]. (R2), (who has a) BIMS score of 2 out of 15 (severe impairment), with a [DIAGNOSES REDACTED]. (V3) Activity Director (came into the common area) and saw (R2) touching (R1) inappropriately. (V3) immediately stopped (R2) and removed (R1) from the common area and R2 (was taken) to (his) room. V1, V2 (Director of Nursing), the Power of Attorney (POA) and Doctor of each resident (were immediately notified) of the incident. Investigation was completed and the care plan updated; (R1) will be kept at the nurse's station when out in the common area to be monitored. (R2) will be monitored when in common areas and redirected away from female residents. On 1/05/20 at 10:50 AM, V3 (Activity Director) stated, On 12/27/20 at 11:30 AM, I walked into the common area on the C wing by the nurses' station. I saw (R1) sitting in her wheelchair next to (R2) who was sitting on the love seat. (R2) had his hand down between (R1's) legs. I immediately told (R2) to 'stop that.' (R2) jerked his hand out from (R1's) legs and hunched away. (R2) acted guilty, like (he) knew what (he) was doing was wrong. I immediately took (R1) away from the common area into (R1's) room. Two nurses were at the desk, but both were unable to see what (R2) was doing from their location. I told them what happened and then left as I needed to help another resident go to an appointment. Since (the incident), (R1) sits behind the nurses' desk. (R1) is very confused and doesn't talk. On 1/06/21 at 3:35 PM, V10 (Registered Nurse) by telephone interview, stated, I could not see the incident from where I was sitting at the nurses' desk. I could see that (R2) was sitting where (he) usually does when (he) watches television. Christmas decorations obstructed my view and I could not see (R1) sitting there. The first I was aware that something happened was when (V3) told (R2) to stop and called out to (V11/Licensed Practical Nurse/LPN) and myself. I was busy with my residents and was not involved with what happened after that. I don't normally work on the C wing and don't know the residents that live on this wing very well. On 1/05/21 at 12:20 PM, V12 (Minimum Data Set and Care Plan Coordinator) stated, We had an IDT (Interdepartmental Team) meeting the day of the incident (12/27/20) and I noted the meeting and preventive measures that were put into place in both (R1's) and (R2's) Care Plans. When asked if (R1's) vulnerability should be addressed in the care plan, V12 stated, I was not going to, but that's an interesting idea. I should check this for all the residents to see if this is a systemic issue. On 1/05/21 at 9:30 AM, V2 (Director of Nursing) stated, I haven't been working here long. (R1) is nonverbal and is unable to tell you how (she) is feeling, although (she) does not appear to have been in distress. (R2) is friendly. (He) likes to walk in the halls. On 1/05/21 at 10:00 AM V4 (Social Service Director) stated, This is my sixth week at this facility, so I really don't know all the residents yet. I was told about the incident in December with (R1) and (R2) but cannot say if it has affected (R1) in any way. (R1) is sitting behind the nurses' desk or in bed when I see (her). (R1) isn't able to converse and I'm not sure how much (she) understands when I talk to (her). (She) doesn't show a lot of emotion. I see (R2) walking up and down the hallways a lot. We say hello to each other and I talk with (him) but I really don't know (R2) either. On 1/05/21 at 3:05 PM, V1 (Administrator) stated, (R1) is being kept in the nurses' station where (she) can be observed. I've seen (R1) several times and (she) doesn't appear to be any different than before the incident. I did not realize that (R2) had inappropriately touched (R1) previously. That was long before I started working here. R1's [DIAGNOSES REDACTED]. R1's current care plan given on 1/05/20 includes the following: Cognitive Loss/Dementia; (R1) has severely impaired cognitive abilities, (R1) has [MEDICAL CONDITION] and suffers from [MEDICAL CONDITION]. (R1) remains in constant state of confusion and it is difficult to effectively communicate with (her). (R1) often just repeats unclear statements for long periods of time; and, Communication; Expressive (R1) only uses understandable words intermittently; and, Comfort/Pain, (R1) may not be able to convey feelings of pain due to dementia. R1's Minimum Data Set (MDS), dated [DATE] (Annual), Section B0700, Makes Self Understood - 3 - Rarely/never understood; B0800, Ability to understand others - 3 - Rarely/never understands; Section C - Brief Interview for Mental Status - 99 - unable to complete the interview; Section G - Functional Status, Transfers, Total Dependence/Two Plus persons physical assist; E,F, Locomotion on and off Unit - Total Dependence/One person Assist (resident in wheelchair); Range of Motion - 2/2 - Upper extremity Impairment on both sides; Lower extremity, Impairment on both sides. R1's has Behavior Tracking for: Depression, Tearful episodes in relation to increased anxiety; [MEDICAL CONDITION], Self Harm; Depression, Refusing Cares; Depression, [MEDICAL CONDITION]. On 11/18/20, V20 (Licensed Practical Nurse) charted in the Nurses' Note, (R1) is dependent of staff for all cares. One assist transfers. On 12/24/20 V20 charted in the Nurses' Note, (R1) is nonverbal; unable to voice needs. Dependent of staff for all Activities of Daily Living. One person transfers. On 12/27/20 V11 (Licensed Practical Nurse) charted on R1's A.I.M.(Assess, Intercommunicate, Manage) document, (R1 was) inappropriately touched between legs by (R2). This has occurred before was checked. On 12/31/20, V20 states, (R1) is nonverbal and dependent of staff for all activities of daily living. One person assist transfers. R2's Minimum Data Set (MDS), dated [DATE], Section B0700, Makes Self Understood 1 - Usually Understood; B0800 - 1 - Usually Understands; Section G, Functional Status, B. Transfer, Supervision/Set up Only; D. Walk in Corridor, Supervision/Set up Only; E. Locomotion on Unit, Supervision/Set up Only. R2's Care Plan does not have interventions for inappropriate touching of other residents or how R2 will be monitored when out of R2's room except to redirect R2 away from female residents when in the common area. On 12/27/20, V11 charted in R2's A.I.M. (Assess, Intercommunicate, Manage) document, (R2) touching (R1) inappropriately over clothes. R1 is a vulnerable, totally independent resident. R1's Care Plan did not include Potential Harm after any of the incidents R1 was subject to. On 12/25/20, V20 charted in the Nurses' Note, (R2) is alert. (R2) ambulates with wheeled walker independently and is independent with transfers. On 12/31/20 V20 charted in the Nurses Note, (R2) is independent with ambulation, with use of wheeled wheelchair, independent with transfers. The Final Incident Report sent to the Illinois Department of Public Health, Long Term Care, dated 10/06/20 and signed by V1 (Administrator) stated, (R3) is a [AGE] year old male, with a BIMS (Brief Interview for Mental Status) score of 99 (Resident unable to complete the interview) (and has) a [DIAGNOSES REDACTED]. (R1) is a [AGE] year old female with a BIMS of 99 and a [DIAGNOSES REDACTED]. When CNA (Certified Nursing Assistant) walked into the room the two residents were asleep. The staff woke the residents and took (R3) to (his) room. The nurse completed a body assessment on both residents with no signs or symptoms of foul or inappropriate activities. Intervention: (R3) was taken back to (his) room and monitored by staff. (R1) was moved to (another wing) to prevent the incident from happening again. Both parties POA's (Power of Attorney) were notified of incident; MD (Medical Doctor) was notified with no new orders, DON (Director of Nursing) and Administration was notified of incident. R3's Minimum Data Set (MDS), dated [DATE], Section B0700, Makes Self Understood - 2 - Understood; B0800 - 1 - Usually Understands; Section G, Functional Status, D. Walk in Corridor, Supervision/Set Up. There are no interventions in R3's care plan which address R3 stripping, going into other resident rooms, getting into other resident beds, urinating in places other than the toilet, intimidation of other residents, aggression, redirection difficulties. On 10/06/20, V11 charted in R3's A.I.M. (Assess, Intercommunicate, Manage) document, (R3) laying in bed (on top covers) partially clothed, sleeping. On 10/09/20, V6 (Licensed Practical Nurse) charted in the Nurses' Note, (R3) wandering around most of the time. (R3) is nude - redirection and dressed multiple times. On 10/10/20, V5 (Licensed Practical Nurse) charted in the Nurses' Note, (R3) continues to be naked, removing clothing when dressed again et again. On 10/12/20, V17 (Registered Nurse) charted in the Nurses' Note, (R3) noted walking in hall (without) anything on this shift. On 10/13/20, V11 charted in R3's A.I.M. (Assess, Intercommunicate, Manage) document, (R3) observed laying naked in roommates bed with him. Behavior evaluation, changes described: stripping, getting in bed with other residents. On 10/13/20, V17 (Registered Nurse) charted in the Nurses' Note, (R3) has been walking in and out of other resident rooms, standing over their beds and staring at them. He has removed all of his clothing before, doing this twice, other residents have complained of feeling threatened by (R3). On 10/14/20, V5 charted in the Nurses' Note, (R3) wanders independently. Wanders in et out of others' rooms. On 10/17/20, V11 charted in the Nurses' Note, (R3) alert with constant confusion, disoriented. (R3) requires constant redirection and reorientation. (R3) continues to come out into hallway without pants or (disposable briefs) on, completely exposing his genitalia. Pants and (disposable briefs) five times over, behavior continues to occur. Speech is garbled, unclear, and nonsensical. Unable to communicate needs. On 10/17/20, V17 charted in the Nurses' Note, (R3) walking around facility naked and into other resident's rooms, exposing himself, urinating on floors and in corners, spoke with him several times. (R3) does not comprehend anything I've said to him. On 10/18/20, V11 charted in R3's A.I.M (Assess, Intercommunicate, Manage) document, Increased Inappropriate behavior, wandering. (see Nurses Notes, 10/17/20) Afterwards R3 continued to wander into other resident rooms, genitalia completely exposed. Also observed urinating on floor in other resident's rooms and wandering into other residents' beds and sleeping in them. No orders for change in medications. On 11/01/20 V17 charted in the Nurses' Note, (R3) (with) advanced dementia status, continues to wander, is aggressive at times, sometimes enters other resident rooms and is often no-compliant with redirection back to his room or to common areas. On 1/07/21, V16 charted, (R3) continues to wander into peers' rooms and rummage through peers belongings. On 1/07/21 at 1:40 PM V1 stated, When I checked there was no behavior tracking being done for (R3). A summary of the Final, (Five Day) Incident Report sent to the Illinois Department of Public Health, Long Term Care, dated 10/21/20 and signed by V1 (Administrator) stated, On 10/14/20, V15 (Agency Certified Nursing Assistant/CNA) reported that (R4) had told V15 'Things get awkward when (R3) comes into (R4's) room. (R3) lays in bed with (R5), (R4's) Roommate. (R4) said that he saw shadows of the two men moving around. (R4) also said that both (R3) and (R5) went into the bathroom together and one of the two men peed on the floor. (R4) said he did not see any sexual contact between (R3) and (R5). (R5) said that he wanted to move because (R4) did not want him in the room and would call him names.' (R5) was moved to another room. (R3) is not able to answer questions (due to cognitive impairment). Staff say (R3) needs to be redirected out of other resident's rooms. In a statement written on 10/14/20, (V16/Agency Certified Nursing Assistant) stated, '(R3) has been in (R5), (R13), (R14's) rooms so far this morning.' The intervention was to move (R3) into a room closer to the nurses' station. The investigation determined that the allegations were false. On 10/22/20 V11 documented in an A.I.M. (Assess, Intercommunicate, Manage), (R3) (was) observed laying naked in (R5's) bed with (R5). Behavioral Changes: (R3), getting into bed with other residents. The Final Incident Report sent to the Illinois Department of Public Health, Long Term Care, dated 8/09/19 and signed by V13 (Previous Administrator) stated, (R1) is a [AGE] year old female with severe cognitive impairment. [DIAGNOSES REDACTED]. (V18/Activity Assistant) pushed (R1) to the dining room upon completion of an afternoon activity. (R2) came in and sat down next to (R1). As activity assistant came back through the dining room; she noted (R2) touching the breast of (R1). Immediately (V18) called for a nearby employee who escorted (R1) to (her) nurse and an assessment was immediately performed. No indication observed upon assessment at that time that there was injury physical or mental in nature. (R2) was placed on one on one. (Physicians of both (R1) and (R2) and responsible parties were) notified, as well as local police department officer. (R1's) family member spoke to (V13) that evening regarding the incident. No new orders from physician at this time. In conclusion, Physician (is) to complete medication review for (R2) due to inappropriate sexual behavior and (R2) to be placed on 15 minute checks and 1:1 while in common areas until medical review is complete. (R1) will be visualized by staff when in common areas. Continue to monitor for seven days for signs and symptoms of injury. The Immediate Jeopardy was identified on 1/11/21 at 11:30 AM. The Immediate Jeopardy began on 8/09/19 when R2 touched R1 inappropriately on the breast and interventions were not put into place to ensure R1's safety. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/11/20 at 12:30 PM. The surveyor confirmed through observation, interview and record review the facility took the following action to remove the immediate jeopardy. Interventions to sufficiently protect resident especially a vulnerable resident: 1. 1:00pm: R2 was moved into a room with R3. This is the first room on the hall closest to the nurses' station that is visually easier to see for staff. A 1:1 staff member was placed with both residents to be visually monitored 24 hours daily to prevent and protect all residents, especially vulnerable residents from occurrence or reoccurrence of incident from happening. V2 (Director of Nursing) will be responsible for overseeing the scheduling for the 1:1 staff. V1 (Administrator) states that there is no plan to decrease the 1:1 supervision in the future, but if the level of supervision for R2 and R3 is decreased the facility will assign R2 and R3 to separate rooms. 2. In-servicing training on Abuse policy and Sexual Harassment has been initiated by V2 (Director of Nursing) with all staff, of all departments. Remaining employees will be required to be trained prior to reporting to work their next scheduled shift. To be completed by 1/13/2021. 3. In-servicing training on Behavior tracking has been initiated by V4 (Social Service Director) with all staff, of all departments. Remaining employees will be required to be trained prior to reporting to work their next scheduled shift. To be completed by 1/13/2021. 4. In-service training was done with V21 (MDS coordinator) and V12 (Care plan/MDS coordinators) on Comprehensive Care Planning and Revision, done by V13 (Reimbursement Specialist) on 1/12/2021. 5. R3's issue of removing his clothing was addressed with family, reversed clothing was purchased for him to wear. The clothing arrived on 11/18/2020 and this has prevented R3 from removing his clothing unnecessarily, protecting other resident and vulnerable residents from being exposed to R3's continued disrobing.

Based on interview and record review the facility failed to avoid injury to a resident's bilateral lower extremities during a transport for one resident (R1) of three residents reviewed for accidents in a sample of five. The facility's failure to properly transport R1 resulted in traumatic injuries to R1's lower extremities. Findings include: Facility Transportation Driver Job Summary, undated, documents that the Transportation Driver's general duties include: accompanying residents to appointments, lifting residents in and out of the vehicles, remains with the resident and assits with handling the resident during the appointment or outing; transports resident to and from scheduled appointment and approved locations in a safe and responsible manner; and is responsible for the care and well-being of all residents. R1's Care Plan, admitted [DATE], documents that R1 has cognitive impairment and requires staff assistance for Activities of Daily Living. R1's Physician order [REDACTED]. R1's Physician Telephone Order, dated 5/15/19, documents an order to clean the abrasions to right second, third, fourth and fifth toe and left great toe with wound cleanser, medicated dressing ([MEDICATION NAME]) and a dry dressing (Kerlix) two times a day and as needed and to follow-up with V3 (Wound Physician). R1's AIM for Wellness, dated 5/16/19, documents that during transport of resident to doctor appointment resident feet lowered to the ground and abrasion noted to right second, third, fourth and fifth toes and left great toe. V3's (Wound Physician) Initial Wound Evaluation and Summary Management, dated 5/21/19, documents traumatic wounds: right dorsal foot (1.0 X 0.7 X not measurable centimeters/cm); right distal second toe (1.3 X 1.7 X not measurable cm); right distal third toe (2.5 X 1 X not measured cm); right distal fourth toe (3.0 X 1.3 X 0.1 cm); right dorsal fifth toe (1.5 X 1.5 X not measurable cm); and left plantar first toe (2.5 X 1.5 X 0.1 cm). All wounds required a daily treatment ([MEDICATION NAME] or Collagen). On 11/26/19, at 3:20 pm, V3 (Wound Physician) stated, These were traumatic wounds. R1 has a [DIAGNOSES REDACTED]. V3 verified that the wounds were a result during the transport of R1 to the doctor appointment. On 11/26/19, at 11:25 am, V2 (Transportation Driver) stated, I was transporting (R1) to a doctor appointment at the hospital (Pekin Hospital). As we were leaving, I wheeled him across the parking lot, from the door to the van. I noticed blood on both of his socks once I got him to the van. He was not wearing shoes. He did say anything about (his toes) hurting. On 11/16/19, at 1:10 pm, V1 (Administrator) verified that R1 did not have on shoes during the transport due to [MEDICAL CONDITION] and that V2 (Transportation Driver) did transport R1 across the parking lot to the van.

Based on record review and interview, the facility failed to reposition a resident as needed in order to prevent a pressure ulcer for one of three residents (R1) in a sample of three reviewed for pressure ulcers. This failure resulted in R1's coccyx pressure ulcer deteriorating to unstageable with necrosis requiring surgical debridement. Findings include: R1's Nursing Admission Assessment sheet dated 2/12/19 notes that R1's coccyx is excoriated and almost resolved. R1's care plan dated 2/12/19 notes that R1 requires staff assistance to turn and position every two hours. On 2/21/19 facility wound clinic notes that R1 has a Pressure wound measuring 1 cm x 0.7 cm x 0.1 cm. R1's hospital records note that R1 was admitted to the hospital on [DATE] for unrelated issue and coccyx wound measured 2.5 cm x 2.5 cm x 0.5 cm. R1's was readmitted to the facility on [DATE] from the hospital and on 3/14/19 facility wound clinic noted R1's coccyx wound to measure 2.5 cm x 2.5 cm. Hospital records note that R1 was admitted to the hospital on [DATE] due to confusion and lethargy. On 4/8/19 hospital records note that R1's coccyx wound measures 6 cm x 8 cm x 0.5 cm. Hospital wound recommendations note that wound is completely necrotic and plan is to take R1 into surgery on 4/9/19. Hospital postoperative notes dated 4/10/19 note that after surgical debridement R1's coccyx wound measured 7.5 cm x 7 cm with 13 cm of tunneling and bone exposed. On 4/10/19 at 12:15 P.M. V5 (Medical Doctor/Surgeon) stated that R1's coccyx wound had no [DIAGNOSES REDACTED] and was a direct result of prolonged periods of pressure on that area and/or sitting in one position too long. On 4/10/19 at 11:40 A.M. V4 (Regional Wound Ostomy Nurse Coordinator) stated that it was her professional opinion that R1's pressure sore on her coccyx would have been preventable with timely repositioning and proper care. On 4/11/19 at 10:20 A.M. V6 (R1's son) stated that that when he would visit R1 at the facility, he noticed that R1 would sit for extended periods of time without any repositioning by staff.

Based on interview and record review, the facility failed to provide supervision to prevent a fall with injury for one of five residents (R3) reviewed for falls, failed to provide transfer assistance to a resident who is non-weight bearing on one leg and develop a comprehensive plan of care related to assistance with Activities of Daily Living (ADLs) for one of one resident (R106), and failed to provide supervision during toileting and ensure a fall prevention alarm was functioning properly for one of five residents (R15) reviewed for accidents in the sample of 20. These failures resulted in one resident (R3) being sent to the emergency department with a laceration to the forehead. Findings include: 1. R3's current Physician order [REDACTED]. R3's Fall Risk Assessment, dated 3/21/18 documents that R3 is High Risk for falls. R3's current Care Plan includes the following identified problems: Falls, history of frequent past falls, inability to self transfer, not aware of limitations, attempts self transfers, knees are weak. Also include are the following interventions: Assist and gait belt for all transfers, Check routinely when in room for safety, Keep call light in reach and answer promptly. R3's Nursing Progress Notes, dated 7/29/18 at 11:42 A.M. document, (R3) had a fall this morning and hit (R3's) head on floor. Laceration to (R3's) forehead. Sent to ER (emergency room ) for evaluation. Steri strips applied to forehead while in ER. V9/daughter took (R3's) glasses that broke due to fall. On 8/16/18 at 11:14 A.M., V2/Certified Nursing Assistant (CNA) stated, It was sometime before six in the morning. We had gotten (R3) out of bed into (R3's) wheel chair. We left (R3) in (R3's) room in (R3's) wheel chair. I'm not sure how long (R3) was in the room. We were busy getting other people up. On 8/16/18 at 11:21 A.M., V13/Certified Nursing Assistant (CNA) stated, It was about 5:30 in the morning. We had gotten (R3) up in (R3's) wheel chair. We left (R3) in (R3's) room. I was across the hall and saw (R3) try to stand up by (R3's) self. (R3) fell and hit (R3's) head, hard. (R3) was bleeding. I guess we shouldn't have left (R3) in (R3's ) room. On 8/16/18 at 11:30 A.M, V2/Director of Nurses (DON) stated, I can't find the investigation for R3's fall. I don't know what happened to it. I don't know what the root cause of R3's fall is. At this same time, V2/DON verified that R3's care plan had not been reviewed and updated with new interventions to prevent further falls. 2. The facility policy, titled Comprehensive Care Planning (11/01/17) documents, It is the policy of (the facility) to comprehensively assess and periodically reassess each resident admitted to this facility. The results of this resident assessment shall serve as the basis for determining each resident's strengths, needs, goals, life history and preferences to develop a person centered comprehensive plan of care for each resident that will describe the services that are to be furnished to attain or maintaining the resident's highest practicable physical, mental and psychosocial well-being. A physician's orders [REDACTED]. R106's medical record contains a Baseline Care Plan, dated 7/20/18, that documents R106 is dependent on staff for bed mobility, toileting, transferring, dressing and hygiene, due to the inability to bear weight on the left leg, weakness and balance issues. R106's medical record does not contain a comprehensive Plan of Care to address specific needs related to Activities of Daily Living. On 8/13/18 at 10:44 AM, R106 stated last Tuesday (8/07/18) afternoon, she was transferred to the toilet by V5 (Certified Nursing Assistant) and a Physical Therapist and left alone on toilet for 30 minutes. R106 stated she started crying because she was left on the toilet so long and was uncomfortable. R106 stated she waited for staff assistance as long as she could and ended up putting weight on her non-weight bearing left foot to transfer herself to the wheelchair. R106 stated she reported this to the administrator and he spoke with her about it. On 8/15/18 at 12:37 PM, V5 stated she did assist in transferring R106 to the toilet in the afternoon on 8/07/18. V5 stated since R106 is alert and oriented, she was left alone and given the call light. V5 stated she then went to assist another resident in a different room. V5 was uncertain as to how long she was in the other resident room, but when she was finished she noted R106's call light was on. V5 stated when she entered R106's room, R106 had already transferred herself to her wheelchair. On 8/15/18 at 9:45 AM, V1 (Administrator) stated R106 did report to him last week (8/07/18) that staff transferred her to the toilet, leaving her alone for 30 minutes, resulting in R106 transferring herself and putting weight on her left leg. On 08/16/18 at 11:11 AM, V2 (Director of Nursing) stated since R106 is alert and oriented, she wouldn't expect staff to stay directly with R106 while toileting, but to closely watch R106's call light to be alert as to when she was finished. On 8/16/18 at 10:33 AM, V6 (Physical Therapist Assistant) stated R106 was on a non-weight bearing status of the left leg until 8/15/18. V6 stated that if weight is put on a broken leg that has been declared non-weight bearing, the potential for a decline in healing/progress is present. 3. R15's current fall prevention care plan documents the following fall prevention interventions: Alarming seatbelt to wheelchair while up in wheelchair to remind (R15) to request help in transfer; and ensure (seatbelt) alarm is functioning. On 08/14/18 at 03:45 PM, R15 was sitting in the front lobby during a music activity. R15 had an unfastened seatbelt in R15's wheelchair, which was not alarming. V3 (Minimum Data Set Assessment Coordinator) verified that R15's seatbelt was unfastened, fastened the belt around R15's waist, and instructed R15 to unfasten the seatbelt. R15 then unfastened the seatbelt, which did not alarm. V3 verified that R15's alarming seatbelt was not functioning properly, and stated It's supposed to be fastened when she is in her wheelchair to remind her to ask for help before getting up. It's not working properly; it should alarm when it's unfastened.

Based on observation, interview, and record review, the facility failed to provide range of motion exercises to residents with functional limitations for two of three residents (R38 and R52) reviewed for range of motion in the sample of 20. As a result, R38 had a decline in mobility of multiple joints over a three month period, including a significant decline of little to no use of his right wrist, right fingers, and right thumb. Findings include: The facility's Range of Motion Protocol (revised 09/2008) documents the following: It is the policy of (facility) to provide Range of Motion exercises for residents who through assessment demonstrate the need for exercise to prevent functional decline in range of motion. This policy documents, The interdisciplinary team will identify those residents in need and consider the resident's age, diagnosis, prognosis, current joint condition, functional ability and any mobility restrictions. This policy also documents, Range of motion exercises will be conducted as scheduled by nursing staff based on need determined by assessment of risks. The facility's Contracture Prevention policy (Revised 09/2008) documents: All residents will be encouraged to maintain the highest level of physical functioning. Within 14 days of admission, all residents will be assessed to determine the mobility of each joint. Any limitations will be noted on the Range of Motion Assessment. 1. R38's Range of Motion Assessments dated 01/05/18, 01/22/18, 04/10/18 and 05/14/18 document a High Risk Score (indicating a recommendation by Physical Therapy or Occupational Therapy with physician approval, that may include splinting). These assessments also document the following: R38's right wrist, right fingers, and right thumb were assessed to have moderate impairment (50-80% functional range of motion of joint). These same assessments also document R38's right and left hip, left ankle, and left toes were assessed to have full range of motion (>80% functional range of motion to joint). R38's Range of Motion assessment dated [DATE] documents a High Risk Score (indicating a recommendation by Physical Therapy or Occupational Therapy with physician approval, that may include splinting). This assessment also documents the following: R38's right wrist, right fingers, and right thumb were assessed as, Cont, (indicating a contracture with less than 25% functional range of motion of joint). This same assessment documents R38 was assessed to have moderate impairment (50-80% functional range of motion of joint) to R38's right and left hip, left ankle, and left toes. On 08/13/18 at 03:18 PM, R38 was lying in bed holding a rolled washcloth in his right hand. On 08/14/18 at 01:30 PM, R38 was lying in bed holding a padded carrot in his right hand. R38 was unable to release the carrot and could not move his right fingers or right thumb when asked. On 08/14/18 at 01:43 PM, V3 (Minimum Data Set Assessment Coordinator) stated that R38 has a right hand contracture and little to no use of his right hand. V3 stated that R38 is currently not on any range of motion program and stated that anyone with a contracture should be. V3 verified that R38's Range of Motion Assessments document a decline from (MONTH) (YEAR) to (MONTH) (YEAR) in R38's right wrist, right fingers, right thumb, right hip, left hip, left ankle, and left toes. V3 also verified that R38 has not been evaluated by physical therapy or occupational therapy after R38 was initially assessed as a High risk in (MONTH) (YEAR). On 08/15/18 at 08:25 AM, V8 (R38's Physician) verified that R38 currently has a right hand contracture and has little to no use of his right hand. V8 stated that R38 should have been receiving range of motion exercises, especially since R38 was identified as a high risk for contracture development. 2. R52's Range of Motion Assessments dated 12/18/17 and 3/19/18 document a High Risk Score (indicating a recommendation by Physical Therapy or Occupational Therapy with physician approval, that may include splinting). These assessments also document the following: R52's bilateral shoulders, elbows, wrists, fingers and thumbs show a 25-50% functional range of motion to the joints. R52's Minimum Data Set Assessment, dated 7/16/18 includes the following documentation; Section G110 (Activities of Daily Living) dependent on staff for all ADLs, Section G400 (Range of Motion) impairment on both sides, and Section O500 (Range of Motion Programs) no program. On 8/13/18 at 10:31 A.M., R52 was sleeping in a high back reclining wheel chair in (R52's) room. R52's fingers of both hands were in a contractured position. No splint was present to R52's hands. R52's current Care Plan does not address R52's contractures or a range of motion program to prevent further decline. On 08/15/18 at 9:20 AM, V11/Certified Nursing Assistant (CNA) stated, I didn't do range of motion exercises on (R52) today. (R52) doesn't have a program. On 08/15/18 at 9:45 AM, V3/Restorative Nurse stated, (R52) has contractures in (R52's) hands. (R52) doesn't have a range of motion program.

Based on observation, interview and record review, the facility failed to follow facility policies and procedures and failed to implement pressure ulcer interventions for two of three residents (R1 and R3) reviewed for pressure ulcers in the sample of three. This failure resulted in R3 developing a new left heel pressure ulcer that deteriorated from a Stage II to unstageable after it had developed. Findings include: The facility's Pressure Sore Prevention Guidelines (Revised 11/12) documents the following: Policy: To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as high or moderate risk for skin breakdown as determined by the Braden Scale. The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks. After the weekly assessments are completed, they must then be done with the annual and quarterly Minimum Data Set, with a significant change in condition, or if a pressure ulcer develops. The facility policy also states that any resident assessed as moderate or high skin risk shall have a daily skin check. A brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. The facility's Decubitus Care/Pressure Areas policy (Revised 05/07) documents the following: Documentation of the pressure area must occur upon identification and at least once each week on the Treatment Administration Record. 1. The facility's Monthly Wound Tracking Report dated 1/27/17 documents that R3 currently has pressure ulcers on the following areas: A stage III to R3's sacrum, A stage IV to R3's right heel, and a stage II to R3's left heel. On 1/31/17 at 10:00 a.m., E7, Corporate Nurse, provided an undated, handwritten document indicating R3's pressure ulcers developed on the following dates: R3's sacrum and right heel on 2/26/15; and R3's left heel on 1/20/17. R3's Braden Scale for Predicting Pressure Ulcer Risk documents R3's last Braden Scale assessment was conducted on 1/12/17. This same form documents R3 received a score of 12, indicating that R3 is at high risk for development of a pressure ulcer. R3's Physician order [REDACTED]. R3's current Pressure Ulcer care plan documents the following interventions: Complete Avoidable/Unavoidable Pressure Ulcer Assessment as needed to investigate contributing factors and prevention interventions used. This same care plan also states Braden Scale score - if high risk, daily skin check with documentation. Skin check daily during cares and during bath/shower. On 1/31/17 at 1:15 p.m., E2, Director of Nursing, provided R3's shower sheets dated 12/13/17, 12/27/17, 1/3/17 and 1/17/17. E2 stated that a shower sheet should be completed on R3 daily if R3 is getting a daily sponge bath. E2 then stated that E2 is unable to provide documentation of daily shower sheets on R3 and stated that R3 is getting weekly skin checks completed, not daily, because R3 is seeing Z3 (R3's Wound Doctor). E2 verified that E2 is unable to provide documentation of daily skin checks conducted on R3 and confirmed that a recent Assessment of Avoidable/Unavoidable Pressure Ulcer form has not been completed on R3. R3's Treatment Administration Record dated 12/2016 has no documentation of any brief weekly narrative describing R3's pressure ulcers on the back of this treatment sheet. R3's Treatment Administration Record dated 1/2017 has brief narratives regarding R3's sacral and right heel pressure ulcers documented on the following dates: 1/4/17, 1/6/17 and 1/18/17. On 1/31/17 at 1:15 p.m., E2, Director of Nursing, verified that R3's Treatment Administration Records were incomplete and did not contain weekly documentation regarding R3's pressure ulcers. R3's Weekly Wound Tracking Sheet documents R3 developed an unstageable left heel pressure on 1/20/16 ulcer measuring 1 centimeter in length by 0.5 centimeters in width. This same form documents that the depth of R3's unstageable left heel pressure ulcer was unable to be measured on 1/20/16. This same form documents on 1/27/17, R3's left heel pressure ulcer was staged as a stage II, measuring 1.3 centimeters by 0.5 centimeters by 0.1 centimeters, and indicated R3's pressure ulcer had deteriorated since 1/20/17. On 2/1/17 at 10:00 a.m., E10, Registered Nurse, performed R3's pressure ulcer dressing changes. A round, pink open area measuring approximately 0.8 centimeters by 0.5 centimeters by 0.1 centimeters was observed on R3's left heel. R3's wound documentation dated 1/27/17 and completed by Z3 (R3's Wound Doctor) documents that R3's stage II left heel pressure ulcer deteriorated from 1/20/17 to 1/27/17. On 1/31/17 at 3:30 p.m., Z3, R3's Wound Doctor, stated that R3's left heel pressure ulcer deteriorated from 1/20/17 to 1/27/17. Z3 stated, Something caused it to deteriorate. It should have never developed in the first place if (R3's) heel was floated. (R3's) left foot has good blood flow and (R3) is eating adequate amounts every day, so (R3's) left heel wound is definitely from pressure. Z3 then stated that Z3 expects all care plan interventions to be followed, and if care plan interventions are not being followed, it could cause further breakdown of R3's pressure ulcers. 2. R1's Physician order [REDACTED]. R1's current care plan documents the following: Braden Score - high risk. Daily skin check with documentation and as needed with any new open area. R1's Braden Scale for Predicting Pressure Ulcer Risk documents R1's last Braden Scale assessment was conducted on 11/20/16. This same form documents R1 received a score of 14, indicating that R1 is at high risk for development of a pressure ulcer. On 1/31/17 at 2:00 p.m., E2, Director of Nursing, verified that no further Braden Scale assessment has been conducted on R1 since 11/20/16, and one should have been completed after R1's open abrasion area developed.

Failures at this level required two deficient practice statements. A. Based on interview and record review, the facility failed to ensure one of six residents (R8) reviewed for falls was safely transferred from bed to wheelchair in the sample of 19. This failure resulted in R8 falling and sustaining fractures of the second, third, and fourth fingers (left hand). The facility also failed to conduct a thorough investigation of R8's fall and failed to accurately report the investigation results to the State Agency. B. Based on observation, interview, and record review, the facility failed to assess the risk for entrapment in the use of side rails for two residents (R8, R6) reviewed for side rails in the sample of 19 and six residents (R33-R38) in the supplemental sample. This failure has the potential to put residents at risk for entrapment, strangulation, or suffocation if residents become lodged within the rail Findings include: A. The facility's Abuse Prevention Program Policy (revised 10/14/2016) defines serious bodily injury as an injury requiring medical intervention such as surgery, hospitalization . and directs the Administrator or designee to investigate the incident resulting in the injury. The Abuse Policy documents Within five working days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health. The facility's undated Transfer Belts/Gait Belt Policy documents the gait belt is to be placed around the resident's waist or applied around the upper chest just below the axilla (armpit) area, and Grasp the secured gait belt to provide security and balance during the transfer. R8's Physician order [REDACTED]. R8's Minimum (MDS) data set [DATE] and 10/27/16 documents R8 is cognitively intact and requires extensive assistance with bed mobility, transfers, and dressing. R8's Fall Risk assessment dated [DATE] and 9/22/16 document R8 is at high risk for falls. R8's Care Plan dated 7/27/16 (prior to R8's fall) documents Use 1 (one) assist and gait belt for all transfers. Use additional assist as needed when Resident is not feeling well, feeling weak or dizzy. R8's Nurse's Notes dated 9/22/16 at 6:15am written by E17, Licensed Practical Nurse (LPN), documents Res (resident) was being transferred to (geriatric) chair by CNA (Certified Nursing Assistant) when E16 (CNA) lost grip of res and (R8) fell to floor on L (left) side of body to bedroom floor resulting in S/T (skin tear) on L (left) hand and bruising. Res sent to (hospital) ER (emergency room ) for further evaluation. R8's Hospital Radiology Report dated 9/22/16 documents Acute mildly displaced fractures of the second and third distal phalanges and acute nondisplaced fracture of the fourth distal phalanx. R8's Hospital Records document R8 was admitted to the hospital on [DATE] for Irrigation and debridement with open reduction and pin fixation left long finger open distal phalanx fracture. On 11/30/16 at 2:30pm, E17, LPN, stated (E17) did not witness R8's fall. E17 stated E16, CNA, was alone in the room with R8. E17 stated R8 told E17 that E16 did not use the gait belt properly, it (gait belt) did not feel right when on, and felt like (R8) was going to fall. On 11/30/16 at 2:00pm, R8 stated a new CNA (E16) dropped (R8) when transferring (R8) from the bed to the (geriatric) chair. R8 stated the gait belt was not secured correctly and (E16) had it (gait belt) around (R8's) arm. R8 stated (R8) fell on (R8's) hand and had a compound fracture of (R8's) finger and had to have a pin put in it. On 11/30/16 at 3:20pm, E16, CNA, stated on 9/22/16 (E16) was transferring (R8) from the bed to the wheelchair and the gait belt slipped out of (E16's) fingers, the wheelchair moved, and (R8) fell to the floor. E16 stated the wheelchair was not locked all the way, and that (R8) was very shaky that morning prior to the fall. On 11/30/16, E18, Corporate Administrator, provided the Final Investigation of R8's fall dated 9/29/16, written by E1, Administrator, and submitted to the State Agency on 9/29/16. The Final Investigation documents The CNA transferring (R8) was correctly transferring (R8) at the time of occurrence. On 11/30/16, E19, Traveling Administrator, provided an outline of the investigation of R8's fall which documents Root Cause (of the fall): resident weakness to the leg. E16's Job in Jeopardy (disciplinary action) dated 9/22/16 and signed by E1, Administrator, on 9/26/16 documents Your conduct has placed your job in jeopardy, Fail(ed) to correctly transfer residents per policy. E16's Job in Jeopardy disciplinary action documents Following suspension, (E16) was found at fault and terminated. E16's Employee Data Sheet provided by E18 on 11/30/16 documents E16's termination date as 9/24/16. B. The Summary of FDA (Federal Drug Administration) Hospital Bed Dimensional Limit Recommendations dated 3/10/2006 retrieved from http://www.fda.gov/cdrh/beds/guidance/1537.html documents the dimensional limit (space) within the (bed) rail (identified as Zone 1) must be less than four and three quarters inches to prevent the risk of entrapment of resident's head or limbs. 1. R8's Physician order [REDACTED]. R8's Minimum Data Set ((MDS) dated [DATE] and current Care Plan document R8 is cognitively intact, has limited use of all extremities, and requires extensive assistance with bed mobility. R8's Fall Risk Assessments dated 9/22/16 and 10/28/16 document R8 is assessed as high risk for falls. R8's Side Rail assessment dated [DATE] documents R8 has poor bed mobility and difficulty with balance/poor trunk control. On 11/29/16 at 10:00am and 2:00pm and 11/30/16 at 9:45am and 2:00pm, R8 laid in the bed with bilateral half (top) side rails raised. R8's side rails contained no padding to prevent entrapment. On 11/30/16 at 9:45am, R8 used (R8's) right hand to attempt to turn self, and moved (R8's) legs. R8 stated (R8) uses the side rail to help move self in bed. On 11/30/16 at 10:30am, R8 transferred from wheelchair to bed with extensive assistance from E3 and E12, Certified Nursing Assistants (CNA), using a stand and pivot transfer. R8 was unable to use (R8's) left hand/arm and held the left hand with the right hand. On 12/1/16 at 9:15am, E11, Certified Nursing Assistant (CNA), confirmed the following bilateral side rail measurements: width of the side rail 34 inches and height 19 inches. The side rail is divided into six sections (Zone 1), by three-quarter inch bars, resulting in five separate spaces measuring widths of 5.5 (five and one-half) inches, 5.5 inches, 7.5 (seven and one-half) inches, 5.5 inches, and 5.5 inches, and heights of 8 (eight) inches, 17.5 inches, 17.5 inches, 17.5 inches, and 8 inches. The height of the side rail extending above the mattress is as follows: 5 (five) inches, 7 (seven) inches, 9 (nine) inches, 7 inches, 5 inches. These spaces have the potential to cause entrapment or wedging of R8's head, neck, or limbs and cause serious injury or death. On 12/1/16 at 9:30am, E2, Director of Nursing (DON), walked to the doorway of R8's resident room, refused to enter the room to confirm the measurements of the siderails, and stated, I believe you - I don't have to verify the measurements. 2. R6's physician's orders [REDACTED]. R6's Minimum Data Sheet ((MDS) dated [DATE] documents that R6 has impairments on both sides of lower extremities and requires limited assistance with bed mobility. R6's Care Plan dated 2/9/16 documents: Restorative Nursing Program-Bed Mobility. Program/Need weakness, CVA (Cerebral Vascular Accident). Strengths/Preferences Resident able to grab hold of side rail and pull self over in bed. R6's Side Rail Consent dated 5/4/16 documents Types of Side rail: Bilateral 1/2 side rails to be used at all times when resident is in bed. The intent of the side rail is to enable the resident to increase independence and participation in bed mobility and/or transfer. Related physical condition weakness, CVA (Cerebral Vascular Accident). On 11/29/16 at 11:00-11:05 a.m., R6 laid in bed with 1/2 side rails raised. Side rails contained no padding to prevent entrapment. On 12/1/16 at 8:15-8:25 a.m., R6 independently transferred self from wheelchair to bed grasping side rail with right hand during the transfer. The side rail is divided into five sections, by three-quarter inch bars, resulting in five separate spaces measuring widths of 6 (six) inches, 6 inches, 7.5 (seven and one-half) inches, 6 inches, and 6 inches, and heights of 8.5 (eight and one-half) inches, 16 (sixteen) inches, 18 (eighteen) inches, 16 inches, and 8.5 inches. The height of the side rail extending above the mattress is as follows: 7 (seven) inches, 8.5 inches, 9.5 (nine and one-half) inches, 8.5 inches, 7 inches. These spaces have the potential to cause entrapment or wedging of R6's head, neck, or limbs and cause serious injury or death. On 12/1/16 at 1:25 p.m., E9, Licensed Practical Nurse (LPN) stated Everyone can pretty much fit their head through the side rails if they wanted to. 3. On 12/1/2016 at 10:00AM, R33 was observed lying in bed with one half side rail up on the bed. R33 did not respond when asked why the rail was on the bed. Zone One (within the rails) measures: 5.5in. (inches) x10.0in., 5.5 x 17.0 in. and 7.5 x 17.5 in. R33 Minimum Data Set ((MDS) dated [DATE] documents R33 is severely cognitively impaired and requiring supervision of one with bed mobility, and extensive assist of one with transfer. 4. On 12/1/2016 at 10:05AM, R34 was observed lying in bed with one half side rail up on the bed. R34 stated, I use the rail to move and prop myself up when I'm eating. Zone One (within the rails) measures: 5.5in. x10.0in., 5.5 x 17.0 in. and 7.5 x 17.5 in. R34 Minimum Data Set ((MDS) dated [DATE] documents R34 is moderately cognitively impaired and requiring limited assist if one with bed mobility, transfer and ambulation. 5. On 12/1/2016 at 10:10AM, R35 was observed lying in bed with both half side rails up on the bed. R35 stated, I use my rails to pull myself around in bed. I'm an amputee. Zone One (within the rails) measures: 5.5in. x10.0in., 5.5 x 17.0 in. and 7.5 x 17.5 in. R35 Minimum Data Set ((MDS) dated [DATE] documents R35 is severely cognitively impaired and requiring extensive assist if two with bed mobility, totally dependant with two assist for transfer and unable to ambulate. R35 was lying on a low air loss mattress. 6. On 12/1/16 at 10:12AM, R36 was sitting up in the wheelchair. The siderails in Zone One on R36's bed measure: 5.5in. x10.0in., 5.5 x 17.0 in. and 7.5 x 17.5 in. R36 stated, When I get in bed, I use the (bed) rails to move in bed. I use the urinal which they sit on the bedside table. I have to struggle to reach it when I'm in bed. They tell me I have to use the rails but they are difficult. The 10/10/16 MDS documents R36 as cognitively intact and requiring extensive assist of two with bed and transfer mobility. 7. On 12/1/16 at 10:15AM, R37 was sitting up beside the bed. Zone One side rail up on the side of his bed measures: 8.5in.x 8.5in, 4.0in x 17.0in., 7.5in. x 17.0in. R37's 9/7/16 MDS documents him as severely cognitively impaired and as requiring extensive assist of two with bed mobility and as dependant on two assist for transfers. 8. On 12/1/16 at 10:18AM, R38 was lying in bed. Zone One side rails up on both sides of the bed measures: 8.5in.x 8.5in, 4.0in x 17.0in., 7.5in. x 17.0in. R38's 9/7/16 MDS documents her as severely cognitively impaired and as requiring extensive assist of two with bed mobility and as dependant on two assist for transfers. On 12/2/16 at 9:08am, E19, Traveling Administrator, stated E21, Maintenance Director, is responsible for completing the undated Siderail Zone Assessment Yearly document for residents using siderails. E19 was unable to provide any resident siderail zone assessments. On 12/2/16 at 9:36am, E21, Maintenance Director, stated (E21) has not assessed any residents' siderails for the past two years that (E21) has been employed by the facility.

Based on observation, interview, and record review, the facility failed to prevent a facility acquired pressure ulcer from deteriorating and failed to provide pressure ulcer treatments as ordered by the physician for one of three residents (R1) reviewed for pressure ulcers in the sample of seven. These failures resulted in R1's pressure ulcer deteriorating to a stage IV pressure ulcer resulting in R1 requiring hospitalization for surgical debridement of the wound. As a result, R1 required intubation, sedation, [MEDICAL CONDITION] and a suprapubic catheter placement due to the extensive area of wound involvement. R1 continues to be hospitalized in a sedated state, unable to communicate. These failures resulted in an Immediate Jeopardy. Findings include: The facility Pressure Ulcer Prevention Guidelines Policy dated 11/2012, states To provide adequate interventions for the prevention of pressure ulcers for residents who are identified as HIGH or MODERATE risk for skin breakdown as determined by the Braden Scale .The nurse will complete a skin assessment on all residents upon admission then weekly for four weeks .The following guidelines will be implemented for any resident assessed at a Moderate or High skin risk: Turn and reposition every two hours (Turning and positioning may be more often than every two hours for high risk, if indicated), Range of Motion (Range of Motion as indicated by the resident's need and/or assessment. Specify approaches on the Care Plan), Special Mattress (Specify type of mattress on the Care Plan), Positioning Devices (as needed-Devices while in chair or in bed as needed to maintain turning. Specify on Care Plan), Incontinence Care (May include lotions, barrier creams), Daily Skin Checks for High Risk (Follow protocol for coding skin condition), Weekly Skin Checks (Observe and measure weekly) .Nutritional Supplement (High Risk), Care Plan Entry. Any resident scoring High or Moderate risk for skin breakdown will be noted on the Treatment sheet and signed off by the nurse. In addition, a brief weekly narrative will be completed describing the resident's skin condition on the back of the treatment sheet. The facility Skin Condition Monitoring policy dated 11/1/12, states Upon notification of a [MEDICAL CONDITION], wound, stasis ulcer, or other skin abnormality, the Charge Nurse will assess and document findings. The Charge Nurse will then implement the following policy: a. Notify the physician and obtain treatment order if needed .Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: a. Characteristic 1. Size 2. Shape 3. Depth 4. Color 5. Presence of granulation tissue or necrotic tissue. b. Treatment and response to treatment. c. Prevention techniques. The facility Pressure Ulcers-Nutritional Intervention policy dated 7/2010, states It is the policy of (the facility) that nutritional interventions shall be utilized as one of the means of treatment to improve the healing process in residents with pressure ulcers and for the prevention of new pressure ulcers. 1. Food Service Manager will be notified by nursing staff if a resident is admitted with or acquired pressure skin breakdown at the facility. 2. Residents with pressure ulcers will have a program of increased protein, calories, vitamins, minerals and fluids developed by the dietician and ordered by the resident's physician. 3. Incorporate the additional nutrients into the meal or snack pattern of the resident's diet according to intake. 4. Nourishments will vary depending on the stage of the pressure ulcer and on the potential intake of the resident .6. Residents admitted or identified with stage II, III, or IV pressure ulcers are referred to the dietician in a telephone consultation to review nutritional needs .8. Residents on modified diets will have a supplement regimen determined by the dietician and ordered by the physician. A Facility Physician order [REDACTED]. A Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 7/14/16, documents R1 required total assistance of two staff for transfers and bed mobility, is unable to ambulate, is incontinent of bowel and bladder, and has limited range of motion in bilateral upper and lower extremities. The MDS with the ARD of 7/14/16, also documents R1 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating R1 was cognitively intact and R1 was verbal and able to make needs known. A Nursing Admission assessment dated [DATE], documents R1 did not have any pressure ulcers present on admission. R1's initial Care Plan dated 7/1/16, documents R1 is at risk for skin breakdown per Braden Risk Assessment with interventions which include: skin check weekly by nurse; incontinent care and barrier cream after incontinence as needed; report any new skin concerns to the doctor for treatment and follow up; prevent skin areas from prolonged contact, use pillows for positioning, float heels, assist to turn and reposition at least every two hours and as needed. R1's Braden Scales for Predicting Pressure Ulcer Risk dated 7/1/16 and 7/7/16, document R1 is at High Risk for developing pressure ulcers. R1's medical record does not document the completion of the Braden Scale for the next two weeks (7/14/16 and 7/21/16) as facility policy indicates. On 8/9/16 at 12:05 p.m., E7 (Wound Nurse) verified R1's Braden Scales for the weeks of 7/14/16 and 7/21/16 were not completed. R1's Medical Record dated 7/1/16 through 7/17/16, does not document R1 received daily skin checks or weekly skin narratives, as facility policy indicates for high risk residents. R1's Medical Record dated 7/1/16-7/17/16, does not document R1 received weekly skin checks by nurse as R1's care plan indicates. A Shower/Abnormal Skin Report dated 7/6/16, documents R1 has no skin breakdown. A Shower/Abnormal Skin Report dated 7/13/16, completed by E8 (Certified Nurse Aide/CNA), documents R1 has an open area to the coccyx area. The Shower/Abnormal Skin Report dated 7/13/16 was signed by E8 and E9 (Licensed Practical Nurse/LPN) on 7/13/16. On 8/10/16 at 10:21 a.m., E8 (Certified Nurse Aide) stated E8 frequently cared for R1. E8 stated R1 required total dependence for cares. E8 stated E8 identified a small open area on the top of (R1's) tailbone. It was smaller than the tip of my finger and red in color. I reported it to (E9-Licensed Practical Nurse). (E9) stated 'I'll pass it on.' I found it on second shift at approximately 3:00 p.m. I did not see a dressing to the wound anytime soon. I reported it everyday. (The Nurses) finally got him a special mattress (low air loss mattress) and a dressing to (R1's) wound. Prior to the special mattress (R1) had a regular facility mattress. On 8/10/16 at 12:05 p.m., E9 (Licensed Practical Nurse) stated E9 was R1's Nurse on 7/13/16. E9 stated I signed the shower sheet that (E8-Certified Nurse Aide) gave me indicating (R1) had an open area on the coccyx area. Sometimes I'm handed a stack of shower sheets and I sign one, flip to the next sheet, sign it and flip to the next sheet. I did not assess (R1's) wound or notify anyone. I missed it and I take responsibility for that. R1's Medical Record dated 7/13/16 through 7/17/16, does not document any assessment, treatment, or monitoring of R1's open area documented on the Shower/Abnormal Skin Report dated 7/13/16. On 8/16/16 at 9:35 a.m., E16 (Licensed Practical Nurse) stated I took care of (R1) approximately five nights a week. (R1) had a pressure ulcer on coccyx area that started out as purple/red color, not open. When I came to work about five days later (the coccyx) wound was open and dark purple. I know the Santyl that was ordered didn't come in when originally ordered and I don't know why it didn't come. I worked night shift. The (Certified Nurse Aides) were able to turn (R1). (R1) was cooperative. I know pillows were used to position (R1) but (R1) would smash the pillows down. We did not attempt anything else other than the pillows as far as I know. On 8-11-16 at 9:10 a.m., E12 (Licensed Practical Nurse) stated, I was one of (R1's) primary nurses I saw the wound as a blister on (R1's) coccyx. I do not recall a treatment being ordered at that time. On 8-11-16 at 8:50 a.m., E3 (Assistant Director of Nursing) stated, The open area that was found on (R1) on 7-13-16 would have been a stage two pressure ulcer at minimal, but possibly a stage three pressure ulcer according to depth. When the area was found on (R1) the nurse should have assessed and measured the area and obtained a treatment. We should have looked at the Braden score . We would have looked at off loading the pressure and obtained a pressure reducing mattress. R1's Nurse Progress Notes dated 7/18/16 at 11:00 p.m., states Certified Nurse Aide (Unknown) notified this Nurse (E11-Licensed Practical Nurse) of open area on mid coccyx. Area measuring nine centimeters (cm) by four cm shear skin. Denies pain at this time. (Treatment) order in place. (Z4-R1's primary physician), (Z3-Power of Attorney), Administrator (E1) notified. R1's Nurse Progress Notes dated 7/19/16 at 10:30 a.m., document a new physician order [REDACTED]. A Progress Note Details (Wound Report), completed by Z1 (Advanced Practice Nurse) dated 7/19/16 at 9:39 a.m., documents (R1) has (history) of [MEDICAL CONDITION]; associated signs and symptoms: decrease sensation, decrease mobility. The Progress Note continues to document, R1 has an unhealed Medial Sacral chronic Unstageable Pressure Injury obscured full-thickness skin and tissue loss pressure ulcer. The Progress Note documents the measurement of the Medial Sacral wound to be 9 cm length by 4 cm width, with an area of 36 square cm. There was no drainage noted. The patient reports a wound pain of level (two). Wound bed is 1-25% adherent, yellow slough. Z1 also documented a new treatment order to apply [MEDICATION NAME] until Santyl (wound [MEDICATION NAME] ointment) becomes available, then use Santyl to wound bed daily and cover with border dressing daily. On 7/19/16, Z1 also ordered R1 to receive a pressure redistribution mattress (low air loss mattress). On 8/16/16 at 8:50 a.m., Z1 (Advanced Practice Wound Nurse) stated when I documented 'chronic pressure ulcer' I meant that (R1) had to have had the sacral pressure ulcer for a week prior to me seeing it. I called Z4 (R1's primary physician) on Wednesday (8/3/16) because (R1) had not been sent to the hospital for surgical debridement like I had ordered on [DATE]. When I called (Z4) he told me 'I told them to send him to the hospital yesterday' .the facility should have acted on (R1's sacral wound) sooner. It had to be bad and they did not act upon it. When I ordered a pressure redistribution mattress that meant something different than (R1) already had on his bed. (E7-Wound Nurse) knows that when I order it. A Treatment Administration Record (TAR) dated 7/20/16, documents pressure redistribution mattress. The TAR on day shift from 7/20/16 through 7/26/16, documents E11 (Licensed Practical Nurse) circled E11's initials indicating the pressure redistribution mattress was not available on those dates. On 8/16/16 at 12:13 p.m., E11 verified that E11 circled her initials on R1's TAR dated 7/20/16 through 7/26/16 because R1's pressure redistribution mattress was not obtained. E11 stated (R1) still had his old mattress on his bed so I wasn't going to sign it off that the new mattress was in place. A Manufacturer pamphlet (date unknown), for the mattress originally on R1's bed (Panacea Mattress), states may be appropriate through Stage II wounds. Mattress wound Stage ratings are general usage guidelines. Resident-specific assessment could alter your particular usage of these mattresses. On 8/17/16 at 9:15 a.m., Z14 (Mattress Supplier Account Manager) stated I spoke to a product manager regarding the Panacea original mattress (original mattress on R1's bed). If a pressure ulcer progresses past a stage II we would suggest a powered or a air mattress such as a Panacea convertible or a Panacea Air Advanced (Low Air Loss Mattress). On 8/16/16 at 2:50 p.m., E2 (Director of Nursing) stated According to the manufacturer's guidelines the Panacea Mattress should be used for residents with pressure ulcers through a Stage II. When a pressure ulcer advances past a Stage II then a different mattress should be used. I would need to look at the facility policy for any other recommendations. An Equipment Delivery Invoice dated 7/27/16, documents R1's low air loss mattress was not ordered until 7/26/16 at 5:19 p.m. (despite order written on 7/19/16) and was not delivered to R1 until 7/27/16. On 8/9/16 at 12:05 p.m., E7 (Wound Nurse) stated (R1) was high risk for skin breakdown according to (R1's) admission Braden Scale on 7/1/16. I took care of (R1's) wounds. (R1's) wound on the sacral area was unstageable from first identifying it. On 7/19/16 (Z1) ordered [MEDICATION NAME] until Santyl came in. That day I ordered Santyl from the (Pharmacy). A week later I came in to work and there was a request (from Insurance) for more information for the use of Santyl. I provided that information to the insurance. Then the next week (E7 came to work) the (Santyl) still wasn't here (7/26/16). The next week (8/2/16) the Santyl was still not here and I lost my temper. I only work 12 hours per week and the floor nurses should have addressed Santyl not being obtained. If the Santyl would have been used (on R1's pressure ulcer) the pressure ulcer probably wouldn't have progressed to the point of requiring surgical debridement. The wound worsened over the three week period. I notified (Z1) on 8/2/16. When (Z1) observed (R1's) wound (on 8/2/16) he said 'oh sh**, oh sh**, oh sh**', because it looked so bad. (R1) was paralyzed and should have been turned at least every two hours and put on a low air loss mattress. The air mattress did not arrive until 7/27/16 because it was not ordered until 7/26/16. I don't know why the nurses did not order it. (Z1) was concerned that the Santyl had not been used and (R1's) wound had gotten worse. In all honesty I feel like (R1) was neglected. I am upset over this. [MEDICATION NAME] does not work as good as Santyl. On 8-10-16 at 1:35 p.m., Z6 (Facility Wound Specialist Physician) stated, The facility is responsible to obtain the Santyl (Wound [MEDICATION NAME] Ointment). I would have expected this treatment to be obtained within 24 hours. It should have been obtained. The facility should have informed me, or Z1 (Z6's Advanced Practice Nurse) when (R1's) wound worsened. I was not informed. I usually leave wound issues up to (Z1). When (R1's) coccyx wound was found on 7-13-16, a physician should have been notified and a treatment should have been obtained. On 8/16/16 at 9:35 a.m., E16 (Licensed Practical Nurse) stated I know the Santyl that was ordered didn't come in when originally ordered and I don't know why it didn't come. I worked night shift. The (Certified Nurse Aides) were able to turn (R1). (R1) was cooperative. I know pillows were used to position (R1) but (R1) would smash the pillows down (due to his weight of 299 pounds). We did not attempt anything else other than the pillows as far as I know. On 8/16/16 at 10:15 a.m., E1 (Administrator) stated no one reported to me that (R1) would not turn and reposition. No one reported to me that the positioning devices (pillows) were not working for (R1). If (R1) refuses to turn and reposition, it should be documented .We would discuss (R1) refusing to turn and reposition at morning meeting. It was never discussed at morning meeting. Morning meeting includes all the nursing supervisors. It was never discussed at morning meeting because the nurses or (Certified Nurse Aides-CNAs) never reported it to any manager or myself. I would hope the nurse or CNAs would have reported it so we could have discussed additional interventions. A Progress Note Details (Wound Report), completed by Z1 on 7/26/16, documents R1's Medial Sacral wound (Wound #1) measurements are 10.5 cm length by 8 cm width, with an area of 84 (square) cm. No sinus tract has been noted. No undermining has been noted. There is no drainage noted. The patient reports a wound pain of level (two). Wound bed is 51-75% adherent, yellow slough, 1-25% granulation Periwound does not exhibit signs or symptoms of infection .Wound #2 (New Wound) Left Inferior Buttock is an acute skin tear and has received a status of Not Healed. Initial wound encounter measurements are 1.5 cm length by 0.6 cm width, with an are of 0.9 (square) cm. A sinus tract has been noted at (midnight position). No undermining has been noted. There is a small amount of drainage noted .Cleanse wound #1 (Medial Sacral) with Saline, protect periwound with Skin Protectant, Apply Santyl to wound bed, cover wound with Barrier Island Dressing, Change daily and (as needed) for soiling and/or saturation; Cleanse wound #2 with cleanser, protect with skin prep, Apply [MEDICATION NAME] to wound bed, change every 72 hours and (as needed) for soiling and/or saturation .Sacral area slow to heal, contributing factors are obesity, (history) of stroke, incontinence, generalized weakness. Plan to continue with low air loss mattress. Heel Offload, keep skin dry, keep turning patient, will follow up in one week. R1's Medical Record dated 7/19/16 through 7/26/16, does not document any information regarding the Acute Skin Tear to R1's left inferior buttock area, noted by Z1 on 7/26/16. On 8/9/16 at 12:05 p.m., E7 (Wound Nurse) stated R1's skin tear to the left inferior buttock was not identified until Z1 was assessing R1's sacral pressure ulcer on 7/26/16. E7 stated R1 has daily treatment orders and should be getting daily skin checks according to the facility policy. A Progress Note Details (Wound Report), completed by Z1 on 8/2/16, documents Wound #1 (Medial Sacral) has a status of Not Healed. Subsequent wound encounter measurements are 10.5 cm length and 6.5 cm width with an area of 68 (square) cm. No sinus tract has been noted. No undermining noted .Wound bed is 76-100% moist, yellow slough .Periwound skin does not exhibit signs and symptoms of infection .Consulted (Surgical) services for deep debridement of Wound #1 and Wound #2 .This wound (#1 Medial Sacral) was first seen on 7/19/16, on that initial visit Santyl was ordered for the treatment of [REDACTED]. At the time orders were written, Santyl was not available. Staff was informed to use [MEDICATION NAME] until Santyl became available. Today I (Z1) was informed that Santyl was not approved by (R1's) insurance, therefore (R1) did not benefit from Santyl. Today on evaluation the wound needed to be debrided. On a closer look (R1) has a tunnel ulceration with slough near the anus area. (R1) is also receiving [MEDICATION NAME] (Anticoagulant). In light of all that I felt that (R1) may be better served if the wounds are debrided by surgical service. Given the extent of debridement, location of areas that needs to be debrided and the fact that (R1) is on [MEDICATION NAME], I felt the (Nursing Home) setting is not the appropriate place for any kind of debridement for (R1). (E7-Wound Nurse) notified (Z4-R1's Primary Physician). Keep (R1) off his back. Turn (R1) every two hours to the right and left side, (R1) will need Santyl post debridement. Will (follow up) with (E7) in one or two days regarding surgical consult. A Fax Transmittal Form dated 8/2/16 (sent by E7-Wound Nurse), documents Z4 was notified of Z1's request for a surgical consult for R1's sacral pressure ulcer. E7 also documented (R1) was supposed to be on Santyl 3 weeks ago and was not approved by insurance. On 8/10/16 at 10:17 a.m., Z1 (Advanced Practice Wound Nurse) stated Z1 started treating R1 on 7/19/16. Z1 stated R1's sacral wound was a pressure ulcer. Z1 stated R1 laid on his back all the time and had a hard time moving due to recent stroke. I was not aware that Santyl was not being used on (R1's) sacral wound like I had ordered on [DATE]. No one asked me to fill out a form for the insurance company. Z1 stated that if Santyl had been used as ordered the Santyl would have most definitely help stop the wound progression. Z1 stated the sacral wound wouldn't have been as far gone. By the time I observed the wound on 8/2/16 it was too deep and I was concerned with bone involvement. I couldn't believe how the wound had declined from the week before. I was not notified in between my visits of the decline in the wound. I had (R1) referred to a vascular surgeon for surgical debridement because it was not appropriate for me to debride the wound in the nursing home setting. Someone (at the facility) should have jumped on (R1's wound decline) much sooner. (R1's) dressing was supposed to be done daily so the nurses should have identified the decline of (R1's) wound and notified a physician immediately. On 8/9/16 at 2:45 p.m., Z4 (R1's primary physician) stated the facility has had a lot of staff turnover and has had issues with wound care not being consistent. I would have wanted to know about (R1's) wound decline. I was not notified. I would have looked at his labs, nutritional status and the medical side of (R1's) health. On 8/10/16 at 1:50 p.m., E13 (Dietary Manager) stated I was not aware of (R1's) pressure ulcer until late last week after (R1) was discharged (to the hospital). I would have notified the (Registered Dietician). E13 stated no nutritional interventions were implemented for R1. E13 stated the Registered Dietician had not assessed R1 since he was admitted on [DATE]. E13 stated the (Registered Dietician) was here in the middle of July and didn't see (R1). My mistake, somehow I missed putting him on the (Registered Dietician's) list. An SBAR (Situation Background Assessment Recommendation) Communication Form dated 8/3/16 at 3:00 p.m., documents Z4 (R1's Primary Physician) was notified of R1's worsening pressure ulcer. The SBAR documents Wound appears infected, discolored, infected .(R1) sent to (Hospital) for consult/wound debridement surgically per (Z4 and Z1's) request. An Ambulance Transport Narrative dated 8/3/16 at 4:37 p.m., documents (The facility nurse) related that (R1) has a stage IV decubitus ulcer on (R1's) coccyx which (R1's) physician wants checked in the Emergency Department for possible surgical consult. (R1) is non verbal but will acknowledge with nods and shakes of his head. An Emergency Department (ED) Progress Note dated 8/3/16, documents R1 Presents to the ED for a wound evaluation to his buttocks. (R1) has a history of left paralysis from ([MEDICAL CONDITION]) and history of decubitus ulcers. Nursing Home is concerned about a worsening wound to his buttocks, low grade fever, decreased (blood pressure) and elevated pulse. On 8/15/16 at 4:00 p.m., Z12 (Emergency Department Physician), stated (R1) was in bad shape when he came into the Emergency Department. (R1's) blood pressure was low and the sacral pressure ulcer looked bad. When I documented (R1) had a history of [REDACTED]. I would have no way of knowing if (R1) had prior decubitus ulcers. Basically it means the decubitus ulcer was there when (R1) came through the Emergency Department doors. A Hospital Progress Note dated 8/4/16, documents R1 was brought to the Emergency Department (ED) on 8/3/16 with signs and symptoms [MEDICAL CONDITION]. R1 was found to be Hypotensive in the ED. R1 was given Three liters of (Normal Saline) and admitted to ICU as (R1) was still hypotensive .Source [MEDICAL CONDITION] is the decubitus wound which looks bad. Surgery called to debride the wound. An Intensive Care Unit (ICU) Progress Note dated 8/3/16, stated R1 was admitted to the ICU for septic shock, decubitus wounds, diarrhea, and (Acute [MEDICAL CONDITION]) .consult for possible (Acute Coronary Syndrome) and elevated troponin. (Troponin is a lab test primarily used to help diagnose a [MEDICAL CONDITION]) R1's Debridement of Decubitus Ulcer Operative Note dated 8-5-16 and signed by Z5 (Surgeon) documents, We (surgical staff) started with the sacral wound. A combination of sharp and cautery excisional debridements were used to remove dead tissue deep to the muscle. An extensive amount of necrosis was noted. The tissue has a very bad smell, almost smelled like stool. Some pus was also noted .The necrotic tissue was very close and may be involving part of the anal sphincter. Attention was turned the area of skin necrosis posterior to the scrotum. A combination of sharp and cautery excisional debridements were used to remove dead tissue Necrotic tissue was so deep in the middle of the wound and extends to likely involving the scrotum. Not safe to continue with more debridement, as we are getting closer to the scrotum and possibly the posterior part of the penis. On 8-10-16 at 10:15 a.m., Z7 (Hospital Certified Wound Care Nurse) stated, I was present for (R1's) first coccyx wound debridement (8/4/16). Hard eschar (dead tissue) covered (R1's) coccyx/sacral area. The eschar was debrided from the wound and the wound was a stage four pressure ulcer. Had pressure been resolved it (pressure ulcer) could have been prevented. On 8-10-16 at 12:15 p.m., Z5 (Surgeon) stated, (R1's) sacral wound was the worst pressure wound I have ever saw. It was nine centimeters (cm) deep. Worst case of neglect I have saw. Pure nursing home neglect. There is no reason (R1) should have developed this wound in a month or two time. It (pressure wound) was definitely caused by pressure. They (nursing facility) could not have provided pressure relief. (R1) should not be in this condition when (R1) is only in his forties. I did the first coccyx wound debridement at the hospital, and after removing the necrosis (dead tissue) the wound was a stage four that had tunneled around the rectum into the scrotum. (R1's) wound now has caused (R1) to be intubated and sedated, and (R1) required a [MEDICAL CONDITION] and supra-pubic catheter. (R1) was also septic. (R1) is going to require several more debridements of the wound. On 8-10-16 at 10:30 a.m., R1 was lying in a bed on the right side in the ICU (Hospital Intensive Care Unit). R1 was intubated and sedated. R1 had a [MEDICAL CONDITION] and a supra-pubic catheter. Z8 (Certified Wound Nurse) provided pressure ulcer care to R1. Z8 removed multiple four by four dressings saturated in pinkish/yellow drainage from R1's stage four sacral pressure ulcer. Z8 then obtained R1's sacral pressure ulcer size measuring approximately 33 cm (centimeters) long by 9.5 cm wide by 9 cm deep. R1's Sacral Pressure Ulcer extended from R1's sacral region, around both sides of R1's anus, and into the scrotum. The Pressure Ulcer was beefy red with large amounts of yellowish/pinkish drainage, and had an approximate four cm round necrotic area over R1's tail bone. On 8-10-16 at 9:00 a.m., Z3 (R1's Family Member) stated, Every time I visited (R1) at the facility he was on his back. (R1) is going to be devastated when he wakes up at the hospital and sees that he has all of them tubes and problems. The Immediate Jeopardy was identified on 8-18-16 at 2:15 p.m. to have begun on 7-13-16 when E8 (Certified Nurse Aide) identified an open area to R1's sacral area and the facility failed to act upon treating the area. E1 (Administrator) and E3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 8-18-16 at 2:30 p.m. The immediacy was not removed at the time of the exit.

Based on observation, interview, and record review, the facility neglected to follow their policy/wound protocol by neglecting to provide wound treatments as ordered, neglecting to initially assess a pressure ulcer and notify the physician, neglecting to notify the physician of changes in condition for a worsening wound, and neglecting to provide nutritional interventions for a pressure ulcer for one of three residents (R1) reviewed for provision of nursing care in the sample of seven. This failure resulted in R1's pressure ulcer deteriorating to a stage four and R1 requiring hospitalization for surgical debridement. R1 continues to be hospitalized in a sedated state, intubated and with a [MEDICAL CONDITION] and suprapubic catheter as a result of the extensive wound damage. These failures resulted in an Immediate Jeopardy. Findings include: Facility Abuse Prevention Program Policy dated 11/11/11, states This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and 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 mistreatment, neglect or abuse of our residents Neglect is the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. A Facility Physician order [REDACTED]. A Facility Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 7/14/16, documents R1 requires total assistance of two staff for transfers and bed mobility, is unable to ambulate, is incontinent of bowel and bladder, and has limited range of motion in bilateral upper and lower extremities. The MDS with the ARD of 7/14/16, also documents R1 scored a 13 out of 15 on the Brief Interview for Mental Status, indicating R1 is cognitively intact. A Nursing Admission assessment dated [DATE], documents R1 does not have any pressure ulcers present on admission. A Shower/Abnormal Skin Report dated 7/13/16 completed by E9 (Licensed Practical Nurse), documents R1 had an open area on the sacral area. R1's Medical Record dated 7/13/16 through 7/17/16, does not document any assessment, treatment or monitoring of R1's open area at the sacral area. On 8/10/16 at 10:21 a.m., E8 (Certified Nurse Aide) verified that R1 was totally dependent for cares and that E8 identified a small open area on R1's coccyx and reported such to E9 on 7/13/16. On 8/10/16 at 12:05 p.m., E9 (Licensed Practical Nurse) stated E9 was R1's Nurse on 7/13/16. E9 stated I signed the shower sheet that (E8-Certified Nurse Aide) gave me indicating (R1) had an open area on the coccyx area. Sometimes I'm handed a stack of shower sheets and I sign one, flip to the next sheet, sign it and flip to the next sheet. I did not assess (R1's) wound or notify anyone. I missed it and I take responsibility for that. E9 verified that the Charge Nurse was not notified so that an assessment could be completed per policy. On 08/11/16 at 9:35a.m. E12 (Licensed Practical Nurse) stated, I was one of (R1's) primary nurses. I do not recall a treatment being ordered at that time. R1's clinical record documents that orders for R1's pressure ulcer were not received until 07/18/16. R1's Nurse Progress Notes dated 7/18/16 at 11:00 p.m., states (Certified Nurse Aide) notified this Nurse (E11-Licensed Practical Nurse) of open area on mid coccyx. Area measuring nine centimeters (cm) by four cm shear skin. Denies pain at this time. (Treatment) order in place. (Z4-R1's primary physician), (Z3-Power of Attorney), Administrator (E1) notified. R1's Nurse Progress Notes dated 7/19/16 at 10:30 a.m., document a new physician order [REDACTED]. Facility Skin Condition Monitoring policy dated 11/1/12, states Upon notification of a [MEDICAL CONDITION], wound, stasis ulcer, or other skin abnormality, the Charge Nurse will assess and document findings. The Charge Nurse will then implement the following policy: a. Notify the physician and obtain treatment order if needed. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: a. Characteristic 1. Size 2. Shape 3. Depth 4. Color 5. Presence of granulation tissue or necrotic tissue. b. Treatment and response to treatment. c. Prevention techniques. On 8/9/16 at 12:05 p.m., E7 (Wound Nurse) stated (R1) was high risk for skin breakdown according to (R1's) admission Braden Scale on 7/1/16. I took care of (R1's) wounds. (R1's) wound on the sacral area was unstageable from first identifying it. On 7/19/16 (Z1) ordered [MEDICATION NAME] until Santyl came in. That day I ordered Santyl from the (Pharmacy). A week later I came in to work and there was a request (from Insurance) for more information for the use of Santyl. I provided that information to the insurance. Then the next week (E7 came to work) the (Santyl) still wasn't here (7/26/16). The next week (8/2/16) the Santyl was still not here and I lost my temper. I only work 12 hours per week and the floor nurses should have addressed Santyl not being obtained. If the Santyl would have been used (on R1's pressure ulcer) the pressure ulcer probably wouldn't have progressed to the point of requiring surgical debridement. The wound worsened over the three week period. I notified (Z1) on 8/2/16. When (Z1) observed (R1's) wound (on 8/2/16) he said 'oh s***, oh s***, oh s***,' because it looked so bad. (R1) was paralyzed and should have been turned at least every two hours and put on a low air loss mattress. (R1) probably wasn't being turned every two hours. (Z1) was concerned that the Santyl had not been used and (R1's) wound had gotten worse. In all honestly I feel like (R1) was neglected. I am upset over this. [MEDICATION NAME] does not work as good as Santyl. On 8/16/16 at 9:35 a.m., E16 (Licensed Practical Nurse) stated I took care of (R1) approximately five nights a week. (R1) had a pressure ulcer on coccyx area that started out as purple/red color, not open. When I came to work about five days later (the coccyx) wound was open and dark purple. I know the Santyl that was ordered didn't come in when originally ordered and I don't know why it didn't come. I worked night shift. The (Certified Nurse Aides) were able to turn (R1). (R1) was cooperative. I know pillows were used to position (R1) but (R1) would smash the pillows down. We did not attempt anything else other than the pillows as far as I know. A Medication Administration Policy dated 7/3/13, states If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. On 8/10/16 at 10:17 a.m., Z1 (Advanced Practice Wound Nurse) stated Z1 started treating R1 on 7/19/16. Z1 stated R1's sacral wound was a pressure ulcer. Z1 stated R1 laid on his back all the time and had a hard time moving due to recent stroke. I was not aware that Santyl was not being used on (R1's) sacral wound like I had ordered on [DATE]. No one asked me to fill out a form for the insurance company. Z1 stated that if Santyl had been used as ordered the Santyl would have most definitely helped stop the wound progression. Z1 stated the sacral wound wouldn't have been as far gone. By the time I observed the wound on 8/2/16 it was too deep and I was concerned with bone involvement. I couldn't believe how the wound had declined from the week before. R1's Wound Progress Notes dated 7/19/16, 7/26/16, and 8/2/16 documents weekly deterioration of R1's sacral wound to the point of requiring hospitalization and surgical debridement on 8/3/16. On 08/10/16 at 10:17 a.m. Z1 stated I was not notified in between my visits of the decline in the wound. I had (R1) referred to a vascular surgeon for surgical debridement because it was not appropriate for me to debride the wound in the nursing home setting. Someone (at the facility) should have jumped on (R1's wound decline) much sooner. (R1's) dressing was supposed to be done daily so the nurses should have identified the decline of (R1's) wound and notified a physician immediately. On 8/11/16 at 8:50 a.m., E3 (Assistant Director of Nursing) stated The open area was found on 7/13/16 on (R1) which would have been a stage two at minimum or could have been a stage three according to the depth. When the area was found the nurse should have measured and assessed the area, informed the physician about the area and obtained a treatment. We would have looked at a Braden Score and depending on weight and mobility follow the dietary policy to report to the Dietician and implement additional nutritional interventions. If the Santyl did not come in I would expect the (Director of Nursing) and (Assistant Director of Nursing) and management to be notified. I would also let the wound physician know. I would expect the nurse to notify the physician about the wound and wound worsening and the residents overall condition . On 8/9/16 at 2:45 p.m., Z4 (R1's primary physician) stated the facility has had a lot of staff turnover and has had issues with wound care not being consistent. I would have wanted to know about (R1's) wound decline. I would have looked at the labs, nutritional status and the medical side of (R1's) health. A Notification for Change in Resident Condition or Status dated 7/1/12, states The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been .a significant change in the resident's physical/emotional/mental conditions. On 8/10/16 at 1:50 p.m., E13 (Dietary Manager) verified that she was not aware of R1's pressure ulcer until after R1 went to the hospital on [DATE]. E13 stated, I would have notified the (Registered Dietician). E13 stated no nutritional interventions were implemented for R1. E13 stated the Registered Dietician had not assessed R1 since he was admitted on [DATE]. E13 stated the (Registered Dietician) was here in the middle of July and didn't see (R1). My mistake, somehow I missed putting him on the (Registered Dietician's) list. On 8/11/16 at 11:00 a.m., E14 (Registered Dietician) stated I was never notified of (R1's) pressure ulcer. I have never done a dietary assessment on (R1). If I was notified I would have started a bridge plan such as ordering a supplement or maybe revising the diet. I also may have added protein or a multivitamin. I would also monitor labs such as Hemoglobin A1C and an [MEDICATION NAME] to check for protein needs. Facility Pressure Ulcers-Nutritional Intervention policy dated 7/2010, states It is the policy of (the facility) that nutritional interventions shall be utilized as one of the means of treatment to improve the healing process in residents with pressure ulcers and for the prevention of new pressure ulcers. 1. Food Service Manager will be notified by nursing staff if a resident is admitted with or acquired pressure skin breakdown at the facility. 2. Residents with pressure ulcers will have a program of increased protein, calories, vitamins, minerals and fluids developed by the dietician and ordered by the resident's physician. 3. Incorporate the additional nutrients into the meal or snack pattern of the resident's diet according to intake. 4. Nourishments will vary depending on the stage of the pressure ulcer and on the potential intake of the resident .6. Residents admitted or identified with stage II, III, or IV pressure ulcers are referred to the dietician in a telephone consultation to review nutritional needs .8. Residents on modified diets will have a supplement regimen determined by the dietician and ordered by the physician. On 8-10-16 at 10:30 a.m., R1 was lying in a bed on the right side in the ICU (Intensive Care Unit). R1 was intubated and sedated. R1 had a [MEDICAL CONDITION] and a supra-pubic catheter. Z8 (Certified Wound Nurse) provided pressure ulcer care to R1. Z8 removed multiple four by four dressings saturated in pinkish/yellow drainage from R1's stage four sacral pressure ulcer. Z8 then obtained R1's sacral pressure ulcer size measuring at approximately 33 cm (centimeters) long by 9.5 cm wide by 9 cm deep. R1's Sacral Pressure Ulcer extended from R1's sacral region, around both sides of R1's anus, and into the scrotum. The Pressure Ulcer was beefy red with large amounts of yellowish/pinkish drainage, and had an approximate four cm round necrotic area over R1's tail bone. On 8-10-16 at 12:15 p.m., Z5 (Surgeon) stated, (R1's) sacral wound was the worst pressure wound I have ever seen. It was nine centimeters (cm) deep. Worst case of neglect I have seen. Pure nursing home neglect. There is no reason (R1) should have developed this wound in a month or two time. It (pressure wound) was definitely caused by pressure. They (nursing facility) could not have provided pressure relief. (R1) should not be in this condition when (R1) is only in his forties. I did the first coccyx wound debridement at the hospital, and after removing the necrosis (dead tissue) the wound was a stage four that had tunneled around the rectum into the scrotum. (R1's) wound now has caused (R1) to be intubated and sedated, and (R1) required a [MEDICAL CONDITION] and supra-pubic catheter. (R1) was also septic. (R1) is going to require several more debridements of the wound. On 8-10-16 at 10:15 a.m., Z7 (Certified Wound Care Nurse) stated, I was present for (R1's) first coccyx wound debridement (8/4/16). Hard eschar (dead tissue) covered (R1's) coccyx/sacral area. The eschar was debrided from the wound and the wound was a stage four pressure ulcer. Had pressure been resolved it (pressure ulcer) could have been prevented. On 8-10-16 at 9:00 a.m., Z3 (R1's Family Member) stated, at home (R1) was able to move around until he had a Stroke. The only reason he needed nursing home care was to receive rehabilitation. The doctor thought he could make a full recovery with therapy. Every time I visited (R1) at the facility he was on his back. (R1) is going to be devastated when he wakes up at the hospital and sees that he has all of them tubes and problems. The Immediate Jeopardy was identified on 8-18-16 at 2:15 p.m. to have begun on 7/13/16 when E8 (Certified Nurse Aide) identified an open area to R1's sacral area and the facility Neglected to act upon treating the area. E1 (Administrator) and E3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on 8-18-16 at 2:30 p.m. The immediacy was not removed at the time of the exit.

Based on interview and record review, the facility failed to obtain a physician ordered medication for one of three residents (R1) reviewed for pressure ulcers in the sample of seven. This failure resulted in R1's sacral pressure ulcer to deteriorate to a Stage IV and required surgical debridement. Findings include: A Medication Administration Policy dated 7/3/13, states If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. A Progress Note Details (Wound Report), completed by Z1 (Advanced Practice Nurse) dated 7/19/16 at 9:39 a.m., documents R1 has an unhealed Medial Sacral chronic Unstageable Pressure Injury obscured full-thickness skin and tissue loss pressure ulcer. The Progress Note documents the measurement of the Medial Sacral wound to be 9 cm length by 4 cm width, with an area of 36 square cm. There was no drainage noted. The patient reports a wound pain of level (two). Wound bed is 1-25% adherent, yellow slough. Z1 also documented a new treatment order to apply Medihoney until Santyl (wound debriding ointment) becomes available, then use Santyl to wound bed daily and cover with border dressing daily. A Progress Note Details (Wound Report), completed by Z1 on 7/26/16, documents R1's Medial Sacral wound (Wound #1)measurements are 10.5 cm length by 8 cm width, with an area of 84 (square) cm. No sinus tract has been noted. No undermining has been noted. There is no drainage noted. The patient reports a wound pain of level (two). Wound bed is 51-75% adherent, yellow slough, 1-25% granulation Periwound does not exhibit signs or symptoms of infection .Cleanse wound #1 (Medial Sacral) with Saline, protect periwound with Skin Protectant, Apply Santyl to wound bed, cover wound with Barrier Island Dressing, Change daily and (as needed) for soiling and/or saturation . A Progress Note Details (Wound Report), completed by Z1 on 8/2/16, documents Wound #1 (Medial Sacral) has a status of Not Healed. Subsequent wound encounter measurements are 10.5 cm length and 6.5 cm width with an area of 68 (square) cm. No sinus tract has been noted. No undermining noted .Wound bed is 76-100% moist, yellow slough .Periwound skin does not exhibit signs and symptoms of infection .Consulted (Surgical) services for deep debridement of Wound #1 and Wound #2 .This wound (#1 Medial Sacral) was first seen on 7/19/16, on that initial visit Santyl was ordered for the treatment of [REDACTED]. At the time orders were written, Santyl was not available. Staff was informed to use Medihoney until Santyl became available. Today I (Z1) was informed that Santyl was not approved by (R1's) insurance, therefore (R1) did not benefit from Santyl. Today on evaluation the wound needed to be debrided. On a closer look (R1) has a tunnel ulceration with slough near the anus area. (R1) is also receiving Coumadin (Anticoagulant). In light of all that I felt that (R1) may be better served if the wounds are debrided by surgical service. Given the extent of debridement, location of areas that needs to be debrided and the fact that (R1) is on Coumadin, I felt the (Nursing Home) setting is not the appropriate place for any kind of debridement for (R1) . On 8/9/16 at 12:05 p.m., E7 (Wound Nurse) stated On 7/19/16 (Z1) ordered medihoney until Santyl came in. That day I ordered Santyl from the (Pharmacy). A week later I came in to work and there was a request (from Insurance) for more information for the use of Santyl. I provided that information to the insurance. Then the next week (E7 came to work) the (Santyl) still wasn't here (7/26/16). The next week (8/2/16) the Santyl was still not here and I lost my temper. I only work 12 hours per week and the floor nurses should have addressed Santyl not being obtained. If the Santyl would have been used (on R1's pressure ulcer) the pressure ulcer probably wouldn't have progressed to the point of requiring surgical debridement. The wound worsened over the three week period .(Z1) was concerned that the Santyl had not been used and (R1's) wound had gotten worse .Medihoney does not work as good as Santyl. On 8/10/16 at 10:17 a.m., Z1 (Advanced Practice Wound Nurse) stated Z1 started treating R1 on 7/19/16. Z1 stated R1's sacral wound was a pressure ulcer. Z1 stated R1 laid on his back all the time and had a hard time moving due to recent stroke. I was not aware that Santyl was not being used on (R1's) sacral wound like I had ordered on [DATE]. No one asked me to fill out a form for the insurance company. Z1 stated that if Santyl had been used as ordered the Santyl would have most definitely helped stop the wound progression. Z1 stated the sacral wound wouldn't have been as far gone. By the time I observed the wound on 8/2/16 it was too deep and I was concerned with bone involvement. I couldn't believe how the wound had declined from the week before. I had (R1) referred to a vascular surgeon for surgical debridement because it was not appropriate for me to debride the wound in the nursing home setting. Someone (at the facility) should have jumped on (R1's wound decline) much sooner . On 8-10-16 at 1:35 p.m., Z6 (Facility Wound Specialist Physician) stated, The facility is responsible to obtain the Santyl (Wound Debriding Ointment). I would have expected this treatment to be obtained within 24 hours.

Based on interview, and record review the facility failed to notify the physician of R1's initial development and decline of a pressure ulcer, R1 not receiving a physician prescribed pressure ulcer treatment, and R1 failing to receive speech, occupational, and physical therapy as ordered by the physician. The facility also failed to notify the facility's Dietician of R1's pressure ulcer. These failures had the potential to affect one of three residents (R1) reviewed for notification of change in the sample of seven and resulted in R1 not receiving care and services to prevent R1's pressure ulcer from deteriorating to a stage four pressure ulcer. R1 currently is hospitalized , intubated, sedated for several surgical debridements of the pressure ulcer, and has required a [MEDICAL CONDITION] and a supra-pubic catheter due to the wound progression. Findings include: The facility's Notification for Change in Resident Condition or Status policy dated 7-1-12 documents, The facility and/or facility staff shall promptly notify appropriate individuals (i.e., Administrator, DON/Director of Nursing, Physician, Guardian, Healthcare Power of Attorney, etc,) of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical, emotional, and the onset of pressure ulcers or stasis ulcers Notifications will be made within twenty four hours of a change occurring in the resident's medical/mental condition or status. The facility's Pressure Ulcer-Nutritional Intervention policy dated 7/2010 documents, Residents admitted or identified with stage two, three, or four pressure ulcers are referred to the dietician in a telephone consultation to review nutritional needs. The Facility's Medication Administration policy dated 10/2007 documents, If a medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. A Shower/Abnormal Skin Report dated 7/13/16, completed by E8 (Certified Nurse Aide/CNA) and signed by E9 (Licensed Practical Nurse) documents R1 has an open area to the coccyx area. R1's Medical Record dated 7/13/16 through 7/17/16, does not document any assessment, treatment, or monitoring of R1's open area documented on the Shower/Abnormal Skin Report dated 7/13/16. R1's Wound Progress Notes dated 7/19/16, 7/26/16, and 8/2/16 and signed by Z1 (Advanced Practice Nurse) documents weekly deterioration of R1's sacral wound to the point of requiring hospitalization and surgical debridement on 8/3/16. A Progress Note Details (Wound Report), completed by Z1 (Advanced Practice Nurse) dated 7/19/16 at 9:39 a.m., documents (R1) new treatment order to apply [MEDICATION NAME] until Santyl (wound [MEDICATION NAME] ointment) becomes available, then use Santyl to wound bed daily and cover with border dressing daily. A Fax Transmittal Form dated 8/2/16 (sent by E7-Wound Nurse), documents (R1) was supposed to be on Santyl 3 weeks ago and was not approved by insurance. A Progress Note Details (Wound Report), completed by Z1 (Advanced Practice Nurse) on 8/2/16, At the time orders were written, Santyl was not available Staff was informed to use [MEDICATION NAME] until Santyl became available. Today I was informed that Santyl was not approved by (R1's) insurance, therefore (R1) did not benefit from Santyl. Today on evaluation the wound needed to be debrided . R1's Dietary Progress Notes from 7-13-16 to 8-3-16 do not include any Dietician notes or assessments. A Hospital Discharge Summary dated 7/1/16 documents, (R1) will require ongoing therapies including physical therapy, occupational therapy, and speech therapy for swallow, language, and cognition. R1's Admission Physician order [REDACTED]. R1's Therapy Record from 7-1-16 to 8-3-16, does not include R1 receiving any therapy services. On 8/9/16 at 2:30 p.m., Z9 (Physical Therapist/Therapy Program Director) stated R1 did not receive any therapy while in the facility (7/1/16-8/3/16). Z9 stated I'm not able to do anything until approval is received by the facility. The facility did not get it approved by the corporation. On 8/9/16 at 12:05 p.m., E7 (Wound Nurse) stated On 7/19/16 (Z1/Advanced Practice Nurse) ordered [MEDICATION NAME] until Santyl came in. That day I ordered Santyl from the (Pharmacy). A week later I came in to work and there was a request (from Insurance) for more information for the use of Santyl. I provided that information to the insurance. Then the next week (E7 came to work) the (Santyl) still wasn't here (7/26/16). The next week (8/2/16) the Santyl was still not here and I lost my temper. I only work 12 hours per week and the floor nurses should have addressed Santyl not being obtained. If the Santyl would have been used (on R1's pressure ulcer) the pressure ulcer probably wouldn't have progressed to the point of requiring surgical debridement . [MEDICATION NAME] does not work as good as Santyl. On 8-9-16 at 11:00 a.m., Z2 (Pharmacist) stated, The pharmacy received an order for [REDACTED]. We let the facility know we needed a prior authorization from the physician, but never received one. The facility should have called the physician to get a prior authorization or to let the physician know the Santyl was not covered. On 8-10-16 at 1:35 p.m., Z6 (Wound Physician) stated, The facility should have called me or (Z1/Advanced Practical Nurse) when the wound worsened . When the coccyx wound was found on (R1) on 7-13-16, a physician should have been notified and an treatment order obtained. On 8-11-16 at 8:50 a.m., E3 (Assistant Director of Nursing) stated, When the open area was found on (R1's) coccyx on 7-13-16 the physician should have been notified about the area and a treatment order obtained We would also report to the dietician for additional nutritional interventions. I would have expected the nurse to notify the primary physician about the wound worsening and the resident's overall condition. I would also expect the physician to be notified when physical, occupational, and speech therapy was not given as ordered. On 8/10/16 at 10:17 a.m., Z1 (Advanced Practice Nurse) stated, I was not aware that Santyl was not being used on (R1's) sacral wound like I had ordered on [DATE]. No one asked me to fill out a form for the insurance company. Z1 stated that if Santyl had been used as ordered the Santyl would have most definitely help stop the wound progression. Z1 stated The sacral wound wouldn't have been as far gone. By the time I observed the wound on 8/2/16 it was too deep and I was concerned with bone involvement. I couldn't believe how the wound had declined from the week before. I was not notified in between my visits of the decline in the wound. I had (R1) referred to a vascular surgeon for surgical debridement because it was not appropriate for me to debride the wound in the nursing home setting. Someone (at the facility) should have jumped on (R1's wound decline) much sooner. (R1's) dressing was supposed to be done daily so the nurses should have identified the decline of (R1's) wound and notified a physician immediately. On 8/9/16 at 2:45 p.m., Z4 (R1's primary physician) stated, I would have wanted to know about (R1's) wound decline. I would have looked at his labs, nutritional status, and the medical side of (R1's) health. (R1) had Physical Therapy, Occupational Therapy, and Speech Therapy ordered on admission 7/1/16. I was not aware that (R1) was not receiving any type of therapy. I did not give orders to discontinue any of (R1's) therapy. The prescreening of a resident prior to admission is to determine if the facility can meet the residents needs. If the facility admits them then the admission orders [REDACTED] On 8-11-16 at 11:00 a.m., E14 (Dietician) stated, I was never notified of (R1's) wounds .I have never done an assessment on (R1) .

Based on interview and record review the facility failed to administer intravenous narcotic pain medicine in accordance with physician orders [REDACTED]. This failure resulted in R6 to become unresponsive and need to be sent to the emergency room to receive a narcotic reversal agent. R6 was then further hospitalized . Findings include: R6's most current Minimum Data Set (MDS) indicates R6 to be without any mental deficits or cognitive impairments. R6's Prescription Ordering Sheet from the local area hospital, dated 2/4/16 states, [MEDICATION NAME] ([MEDICATION NAME]) 2 milligram(mg)/milliliter solution. Administration Instructions: 0.25 ml by intravenous route daily as needed for pain (pain around dressing changes.) R6's Physician order [REDACTED]. 0.25 ml by IV (intravenous) route PRN (as needed) for [DEVICE] dressing changes. R6's PRN Medication Information Sheet indicates on 2/6/16 at 6:00 P.M., R6 received a dose of IV [MEDICATION NAME] prior to the wound vac (vacuum) change. R6's Nurse's Notes on 2/6/16 at 10:30 P.M. state, Resident was unarousable .EMT (Emergency Medical Technician) notified and patient transferred to (local area hospital) for eval (evaluation) and treatment .EMT's arrived, patient was alert with confusion at that time with respirations between 7-8 per minute. R6's Nurse's Notes on 2/7/16 at 9:00 A.M. state, Call placed to (local area hospital). Resident (R6) admitted to the intermediate unit for altered mental status. [MEDICATION NAME] (narcotic reversal agent) was administered. (R6) alert and oriented at this time per (local area hospital) RN (Registered Nurse.) On 2/19/16 at 1:30 P.M., E13 (Registered Nurse) stated, (R6) had asked for pain medicine. I misread (the order) and instead of 0.25 ml (0.5 mg), I thought it was 2 mg, so (R6) received the full IV dose of the medicine. A Final Investigation Report sent to the local state agency documents on 2/6/16 (R6) received an incorrect medication dosage .(R6) was admitted for altered level of consciousness. E13 stated (E13) was confused about the order and inadvertently made the error. Local area hospital discharge summary states (R6) recently readmitted for acute metabolic [MEDICAL CONDITION] due to accidental overdose with [MEDICATION NAME] at her SNF (Skilled Nursing Facility) .

Based on observation, record review, and interview, the facility failed to identify the development of new pressure ulcers, failed to monitor existing pressure ulcers, and failed to update interventions to prevent the development of new pressure ulcers for three residents (R7, R11, and R17) of six residents reviewed for pressure ulcers in a sample of 24. This resulted in R17 having three unidentified new facility-acquired pressure ulcers, one unstageable and two Stage 2. Findings include: The facility's Pressure Sore Prevention Guidelines Policy dated, 11-12 documents, Skin risk and appropriate interventions are to be placed on the Care Plan.If despite interventions a Pressure Ulcer develops, the care plan must reflect updated interventions for healing of ulcers and additional interventions for further prevention of pressure ulcers. 1. R17's MDS (Minimum Data Set), dated 5-27-15, documents R17 has one stage two pressure ulcer, not present on admission and one unstageable pressure ulcer, not present on admission. This MDS also documents R17 requires assist with bed mobility, is non-ambulatory, and requires a wheelchair for mobility. R17's medical record documents R17 was admitted to the facility on [DATE]. R17's Braden Skin Assessment, dated 5-20-15, documents a score of 16 (High Risk) for pressure ulcers. The Assessment Schedule, provided by the facility, dated 9-27-10, documents Braden skin assessments are to be done every week for four weeks then every 90 days and on development of pressure ulcer or change in condition. No weekly Braden Assessments are in R17's medical record and no Braden Assessments addressing R17's pressure ulcers acquired after admission are in R17's medical record. On 7-27-15 at 1:35 p.m., E12 (LPN/Licensed Practical Nurse) was preparing to perform wound care to R17's coccyx. During the wound care when R17 was turned and positioned for the care an open area was identified on R17's right ischium, dime size, red in color. Also during the wound care another open area was identified to R17's right buttocks approximately 1 cm (centimeter) by 1 cm with reddish pink color. At this same time, E12 was requested to remove R17's socks to inspect R17's heels. R17 had a dark blackish quarter shaped area to the right heel. E12 stated, the areas to (R17's) right ischium, right buttocks, and the area to (R17's) right heel should have been seen or identified by skin checks before now.I did not know the three new areas were there until now, and I do not have a treatment order for them. R17's TARS (Treatment Administration Sheets) dated 7-1-15 to 7-31-15, documents a treatment order for (R17's) coccyx.clean with Therawork, pat dry, apply calcium alginate and dry dressing daily and as needed, with the ulcer documented as measuring 1 cm. x 0.5 cm. x 0.1cm. Also on these same TARS a new treatment order dated 7-27-15 for (R17's) right buttock with a documented measurement of 0.7 cm. x 0.7 cm., right ischium documented as 1 cm x 1 cm., and R17's right heel documented as eschar unstageable measuring 3.2 cm. x 2.8 cm. A new order for heel boots while in bed was also obtained on 7-27-15 by facility. On 7-28-15 at 11:01 a.m. E2 (DON/Director of Nursing) stated, R17 has an unstageable pressure ulcer to R17's sacrum which was acquired at the facility on 5-6-15.R17 also had a stage two pressure ulcer to (R17's) buttocks acquired at the facility on 5-26-25, (which is now healed). (R17) now has a new acquired pressure ulcer to R17's buttocks, right ischium, and a darkened unstageable pressure area to (R17's) right heel identified on 7-27-15.(R17) only has a Braden Skin assessment dated [DATE] in (R17's) medical records.there is no new Braden Assessments after R17's pressure ulcers were identified.the staff did not do a new Braden Assessment every week for four weeks and did not do a Braden Assessment on the new development of (R17's) pressure ulcers according to the facility's Health Care Assessment schedule. R17's Bed Mobility Care Plan dated 6-8-15, documents, Assess skin/buttock for shearing during daily cares.Report red areas or problems with skin integrity to nurse for report to doctor. R17's Pressure Ulcer Care Plan dated 6-8-15, documents Complete Avoidable/Unavoidable Pressure Ulcer Assessment as needed to investigate contributing factors and prevention interventions used.High Risk-daily skin check with documentation and as needed with any new open area. On 7-28-15, R17's Skin Care Plan does not address the three newly acquired pressure areas identified on 7-27-15. On 7-28-15 at 11:35 a.m., E11 (CPC) stated, I do not have any updates on (R17's) care plan identifying the pressure area to R17's buttocks, right ischium, or right heel.I was not told or aware of the areas.they should have been on the care plan. 2. The facility's Skin Condition Monitoring Policy dated 11-1-12, documents, Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed.Documentation of the area must include the following: Characteristic, Size, Shape, Depth, Color, Presence of granulation tissue or necrotic tissue.Treatment and response to treatment.Observe and measure pressure ulcers at regular intervals.Prevention techniques. R11's POS (Physician order [REDACTED]. R11's ADL (Activities of Daily Living) plan of care, dated 6-6-15, documents (R11) is dependent upon staff for all cares and meeting (R11's) needs. On 7-28-15 at 10:01 a.m., E17 LPN (Licensed Practical Nurse) performed a treatment to R11's open area on R11's penis. R11's open area was approximately 3 cm/centimeters by 0.5 cm. and red in color. The open area was on the left upper side of the penis. On 7-31-15 at 11:10 a.m. E2 (DON/Director of Nursing) stated, (R11's) open area to the penis was facility acquired on 3-12-15.there is no documentation on measurements or monitoring (R11's) open area for worsening or improvement. R11's POS dated 7-1-15 to 7-31-15, documents, treatment for [REDACTED]. R11's current Skin Care Plan, dated 6-6-15, does not address any open areas. On 7-28-15 at 11:01 a.m., E2 DON (Director of Nursing) stated, (R11's) open area on the penis is caused from the catheter tubing pressing/friction against (R11's) penis and was acquired at the facility.there should be an intervention in place to prevent the pressure against (E11's) penis. On 7-28-15 at 11:35 a.m., E11 CPC (Care Plan Coordinator) stated, there are no documented skin issues on (R11's) care plan.all open areas should be on the plan of care with interventions in place. 3. R7's POS (physician's orders [REDACTED]. On 7-27-15 at 11:15 am, R7 was lying in bed with a dressing dated 7-24-15 on R7's cocccyx. E12 (Treatment Nurse) verified the dressing was dated 7-24-15, three days earlier, and stated the dressing is ordered to be changed every day and as needed. R7's TAR (Treatment Administration Record) for July 2015 shows R7's coccyx treatment was not signed off as being completed on 7-23-15, 7-25-15 and 7-26-15. R7's Treatment Record documents on 7-7-15 and 7-15-15, R7's coccyx wound measured 1.8 cm (centimeter) x 0.6 cm. R7's Treatment Record for 7-24-15 documents R7's wound size as 2 cm x 1 cm.

Based on interview and record review the facility failed to protect one of seven residents (R22) in a sample of 24 from verbal abuse reviewed for abuse in the sample of 24 and one of two residents (R27) in the supplemental sample. This failure resulted in R22 and R27 being subjected to verbal abuse a second time. Findings include: The facility policy revised 11/11/11 and titled Abuse Prevention Program documents, in part, .During orientation of new employees, the facility will cover.Staff obligations to prevent and to immediately report abuse, neglect.Annually, supervisory personnel will receive training on their obligations under law when receiving an allegation of abuse, neglect.and how to monitor and correct inappropriate or insensitive actions, words or body language.All residents,.or others are encouraged to report their concerns or suspected incidents of potential/alleged mistreatment, neglect and abuse of residents.Supervisory shall immediately inform the administrator.of all reports of potential/alleged mistreatment , neglect and abuse of residents.Employees accused of alleged mistreatment , neglect, abuse.shall not complete their shift as a direct care provider to residents. On 7/28/15, during the Group meeting, R27 stated E26 Certified Nurse Aide (CNA) swore during cares to R27's roommate (R22) on two different occasions. R27 stated it was reported to E15, Licensed Practical Nurse/Resident Care Coordinator (LPN\RCC). R27 stated E26 continued to work after the first event of swearing was reported to E15. On 7/30/2015 at 9:40AM, R27 stated a couple of weeks ago, E26 CNA, entered the room during the night to toilet R27's roommate, R22. R22 did not want to sit on the dirty toilet seat and E26 argued with R22 saying, I don't know why you can't sit on that (soiled toilet seat), it's your mess anyway. You are the only one who uses it! R27 stated E26 then received a cell phone call while toileting R22. While E26 was still in the residents' bathroom, E26 argued and swore during the phone call using f*#king several times. R27 stated it was disrespectful to R22 and upset R27 that R22 had to hear it. R27 said, R22 has dementia but is such a nice lady that it just was not right for R22 to have to listen to that language. R27 stated this event happened over a weekend sometime after the 4th of July (2015). R27 stated it was reported to E15 Licensed Practical Nurse/ Resident Care Coordinator (LPN/RCC) the following Monday morning. R27 stated E15 took R27 into E15's office to discuss the event and R27 gave E15 the name of the CNA and exactly what had been said. R27 stated after the first event had been reported, E26 came into R27 and R22's room to answer R22's call light. R27 stated, (E26) came in and said, 'what do you want?' to R22, then said,'I'm so tired of answering these f*#king call lights! I'm the only one working this hall and these f*#king call lights just keep going off! R27 stated E26 must have just felt comfortable in talking that way to us. The Quarterly Minimum Data Set ((MDS) dated [DATE] documents R27 as cognitively intact. The 6/26/15 Social Service notes document R27 as cognitively intact. R22's Annual MDS dated [DATE] documents R22 as having severe cognitive impairment and requiring assist with toileting, transfer and hygiene. On 7/30/2015 at 9:30AM, E15 LPN\RCC, stated there had not been any resident complaints given to her, only that staff had been loud at night. On 7/30/15 at 11:35AM, E1 Administrator stated, (E15) told me that (R27) reported (E26) for having a bad attitude on a Monday following a weekend. At 11:50AM, E1 stated both employees had been suspended pending investigation. On 7/31/15 at 10:00AM, E2 Director of Nursing verified E26 CNA, had access to all the residents in the facility over the last two weeks. On 7/31/15 at 9:28AM, E1 stated E26 was terminated for verbal abuse.

Based on observation, record review and interview the facility failed to secure a mechanical lift with sling for one resident (R1) and failed to implement new interventions for two residents (R4 and R15) of eight reviewed for falls in a sample of 24. This resulted in R1 receiving a displaced fracture involving the proximal right humeral head/neck with medial and anterior displacement of the humeral shaft. Finding include: 1. R1's POS (Physician order [REDACTED]. R1's care plan dated, 8-18-14, documents, (R1) has risk factors that require monitoring and intervention to reduce potential for self injury.Risk factors include non-ambulatory, weakness.Use (mechanical lift) for all transfers.Observe for and educate on proper technique and use of device. R1's nursing notes dated 11-10-14, document, CNA's (Certified Nursing Assistant) were transferring (R1) and strap came undone and (R1) fell to floor.complains of lower back pain and shoulder pain.call doctor.order to send (R1) to ER (emergency room ) for X-rays. R1's Diagnostic Report dated 11-10-14, documents, Displaced fracture involving the proximal right humeral head/neck with medial and anterior displacement of the humeral shaft. On 7-29-15 at 10:30 a.m., E1 Administrator stated, according to the incident report dated, 11-10-14, the (mechanical lift) slipped off the hook while transferring (R1) from (R1's) wheelchair to (R1's) bed.because there was a problem with how the sling was attached we immediately did in-service with all CNA's.the maintenance person (E16) (Maintenance Director) looked at the (mechanical lift) to make sure it was functioning correctly.the nurse on duty (E23) LPN (Licensed Practical Nurse), who no longer works here, wrote (E19, E20) CNA's on the incident report but (E21) CNA and (E22) CNA were directly responsible for the incident.I do not have documented interviews from (E21 and E22) and did not talk directly to (E21 and E22) about the incident.but both (E21 and E22) were in-serviced separately on Mechanical Lift Demonstration.(E19, E20, E21, and E22 CNA's) also no longer work here. A Mechanical Lift Demonstration form dated, 11-10-14 was signed by E21 and E22. R1's care plan dated 8-18-14, documents a new intervention dated 11-10-14, CNA's re-educated on proper use of (mechanical lift), Maintenance to look at (mechanical lift). A Monthly Mechanical Lift Inspection form dated 11-10-14 documents, checked by (E16) due to fall.all areas checked as compliant. 2. R15's Admission MDS dated [DATE] documents R15 as cognitively intact and requiring extensive assist with transfer, toileting and hygiene. R15's current Care Plan documents R15 is to have assist with ambulation and toileting. R15's Nurses Notes document R15 fell on [DATE] while in therapy, 7/8/15 at 11:55PM and 7/14/15 at 2PM in R15's bathroom. R15 states (R15) is supposed to wait for help to toilet and get out of bed. R15 stated (R15) was already on the floor by the time the staff came to assist. E11, LPN/ MDS Coordinator verified, in a signed statement, the current Care Plan is the interim Care Plan and was not updated with new interventions after each fall. 3. Falls (undated) document that on 10/19/14, R4 fell by leaning/reaching out of the wheelchair and dycem was implemented as the intervention. R4's current Care Plan, dated 5/22/15, documents a fall intervention on 1/28/14, as a non-skid pad, to be in R4's wheelchair. On 7/27/15, at 9:00 am, 9:55 am, 10:00 am, 10:30 am and 1:15 pm, R4's wheelchair did not have a non-skid pad. On 7/28/15, at 8:45 am - 9:00 am (continual observation in dining room), 9:45 am and 1:40 pm, R4's wheelchair did not have a non-skid pad. On 7/28/15, at 10:45 am, E8 (Registered Nurse/RN) verified that if R4's Care Plan documents dycem in wheelchair that R4's wheelchair should have a non-skid pad.

Based on observation, interview, and record review the facility failed to maintain the temperature of hallway heaters to prevent a thermal hazard to independently mobile residents. This failure resulted in R4 sustaining a burn with blister to the left elbow on 1/13/15. The facility also failed to develop and implement policies and procedures following R4's burn to ensure hallway heaters no longer posed a thermal hazard. These failures have the potential to affect four of five residents (R1, R3, R4, R5) on the sample reviewed for thermal hazards and 94 residents (R6-R99) on the supplemental sample. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/04/15, the facility remains out of compliance at a Severity Level 2. Additional time is needed to evaluate the implementation of the policies and procedures as well as inservicing of staff to determine the effectiveness of these changes. Findings include: On 3/3/15 at 4:20a.m. during a tour of the facility, a wall heater located on the C100 hall across from C106 was attached to the wall approximately three feet high, at about the same height as a hand rail. The heater was hot to the touch, and the housing of the heater was loose making it accessible to anyone in the hall. A heater located across from room C103 felt even hotter than the first. On 3/03/15 at 5:40a.m. E1 (Administrator) stated the facility had one resident who was burned by one of the hallway heaters, "...about one month ago..." R4 had received a burn after, "R4 put an arm on the heater in the hallway and got some redness from that." An incident final investigation dated 1/14/15 states, "R4 was found to have a small blister on R4's left elbow during R4's shower...R4 has a tendency to wheel self up toward the wall heaters and laying R4's arm on it" The incident report states, "R4 often roams around the building of R4's own free will. In order to prevent reoccurrences R4 will be closely monitored by staff while in the hallways and removed from potential hazardous situations. Maintenance also checked the heaters to make sure they are functioning properly." A nurse's note dated 1/13/15 at 8:00p.m. states, "R4 found to have a burn with blister on left elbow during shower. Area 9cm (Centimeters) by 5cm with blister in the center...R4 has a habit of wheeling self in wheelchair up to the wall heater and laying R4's arm on it." On 3/03/15 at 8:45a.m. E11 (Maintenance person) used an infrared-thermometer to check the temperatures of the wall heaters in the four C-wing halls and the four B-wing halls. E11 stood in front of a heater located next to room C105 then pointed the infrared-thermometer at the heater approximately two inches from the heater, which registered 141 degrees Fahrenheit. E11 verified the reading by feeling the wall with a bare hand, which felt neither hot nor cold, then measured the temperature of the wall using the infrared-thermometer which measured the wall as 79 degrees Fahrenheit. E11 then rechecked the temperature of the wall heater, which remained 141 degrees Fahrenheit. E11 measured the temperature of the wall heater located next to room C206 which measured 160-162 degrees Fahrenheit. E11 stated, "That one seems pretty hot." E11 continued measuring the temperatures of all the wall heaters in the facility. The heater across from room C106 measured 145 degrees Fahrenheit. The heater across from room B303 measured 148 degrees Fahrenheit. The heater next to the men's restroom on the B100 hall measured 143 degrees Fahrenheit. The heater next to room B405 measured 173 degrees Fahrenheit. The heater next to room B106 measured 150 degrees Fahrenheit. On 3/03/15 12:55p.m. E5 (Dietary Manager) instructed E11 on calibrating a stem thermometer using a cup of ice and water in order to compare the temperature readings of the infrared-thermometer. E11 placed the stem thermometer and also a digital thermometer in a cup filled with ice and a small amount of water. E11 verified the digital thermometer read 32.3 degrees Fahrenheit, the stem thermometer read 32 degrees Fahrenheit and the infrared-thermometer read 32 degrees Fahrenheit. The facility's Infrared-Thermometer instruction manual dated 10/2002 states, "Infrared thermometers measure the surface temperature of an object...To measure a temperature, point unit at object and pull the trigger." On 3/03/14 at 8:35a.m. E11 stated that after R4 had been burned 1/13/15, E11 and E19 (Maintenance Director), "...checked all the C-wing hallway heaters. They were all working properly, not blowing any hotter than suppose too." E11 stated E19, "...usually wrote some sort of report about how E19 fixed something or what E19 did to repair equipment." E11 was unable to provide documentation that E11 and E19 adjusted the temperature of the wall heaters. On 3/03/15 at 6:30a.m. R4 was self-propelling a wheelchair in the dining room. R4 was able to remember that R4 received a burn to R4's left arm on the heater, "by room 6." On 3/03/15 at 1:10p.m. R22 stated, "The registers are warm, too warm for someone older." On 3/03/15 at 1:25p.m. R10 stated, " I have never touched the registers because I was told by the CNAs (Certified Nurse Aides) and nurses not to touch them because I could get burned." On 3/03/15 at 1:00p.m. E13 (Licensed Practical Nurse) stated, "I keep an eye on them (residents) to make sure that when people sit in front of the grill to watch out for them so they don't get burned..." On 3/03/15 at 12:55p.m. E20 (Licensed Practical Nurse) stated, " The B400 hallway heater gets hot by where I park the med cart." On 3/03/14 at 1:15p.m. R65 stated, "Sometimes they (staff) park the (mechanical) lift next to the heater in the hallway by my room. It gets really hot and when they bring it in the room, sometimes they have to let it cool off before they can use it," on R65. On 3/03/15 at 1:20p.m. R5 stated, "I've noticed that some of the heaters in the hall get very warm." On 3/04/15 9:30a.m. R69 stated, "I have touched the register before. I didn't get burned but thought it was pretty hot." On 3/04/15 at 8:30a.m. E1 (Administrator) stated the facility had no documentation the wall heaters had been adjusted after R4's burn on 1/13/15. E1 also stated the facility was, "...periodically temping the heaters but there is no documentation for that." E1 stated, "The temperature of the heaters should be 120 degrees or less." On 3/03/15 at 2:00p.m. E2 (Director Of Nurses) provided documentation that there were 98 independently mobile residents in the facility at the time of the survey. An Immediate Jeopardy was identified at approximately 1:40p.m. 3/04/15. It began on 1/13/15 when R4 sustained a burn to R4's left elbow while leaning against a wall heater in the hallway. E1 (Administrator) and E15 (Director of Business Operations) were notified of the Immediate Jeopardy on 3/04/15 at 2:00p.m.. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immedicate Jeopardy: The facility completed a 100% audit of all wall heaters. They were continually adjusted until all temperatures were at or below 113 degrees. (Completed: March 3, 2015) at 113 degrees it would take two hours to develop a second degree burn, so it was decided that was a safe temperature threshold. A Quality Assurance Program was put into place where all heaters will be tested daily using an infrared thermometer to ensure they remain at or below 113 degrees. (Completed: March 3, 2015) A daily tracking log will be maintained and submitted to the Administrator to monitor for discrepancies. The daily temping will be done by maintenance Monday through Friday and on Saturday and Sunday the weekend manager will be responsible for temping them. Any emergent needs will be reported to maintenance and the Administrator. Additionally, the Administrator will conduct random temperature audits and log appropriately. The facility conducted an in-service with staff to educate them that heaters are only to be adjusted by the maintenance department. Staff was also educated to redirect residents from sitting in front of and/or leaning on wall heaters. Residents will be closely monitored by staff during their rounds and throughout their daily activity. The in-service was conducted by the Administrator, DON and ADON. No employee will be allowed to start their shift until they have completed the training. (Started: March 3, 2015; Projected Completion: March 5, 2015) All wall heater faces were screwed into the brick wall so that no one but maintenance can adjust the temperatures therefore removing the opportunity for any further incidents. (Completed March 4, 2015)

A. Based on interview, record review, and observation the facility failed to provide adequate supervision to prevent falls, failed to evaluate and analyze cause of falls, failed to implement fall related interventions, and failed to monitor effectiveness and modify fall related interventions for one of three residents (R2) reviewed for falls in the sample of three. These failures resulted in R2 falling and sustaining head/facial lacerations on three separate occasions and a fracture of the left elbow. Findings include: R2's physician's orders [REDACTED]. status as severely impaired. The MDS documents that R2 requires a two person extensive assistance with bed mobility, transfers, walking, and toilet use. The MDS documents R2 is not steady and is only able to stabilize with staff assistance. The MDS documents that R2 uses a walker and wheelchair for mobility. R2's POS dated 2/01/15, documents an order dated 2/03/15 as "Nurse to verify placement and function of alarm every shift." R2's fall care plan documents an intervention dated 12/20/14 to add half side rails for mobility. R2's fall care plan documents an intervention dated 11/28/15 to provide a motion sensor alarm and to continue with 15 minute checks. On 2/17/15 at 11:05 A.M., R2's Medication Administration Record (MAR) documents the nurse is to verify placement and function of the alarm every shift was not initialed on 2/11/15 for second shift and 2/08/15, 2/12/15, 2/14/15, and 2/17/15 for the third shift. On 2/17/15 at 11:05 A.M., R2 was lying in bed. No side rails were present on R2's bed. A motion alarm was on top of a bedside table angled toward R2's bed. Alarm did not sound when activated. At 11:10 A.M., E17 Licensed Practical Nurse (L.P.N.) called E25 (Maintenance Assistance) concerning the motion alarm not working. At 11:25 A.M., E25 took the alarm from the bedside table and exited room. On 2/17/15 at 11:05 A.M., E17 confirmed that R2's motion alarm was not working. E17 confirmed that there are no initials documented to verify placement and function of alarm on 2/11/15 for second shift and 2/08/15, 2/12/15, 2/14/15, and 2/17/15 for third shift. On 2/17/15 at 11:30 A.M. E17 confirmed that R2's bed did not have side rails. On 2/17/15 at 1:00 P.M., E17 stated that at 12:15 P.M. the motion alarm was working and placed back in room. E17 stated that from 11:05 A.M. to 12:15 P.M. no alarm was present in R2's room and that no one implemented a new fall intervention during that time. On 2/18/15 at 9:00 A.M., R2 was sitting across from the nursing station in a wheel chair facing a television. R2 had a hematoma and a large laceration with bruising above R2's right eye socket. Nurse's Notes dated 2/17/15 at 8:45 P.M. document that R2 was found on floor beside the bed. Nurse's Notes dated 2/17/15 at 9:00 P.M., document R2 was sent to the emergency room . Nurse's Notes dated 02/18/15 at 12:10 A.M., document that R2 returned to facility. Nurse's Notes at that time document R2 having a laceration in right eyebrow with five to six sutures, laceration to right upper nose with two sutures, laceration under right eye with three sutures, right eye swollen and dark purple, nose swollen, dried blood noted in bilateral nares and in mouth, and an abrasion under chin. On 2/18/15 at 9:30 A.M., E21 Certified Nurse's Assistant (C.N.A.) stated that E21 was on break at the time of R2's 2/17/15 fall. R2 stated, "Myself and (E20/C.N.A.) were assigned to (R2). I think (E20) filled out (R2's) 15 minute checks. (R2)'s alarms go off all the time. I do not think they keep (R2) from falling. One on one is a better way to go with (R2). A one on one is the only way to keep (R2) from falling. There is not enough staff to care for (R2). (R2) was antsy before I went to break so I took the bed remote away from (R2), because (R2) was moving the bed up and down." On 2/18/15 at 9:35 A.M., E20 (C.N.A.) stated, "I was on the 300 wing hallway helping another resident at the time of (R2's) 2/17/15 fall. E(R2)'s alarm frequently goes off. (R2) rips bed alarms apart. I thought (R2) did well in (R2)'s recliner. I think if someone was a one on one it would probably work good. No one has asked me about new interventions for (R2)." On 2/18/15 at 10:15 A.M., E15 Care Plan Coordinator stated, "I do not know the root cause of (R2's) 2/17/15 fall. I think the C.N.A.'s found (R2) on the floor. I am unsure who exactly found (R2) on the floor. (R2) prefers to sleep in the recliner. We do not have a recliner for (R2) to use. I didn't think about using the recliner in the TV room. The Interdisciplinary Team (IDT) decided on a perimeter mattress. The mattress was put on (R2)'s bed at 8:00 A.M. There were no new interventions added to (R2)'s care plan until this morning at 8:00 A.M., approximately 8 hours after (R2) returned from the hospital to the facility." On 2/18/15 at 10:30 A.M., E25 confirmed that E25 put a perimeter mattress on R2's bed at 8:00 A.M. On 2/18/15 at 10:45 A.M., E16 Registered Nurse (R.N.) stated, "On 2/18/15, (R2) came back to the facility around 12:10 A.M. per ambulance transport. (R2) stayed in (R2's) room all night. I talked to (E15) about (R2) transferring back to facility. (E15) told me it was ok for (R2) to come back by ambulance. We continued with (R2)'s sensor alarm and fifteen minutes checks. (R2) wasn't kept in constant sight. (R2) is quick and gives no warning when (R2) gets up. The most effective intervention would be a one on one. (E15) did not instruct me to do anything different for (R2)." On 2/18/15 at 2:25 P.M., E11 C.N.A. stated, "I was called to (R2's) room on 2/17/15 after (R2's) fall. I sat with (R2) and there was blood coming from (R2)'s eye. (R2) hit (R2)'s head on the corner of the night stand. No one has called me to investigate (R2)'s fall. (R2) falls frequently. (R2) did not fall as bad when (R2) had (R2)'s recliner. (R2) has an alarm. It did not go off when (R2) got up and fell . One of the C.N.A.s mentioned that the alarm had been moved because it kept going off. I am not sure who moved it. If there were more C.N.A.s it would help. We need three C.N.A.s down that hall because they are all two assist. No one can get their 15 minute checks done. There was no C.N.A.s on the hall when (R2) fell . (R2) hit (R2)'s head so hard the nurse heard it from the nurse 's station." On 2/18/15 at 2:25 P.M., E19 R.N. stated, "I found (R2) on the floor on 2/17/15 at 8:45 P.M. I found (R2) in the prone position and that (R2) appeared to have hit (R2's) face on the bedside table. At the time of (R2's) fall (E19) was sitting at nurse's station and heard (R2) fall. No one was on hallway at the time of the fall. One C.N.A. was on break and the other C.N.A. was helping a resident on another hall. I really hope for one on one assist for (R2). I think it would prevent (R2) from falling." R2's Resident Monitoring - 15 minute sheet dated 2/17/15, is incomplete from 1:30 P.M. to 12:00 A.M. On 2/18/15 at 9:15 A.M., E24 C.N.A. verified (E24) has not completed 15 minute checks for R2. On 2/18/15 at 9:15 A.M., E26 (CNA) stated, "I have not filled out 15 minute checks for (R2) today. I came on at 6:00 A.M. I usually fill out 15 minute checks on my breaks because I don't have time until my break. I am not sure of any new interventions for (R2). I haven't worked in a couple of days. I think (R2) needs a one on one because (R2) breaks (R2)'s alarms. No one has asked me what would work to prevent (R2) from falling." On 2/18/15 at 11:00 A.M., E1 Administrator stated, "After a resident falls, a quality assurance form is completed. The form is an internal form and I can answer questions regarding information contained on the form, but I can not provide a completed form for review. (R2) has had eighteen falls from 10/03/14 to 2/17/15. After a fall the IDT (Interdisciplinary Team) reviews it the next day during morning meeting to add new fall prevention interventions. On 12/20/14 at 6:00 A.M., (R2) was found lying next to the recliner. The IDT added the intervention of half side rails for mobility. The family refused the intervention so the side rails were not implemented. The IDT team did not re-evaluate or provide a new intervention when the family refused the side rails. On 1/25/15 at 3:40 P.M., (R2) fell attempting to self ambulate. The IDT added the intervention of therapy to evaluate and treat. (R2) was not evaluated by therapy and did not receive services. (R2's) falls on 12/31/14, 01/09/15, and 01/25/15 were caused from (R2) tripping over or being tangled up in a blanket. The IDT team has not discussed the blanket but I think we should have. On 2/2/15 at 4:40 P.M., (R2) was found on floor next to recliner. At that time (R2) alarm did not sound. New interventions to check the battery on the motion alarm and replace the battery if needed every shift was added to the care plan, and a new order for (R2) to see an orthopedist was added due to a left elbow fracture. (R2) has not been to the orthopedist. On 2/17/15 at 8:45 P.M., (R2) fell . The root, cause, and analysis of the fall has not been determined yet. They have five days to figure that out and complete the investigation. The IDT decided to put a perimeter mattress on (R2's) bed because it is the least restrictive intervention they could come up with. I am unsure who found (R2) on the floor. (R2) fell from bed and I am unsure if the motion alarm was sounding or not sounding. A one on one could have prevented the falls. We have not tried a one on one because it is the last resort because of staffing and cost effectiveness. We are not equipped to do a one on one. I am aware that (R2) breaks alarms and that the alarms probably annoy (R2). I would expect the staff to replace the alarm right away if the alarm is not working or the batteries need replaced. It is my expectation that if a C.N.A. takes a break the other C.N.A. stay on the hallway. Fifteen minute checks should be filled out after the check is done. The C.N.A.s should communicate with each other. The C.N.A.s should not be waiting to complete their fifteen minute checks until break or the end of their shift. Blanks on the fifteen minute check sheets and on the Medication Administration Record would indicate that they did not do it. The Director of Nursing should be monitoring that. (R2) started falling more after (R2) was sent to the hospital in October. After they adjusted (R2)'s psychotropic medications (R2) began falling more. You know how it is they medicate them and send them back all doped up and they start falling. I think the psychotropic medications have caused (R2) to fall more." On 2-17-15 at 3:15 p.m., E1 (Administrator) stated, "We had a system failure with (R2). I spoke with corporate and they agree we have had a system failure." On 2/18/15 at 2:00 P.M., R2's spouse stated, "I visit every other day. (R2) did not have falls prior to being here. We feel like the staff are not here on time. When (R2)'s light is on they do not respond for at least twenty minutes. This has went on for at least six months on all shifts. I think they are short staffed. During the meal time the staff are in the dining room and no one is left on the hall to toilet (R2). When I am here visiting it takes them at least three hours before they toilet (R2). (R2) never falls when I am here because I help (R2) to the bathroom. The staff just walk on by when the call light is on. When I go to get staff to help take (R2) to the bathroom the staff tell me (R2) is not the only one we take care of here. I have never heard (R2)'s alarm work before today. (R2) has declined because the staff do not walk (R2). I feel like (R2) has fell more since (R2) has returned from the hospital in October." ¡¡ On 2/19/15 at 10:30 A.M., E4 C.N.A. and E12 C.N.A. transferred R2 from the wheelchair into the bed. The motion sensor alarm was on bedside table pointing away from the bed. E4 and E12 left R2's room. On 2/19/15 at 10:40 A.M., E4 confirmed R2's motion alarm was pointed away from the bed. E4 confirmed the motion alarm should point towards the bed. E4 confirmed that it would not sound if R2 got out of bed. E4 confirms E4 did not check it prior to leaving the room. ¡¡ ¡¡ The 12/2009 Fall Prevention Policy documents, "Report all falls during the morning Quality Assurance meetings Monday through Friday. All falls will be discussed and comments will be written on the Fall Tracking Form and any new interventions will be written on the care plan." ¡¡ ¡¡ B. Based on observation, interview, and record review, the facility failed to implement fall interventions for one of three residents (R1) reviewed for falls in the sample of three.' ¡¡ Findings include: On 2-18-15 at 9:00 a.m., R1 was propelling self in a wheelchair, down the hallway. R1 did not have an alarm attached to the wheelchair or to self. ¡¡ R1's current fall care plan includes interventions to provide R1 with a television remote and apply a body alarm to R1 while in the wheelchair. ¡¡ On 2-18-15 at 8:50 a.m., E4 (CNA) verified R1 did not have an alarm on. On 2-18-15 at 10:00 a.m., E1 (Administrator) stated, "The nurse misunderstood this morning. (R1) should have had an alarm on." On 2-17-15 at 2:25 p.m., E2 (Care Plan Coordinator) stated, "(R1's) current fall interventions include educating (R1) to seek assistance, provide (R1) with a television remote, and attach a body alarm to (R1's) self and wheelchair." On 2-17-15 at 2:00 p.m., E6 (Certified Nursing Assistant/CNA) stated, "(R1) does not have a television remote. (R1) never has. We do not have spare remotes to give out. (R1) watches television every night." On 2-17-15 at 2:45 p.m., E1 verified E1 had told staff to get R1 a remote, but the staff did not. E1 verified R1 should have had a remote since sustaining a fall on 1-30-15, but had not received it yet.

Based on observation, interview, and record review, the facility failed to maintain a safe physical environment for three of three residents (R1, R2, R3) reviewed for environmental hazards in the sample of three and one resident (R31) in the supplemental sample. This failure resulted in R2 falling and obtaining a left lower arm fracture. Findings include: 1. R2's Nurses' Notes dated 6-3-14 at 9:00 p.m., document R2 was trying to close the closet door, tripped over the walker, fell , complained of left wrist pain, and was sent to the Emergency Department. A Final Investigation Report dated 6-6-14 and signed by E1 (Administrator), documents on 6-3-14, R2 was found laying in R2's room, on the floor, with the walker on top of R2. R2 stated the closet door stuck when R2 was trying to close it and R2 tripped, fell , and complained of left wrist pain. R2 was sent to the emergency room and was admitted to the hospital for a left wrist and elbow fracture. R2's X-ray report dated 6-3-14, documents R2 has a non-displaced distal radial (forearm) fracture. On 6-17-14 at 1:50 p.m., R2 was in a wheelchair with the left arm wrapped and in a sling. R2 stated, "I was trying to close my closet door a couple weeks ago, and the door stuck to the floor. I tried to jerk the door, until the door finally broke loose, causing me to trip and fall. I fractured my arm because of the fall. My middle closet door sticks to the floor, also. The staff knew the closet door did not work right, but no one fixes anything around here, until someone gets hurt. Maintenance did not fix my closet door until I fell and fractured my arm. Maintenance still has not fixed my middle closet door. My bed does not lock, either. I am afraid when I am going to bed that my bed is going to move and make me fall. The staff know about that and have not fixed it, either." On 6-17-14 at 1:55 p.m., R2's right head of the bed and left foot of the bed brakes would not lock, and the right foot of the bed brake was missing, causing the bed to move freely. R2's middle closet door rubbed against the floor and was hanging off of the hinges at the top, causing it to catch on the floor, when attempting to open it. On 6-17-14 at 2:30 p.m., Z2 (Physical Therapy Assistant) transferred R2 from the wheelchair to the bed. During the transfer, R2's bed moved. Z2 stated, "When I transferred (R2) to bed, R2's bed brakes did not work, causing (R2's) bed to move. That is a fall risk for (R2)." On 6-17-14 at 2:30 p.m., E7 (Certified Nursing Aide/CNA) stated, "(R2) fell a couple of weeks ago. (R2) was lying on the floor with the walker. (R2) told me that the closet door would stick on the floor, and caused (R2) to fall. I know (R2's) closet door in the middle is off track, and doesn't work. (R2's) brakes on the bed do not work, either. I have reported (R2's) brakes on the bed not working to maintenance for several days now. I have given maintenance a slip stating (R2's) brakes do not work. It is a fall risk to (R2)." On 6-17-14 at 2:05 p.m., E3 (Maintenance Director) stated, "I am not aware of (R2's) brakes on the bed not working or (R2's) other closet door not working. I was told (R2) tripped and fell because the other closet door was sticking. I raised (R2's) that closet door up after the fall. On 6-18-14 at 9:45 a.m., E8 (CNA) stated, "(R2's) closet door has stuck for several months, prior to (R2) falling. I just used a hanger to open it. I did not report (R2's) closet door not opening right, because it does no good to report it." On 6-18-14 at 8:45 a.m., E1 (Administrator) stated, "(R2) fell because the closet door got stuck. The staff had not reported the closet door sticking, prior to (R2) falling. The staff should report any closet doors sticking to the floor immediately to myself or maintenance. If the staff report repairs needing done to maintenance, and the repairs do not get done, then the staff should report to a charge nurse or myself." 2. R1's Final Investigation Report dated 6-4-14 and signed by E1, documents, "On 6-1-14, (R1) got stuck on the non skid strips in front of R1's chair, and fell , resulting in a mid back fracture. To prevent reoccurring falls, physical therapy is to evaluate (R1), and the non skid strips in front of (R1's) chair will be removed." On 6-17-14 at 1:15 p.m. and 6-18-14 at 9:35 a.m., R1 was sitting in the reclining chair, with three non skid strips on the floor in front of the chair. On 6-18-14 at 9:55 a.m., E1 verified the three non skid strips were still on the floor in front of R1's chair, and should have been removed to prevent further falls. 3. On 6-17-14 at 9:20 a.m., the 100/300 C Hall shower room had a chair commode with four partially rusted out legs, that were missing paint. On 6-17-14 at 1:15 p.m., R1 stated, "I have noticed the legs on the shower chair being rusty. I have told the staff that continuing to use that chair could be fatal. They still have not got a new one." On 6-17-14 at 1:50 p.m., R2 stated, "The bottom of the shower chair I use is rusty, and I am afraid I am going to fall." On 6-17-14 at 1:40 p.m., R3 stated, "The legs on the shower room chair are rusty. It is not safe. It could break." On 6-17-14 at 1:30 p.m., R31 stated, "The shower chair is dirty and rusty. It always looks unsafe to sit on." On 6-17-14 at 9:20 a.m., E2 (Housekeeping Supervisor) stated, "No one has reported the chair commode having rusty legs. It needs to be replaced." On 6-17-14 at 1:35 p.m., E9 (CNA) stated, "I have known about the shower commode chair legs being rusty for months. I tell maintenance about it." An undated Maintenance Services policy documents, "The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times."

Based on interview and record review the facility failed to administer insulin as ordered by a physician for one of nine residents (R4) reviewed for insulin administration in a sample of 13. This failure resulted in a three day hospitalization in intensive care for R4. Findings include: R4's Nurse's Notes document on 1/31/14 at 7:45 p.m. "medication discrepancy discovered (R4) given inappropriate amount of insulin, [MEDICATION NAME] (insulin). Z1 (Physician) notified....send to ER (emergency room ) for evaluation." R4's MAR (Medication Administration Record) documents R4 gets a sliding scale of [MEDICATION NAME] insulin. On 1/31/14 at 7:00 p.m. R4's MAR documents R4's blood sugar level was 338. R4's MAR documents for a blood sugar reading of 338 R4 would receive 8 units of insulin. The same MAR also documents R4 received [MEDICATION NAME] (insulin) 30 units at 8:00 p.m. R4's hospital report dated 1/31/14 documents "sent to ED (Emergency Department) because he (R4) received too much insulin....patient was supposed to get [MEDICATION NAME] 8 units and [MEDICATION NAME] 30 Units but instead received 84 units of [MEDICATION NAME]and 30 units of [MEDICATION NAME]." R4's History and Physical dated 2/1/14 documents: "........yesterday he (R4) got a wrong dose of 84 units of [MEDICATION NAME]instead of 8 at 7:20 p.m........his sugar (blood sugar) was 266 however, began to drop and had to be put on a D10 ([MEDICATION NAME]/sugar) IV (intravenous) drip and sent to the ICU (Intensive Care Unit) with q (every) 1 hour vitals and accu checks (blood sugar monitoring)." The same history and physical documents R4 was on the D5 IV drip for 8-10 hours. On 3/13/14 at 1:30 p.m. E4 LPN (Licensed Practical Nurse) reported that E4 completed R4's blood sugar reading on 1/31/14 around 7:20 p.m. E4 stated "I can't remember what the reading was." E4 stated E4 misread the MAR and thought it said R4 was to get 84 units of insulin based on R4's sliding scale. E4 stated needing to use 2 syringes to administer the insulin. E4 stated after administering the insulin to R4, E4 went back to R4's medication cart and realized the wrong amount of insulin was administered to R4. E4 reported calling the physician right away and R4 was sent to the hospital. On 3/13/14 at 10:05 a.m. R4 stated on 1/31/14 a nurse gave him insulin about 7:30 p.m R4 stated the nurse then came back a short time later and told R4 he was given too much insulin and "could die." R4 reported coming back to the facility on a Sunday and on the following Monday R4 spoke to E2 DON (Director of Nursing) because R4 was afraid a nurse would give the wrong medicine or the wrong dose of Insulin and "they would kill me."

Based on record review and interview the facility failed to document assessments of resident's pain location and intensity before administering scheduled and non scheduled pain medications, and failed to assess residents' responses to pain medications that were administered for seven of seven residents (R3, R8, R9,R10, R11, R12, R14) reviewed for pain in a sample of 13. Findings include: On 8-28-13 at 10:40a.m. E2 (Director of Nursing) stated that pain assessments are performed on all residents at least once per shift and also performed when non scheduled pain medications are administered. On 8-28-13 at 9:15p.m. E28 (Licensed Practical Nurse) stated that every resident receives a pain assessment at least once per shift, before non scheduled pain medications are administered. E28 stated that residents are also assessed for the effectiveness of the pain medications administered. On 8-28-13 at 9:30a.m. E8 (Licensed Practical Nurse) stated that every resident receives a pain assessment at least once per shift. On 8-28-13 at 11:49 E2 (Director of Nurses) stated, "Pain is a problem. If it is not documented then they are not assessing." 1. A physician's orders [REDACTED]. R3's pain management flow sheet dated 8/01/13 to 8/26/13 does not include an assessment for pain on the following dates 8/02/13 to 8/05/13, 8/09/13 to 8/12/13, 8/17/13 to 8/18/13, 8/20/13 to 8/22/13, 8/24/13, 8/26/13, 8/27/13. The same pain management flow sheet documents that only one pain assessment was performed on the remaining days. 2. A physician's orders [REDACTED]. A controlled substances log dated 8/20/13 to 8/28/13 documents that R8 had been administered the pain medication [MEDICATION NAME]/[MEDICATION NAME] 23 times during that time . R8's pain management flow sheet and pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. A physician's orders [REDACTED]. A controlled substance log dated 8/22/13 to 8/28/13 documents that R9 been administered the pain medication [MEDICATION NAME]/ [MEDICATION NAME] seven times during that time. R9's pain management flow sheet and pain administration record dated 8/2013 document that R9 was assessed for intensity, location of pain, and effectiveness of pain medications only four times from 8/1/13 to 8/27/13. 4. A physician's orders [REDACTED]. A controlled substance log documents dated 8/23/13 to 8/27/13 documents that R12 had been administered the pain medication [MEDICATION NAME]/ [MEDICATION NAME] seven times during that time. R12's pain management flow sheet and pain administration record dated 8/2013 document that R12 was assessed for intensity, location of pain, and effectiveness of pain medications only six times. 5. A physician's orders [REDACTED]. R14's Pain Management Flow Sheet dated 8/1/13 through 8/28/13, documents R14's pain was only assessed once per day on 8/4/13 to 8/7/13, 8/9/13 to 8/13/13, 8/15/13, and 8/27/13 to 8/28/13. R14's pain was not assessed on 8/1/13 to 8/3/13, 8/8/13, 8/14/13, 8/16 to 8/26/13. 6. A physician's orders [REDACTED]. R11's Pain Management Flow Sheet dated 8/1/13 through 8/28/13, documents R11's pain was only assessed once per day on 8/1/13 to 8/2/13, 8/5/13, 8/8/13, 8/9/13, and 8/11/13, 8/12/13, 8/15/13, 8/24/13, 8/25/13, and 8/27/13. R11 received PRN pain medication on 8/9/13 at 3:20 a.m. and 8/13/13 at 3:40 a.m. and a pain assessment was not documented pre or post administration of medication and did not include location of pain or intensity. 7. A physician's orders [REDACTED]. R10's Pain Management Flow Sheet dated 8/1/13 through 8/28/13, documents R10's pain was only assessed once per day on 8/2/13, 8/6/13, 8/8/13 to 8/11/13, 8/13/13, 8/15/13, 8/21/13, 8/24/13, 8/25/13, 8/27/13.

Based on observations, record review and interview, the facility failed to assess, develop and implement individual pain interventions for one of one resident (R3) experiencing pain in the sample of 22. This failure resulted in R3 having episodes of pain in the chest and back as result of fall. The facility also failed to follow their policy to monitor pain for eight of eight residents (R3, R7-12, and R14) reviewed for pain in the sample of 22. Findings include: 1. Facility Pain Prevention and Treatment policy dated 1/2010 documents "an assessment of pain will be completed with changes in residents condition, self reporting of pain, or evidence of behavior cues indicative of the presence of pain and documented in the nurses notes or on the Pain Management Flow Sheet. This will include, but not limited to, date, rating, treatment intervention, and resident response. The Pain Management will be initiated for those residents with daily pain, [DIAGNOSES REDACTED].e., fractures)". On 7/21/2013 from 4:30 p.m. to 4:45 p.m., R3 was sitting near the nurses' station in a wheelchair displaying facial grimacing and yelling loudly "Ow". On 7/21/2013 at 4:45 p.m., when R3 was asked about pain R3 nodded (R3's) head yes and pointed at (R3's) center upper chest and back. On 7/21/2013 at 4:50 p.m., E15 (Patient Care Coordinator) asked R3 if R3 was having pain. R3 replied, "Yes". On 7/22/2013 at 11:10 a.m., E23 (Certified Nurse Assistant, CNA) stated, "R3 always complains of pain and seems to hurt everywhere, everyday." On 7/22/2013 11:30 a.m., R24 stated, "R3 do you (R3) have pain?" R3 pointed at R3's chest and stated, "Yes. Terrible pain." R24 stated, "Ask the nurse and she can give you (R3) something." On 7/22/2013 at 2:20 p.m., E20 (CNA) and E21 (CNA) transferred R3 from a wheelchair to a reclining chair using a transfer (gait) belt across R3's upper chest area. During placement of the transfer belt R3 yelled "Ow. Ow. Just a minute". During transfer, R3 yelled, "Take it off. Ow. Ow. Ow. Down. Down." E11 (Registered Nurse Consultant), E22 (CNA), and E1 (Administrator) were present during transfer. On 7/22/2013 at 9:55 a.m., E4 (Care Plan Coordinator) confirmed that R3's care plan dated 5/23/2013 did not include interventions for pain. On 7/22/2013 10:07 a.m., E18 (Licensed Practical Nurse, LPN) stated, "We are not doing a pain management flow sheet for R3." On 7/22/2013 at 10:12 a.m., E2 (DON) stated, "Every resident, every shift should have a pain assessment completed." E2 stated, "I am having a problem getting the staff to fill them out." On 7/22/2013 at 3:15 p.m., Z1 (R3's Physician) states, "I was not aware that (R1) was having pain issues. Thanks for letting me know and I will call R3's nurse. I didn't really have (R3) on any strong pain medicine. I will talk to facility about completing R3's transfers." Fall Analysis Log documents R3 fell on [DATE] resulting in rib pain. Local emergency room report dated 5/23/2013 R3 states, "acute (new) fractures of R3's third, fourth, eighth and ninth ribs." Fall Analysis Log documents R3 fell on [DATE] resulting in about a 2 inch cut on R3's forehead requiring 8 stitches and R3 fell on [DATE] with no injury. Nurses' notes document R3 with unrated signs and symptoms of pain or discomfort on 5/22/2013, 6/17/2013, 7/07/2013, 7/08/2013, 7/21/2013, and 7/22/2013. PRN (as needed) Medication Information Sheet indicates that R3 received pain medication at 7/22/2013 at 7:30a.m., and next on 7/23/2013 at about 6:30 a.m. PRN (as needed) Medication Information sheet indicates on 7/23/2013 at about 6:30 a.m., R3 assessed for pain R3 indicated 10 on a scale of zero to 10 with 10 being highest level of pain and R3 received 50 milligrams (m.g) of [MEDICATION NAME] (pain medication). 2. R12's Physician order [REDACTED]. R12's physician progress notes [REDACTED]." R12's Physician order [REDACTED]." These same orders also document the medication order, "[MEDICATION NAME] one tablet by mouth every four to six hours as needed for pain." Facility's Pain Prevention & Treatment Policy dated January 2010 documents, "The Pain Management Flow Sheet will be initiated for those residents with but not limited to: routine pain medication, daily pain, [DIAGNOSES REDACTED].e. arthritis, wounds, fractures, etc.)" On 07/23/13 at 1:42 p.m., R12 was laying in R12's bed. R12 verified that R12 takes [MEDICATION NAME] daily, "for my back pain and pain in my left leg." R12 then stated that facility staff does not ask about R12's pain, or the effectiveness of R12's scheduled [MEDICATION NAME] dose. R12 also stated, "it ([MEDICATION NAME]) really isn't effective at all. My leg always hurts." R12's medical record did not contain Pain Management Flow Sheets, verified by E2, Director of Nursing, on 07/22/13 at 10:12 a.m. On 07/22/13 at 10:45 a.m., E18, Licensed Practical Nurse, stated the facility is not completing Pain Management Flow Sheets. R7's medical record does not contain Pain Management Flow Sheets, as documented on R7's Care Plan dated 04/27/13. R8's medical record does not contain Pain Management Flow Sheets, as documented on R8's Care Plan dated 07/23/13. R9's medical record does not contain Pain Management Flow Sheets, as documented on R9's Care Plan dated 05/12/13. R10's medical record does not contain Pain Management Flow Sheets, as documented on R10's Care Plan dated 04/30/13. R11's medical record does not contain Pain Management Flow Sheets, as documented on R11's Care Plan dated 04/04/13. R14's medical record does not contain Pain Management Flow Sheets, as documented on R14's Care Plan dated 06/28/13.

Based on interview,observation, and record review, the facility failed to obtain physician ordered narcotic pain medication for one resident (R20) of six residents reviewed for pain in the sample of 22 residents. R20 expressed severe pain and did not receive physician ordered narcotic pain medication for forty hours after admission. Findings include: R20 was admitted on [DATE] at 4:00 pm with a [DIAGNOSES REDACTED]. R20's admission orders [REDACTED]. Pain Assessment, dated 8/22/12 at time of admission, indicates that R20 rates her pain at "10" on a pain scale of 1 to 10. Pain Assessment also indicates that R20 has "almost constantly" for pain frequency, has been difficult for her (R20) to sleep and has limited her day to day activities. This Pain Assessment for R20 rated her pain as a "4" for intensity indicating "very severe, horrible." On 8/31/12 at 9:35 am, when questioned how her first few days in the facility had been, R20 stated, "It didn't go good, I was hurting. My back and left shoulder was hurting real bad. They were giving me Tylenol and that wasn't helping me at all." Nurses Notes on 8/22/12 at 5:00 pm state that R20 complained of pain frequently to her back and legs and that the nurse informed R20 that when her (R20's) medications came in from pharmacy she would give her something. Nurses Notes on 8/22/12 at 8:15 pm, state that the facility received a fax from the pharmacy informing the facility that the pharmacy had not received a signed prescription from Z2 (R20's Physician). Z3 (On Call Physician) stated he would notify Z2 in the morning about R20's medication situation. Nurses Notes on 8/23/12 at 2:00 pm, states R20 had "C/O (complaints of) pain. Tyl E (Tylenol Extra Strength) given. (R20) Wants something stronger." This Note also indicates that pharmacy was called and facility was to receive the narcotic pain medication the night of 8/23/12. R20's POS (Physician order [REDACTED]. R20's Nurses Notes on 8/23/12 at 10:00 pm states R20 "Refused to get out of bed this shift D/T (due to) severe pain to back. Still awaiting meds (medications) from pharmacy." On 8/31/12 at 9:10 am, E2 DON (Director of Nursing) stated Z1 (Medical Director) should have been notified if Z2 (R20's Physician) could not be reached. E2 also stated the facility has a narcotic back up box that includes [MEDICATION NAME] 5/325 mg, [MEDICATION NAME] 5/500 mg and [MEDICATION NAME] 10/325 mg that the nurse has access to if needed. E2 stated she did not know why these steps were not taken by nursing staff to obtain R20's medication to relieve her severe pain. On 8/31/12 at 9:40 am, E2 DON states that R20's [MEDICATION NAME] was delivered with the normal delivery the morning of 8/24/12 between 1:00 am and 2:00 am. Controlled Substances Proof of Use Sheet indicates the first dose of [MEDICATION NAME] was administered on 8/24/12 at 8:00 am, forty hours after R20 was admitted complaining of pain. On 8/31/12 at 10:45 am, E10 LPN (Licensed Practical Nurse) confirmed that she gave R20's physician ordered [MEDICATION NAME] on 8/24/12 at 8:00 am.

Based on observation, interview and record review, the facility failed to transfer one of three residents with recent falls on the sample (R1) from the facility van to ground level on 8/9/10, resulting in multiple injuries, including fractures, to R1. The facility also failed to care for one of three residents with recent falls on the sample (R2) in a safe manner using a shower bed, resulting in a fall for R2 on 8/16/10. Findings include: 1. A facility incident report dated 8/9/10 indicated that on that day, a facility employee "carelessly failed to safely transfer a resident (R1) from facility van after an appointment." The report stated that the employee released R1's safety harness and proceeded to push R1's wheelchair onto the lift platform of the van, which was still in the "down" position. The report stated that the resident fell from the van causing serious injury, including two small hematomas and fractures to three toes. The report indicated that R1 was sent to the hospital, and then returned to the facility the next day. The report also indicated that the employee's employment was terminated for causing the incident. A facility investigation report dated 8/9/10 indicated that upon interview with E1 (Administrator) on 8/10/10, E7 (Transport Aide) stated that after returning from appointments at 4:05 PM the previous day, E7 unloaded two other residents and then unhooked the safety harness on R1. E7 said that E7 went to push R1's wheelchair back onto the lift, and then realized that the lift was in the "down" position. E7 stated that as R1 in the chair started to roll off the back of the van, E7 tried to grab the wheelchair, but could not stop it. E7 said the wheelchair caught on the arm rails of the van lift, and the resident fell on the pavement of the parking lot. E7 then stated that E7 ran to R1's side and got R1 a pillow. E7 stated R1 said at the time that R1 was "fine," but there was blood on R1's foot. E7 said that E7 then ran in the building to summon a nurse to evaluate R1. E3 (Assistant Director of Nursing) stated on 9/30/10 at 10 AM that she had been paged outside the building at about 4:15 PM on 8/9/10. E3 said at that time E3 saw R1 lying on R1's left side in the parking lot behind the facility van with the wheelchair off to the side. E3 said R1 had a bruise on the back of R1's head about three to four centimeters (cm) wide and elevated about two cm. E3 said that R1's second toe on R1's foot was misaligned and bleeding. E3 said R1 answered questions appropriately at the time, but was very hot from lying on the pavement. E3 stated that E3 sent a nurse aide in the building to get a mechanical lift and a nurse. E3 said that R1 was then lifted into the wheelchair with the mechanical lift and wheeled back into the building, where nurse E6 did a full assessment of R1. E3 said that E3 and E6 told R1 that R1 had to be sent to the hospital for assessment, but R1 started crying and did not want to go there, since R1 had been in the hospital for a long stay lately. Nurse E6 stated on 9/30/10 at 10:50 AM that by the time she responded to the need for help with R1 out in the parking lot on 8/9/10, staff were already bringing R1 through the door. E6 said that R1's head injury was of the most concern to E6. E6 said that R1 had a "goose egg" on the back of her head, about three centimeters wide and elevated about two centimeters. E6 also said that R1's left leg was bleeding. E6 said that E6 told R1 that R1 had to go to the hospital for evaluation, but that R1 did not want to go. E6 said that R1 did agree to go to the hospital with some reassurance that she would not have to go alone. E6 said that R1's neurological checks and vitals were stable before R1 was transported to the local hospital via ambulance. E6 said that R1 was transferred from the local hospital to the trauma center hospital in Peoria, due to the head injury. E6 said that R1 then came back to the facility the next day. E6 said R1 was at the facility for a few days until R1 repeatedly complained of pain in her left side, and had to be sent to the hospital again. During that second hospital stay, it was learned that R1 also had sustained more fractures from the fall, including broken ribs. A 8/9/10 radiology report from the local hospital indicated that R1 had sustained fractures of the second, third and fourth distal metatarsals of the left foot. A computer tomography (CT) brain scan report for R1 dated 8/9/10 indicated that R1 had sustained a "small epidural and possible subdural hemorrhage in relation to the left frontal lobe and a "small subdural hemorrhage in relation to the right posterior frontal/parietal lobe." In addition to these results, the hospital's emergency room report dated 8/9/10 indicated that R1 sustained a left shoulder contusion and low back strain as well from the fall. R1's nursing notes dated 8/10/10 indicated that R1 returned to the facility from the local hospital at 7 PM that day. The notes indicated that in the evening of 8/13/10, R1 repeatedly complained of chest pain that was not relieved by pain medication. The notes stated that R1 was transferred to a Peoria hospital at 8 PM that day. An 8/23/10 discharge summary report from the Peoria hospital for R1's 8/13/10 admission indicated that an x-ray showed a right 11th rib fracture for R1. The report also stated that a Magnetic Resonance Imaging (MRI) exam done for R1's left foot showed "fractures of the distal metatarsal, cuboid, distal tibia." R1's nursing notes dated 8/23/10 indicated that R1 returned from the hospital at 7 PM that day with new [DIAGNOSES REDACTED]. R1 stated on 9/30/10 at 10:40 AM that almost two months after falling from the van, she still has a little bruise on the back of her head and her left shoulder still hurts some. R1 said that all she really remembers about the accident was when she was actually falling out of the van. R1 said that she had a cast on her foot and ankle for a while, but that came off about a month ago. R1 said that her foot still hurts a little. On 9/30/10 at 11:20 AM, inspection of the facility van with E1 (Administrator) indicated that there was a measured distance of approximately 28 inches from the rear floor of the van, where the power lift is located, to the ground. When the lift was operated, and the lift platform was at the ground level; a beeping alarm and a flashing red light at a box at the rear side of the van was activated. E1 stated at the time that this alarm unit was always in the van, but before the accident, it only activated when pressure was applied to the yellow floor plate adjacent to the rear lift platform. E1 said that this alarm unit was modified after the accident to sound and light all the time when the lift platform is in the "down" position, so as to remind the operator. 2. The facility's August 2010 incident/accident log indicated that on 8/16/10 R2 rolled off a shower bed and fell , sustaining a back injury. The log entry also indicated that a nurse aide was educated concerning the matter. A facility incident report dated 8/16/10 indicated that at 8:30 PM that day, R2 fell in his room and reported back pain. The report also indicated that R2 was sent to the local hospital emergency room for evaluation. The report recommended that the nurse aide involved be educated on "proper lift and transfer technique from shower bed." The local hospital emergency room report dated 8/17/10 indicated that R2 was diagnosed with [REDACTED]. A signed statement dated 8/16/10 from nurse aide E9 indicated that while E9 was cleaning feces off of R2 on a shower bed, the resident slid off the bed. A facility "Supervisor Report of Counsel" form dated 8/17/10 indicated that E9 was counseled for failing to use "proper safety device or equipment and failed to comply with safety precautions." The report further stated that the aide failed to transfer the resident (R2) to the bed from the shower bed before attempting to clean up the resident, resulting in R2's fall. R2's care plan dated 6/30/10 indicated that the resident has "muscle rigidity due to Parkinson's disease," has a "history of falls" and needs to be monitored "for changes in trunk control."