Every finding on record at Village at Victory Lakes, The

Based on observation, interview, and record review, the facility failed to ensure staff used a resident transfer device in a safe manner for 2 of 5 residents (R1, R2) reviewed for safe transfers in the sample of 5. This failure led to R1 being transferred unsafely and dislocating R1's hip.The findings include:R1's Facility Final Report dated 5/8/26 showed on 5/8/26, R1 was being transferred with a assistive transfer device (ATD). R1 was unable to be adjusted safely onto the toilet, was lowered to the floor, and 911 was called to transfer R1 to the hospital.R1's Facility assessment dated [DATE] showed R1 has moderate cognitive impairment. R1 was admitted to the facility on [DATE] with diagnoses which include right femur fracture, post right artificial hip joint replacement, muscle wasting and atrophy, and dislocation of internal right hip prostheses. This assessment showed R1 is a fall risk. This assessment showed R1 is dependent on staff with toileting and bed to chair transfers.On 5/14/26 at 9:00 AM, R1 stated he was incontinent of stool. R1 stated V10 (Certified Nursing Assistant-CNA) cleaned R1 up and was getting him up with the ATD to get to his wheelchair. R1 stated he started to have more incontinence while standing in the ATD so V10 brought him into the bathroom. R1 stated they put the brakes on the ATD and undid the seat from behind R1. V10 started walking back around the ATD away from R1. R1 went to sit back onto the toilet. R1 stated he was too far away from the toilet and sat on the very front edge of the seat. R1 started sliding down the edge of the toilet when V10 came back around the ATD and tried to get R1 all the way onto the toilet. V13 (R1's wife) came into the bathroom. V10 and V13 guided R1 to the floor. R1 stated on the way down he felt a pop and yelled my leg just broke.On 5/14/26 at 9:10 AM, V13 stated they were in R1's room at the time V10 transferred R1 into the bathroom. V13 stated they could not see into the bathroom from where they were sitting in the room. R1 started yelling and V13 rushed into the bathroom to see R1 on the front edge of the toilet. V10 could not get R1 onto the toilet so V13 assisted V10 with lowering R1 to the floor. When R1 was on the way down R1's leg turned inward. R1 started yelling in pain I just broke my leg. R1 stayed on the floor of the bathroom until the paramedics came. V13 went with R1 to a local hospital. V13 stated R1 was admitted with a dislocated right hip. R1 was admitted to the facility after he fell at home, broke his right femur, and had a new hip joint put in.On 5/14/26 at 10:15 AM, V10 was accompanied by V2 (Director of Nursing) for an interview. V10 stated R1 started having loose stools while being transferred with the ATD so V10 brought R1 into the bathroom. V10 stated they put the brakes on the ATD in front of the toilet to get the seat out of the way. The seat rotates out of the way. V10 stated you cannot rotate the one side of the seat out of the way due to the toilet paper holder is in the way so you have to park the ATD in front of the toilet, move the seat out of the way, remove the resident's clothes, and then pushed the ATD over the toilet so they can sit down. V10 stated R1 started sitting down before V10 moved the ATD over the toilet. R1 was on the front edge of the toilet and started sliding down. V10 stated R1 was yelling and V13 came into the bathroom. V10 and V13 lowered R1 to the floor. V10 stated R1's leg rotated inward and R1 yelled I just broke my leg!R1's Hospital Discharge summary dated [DATE] showed R1 was admitted to the hospital with a diagnosis of dislocation of right hip. This summary showed that R1 had a closed reduction of the right hip under general anesthesia on 5/9/26.The facility's Safe Lifting and Movement of Residents Policy dated 7/2017 showed to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.The ATD Manufacture's Instruction Manual dated 8/2019 showed when transferring a resident to the toilet the ATD should be close enough for the resident to be able to sit down on the toilet.once the resident is in place, apply the castor brakes and ask the patient to stand. Remove the patient's clothes as necessary, then pivot the seat halves upwards to allow the patient to lower herself/himself onto the toilet.2. R2's Facesheet dated 5/14/26 showed R2 was readmitted to the facility on [DATE] with diagnoses which include wedge compression fractures of the spine, encounter for other orthopedic aftercare, muscle wasting and atrophy, abnormal gait and mobility, and presence of right artificial knee jointOn 5/14/26 at 9:55 AM, V9 (CNA) used the ATD to transfer R2 to the toilet. V9 moved R2 into the bathroom. The ATD was approximately 1-1.5 feet in front of the toilet. V9 put the brakes on, went around the back of the ATD to rotate the seat halves from behind R2 to the sides of the ATD R2 then lowered R2's pants and brief. V9 then came back around the ATD, took the brake off, and pushed R1 over the toilet to sit down.On 5/14/26 at 10:20 AM, V9 stated you must move the seat out of the way before you get over the toilet. When you are over the toilet the seat cannot rotate past the toilet paper holder. It is in the way unless you park the ATD out in front of the toilet. V9 stated that was the reason they stopped, to move the seat and lower R2's pants. When asked if V9 has told anyone about the ATD not being able to be over the toilet to move V9 stated the CNAs know, but V9 has not told anyone in therapy or the nursing staff.On 5/14/26 at 12:05 PM, V6 (Occupational Therapist) (phone interview) stated the ATD should be in position over what the resident is going to be sitting on (bed, wheelchair, toilet). The seat should only be removed from behind the resident when the resident is ready to sit down. The ATD should not have the brakes off and be moved without the resident sitting on the chair portion. V6 stated moving a resident without the seat or strap in place is unsafe. V6 stated they had not been made aware there is a spacing issue with removing the seat when toileting a resident.On 5/14/26 at 12:30 pm, V2 (Director of Nursing) stated they were not made aware the CNA staff were having problems with the ATD seats and the toilet paper/wall spacing when toileting residents.

Based on interview and record review the facility failed to immediately identify the code status and initiate Cardiopulmonary Resuscitation (CPR) to a resident (R96) who had elected to be a full code. This failure resulted in an approximate 2 - 4 minute delay in initiating CPR to R96 who was pronounced deceased on [DATE] at the facility. This applies to 1 of 3 residents (R96) reviewed for resident death in the sample of 18. This failure resulted in an Immediate Jeopardy on [DATE] when V5 Certified Nursing Assistant (CNA) found R96 without a pulse or respirations, V5 did not begin CPR, she exited R96's room and went to find V3 Registered Nurse (RN). V3 and V5 both returned to R96s room and V3 confirmed that R96 was not breathing and did not have a pulse, both staff without starting CPR or calling a code again left R96s room to inform V6 (RN) that R96 had passed away. V1 (Administrator) and V19 (Assistant Director of Nursing) were informed of the Immediate Jeopardy on [DATE] at 1:19 PM. This surveyor confirmed by interview and record review the Immediate Jeopardy was removed on [DATE] but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the CPR policy revision and in-service trainings. The findings include: R96's face sheet shows he was admitted to the facility on [DATE] with diagnoses including left below the knee amputee, pneumonia, and malignant neoplasm of the bladder and prostate.R96's Physician Order Summary initiated on [DATE] shows that R96 had elected to be a Full Code. R96's Care Plan dated [DATE] also shows R96 has elected to be a Full Code and facility staff should adhere to his desired code status. R96's nursing progress notes show R96 was started on an antibiotic for pneumonia on [DATE]. R96's nursing progress notes then show on [DATE] at 6:00 AM, an entry completed by V6 (RN) shows V6 had been alerted by another nurse and CNA at approximately 5:26 AM, that R96 did not have any respirations or pulse and herself and another nurse then initiated CPR. Emergency Medical Services were contacted and arrived at the facility at 5:35 AM and took over CPR. R96 was pronounced deceased at 5:57 AM. On [DATE] at 2:20 PM, V6 said on [DATE] she was notified by both V3 (RN) and V5 (CNA) and in her opinion, without a sense of urgency that there was an issue with R96 and that your patient is dead. V6 said she went to assess R96 and found him without a pulse or respirations and she could not immediately remember if he was a full code or not. V6 said she went to check his code status and to grab her phone to call 911 and told V3 to begin CPR. V6 said she would guess from the time she was notified to CPR being initiated was less than 2 minutes, however she could not say how long had gone by since V5 first found R96 without a pulse. V6 said she had some concerns with how this code was handled and the fact that neither V3 nor V5 immediately implemented CPR to R96. V6 said when a resident is a full code and found without a pulse or breathing a code should be called and CPR should be initiated immediately without a delay. V6 said she could not speak for anyone else as to why they did not start CPR but she believes they were not aware of the residents code status. V6 said a residents code status is on a report sheet the nurses have as well as in the residents electronic medical record (EMR). On [DATE] at 10:05 AM, V3 (RN) said she was notified by a CNA (V5) sometime around 5:25 AM, on [DATE] that R96 needed to be checked V3 said she went to assess R96 and found him without a pulse and without any respirations. V3 said she could not recall her and V5 then leaving the room to go get R96s primary nurse V6, but she remembers she did CPR with V6. V3 said the report sheet is easily accessible to the nurses but she does not know for sure how a CNA knows a residents code status. On [DATE] at 10:25 AM, V2 (Director of Nursing) said if a resident is a full code CPR should be initiated immediately. V2 said she does not know why V5 did not call a code and initiate CPR maybe she panicked, and V3 also should have immediately started CPR instead of going to find V6, but maybe she did not know R96's code status. V2 verified that V3, V5 and V6 are all CPR certified. V2 verified that nurses have the residents code status on report sheets and that they are also in a residents electronic medical record. V2 said a CNA would have to ask a nurse for a residents code status or check the EMR if a resident is found down. On [DATE] at 12:55 PM, V5 said sometime around 5:30 AM, she went into R96's room and he did not wake up, which was not normal for him. V5 said she felt for a pulse and checked for respirations and R96 did not have either and she was not sure of his code status so she went and got V3 to verify that R96 wasn't breathing. V5 said V3 came to the room and verified that R96 was pulseless and they both left the room to go find V6 and confirm R96's code status. V5 said this was the first time she had found a resident in need of CPR and looking back she should have called for help and immediately started CPR. V5 said she can only guess that it was less than 5 minutes from when she found R96 down to when CPR was finally initiated. On [DATE] at 9:10 AM, V18 (Medical Director) said if a resident is found down CPR should be initiated immediately if there is a delay in CPR it can result in a poor outcome for the patient.The facility provided list of Active CPR certified staff show V3, V5 and V6 are all currently active and certified to perform CPR. The facility provided CPR policy last revised [DATE] shows that when a resident has designated their wishes to be a full code it should be honored. The policy additionally shows that if a resident is found down, unresponsive without a pulse, a licensed staff person should initiate CPR immediately to increase their chances of survival.R96's death certificate shows his cause of death on [DATE] was pneumonia. The facility provided Immediate Jeopardy removal plan was presented to the surveyor on [DATE] at 8:18 AM, and V1 (Administrator) was notified it was accepted at 10:43 AM. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy.1. An Emergency QAPI (Quality Assurance Performance Improvement) meeting was held with facility administration and V18 on [DATE] to discuss revisions to the CPR policy.2. A chart audit was completed on [DATE] for all residents to identify their code status and ensure accuracy.3. The facilities CPR policy was revised to include that all clinical staff that are CPR certified should initiate CPR immediately. 4. All staff will be in-serviced prior to the start of their shift where to find a residents code status in the EMR and to immediately initiate CPR.5. A charge nurse will be designated on each shift and posted in the facility for each shift to take the lead role during a code.6. The Director of Nursing will do random mock CPR code drills with return demonstrations weekly for 3 months.7. The Director of Nursing or designee will audit all new admissions to ensure code status is identifiable.8. The effectiveness of the implemented policies and audits will be reviewed monthly at the QA meeting.

Based on observation, interview and record review, the facility failed to ensure that only authorized personnel entered the medication room.This has the potential to affect all the residents residing at the facility.The findings include:The form CMS 671 dated 3/9/26 show there are 86 residents residing at the facility.On 03/10/2026 at 9:11 AM, V12 (Restorative Certified Nursing Assistant-CNA) approached V16 (Registered Nurse-RN) and asked for the keys for the medication room. V16 (RN) handed V12 (Restorative CNA) the set of keys. V12 opened the medication room and went inside the medication room. V16 (RN) said V12 is not a Nurse but she is the CNA manager so she can enter the medication room, otherwise only Nurses can enter the medication room. On 3/10/26 at 9:35 AM, V9 (Assistant Director of Nursing-ADON) said the Medication room is a secure room where resident's medications including narcotics and over the counter medications were stored. Only authorized personnel which would be the nurses are the only ones allowed to enter a medication room to ensure safety and proper handling of medication. The 2nd floor medication room also has stock meds-over the counter meds that are used for both first and 2nd floor residents.The facility Policy on Medication Storage dated March 2021 states medications and by following manufacturers recommendations or supplier. The medication supply is accessible only to licensed nursing personnel pharmacy personnel or staff members lawfully authorized to administer medications medication rooms cards and medication supplies are locked when not in use or in direct view of person with authorized access.

Based on observation, interview and record review the facility failed to ensure food was served in a manner to prevent cross contamination. This failure has the potential to affect all 85 residents residing in the facility and receiving food from the kitchen. The findings include: On 3/9/26 The noon meal service line in the facility kitchen was observed continuously from 10:56 AM though 12:01 PM. At 11:11 AM, V8 (Dietary AIde) put on gloves and during the entire meal service V8 wore the same gloves. At 11:18 AM, a green bean had fallen into the mashed potatoes and V8 picked it out with her gloved hands and continued to wear the same gloves and plated to serve the mashed potatoes to residents. At 11:23 AM, V8 used her gloved hands to pick up a hamburger patty and place it on a bun and plated it to be served to a resident. At 11:43 AM, V8 picked up 2 sandwiches and plated and served them to residents. During the meal service V8 handled residents meal cards, plates, utensils, trays and took additional items out of the warmer when needed. V8 plated all dinner rolls using the same gloves and plated them to serve to residents. On 3/10/26 at 9:17 AM, V7 (General Manager) said he did notice that V8 had used her hands to pick up meal items during the service on 3/9/26 and she should have used utensils or should have changed her gloves and put on clean gloves to prevent contamination of other food after doing so. The facility completed form CMS-671 shows on 3/9/26 there were 86 residents residing in the facility. The facility provided diet list shows only 1 resident R7 does not receive food from the kitchen due to being fed via a feeding tube. The facility provided Sanitation policy dated 1/24 shows that gloves should be changed and hands washed when moving between tasks or when gloves are dirty.

Based on observation interview and record review the facility failed to ensure a resident was safe during care to 1 of 18 residents (R86) reviewed for safety in the sample of 18.The findings include:R86's face sheet show R86 has diagnoses that include s/p (status post) left hip arthroplasty, dementia with agitation, depression and hypertension.R86's facility assessment dated [DATE] shows R86 is severely cognitively impaired.R86's fall risk assessment dated [DATE] shows R86 is high risk for falls.On 3/8/25 at 11 AM, R86 was in the common area being monitored closely. V15 (Registered Nurse) said R86 was kept in the common area due to being a high fall risk.Review of R86's fall incident report show R86 fell on: 2/16/26- fell out of bed while being changed by a CNA (Certified Nurse Assistant) during care. On 3/5/26 at 9:12 AM, V11 (CNA) said she was R86's CNA last 2/16/26 when R86 fell out of bed. V11 (CNA) said she provided incontinent care to R86. V11 said she was applying R86's incontinent pad, turning R86 in bed side to side. V11 said when she turned R86 to face the opposite side of the bed, R86 was noted to be so close to the edge of the bed and R86 rolled out of bed. V11 said she needed another staff at the opposite side of the bed for R86's safety but everyone was busy, so she went ahead and provided R86's care by herself. On 3/10/26 at 12:58 PM, V21 (Physical Therapist) said he attends daily meetings where fall incidents were discussed. R86 was a fall risk resident due to her fall with injury in the past (witnessed by a Nurse.) Following that incident, R86 had another fall, R86 rolled out bed while being changed, staff should ensure the resident's proper positioning in the bed, not at the edge at the bed. Staff should make sure there was a staff on each side of the bed during care for R86's safety.

Based on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor for 1 of 5 residents (R102) reviewed for catheters in the sample of 18.The findings include:On 3/9/26 at 12:07 PM, R102 was lying in bed in his room. R102's catheter drainage bag was resting directly on the floor to the left side of his bed. R102 said staff position his catheter bag since he's stuck in bed.R102's admission Record dated 3/10/26 shows R102 has hemiplegia and hemiparesis following a cerebral infarction affecting his left, non-dominant side. R102's Order Summary Report dated 3/10/26 shows current, active orders written on 3/3/26 for an indwelling catheter for a diagnosis of (urine) retention and catheter site care to be performed every shift.On 3/10/26 at 1:10 PM, V19, Assistant Director of Nursing/Infection Prevention nurse, said it is not acceptable for a catheter drainage bag to be on the floor due to infection control issues.The facility's Foley Catheter Management Policy (effective 9/1/23) under the heading of Infection Control shows the catheter drainage bag is to be kept off the floor.

Based on observation, interview, and record review the facility failed to ensure a resident was weighed upon admission and readmission and failed to verify the accuracy of a resident's weight for a resident with potential for weight loss which applies to 2 of 7 residents (R1, R14) reviewed for weight loss in a sample of 18.The findings include:1.) R1's Facility assessment dated [DATE] showed R1 is a [AGE] year-old cognitively intact resident with diagnoses which include: dysphagia and aftercare following surgery on the digestive system (feeding tube). R1's Census Sheet printed on 3/12/26 showed R1was admitted to the facility on [DATE], discharged on 1/10/26 (to local hospital), and readmitted to the facility on [DATE]. R1's Weights and Vitals Summary printed on 3/10/26 showed R1 had no weights recorded from 1/7/26 through 1/10/26 and was not weighed until 2/9/26 after being readmitted to the facility on [DATE]. On 3/9/26 at 1:35 PM, V13 Dietitian stated residents who are on tube feeding are at risk for weight loss. R1 can eat pureed foods but get most of their calories from tube feeding. Weights should be done on admission so we can monitor the residents for weight gain/loss and put interventions in place as needed. On admission residents are usually weighed 3 days in a row then as ordered. On 3/11/26 at 11:45 AM, V20 Registered Nurse stated residents are weighed 3 days in a row then as ordered. The facility's Weight Management Policy dated 8/21/24 showed the purpose is to provide a systematic and interdisciplinary approach to obtaining and monitoring of resident weights. This Policy showed all new admissions and readmissions should be weighed within 24 hours of admission. 2. R14's face sheets document that R14 was admitted to the facility on [DATE], severely cognitively impaired with osteoporosis and hypertension. R14's weight dated 1/21/26 was 114 pounds (lbs). On 3/9/26 at 10 AM, R14 had her breakfast tray in an overbed table in front of her in her room. R14 said she did not want to eat. At 12PM, R14 was in the dining room eating lunch, R14 was only taking bites of her Salisbury steak and green beans. R14 said she was not hungry. R14's comprehensive nutritional assessment dated [DATE] documents weight on1/21/26-114 lbs., 1/23/26-100 lbs. Weight on 2/3/26 was 95.7 lbs. Significant weight loss with recommendations of Boost three times a day and medications to help with appetite due to poor po (oral) intake. (Intervention to be approved by family.) R14's weights and vital summary documents: that R14's admission weight of 114 lbs. last 1/21/26 was strike out on 3/3/26 approximately two months after the original entry by V14 (Registered Nurse-RN) with a note of incorrect documentation. On 3/9/26 at 2:20 pm, V14 (RN) said she strike out R14's 1/21/26 weight of 114 lbs. on 3/3/26 because she believed that was an error. V14 said she did not speak to any staff, did not verify who weighed R14 back on 1/21/26, she just went ahead and removed it and said incorrect documentation. On 3/9/26 at 1:45 PM, V13 (Dietician) said R14 was a resident that had weight loss and continued to be at risk for weight loss due to poor appetite. The weight loss has been addressed and put interventions in place. Per family they need to approve all dietary recommendations (instead of supplement TID only daily and hold off with the medication Remeron for now.) However, V14 said the weight from January was struck through in March. The weight should not be removed without verification. Resident's weights are used to monitor resident's nutritional status. On 3/11/26 at 10 AM V9 (ADON) said weight serves as a baseline for comparison and should remain in the medical record.

Based on interview and record review the facility failed to ensure a resident was offered and/or received an influenza vaccination for 1 of 5 residents (R18) reviewed for immunizations in the sample of 18.The findings include:R18's admission Record dated 3/11/26 shows she was admitted to the facility on [DATE]. R18's Immunizations list dated 3/11/26 shows R18's last influenza vaccination was administered on 11/4/24.On 3/11/26 at 1:00 PM, V19, Assistant Director of Nursing/Infection Prevention Nurse, said influenza vaccines are offered to all residents annually and on admission/readmission. V19 said the facility had an influenza vaccine clinic this past fall.The facility was not able to provide documentation that an influenza vaccine was offered and/or administered to R18 between 10/2025 and 3/10/26 when inquired about R18's immunization status.The facility's Immunization Program Policy (effective 9/1/23) shows the facility offers immunizations against seasonal influenza to all residents. Residents are encouraged to stay up to date on vaccinations per CDC recommendations to prevent transmission of influenza within the community. As soon as practical after the influenza vaccine supply is received, the community begins the process of administering vaccine to all residents. Residents are required to either consent to receive or decline to receive the vaccine in writing on the appropriate form.

Based on observation, interview and record review the facility failed to ensure a resident (R1) was transported safely in a shower chair. This failure resulted in R1 sustaining a bimalleolar fracture of the right ankle. This affects 1 of 3 residents (R1) reviewed for accidents in the sample of 3. This past non-compliance occurred from 2/11/26 to 2/19/26. The findings include:R1's Facesheet shows R1 has diagnoses that include, but are not limited to: osteoarthritis of the right and left shoulders, atherosclerotic heart disease, history of poliomyelitis, dementia, and chronic kidney disease stage three. R1's Brief Interview for Mental Status dated 2/6/26 shows R1 is cognitively intact.On 2/23/26 at 9:08 AM, R1 had two wheelchair footrests with R1's name written on it. One footrest was on the seat of the wheelchair and the other was in a bag attached to the back of the wheelchair. R1 was lying in bed with a green cast on R1's right ankle that went up to the top of R1's right calf. R1 was not exhibiting any signs of pain. R1 said on the morning of 2/11/26, V3 (Certified Nursing Assistant- CNA) woke R1 up to provide R1 with a morning shower. R1 said V3 put R1 into a chair without footrests and as V3 started to move the chair and bring R1 to the shower room, R1's foot slipped off due to no footrests but doesn't recall exactly what happened. R1 recalls screaming out in pain and R1's right foot getting injured. On 2/23/26 at 9:46 AM, V3 said on 2/11/26 around 7:35 AM, V3 and V6 (CNA) got R1 up from bed to use the toilet. After using the toilet, V3 and V6 transferred R1 from the toilet to a shower chair that did not have footrests. After V3 took approximately two steps, while still in R1's room, R1 cried out in pain and said R1's right foot hurt. V3 immediately stopped pushing R1 in the shower chair and stated R1's right foot had caught on the ground and rolled under the chair as V3 pushed the chair forward. V3 notified V4 (Registered Nurse- RN) of the incident and V3 put R1 back into bed. R1 was provided an as needed pain medication and an ice pack. V3 cared for R1 the remainder of the day shift on 2/11/26 and said R1 did not want to leave R1's bed. V3 also cared for R1 on 2/12/26 on the day shift and stated R1 did not complain of pain throughout the duration of V3's shift, but R1 again did not want to leave R1's bed. On 2/23/26 at 11:00 AM, V4 said during the initial assessment of R1 after the incident, V4 did not see any swelling or bruising. V4 then notified V10 (Nurse Practitioner) who came and assessed R1. V4 said V10 provided orders to leave R1 in bed, place R1 on non-weight bearing status of the right leg, and to obtain an x-ray. V4 called to obtain an x-ray, which was completed on 2/11/26. On 2/23/26 at 11:16 AM, V9 (Licensed Practical Nurse- LPN) said V4 provided V9 with report at shift change of R1's injury and that an x-ray was going to be completed. V9 said when the results came back from the x-ray company between 10:15 PM and 10:30 PM. V9 notified V10 of the initial results showing there was no fracture. V9 said R1 had no complaints of pain during the evening shift on both 2/11/26 and 2/12/26.R1's Weights and Vitals Summary dated 2/23/26 shows R1 exhibited no pain from 2/11/26 at 2:00 PM until 2/13/26 at 10:39 AM. On 2/23/26 at 10:28 AM, V5 (LPN) said on 2/13/26, V5 was notified by staff that R1 was expressing excruciating pain. V5 provided R1 with as needed pain medication and immediately notified V10 who was already enroute to the facility to complete rounds. V10 gave V5 orders to obtain a stat (immediate) x-ray for R1's right ankle. R1's x-ray results from 2/13/26 shows R1 had minimally displaced acute or subacute fractures of the medial [inner] and lateral [outer] malleoli [ankle bones].On 2/23/26 at 12:17 PM, V10 said on 2/13/26, R1 was expressing excruciating pain in R1's right ankle upon an in-person assessment, after the stat x-ray was completed. V10 ordered staff to send R1 to the emergency room before receiving the results of the x-ray. V10 said R1's age and bone mineral density could have been contributing factors to R1's fracture, but R1's foot getting caught on the floor and rolling under the chair could have been a direct cause of R1's ankle fracture.On 2/23/26 at 12:06 PM, V2 (Assistant Director of Nursing- ADON) said prior to the incident, the procedure of transporting residents to the shower room was to bring a shower chair to the resident's room, disrobe the resident, transfer them to the shower chair, and then wheel the shower chair from the resident's room to the shower room. However, V2 said after the 2/11/26 incident with R1, the facility changed the procedure for residents that utilize footrests. V2 said staff will now use a wheelchair with footrests to bring the resident to the shower room, where staff will transfer the resident from the wheelchair to a shower chair, provide the resident with a shower, place the resident back into their wheelchair when finished with the shower, and take the resident back to their bedroom. Facility provided in-service sign-in sheet dated 2/2026 shows nursing staff were educated on Shower chair use- Shower chairs without foot support are to only be used within the shower room.On 2/23/26 at 1:38 PM, V1 (Administrator) and V11 (Executive Director) said nursing staff had already changed the procedure and began in-servicing staff on 2/14/26. During the weekly weights, falls, and wounds meeting on 12/19/26, the interdisciplinary team gathered and discussed R1's incident and conducted a condensed quality assurance meeting. V1 said staff are actively conducting weekly audits to ensure staff compliance with the updated procedure. V1 said there were no similar accidents prior to R1's 2/11/26 incident and there have been no additional accidents since the procedure change. Prior to the survey date of 2/23/26, the facility had taken the following actions to correct the noncompliance:1. On 2/14/26, the facility updated their shower transfer procedure and identified all residents that are affected.2. On 2/14/26, the facility began in-servicing V3 and the rest of the nursing staff on the updated shower transfer procedure. The facility has also developed a system to ensure all employees not yet in-serviced will receive the in-service information prior to the start of their next shift at the facility.3. On 2/19/26, the facility conducted a quality assurance meeting to discuss the incident, the updated procedure, and to devise ongoing auditing to ensure compliance with the new procedure by nursing staff.

Based on interview and record review the facility failed to ensure a resident was served the noon meal at the scheduled time. This applies to 1 of 5 residents (R1) reviewed for dietary services in the sample of 5. The findings include: On 10/30/25 at 10:20 AM, V9 (R1's spouse) said on 10/26/25, R1 did not fill out the meal ticket form and this was his 2nd time he missed a meal. She had to alert the staff R1 did not receive the lunch meal. On 10/30/25 at 12:02 PM, V6 (Certified Nursing Assistant-CNA) said on 10/26/25, she was R1's CNA. That day it was really busy, V9 came up to her after the noon meal was served and said R1 did not get a noon meal tray. V6 said she called the kitchen, and they said his tray should have gone out, she looked and looked and could not find his tray. She went to the kitchen between 1:00 PM to 1:30 PM to get a meal tray for R1 and the kitchen had closed up and did not have any food remaining for the noon meal. V6 said she got R1 a grilled cheese sandwich. V6 said PM staff delivers meal tickets for the following day, the residents choose their meals, and the tickets are picked up by a different shift. The day staff don't know if the kitchen did not receive a meal ticket for a resident until the meals come, sometimes the kitchen will call and let us know if they did not receive a meal ticket for a resident, but she did not receive a call. R1 needs staff assistance filling out his meal tickets. She is not sure what happened to R1's meal tray and confirmed he did not receive the scheduled noon meal. On 10/30/25 at 1:00 PM, V8 (Dining Service Director) said room trays for the noon meal are delivered between 11:00 AM to 12:00 PM. Meal tickets are printed the day before for the following day, CNA's delivery the meal tickets and should assist the resident on making their selection and tickets are placed in a folder and picked up the following morning. Dietary should print out the census and count the meal tickets and confirm all meal tickets were received. We rely on the floor staff to pass the tickets, pick up the tickets, delivery trays and inform dietary of any missed meals. The kitchen closes down sometime after 1:00 PM, if a resident did not get their meal they have alternatives. He was not aware of R1 not receiving his noon meal on 10/26/25, if the kitchen received a meal ticket the resident should receive a meal. R1's Physician Order Sheets dated October 2025 shows orders for mechanical soft diet. The facility's Meal Service Times and Late Meals policy revised 2024 states, The community will provide three meals daily, at regular times comparable to standard mealtimes in the community or accordance with resident needs, preferences, requests and individualized plan of care.

Based on interview and record review the facility failed to ensure a resident was free from injury during a shower for 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include:Findings Include:R1's face sheet shows she had diagnoses including artificial hip replacement surgery, difficulty walking, and osteoarthritis of the hip.R1's care plan initiated on 12/17/24 shows she is at risk for falls due to unsteady gait, balance, and decreased strength and endurance. The care plan also shows she requires partial to moderate assist for showers, dressing, and transfers. Interventions added on 12/18/24 to R1's care plan to help prevent a fall include keep personal items within easy reach and nursing staff should provide instructions on safety measures. R1's incident note completed by V3 (Licensed Practical Nurse) on 1/7/25 shows that R1 had a fall in the shower room and was very upset. A witnessed fall incident form completed by V3 on 1/7/25 shows that R1 was lying on the floor in the shower room and had a skin tear to her right outer elbow and said she had hit her head and hurt her back during the fall. R1 was sent to a local community hospital for evaluation.R1's hospital records show on 1/7/25 she was brought through the emergency room and complained of head and back pain due to a fall at the facility. R1's hospital records show she received medical tests including X-rays of her knee, hip and spine and scans of her head with no acute findings. R1 was discharged from the emergency room on 1/8/25 and did not return to the facility.On 10/28/25 at 10:25 AM, V4 (Certified Nursing Assistant) said she was in the shower room with R1 when she had a fall on 1/7/25. V4 said she had placed R1's personal items on the top of the heater in the bathroom. V4 said R1 was still in the shower chair, and she was helping dry R1's legs and back off and R1 mentioned she wanted to have lotion put on. V4 said she turned her back to R1 and went to get her wheelchair to bring it closer to R1 and the next thing she knew the shower chair moved and R1 fell out onto the floor. V4 said she should have handed R1 the lotion or had her seated closer to the items, so she did not have to reach for them. V4 also said sometimes the shower chair will move and R1 was a tall lady so with her having her feet on the floor she thinks that maybe why the chair suddenly moved. V4 said R1 was very upset with her after this incident and would not let her care for her.On 10/28/25 at 11:22, V6 (Registered Nurse) said she was called to the bathroom to assist after R1 fell. V6 said the shower chair can still move at times depending on the resident position so she would not walk away from a resident or turn their back to them in the shower room.The facility provided Fall Prevention and Management Program policy last revised on 1/23/25 shows all staff are responsible to prevent resident falls and care plan interventions including personal items should be kept in their reach should be followed to minimize fall risk.

Based on observation, interview, and record review the facility failed to follow the Wound Physician's recommendations, failed to identify, report, and obtain treatment for wounds and failed to provide pressure relieving intervention to prevent the development of pressure ulcers for 4 of 9 residents (R73, R45, R135, R35) reviewed for pressure ulcers in the sample of 20. This failure resulted in R73's MASD-Moisture Acquired Skin Disease to the left and right gluteal area developing into a left gluteal Stage 3 and right gluteal Stage 4 pressure ulcer. The findings include: 1. R73 Predicting Pressure Ulcer score risk dated 10/12/2024 (admission) shows, High Risk On 01/28/25 at 11:11 AM, V2 DON-Director of Nurse changed the dressing for R73's Stage 4 pressure wound to the left buttock and the Stage 4 pressure wound to the left heel. On 01/28/25 at 11:11 AM, V2 DON-Director of Nursing said, R73 did have redness to the right butt cheek upon admission but developed the pressure ulcer in the facility. R73 Admission assessment dated , 05/10/24 at 7:18 PM, shows, Skin MASD in buttocks - very red but intact, Dry scab at Right foot 2 x 1 cm (centimeter), Dry scab at left shoulder - no drainage noted, scattered bruises and scabs at arms and legs due to fall. R73's Initial Wound Evaluation by V11 Wound Doctor dated 10/16/24 shows, unstageable Deep Tissue Injury of the Left Heel, etiology Pressure, Duration Less than 2 days. Size 8.3 cm x 4.1 cm. Skin intact with purple/maroon discoloration. Recommendations: Off-Load Wound; Float Heels in Bed; Pressure Off-Loading Boots. Stage 4 Pressure Wound of the Right Buttock Full thickness. Etiology Pressure Stage 4, duration greater than 14 days. Noted to be present on admission per staff. Wound size 2.6 cm x 1.1 cm x 0.5 cm centimeters. slough 10%. Stage 3 Pressure Wound of the Left Buttock Full Thickness. Etiology Pressure Stage 3, Duration greater than 14 days, noted to be present on admission per staff. Wound size 4.5 cm x 7.3 cm x 0.3 cm. 100% subcutaneous dermis. R73's Current Care Plan on 01/28/25 shows, V11's Recommendation to float heels in bed and to apply pressure off-loading boots has NOT been initiated as an Intervention in R73's Care Plan. R73's Wound Evaluation & Management Summary dated 11/27/24 by V11 Wound Doctor shows, Stage 3 pressure wound of the left buttock full thickness etiology pressure, stage 3, duration greater than 56 days noted to be present on admission per staff, 4.5 cm x 8.1 cm x 0.5 centimeters, 30% slough, 20% granulation, 50% subcutaneous dermis. Recommendations: Cipro 500 milligrams by mouth twice a day for 10 days started yesterday by primary care physician with positive cultures of wound and urinary tract infection. R73's MAR dated November 2024 and December 2024 shows, R73 did not receive the wound physicians recommended antibiotic of Ciprofloxacin 500 milligrams by mouth twice a day for 10 days between November 27, 2024, to December 6, 2024, for the Stage 3 Pressure Wound. On 01/28/25 at 1:43 PM, V2 DON said, the nurse that is given the Physician Order is responsible to ensure it is performed. This would be the reasonability of the Wound Nurse to input the order to pharmacy, obtain the wound culture, and notify the primary care physician. On 01/29/25 at 11:29 AM, V11 Wound Doctor said, R73 had a wound infection. I coordinate with the Infection Control Nurse and the Primary Doctor. The Infection Control Nurse ensures the order goes through appropriately and follows up on the wound culture results. On 01/29/25 at 12:54 PM, V2 DON said, the facility's Infection Control Nurse left in August of 2024. I have had a few different Wound Nurses off and on over the past year. My current Wound Nurse started 3 days ago. The Facility's Nursing Skin Integrity policy dated 03/20/23 shows, the licensed nurse using the EMR -electronic medical record observation tool, is to complete a Head-To-Toe Assessment to identify any/all areas of loss of skin integrity. The includes pressure injuries, non-pressure injuries, skin tears, bruises . Notify sites the wound nurse/DON of any skin integrity issues. Evaluate areas of loss of skin integrity and complete a wound consult as appropriate. If the wound doctor is following the resident's wound, their weekly assessment is sufficient for the week. It is the wound nurse/DON's responsibility to ensure all orders and/or recommendations from the Wound Physician are carried out timely. On 01/28/25 at 11:11 AM, V2 DON-Director of Nursing removed R73 right pressure reduction boot. R73 had a 1 centimeter by 1 centimeter black/purple area on the bony prominence of the medial ball of his right foot that looked like a deep tissue injury. On 01/28/25 at 11:11 AM, V2 DON said, the discoloration to the right medial ball of his right foot was not there last week when I assessed R73 with the wound doctor. On 01/28/25 at 11:11 AM, R73 denied any injury to the foot. On 01/28/25 01:49 PM, V2 DON, said, I have not documented on R73's discoloration. None of the staff reported the discoloration. R73 has no record of recent injury. The wound doctor will see R73 tomorrow. I will call it discoloration and allow the Wound Doctor to make the determination. On 01/29/25 at 9:43 AM, V10 Wound Doctor said, the wound on the right medial ball of R73's foot is a deep tissue injury. Deep tissue injuries are caused from the tissue resting against a surface for too long. R73 also has a diagnosis of diabetes which increases his risk for wound development. I will classify the wound as a pressure ulcer. The Facility's Nursing Skin Integrity policy dated 03/20/23 shows, evaluate areas of loss of skin integrity and complete a wound consult as appropriate. Complete the appropriate entry on the wound care log. 2. R45 Predicting Pressure Ulcer score risk dated 05/21/24 (admission) shows, At Risk On 01/27/25 at 10:00 AM, R45 observed lying on her back. On 01/28/25 at 1:48 PM, R45 observed lying on back, the positioning wedge was sitting on a chair in her room. On 01/29/25 at 9:55 AM, R45 observed laying on her back with the head of the bed up at 45 degrees. On 01/29/25 at 10:08 AM, V10 Wound Care Doctor said, R45's wound was acquired in the facility. It currently measures 1.8 cm (centimeters) x 1.4 cm x 0.2 cm deep. On 01/29/25 11:02 AM, V2 said, on 5/14/24, R45 was Care Planned that she prefers to lay on her back, identified on admission. On 09/07/24 it was observed that R45 had an open area to her coccyx, we added the pressure reducing mattress that day (09/07/24). On 01/29/25 at 11:29 AM, V11 Wound Doctor said, it is not normal for skin to progress from intact tissue to a stage 4 pressure ulcer, it can happen. Skin can break down quickly and then the muscle. Perhaps the air mattress would have prevented the opening of the wound. R45's Admission Skin Observation Tool dated 05/14/24 shows, Skin is intact . R45's Care Plan initiated 05/14/24 shows, R45 likes to lay on her back that can further increase risk of skin breakdown. Care Plan Initiated 05/21/24 R45 is in need of assistance with ADL's-Activities of Daily Living. She insists to stay in bed and needs staff encouragement and substantial maximal assist from staff to roll left and right. R45's Initial Wound Assessment by V11 Wound Care Doctor dated 09/11/2024 shows, Stage 4 Pressure Wound Sacrum Full Thickness, Etiology Pressure, Duration greater than 4 days, Wound Size 3.5 cm x 2.6 cm x 0.4 cm. The facility's Nursing Skin Integrity policy dated 03/20/23 shows, validate a care plan with appropriate interventions initiated. R45's Physician's Orders dated 09/07/24 shows, R45's Pressure Redistribution Mattress was ordered 09/07/24. The facility did not provide R45 with a pressure reducing mattress until after she developed a Stage 4 pressure ulcer. 34117 3. R135's face sheets shows he has diagnosis including respiratory failure, dehydration, emphysema, urine retention, and protein calorie malnutrition. On 1/27/25 at 9:43 AM, R135 was observed lying in bed. V8 (Certified Nursing Assistant-CNA) provided incontinence care. V8 removed his incontinent brief, his sacrum was red with an open area without a protective dressing in place. On 1/28/25 at 10:44 AM, V2 (DON) went to provide wound care to R135. V2 removed his incontinent brief R135's sacrum remained without a dressing in place, his sacrum was red with an open area. V2 said R135 has a pressure ulcer to his sacrum and should have a dressing in place. R135's Admission Evaluation dated 1/21/25 documents an open area to his buttock measuring 0.8 cm (centimeters) x .5 cm. R135's Physician Order Sheets dated January 2025 shows orders including sacrum open area-cleanse with normal saline dry and cover with a foam dressing daily. 37232 4. On 01/27/25 at 01:15 PM, R35 observed in bed. There was an air mattress pump hanging on the foot of the bed. The power switch to the air mattress pump was in the off position. The green power button was not lit up. On 01/28/25 at 08:54 AM, V3 (Registered Nurse) confirmed the air mattress pump on R35's bed was off. V3 added that the pump should be on while R35 was in bed. R35's Order Summary Report printed on 1/28/25 showed an order for an air mattress. R35's Care Plan with an initiated date of 9/11/24 showed R35 was at risk for developing pressure injuries. Listed under interventions was for R35 to receive a pressure relieving/reducing mattress. On 01/28/25 at 01:39 PM, V4 (Certified Nursing Assistant) said an air mattress/pump is a pressure relieving intervention.

Based on observation, interview, and record review the facility failed to ensure staff wore the required PPE (Personal Protective Equipment) in a contact isolation and enhanced barrier precaution room, and failed to ensure gloves were changed during incontinence care to prevent cross contamination. This applies to 4 of 10 residents (R24, R54, R63, R135) reviewed for infection control in the sample of 20. The findings include: 1.) On 1/27/25 at 9:35 AM, outside of R24's open door were two isolation signs, one for Contact Isolation indicating gloves and gowns must be applied when entering the resident room. The second sign was for Enhanced Barrier precautions that showed when providing cares such as dressing, bathing, transferring, providing hygiene, changing briefs or assisting with toileting staff must wear gloves and gowns. Outside of R24's doorway was also a cart containing PPE including gowns, gloves, and masks as well as a bin to place linens and garbage. At 9:37 AM, V7 (Certified Nursing Assistant/CNA) went into the room of R24 without applying a gown or gloves, she proceeded to carry linens and go into the bathroom inside the room where R24 was. At 9:45 AM, V7 exited R24's room to get supplies and and when asked by this surveyor about R24 being on isolation V7 responded she did not get any report that R24 was on any type of isolation. V7 said she had been assisting R24 to the bathroom and to wash up for the day. V7 re-entered R24's room without applying a gown. On 1/27/25 at 9:39 AM, V6 (Registered Nurse/RN) said that R24 was on contact isolation due to a MRSA (Methicillin Resistant Staphylococcus aureus) infection in her wound and staff should be wearing gowns and gloves when inside her room. On 1/27/24 at 12:02 PM, V24 said she is afraid the CNA's at the facility do not really know what infection a resident has because before today they were not wearing gowns in the room when they provide care to her. V24 said she has had chronic MRSA infections in her body. On 1/28/25 at 9:43 AM, V2 (Director of Nursing/DON) said for residents on Enhanced Barrier Precautions staff should be wearing gowns and gloves when providing cares. V2 said, I know what you saw yesterday and yes the staff should have been wearing gowns when they went into her (R24's) room she is on contact isolation for MRSA in a wound. The Enhanced Barrier sign was originally on her door for the wound incision and then when MRSA was found she was placed on contact isolation. R24's active Care Plan and Physician Order Summary both show R24 was placed on contact isolation on 1/22/25 due to MRSA in her surgical incision. The facility provided Initiating Transmission Based Precautions policy effective 3/27/23 shows contact isolation should be used where there is potential to spread a microorganism to other persons and the facility should ensure the proper PPE is available and worn when in isolation rooms. 35178 2.On 01/27/25 at 1:29PM, V14 CNA-Certified Nursing Assistant and V15 CNA provided incontinent care to R54. R54 had a bowel movement. After V14 CNA cleaned R54 she failed to change her gloves before applying a clean incontinent brief, placing clean positioning pillows, and pulling up R54's blankets. 3.On 01/27/25 at 9:55 AM, there was a sign posted to R63's door that showed enhanced barrier precautions. As V14 CNA and V15 CNA provided care to R63 they did not wear gowns. V14 CNA used a urinal to empty R63's urine collection bag without putting on a gown. On 01/27/25 at 10:23 AM, V16 LPN-Licensed Practical Nurse said, when staff are caring for residents on enhanced barrier precautions, they should wear gown and gloves when emptying a catheter. 34117 4. On 1/27/25 at 9:43 AM, V8 (CNA) provided incontinence care to R135. R135's incontinent brief was soiled with stool. V8 cleansed his buttocks, and used the same contaminated gloves and touched multiple surfaces including placing a new brief, adjusted his gown, blanket, his call light and the bed control. On 1/28/25 at 1:41 PM, V2 (DON) said staff should change their gloves after cleaning a soiled body part. The undated facility's Perineal Care Policy states, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections wash and rinse the rectal area thoroughly .remove gloves .wash and dry your hands thoroughly .

Based on interview and record review the facility failed to provide a resident with the bed hold policy when transferring a resident to a hospital for 1 of 2 residents (R23) reviewed for transfers in the sample of 20. The findings include: A facility assessment done on 12/13/24 showed R23's mental status was intact. R23's Progress Note dated 1/10/25 showed R23 was sent to the hospital because he was having abdominal pain. R23's SNF/NF to Hospital Transfer Form dated 1/10/25 showed R23 was being transferred to a local hospital for evaluation of abdominal pain. The same document showed R23 was capable of making decisions. On 01/27/25 at 11:43 AM, R23 stated when he was sent to the hospital on 1/10/25 he was not given the bed hold policy or informed what the facility's bed hold policy was. On 01/28/25 at 12:44 PM, V5 (Licensed Practical Nurse) said she was the nurse that sent R23 to the hospital on 1/10/25. V5 said she did not provide or inform R23 of the facility's bed hold policy on transfer. The facility's Bed Hold Notices policy dated 5/1/19 showed the facility support the resident's rights to be informed of the policy regarding holding a bed prior to and/or upon a resident's transfer to the hospital. The same policy showed before transfer the resident will be informed regarding the facility's bed hold period.

Based on interview and record review the facility failed to ensure R36 and R54's PASRR-Preadmission, Screening & Resident Review was reassessed after being newly diagnosed with a mental illness for 2 of 5 residents (R36, R54) reviewed for PASRR in the sample of 20. The findings include: On 01/29/25 at 9:12 AM, V12 Director of Admission/Community Outreach said, PASRR is usually completed at the hospital prior to admission. If the resident comes from out of state or from their home, it is completed as part of the admission process at the facility. The facility has not been performing the PASRR when a resident is diagnosed with a mental illness after admission. Every resident will be assessed with Level 1 PASRR. That assessment will cue the facility if an additional screening is needed. Diagnosis of a mental illness, psychotropic medications, and behavioral documentation facilitates the need for the type of PASRR the resident needs. I was just notified yesterday of the need for PASRR reassessments with changes in medications and mental health diagnosis. We have been using the current PASRR system but have not been educated on all the details. R36's EMR-Electronic Medical Record on 01/29/25 shows, R36 was admitted to the facility on [DATE]. R36's EMR on 01/29/25 shows, R36 has a Primary Diagnosis of Parkinson's Disease without dyskinesia, without mention of fluctuations, 03/11/24. R36 was diagnosed with anxiety disorder, 04/20/24. R36's PASRR is dated 04/19/23. R54's EMR on 01/29/25 shows, R54 was admitted to the facility on [DATE]. R54's EMR on 01/29/25 shows, R54 has a Primary Diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side. R54 was diagnosed with delusional disorder, 09/02/24. R54's PASRR is dated 01/30/23. The facility PASRR policy dated, 06/01/23 shows, if the individual has a sole diagnosis of dementia, s/he is excluded from further PASRR evaluations. If the person has both a dementia diagnosis and another psychiatric condition, the dementia must be confirmed as primary.

Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner. This failure resulted in R432 being sent to the hospital for 8 days due to increased pain after a transfer. The facility also failed to ensure a resident with a diagnosis of dyspagia was supervised during meals and failed to ensure a resident was provided nectar thick liquids as ordered. This applies to 4 of 18 residents (R5, R7, R44 and R432) reviewed for safety in the sample of 18. The findings include: 1. R432's Face Sheet shows that he originally admitted to the facility on [DATE]. R432's Physical Therapy Evaluation dated 1/8/24 shows that he was referred to therapy for strengthening and decrease level of assistance in bed mobility and transfer. The report shows, Patient exhibiting difficulty performing bed mobility, transfer, sitting balance and ability to stand. The assessment shows that he needs maximum assistance of 2 people for transfer and is dependent on staff for bed-to-chair transfers and has no reports of pain. The assessment shows that R432 is alert and oriented to person, place and time. On 2/5/24 at 1:50 PM, R432 said that he had to go to the hospital due to severe back pain after an incident with a transfer. R432 said that he was using the slide board to transfer from his wheelchair to his bed. R432 said that once he got to the side of the bed, the aide that was behind him came to the front of him and he fell back in bed because no one was supporting his upper half and he hurt his back. R432 said that the pain was a 12 out of 10. R432 said that it was horrible. R432 said that before the incident he would have back pain when he moved but it was only at a 6 out of 10. R432 stated, I had to go to the hospital after that. I could not even lay in the MRI machine, it hurt so bad. They had to sedate me. R432's History and Physical dated 1/8/24 shows, admitted with spinal stenosis with lumbar myelopathy .lumbar fusion and spinal cord stimulator. He is feeling better. R432's Rehabilitation Practitioner Note dated 1/9/24 shows that his pain is 4-5 out of 10 Bed mobility maximal assistance x 2. Slide board transfers-maximal to total assist of 2 . R432's Nursing Note dated 1/10/24 at 5:36 PM shows, Resident complained of severe pain 10/10 stated that he had never felt this bad before and was very concerned. Given norco as ordered with relief. Called [Physician] and made aware. New order received for stat x-ray of the lumbar spine and lidocaine patch . R432's Nursing Notes dated 1/13/24 at 10:00 PM shows, patient complained of pain while sitting in his wheelchair. He is scheduled for PT Norco 5/325 1 tab given at 3:26 PM. He refused to go to therapy due to pain. Patient was put back to bed with 2 assist using the sliding board pain is getting worse per patient 10/10 and unbearable want to go to hospital requesting to call 911 picked up the patient at 4:48 PM. R432's Hospital Notes dated 1/13/24 shows, Presents to ED (Emergency Department) chief c/o (complaint of) low back pain; today while in PT (Physical Therapy), fell backwards onto mattress .Patient requiring multiple doses of narcotics to manage his pain; doesn't feel safe returning to rehab. Plan for admission for pain control, symptom stabilization. R432's Hospital Notes dated 1/14/24 shows, Patient reports he had been doing fair at SNF (Skilled Nursing Facility), but still with significant weakness. Patient reports he had a fall/injury to his back earlier this week while working with PT, for which he was started on a medrol dose pack (steroids) on 1/11. Then today patient was again working with PT and fell backwards on to the bed and had acute worsening of his left sided low back pain of which he presents today .pain control-oxycodone (narcotic pain medication), flexeril (muscle relaxer), lidocaine and diclofenac patches, hydromorphone (narcotic pain medication) for breakthrough . On 2/6/24 at 11:18 AM, V7 (Nurse Supervisor) said that R432 was a slide board transfer and was complaining of increased pain after a transfer. R432 was sent to the hospital for a few days and came back with an increase in pain medication and is now a mechanical lift transfer. On 2/6/24 at 1:18 PM, V21 (Nurse Practitioner) said that R432 was readmitted to the hospital for severe back pain but she was unaware of any incidents that happened that caused the pain. On 2/7/24 at 8:58 AM, V23 (Occupational Therapist) said that when R432 was first admitted , he was able to use the slide board for transfers with two people. V23 said that when R432 first came in, he was unable to sit on the side of the bed independently. V23 said that for a two person assist slide board transfer, the patient should be assisted from the wheelchair to the bed by placing the slide board between the bed and the chair. V23 said that once the resident is in bed, one person should assisted with his trunk due to poor trunk control and one person should assist with his legs and move him to a laying positron in one swift movement so there would be no strain on the back especially with his history of back problems. V23 said that R432 needs assistance with trunk support at all times unless he would fall over in bed. On 2/7/24 at 9:24 AM, V24 (Certified Nursing Assistant) said that himself and another aide put R432 to bed on the evening of 1/10/24. V24 said that they used the slide board. V24 said that after a resident is assisted to the side of the bed with the slide board, one person would direct the resident's feet and one person would direct their trunk. V24 said that he did not remember if he was assisting with the feet or trunk. V24 said that he did not remember if R432 fell back in bed or not and V24 said that he did not remember if R432 complained of pain after the transfer. R432's Face Sheet shows that he was readmitted to the facility on [DATE]. R432's Physical Therapy Evaluation dated 1/22/24 shows he requires maximum assistance of two persons for bed mobility and totally dependent on staff for transfers and is in severe pain. R432's Medication Administration Record (MAR) for January shows that between 1/7/24 and 1/10/24 he was taking a lidocaine patch to his lower back daily and norco 5/325 milligrams (mg)-1 tablet every 4 hours as needed for pain. R432 took the norco five times for pain of 4 to 7 out of 10. After 1/10/24, R432 took norco 5/325 mg-1.5 tablets every 4 hours as needed for pain 12 times between 1/10/24 and 1/13/24 for pain of 3 to 10 out of 10. R432's MAR shows that when readmitted from the hospital on 1/21/24 he was ordered oxycodone 5 mg every 4 hours as needed for pain and flexeril 5 mg every 8 hours as needed for muscle spasms. 35541 2. R5's care plan dated 11/20/23 showed R4 was at risk for choking or aspiration due to her diagnoses of dysphagia and dementia. The care plan showed R5 had a history of pneumonitis due to aspirating food and/or fluids. The care plan showed R5 will be assisted by CNAs (certified nursing assistant) if she eats in her room .Needs supervision during meals, cut foods into small pieces and redirect the resident to chew and swallow one at a time, slowly . R5's hospital records showed R5 was hospitalized on [DATE] with a diagnosis of gastrointestinal bleeding. R5's hospital speech therapy evaluation dated 12/8/23 showed R5 required a mechanical soft with nectar thick liquids due to her risk of choking. The evaluation showed R5 must be fed by staff to ensure R5 was eating slowly and was following the recommended feeding cues. The evaluation showed R5 was not to have straws in her drinks due to her choking risk. R5 was discharged from the hospital, back to the facility, on 12/14/23. On 2/5/24 at 11:56 AM, R5 was in bed, eating lunch. No staff were present in R5's room. R5 swiftly scooped food into her mouth; occasionally dropping food onto her lap. No coughing was noted from R5. Two Styrofoam cups with lids and straws, one containing thickened coffee and the other thickened water, were noted on the tray, directly in front of R5. On 2/5/24 at 1:03 PM, R5 remained in bed. One Styrofoam cup, with a lid and straw, was noted in front of R5 on her bedside table. The contents of the cup appeared to be non-thickened water. V8 Licensed Practical Nurse (LPN) entered R5's room. She picked up the cup, opened the lid and shook the cup, and stated, That's regular water. That's not thickened. V8 closed the cup and placed it back down in front of R5. V8 exited the room. On 2/6/24 at 9:39 AM, V9 Speech Therapist (ST) stated R5 has dysphagia that is chronic and ongoing. V9 stated R5's last speech therapy session was 12/5/23. V9 had not evaluated R5 since she had been readmitted from the hospital on 12/14/23. V9 stated, I saw her in December because staff had reported she was coughing during meals. Upon evaluation, I downgraded her diet to mechanical soft and regular liquids. Upon her discharge from me, I said she needed direct, 1:1, supervision when eating due to her dysphagia and tendency to eat to fast. It looks like her fluids were changed to nectar thick in the hospital . I also see the (physician) order for no straws. She has a tendency to drink and eat too fast. Straws have a tendency to make people gulp and drink faster. That's why she probably shouldn't be using straws. 3. R7's care plan dated 12/4/23 showed R7 required the use of a sit-to-stand (mechanical) lift, with the assistance of two staff, for all transfers and toileting due to her unsteady balance and generalized weakness. On 2/5/24 at 11:41 AM, V10 CNA transferred R7, via sit-to-stand lift, from a wheelchair to the toilet. R7 was hanging onto the lift with her hands. R7's knees were bent as she was unable to bear weight and stand. No other staff were noted in R7's room. On 2/6/24 at 9:31 AM, V2 Director of Nursing (DON) stated all resident transfers, via a sit-to-stand, are to be performed by two staff members, not one. The facility's Lifting Machine, Using a Mechanical policy dated July 2017 showed, At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. 4. R44's care plan dated 12/20/23 showed R44 required the substantial assistance of one staff when being transferred from bed to wheelchair. On 2/5/24 at 10:35 AM, V16 CNA transferred R44, from her bed to a wheelchair, by lifting R44 up, under her armpits, and pivoting her into the chair. R44 was unable to bear weight during the transfer or hold onto V16. No gait belt was used during the transfer. On 2/6/24 at 9:31 AM, V2 DON stated gait belts are to be used to transfer any resident that requires staff assistance. The facility's Gait Belt policy dated 6/1/23 showed, Gait belts are to be used for all transfers that require staff assistance and when assisting residents to ambulate.

Based on observation, interview and record review the facility failed to ensure pressure relieving interventions and pressure injury treatments were in place. The facility failed to report a new pressure wound. These failures apply to 4 of 8 residents (R40, R34, R62, R432) reviewed for pressure injuries in the sample of 18. The findings include: 1. R40's care plan dated 11/29/23 showed R40 was at risk for pressure injuries and/or skin breakdown due to his diagnoses of limited mobility, incontinence, and cognitive deficits. R40's skin/wound note dated 2/3/24 showed R40 was readmitted to the facility, from the hospital, with a new wound to his sacrum that measured 1.5 centimeters (cm) x 0.3 cm x 0.1 cm. The note showed R40 was referred to the facility's wound physician. R40's Order Summary Report dated 2/3/24 showed a physician order for R40's sacral wound to be cleansed with normal saline and covered with an absorbent, foam dressing, every 12 hours as needed for soiled or missing dressing. On 2/5/24 at 9:31 AM, R4 was lying in bed, with his call light on. An odor of stool was noted in R4's room. V12 Infection Prevention Nurse entered R4's room. R4 stated, I think I need a bed pan. V12 rolled R4 onto his side to place a bed pan under him, but R4 was already incontinent of a moderate amount of loose stool. A small, open area was noted to R4's sacral area. No dressing was covering R4's wound and no soiled dressing was noted in R4's incontinence brief. Stool was noted on and around R4's sacral wound. On 2/6/24 at 10:22 AM, V6 Wound Nurse stated R40 was readmitted to the facility on [DATE] with a new wound to his sacrum. R40 stated, Wounds to the sacral area are usually pressure injuries. There are orders for (R40) to have a dressing place over his wound. It should be covered at all times until he sees the wound physician this week. The facility's Pressure Ulcer Prevention and Treatment policy dated 3/3/23 showed. The facility must have a system in place to ensure that care staff and licensed nurses are appropriately initiating intervention, treatment, evaluation and documentation to attempt to prevent further deterioration and provide appropriate interventions for healing. 40085 2. On 2/5/24 at 10:25 AM, R34 said he has a new sore on his heel that has been there since last week. R34 said he wears heel protectors but his heel was hurting so he mentioned it and the (unidentified) staff person looked at it and said he has a sore there so she put a bandage on it. On 2/6/24 at 10:35 AM, V6 (Wound Care Nurse) said no one had reported to her that R34 had a new sore on his heel so she had not assessed the area before today. V6 said R34 has an unstagable pressure area to his right heel measuring 1.5 x 0.4 x 0 depth. V6 said she is unable to say for certain how long he has had the new pressure injury but whomever discovered it should have let her or the other wound nurse know so they could have seen him to assess the wound. V6 said the nurse who discovered it should obtain treatment orders also if the wound nurses are not present. On 2/6/24 at 11:18 AM, V16 (CNA) said she noticed a bandage on R34's heel on Saturday 2/3/24 and he told her he had a sore on his heel. V16 said R34 is usually wearing boot style heel protectors and he takes them off only for bed baths and when he gets up on weekends for bingo. On 2/7/24 at 8:36 AM, V26 (Wound Nurse) said he was not aware until yesterday when the facility called him to ask if he knew about R34's new pressure injury. V26 said no one had informed him of the injury and they could not determine who discovered it because the bandage was not dated or initialed. On 2/7/24 at 8:40 AM, V25 (Wound Care Physician) was providing wound care and doing an assessment of R34's right heel. V25 measured R34's right heel (which presented as a patch of dried skin) to be 0.3 x 0.4 x 0.1 centimeters after V25 removed some slough tissue. The area to R34's heel was superficial and V25 described it as a stage 2 due to the area that sloughed off. V25 said if staff identify a new skin condition for a resident they need to tell the wound care nurse immediately so orders can be obtained. V25 said ideally staff should be checking under R34's pressure prevention boots daily but generally those boots will not cause pressure if the foot is properly positioned in them. R34's Braden Scale to determine pressure risk completed 12/22/23 shows he is at risk to develop a pressure injury. A Skin Observation tool completed for R34 on 2/4/24 (After V16 had seen a bandage on R34's heel) shows No new skin issues. A Skin and Wound Evaluation assessment was not completed for R34 new pressure injury until 2/6/24. R34's active Order Summary shows no treatment orders were obtained for his pressure injury until 2/6/24. The facility provided Pressure Ulcer Prevention and Treatment policy revised on 3/3/23 shows residents should have daily inspection of the skin and any alterations should be reported to the nurse. The licensed nurse will notify the attending physician of any skin alteration. And any pressure ulcers the wound nurse will complete the Skin & Wound Evaluation weekly. 3. On 2/5/24 at 9:25 AM, R62 was lying in bed, his heels were not offloaded and no pillow was underneath his feet. Green boot style heel protectors were sitting in a reclining chair across the room from his bed. On 2/6/23 at 8:48 AM, R62 was in bed, his heels were not offloaded, and his heel protectors were sitting in the same spot in his reclining wheelchair. R62's care plan shows he has a self care deficit and requires maximum staff assistance to turn and reposition. R62's care plan also shows he has a stage 4 pressure injury to his sacrum and left heel. R62's active order summary shows he is to have pressure off loading boots on every shift. R62's Braden Scale for Pressure risk completed 2/3/24 shows he is at a moderate risk to develop new pressure injuries. R62's Wound Evaluation completed 1/31/24 by V25 (Wound Care Physician) shows he has a stage 4 pressure injury to his left heel. A plan of care intervention shows that R62 should have pressure off-loading boots on when in bed. On 2/6/24 at 10:40 AM, V6 (Wound Care Nurse) said for pressure prevention the nursing staff are responsible to make sure R62 has his heel protectors on. The facility provided Pressure Ulcer Prevention and Treatment policy revised on 3/3/23 shows residents at risk for skin impairments should have orders implemented including repositioning and pressure relieving devises. 34490 4. On 2/5/24 at 1:45 PM, V4 and V5 (Certified Nurses Assistants) transferred R432 to bed. R432's heels were placed directly onto the bed. R432's heel protection boots were sitting on his dresser. V4 and V5 exited the room without placing the heel protector boots on R432. R432 stated, Honey, can you put those boots on, they are supposed to be on. R432 said that he currently has some wounds on his foot that are new. On 2/6/24 at 12:35 PM, V6 (Wound Licensed Practical Nurse) performed a dressing change on R432. R432 had a blackened pressure wound on his left heel and a wound on his left posterior ankle. On 2/6/24 at 10:41 AM, V6 said that R432 admitted to the facility with a deep tissue injury of his medial heel and then developed an unstageable pressure ulcer on his left heel on 2/4/24 that was facility acquired. V6 said that R432 should have his heels offloaded by wearing heel protection boots while he is in bed. R432's Physician's Order Sheet printed on 2/6/24 shows an order dated 1/26/24 for heel protector boots while in bed every shift for wound prevention. R432's Skin/Wound Notes dated 2/4/24 shows, During L (left) ankle TX (treatment) this AM an intact, serum filled blister was observed to the resident's R (right) medial heel (3.5 x 3) Orders were received to continue skin prep and heel protector boots until seen by [Wound Physician]. The facility's Pressure Ulcer Prevention and Treatment policy revised on 3/3/23 shows, Reposition resident per care plan using pressure relieving devices (i.e. low air loss mattress, pillows, etc) to prevent bony prominence from rubbing as applicable.

Based on observation interview and record review the facility failed to serve residents the right amount of food to 4 of 4 residents on pureed diets (R38, R433, R62, R12) reviewed for nutritional needs of residents on pureed diets in the sample of 18. The findings include: The facility Diet type report dated 2/5/24 show R38, R433, R62 and R12 were all on pureed diets. The facility spreadsheet for 2/5/24 show the serving size for pureed diet was as follows, steamed broccoli- 4 ounces (oz), cheesy grits-4 oz and grilled chicken broccoli tortellini-6 oz. On 2/5/24 at 12:30 PM, during the lunch service V17 (Dietary Aide) was plating the lunch trays with pureed consistency foods. V17 used a blue scoop for the pureed steamed broccoli and cheesy grits. V17 said those blue scoops were 2 ounces (oz.) Then V17 used the green scoop to serve the pureed chicken tortellini and said the green scoop was 3.5 oz. On 2/6/24 at 11:30 AM, the facility spreadsheet for 2/5/24 was reviewed with V13 (Dietitan) and V18 (Dietary Manager). Both V13 and V18 confirmed that V17 did not use the right scoop sizes according to the spreadsheet V13 (Dietitian) said residents should receive the right amount of food to maintain their weight and receive the nutritional requirements. On 2/6/24 at 1:00 PM, V18 (Dietary Manager) said he had given inservices for staff to follow the spreadsheet and pay attention to the scoop they were using when serving food to the residents. The facility policy under Dining Services dated 10/25/22 shows the community's dietary department should utilize the appropriate service utensils when portioning food items during service.

Based on observation, interview and record review the facility failed to ensure glucometer machines were cleaned in between resident use and failed to ensure Personal Protective Equipment (PPE) was worn appropriately for a resident on contact/droplet isolation for COVID-19 to prevent the spread of infection. This applies to 5 of 18 residents (R16, R434, R182, R8, R432,) reviewed for infection control in the sample of 18. The findings include: 1. On 2/5/24 at 11:35 AM, V3 (Registered Nurse) performed a blood glucose check on R16. After performing the check, V3 took a disinfecting wipe and set it on the nurse's cart. V3 placed the glucometer machine in the center of the wipe and folded the wipe over the top of the machine. V3 had another machine on the cart and wrapped it in the same manner. V3 then checked R434, R182 and R8's blood sugars and wrapped the machines in the same manner after each use. On 2/5/24 at 11:27 AM, V7 (Nurse Supervisor) said that glucometers should be cleaned after each use by vigorously wiping the front, back and sides of the machine using a disinfectant wipe for two minutes and then allowed to air dry before using again. V7 said that it needs to be done that way to prevent infections. The facility's Glucometer Use and Cleaning Policy dated 1/1/24 shows, Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, wipe all surfaces, top, bottom, and sides. Follow the contact time. 2. On 2/5/24 at 9:00 AM, V2 (Director of Nursing) said that R432 is on isolation due to being positive for COVID-19. On 2/5/24 at 1:45 PM, there was a sign on R432's door that showed he was on contact/droplet isolation. V4, Certified Nursing Assistant (CNA) applied a N95 mask, gloves and a gown and entered R432's room. V5 (CNA) applied a N95 mask over her surgical mask, gloves, gown and faceshield and entered R432's room. V4 and V5 performed a mechanical lift transfer to transfer R432 from his wheelchair to bed. During the care, V5's mask kept slipping off of her nose. On 2/6/24 at 11:27 AM, V7 (Nurse Supervisor) said that COVID isolation should include a N95 mask, gloves, gown and a faceshield and should be put on before entering the room. V7 said that staff should not wear a surgical mask under the N95 because it will change the seal of the mask and each staff member has been fitted for the appropriate fitting mask. The facility's Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 policy dated 6/3/20 shows, PPE must be donned correctly before entering the patient area. PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted (e.g., retying gown, adjusting respirator/facemask) during patient care .Put on isolation gown, Put on NIOSH-approved N95 filtering facepiece respirator or higher .Put on face shield or goggles .

Based on observation, interview and record review the facility failed to ensure a resident bed had side rails for bed mobility for 1 of 18 residents (R34) reviewed for accommodation of need in the sample of 18. The findings include: On 2/5/24 at 10:35 AM, R34 said he was recently transferred from one room to this room and they gave him a new bed that doesn't have side rails on it. R34 said uses the side rails to help turn himself from side to side, and to shift positions. R34's bed had an air mattress with no side rails on it. On 2/6/24 at 11:18 AM, V16 (CNA) said she is not sure why R34 does not have the same bed but he did use the side rails to assist himself for re-positioning and turning. On 2/6/24 at 1:50 PM, V2 (Director of Nursing) said she was not aware that R34 was moved into a new bed without side rails but he should have side rails and does use them for bed mobility. On 2/6/24 at 11:21 AM, and 2/7/24 at 8:40 AM, R34's bed still did not have side rails on either side. R34's Face sheet shows he has diagnoses including: osteoarthritis, chronic obstructive pulmonary disease, morbid obesity and carpal tunnel syndrome. A Bed Rail/Assist Bar Evaluation completed on 1/22/24 for R34 shows he requested to have side rails for bed mobility. R34's active order summary shows an order for bed rail to assist with bed mobility initiated on 1/23/24.

Based on observation, interview, and record review, the facility failed to assess and identify a resident's pressure injury to her right lower leg until it was a stage 3 acquired pressure injury from a medical device. This applies to 1 of 3 residents (R2) reviewed for acquired pressure injuries in the sample of 3. This resulted in R2 sustaining a facility acquired stage 3 pressure injury. The findings include: R2's face sheet shows R2 is [AGE] year old who was originally admitted to the facility on [DATE], with diagnoses that include right femur fracture that had undergone hip surgery, history of falling, and diabetes. , R2's Braden scale (predicting pressure score risk), dated 10/30/23, shows R2 is at risk for developing pressure. R2's skin admission assessment, dated 10/11/23, shows R2 had no pressure injury except a surgical incision to right hip. R2's hospital discharge summary, dated 10/11/23, shows an order for R2's right lower extremity to be non weight bearing, and the knee immobilizer to be on at all times. R2's care plan, dated 10/12/23, shows R2 was at risk to develop further skin breakdown, but did not include R2's use of the immobilizer or any care that needs to be done when wearing a knee immobilizer. R2's Wound Evaluation Management Summary, dated 11/1/23, was when R2's pressure injury was discovered to her right lower lateral calf that was a stage 3 measuring 6.5 centimeters (cm) x 2.5 cm x 0.1 cm. The Facility Wound Report, dated 1/3/23, provided to this surveyor shows R2's facility acquired pressure injury to her right lower lateral calf was now a stage 4 measuring 3.5 cm x 1.0 cm x 0.1 cm . On 1/3/24 at 10AM, R2 was in bed on a low air loss mattress. R2's right leg was suspended with a pillow. R2 said she fell at home, hurt her right leg, and had surgery. R2 said she now has a wound at the back of her right leg, but cannot recall what happened. V4 (Wound Nurse), who was also in R2's room, showed this surveyor R2's pressure injury to right lower lateral calf. A huge open wound was noted at the back of R2's right lower leg. V4 said R2's acquired pressure injury came from R2's knee immobilizer (medical device) she was using before. V4 then opened a closet, took a knee immobilizer, and showed this surveyor that this was R2's knee immobilizer. The knee immobilizer has velcro on the side. V4 pointed a hard area at the back part of the immobilizer, and said R2's right lower leg was laying directly on the hard part of the immobilizer; that had caused pressure injury on R2's right lower leg (calf). V4 said R2 was complaining of discomfort to that area. V4 said when the immobilizer was removed to check the skin, V4 had a stage 3 open area to her right lower leg V4 said the order was for R2 to use the immobilizer at all times, but typically, the skin can be checked during care. On 1/3/24 at 10:20 AM, V6 (Wound Doctor) said she took over R2's wound care for the past 4 weeks now. V6 said, (R2) has fragile skin and is also a diabetic. Wearing a knee immobilizer has the potential risk to cause the development of pressure injury. Slight movements can cause the immobilizer to move that can cause skin frictions. V6 said it was important to check the placement of the immobilizer and inspect the skin underneath. On 1/3/24 at 2PM, V2 (Director of Nursing) said since the order of the knee immobilizer was on at all times, no one was checking the skin underneath. V2 also said the order was not clarified to the Ortho if it can be removed for skin checks. V2 also confirmed R2's immobilizer was not part of R2's Physician Order Sheets (POS). On 1/3/24 at 2:15 PM, V7 ( R2's previous Wound Doctor) said, (R2) had an order of wearing the immobilizer at all times from Orthopedic, but generally speaking, when a resident wears an immobilizer, staff has to check the skin from time to time as immobilizer can cause pressure or skin irritations. The facility presented a document entitled Unavoidable Pressure Injury clinical condition, dated 1/4/24. The facility also presented a document from the Orthopedic MD, dated 1/4/24, that R2 has to wear the knee immobilizer until 11/13/23.

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident who was dependent on staff to provide their care for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a humerus fracture. The findings include: R1's face sheet listed the following diagnoses: Alzheimer's, dementia with agitation, coronary artery disease, hyperlipidemia, diabetes, hypothyroidism, hypertension, and transient ischemic attack. R1's Minimum Data Set assessment, completed by facility staff on 10/19/22, showed R1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The same report showed R1 was not ambulatory and that R1's mental status was severely impaired. R1's care plan showed R1 was at high-risk for falls because of R1's dementia and combativeness toward staff. R1's care plan also showed R1 had an ADL self-care deficit because of R1's dementia and that R1 relied on staff to initiate daily care. On 12/14/22 at 10:31 AM, R1 was in her bed with a hard plastic splint to her left upper arm. R1 was not moving around in bed. On 12/14/22 at 8:45 AM, V2 (Director of Nursing) said R1 sustained a fracture to her left arm while at the facility. V2 said they were unsure how R1 fractured her arm. V2 added R1 did not have any incidents/falls that could have resulted in the fracture. On 12/14/22 at 9:36 AM, V4 (Nurse Manager) said the facility did an investigation regarding R1's fractured arm. V4 said they were unsure how R1 fractured her arm. V4 said V3 (Hospice Certified Nurse Assistant) was the first to notice R1 had arm discomfort. On 12/14/22 at 10:36 AM, V6 (Registered Nurse- RN) said prior to R1's fracture, R1 was dependent on staff for activities of daily living (ADLs). V6 said R1 would not have been able to pick herself up off the floor if she had fallen. On 12/14/22 at 12:10 PM, V8 (Certified Nursing Assistant - CNA) said on 11/21/22 around 8:00 AM she rounded on R1. V8 said she rounded on R1 before V3 entered R1's room. According to V8, when she rounded R1 was sleeping in bed and in no distress. V8 said R1 was total care for ADLs and staff had to, Do everything for [R1]. V8 added that R1 can be combative with care such as trying to hit staff. On 12/14/22 at 1:40 PM, V10 (CNA) said R1 was dependent on staff for all care. V10 said R1 would not have been able to pick herself up off the floor if she had fallen. On 12/14/22 at 9:50 AM, V3 said on 11/21/22 around 8:30 AM or 9:00AM, she entered R1's room to give R1 a bed bath. R1 was in bed sleeping in no distress. V3 said she removed the hospital gown that R1 was wearing by undoing the buttons of the gown. V3 said she turned R1 on her right side to wash R1's back. According to V3, when she went to wash R1's left arm pit she noticed R1's arm was, Wobbly and R1, Screamed to leave her alone. V3 said she covered up R1 and went to inform the nurse. On 12/14/22 at 1:30 PM, V9 (Hospice Nurse) said she assessed R1's left arm on 11/21/22. V9 said she noticed swelling and that something was, Sticking out of R1's left arm below the shoulder. V9 said after contacting R1's power of attorney the decision was made to send R1 to the hospital. On 12/14/22 at 5:51 PM, V11 (Orthopedic Doctor) said R1's fracture did not, Spontaneously happen. V11 said R1 had some osteoporosis; however, some type of external force, like a fall, was required to cause R1's fracture. V11 added R1's fracture did not occur by normal arm movement such as moving it to brush her hair. R1's emergency room summary documentation, dated 11/21/22, showed R1 was sent to emergency room because the nursing home staff noted a deformity to R1's left arm. The same document showed when R1 was assessed in the emergency room R1 had an, Obvious deformity to the left arm and tenderness. R1's emergency room x-ray results from 11/21/22 showed, Acute fracture involving the proximal left humerus Significant outward and posterior angulation deformity at the fracture site.

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers for Disease Control (CDC) to separate Coronavirus 19 (COVID-19) positive residents and COVID-19 negative residents. The facility failed to designate dedicated staff to provide care for the positive residents. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to 21 residents (R1-R21) reviewed for infection control in the sample of 21. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on 12/1/2020 when the facility began receiving positive COVID-19 results on 2nd floor residents. The Immediate Jeopardy was identified on 12/7/2020. V2 (Director of Nursing) was informed of the Immediate Jeopardy on 12/9/2020 at 9:23 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 12/9/2020; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Resident Roster dated 12/7/20 shows that there are 56 residents residing in the facility. On 12/7/2020 at 9: 10 AM, V2 (Director of Nursing/DON) said there are 8 residents that are positive for COVID-19 in the COVID Unit on 1st floor. V2 (DON) said there are 10 additional COVID-19 positive residents on 2nd floor. On 12/7/2020 at 9:20 AM on the 2nd floor before entering B WING was R1's room. R1's room had a red sign on the door. V3 (Assistant Director of Nursing/ADON), who was with the surveyor, said that the red sign means R1 is positive for COVID-19. 2nd floor B wing's door was wide open. R2's room had a red sign posted on her door. V3 (ADON) said that R2 is positive for COVID-19. Across from R2's room is R3 and R11's room. R3 and R11 were in their rooms sitting in their wheelchairs. V3 said both R3 and R11 are negative for COVID-19. The next occupied room was R14's room. R14's door had a red sign which V3 confirmed that R14 is positive for COVID-19. Across R14' room is R13's room. R13 was in his room sitting in his wheelchair by his doorway. V3 said R13 is negative for COVID-19. Surveyor asked V3 why residents who are COVID positive were in the same wing/hall with COVID negative residents and why the COVID-19 positive residents were not moved in the COVID unit wing on 1st floor. V3 said the facility decided to keep residents where they were since everyone on 2nd floor were already exposed. At 10:00 AM, V5 (Certified Nursing Assistant/CNA) entered R1's room (COVID-19 positive resident) and at 10:15 AM, V5 (CNA) left R1's room. V5 removed her gown, applied a new gown, and then entered R16's room. R16 was negative for COVID-19. At 10:20 AM, V5 said she was the CNA on B wing. V5 said that there are 6 residents who do not have COVID and 3 residents who are COVID positive that are on her assignment today (B Wing). On 12/7/2020 at 10:25 AM, this surveyor entered 2nd floor C wing which was beside B wing. C wings door was wide open. V7 (Registered Nurse/RN) said C wing is like B wing; there are COVID-19 positive and negative residents. In the middle of C wing was R4 and R5's room. V7 (RN) said both R4 and R5 are positive for COVID-19. Beside R4 and R5's room is R21's room. V7 said R21 is negative for COVID-19. V6 (Certified Nursing Assistant/CNA) was noted to be entering R8's room. R8 had a red sign on his door. V7 said R8 is positive for COVID-19. After V6 (CNA) took care of R8, V6 changed her gown and went to R21's room to provide care. V7 said R21 is negative for COVID-19. At 10:35 AM, V6 said that there are 4 residents who do not have COVID and 7 resident who are COVID positive that are on her assignment today (C Wing). V6 said that she is caring for all the residents down the C Wing including the COVID positive residents. On 12/7/2020 at 10:40 AM, V7 (RN) went to R2's room (positive for COVID-19) to give morning medications. Then V7 went to R17's room to see if R17 needed something (R17 is negative for COVID-19). At 11:00 AM, while surveyor was at C wing, V10 (Housekeeper) was coming out from R5's room (COVID positive) then entered R19 and R20's room to clean (R19 and R20 are COVID negative). On 12/7/2020 at 12:10 PM, V11 (Housekeeper Supervisor) said it's the same housekeeping staff assigned to clean COVID negative resident rooms and COVID positive resident rooms on 2nd floor. On 12/7/2020 at 1:25 PM, V7 (RN) said she had no idea why B and C wing have COVID positive and COVID negative residents. V7 said in the beginning if any resident on 2nd floor tested positive for COVID, they were transferred to the COVID Unit on the first floor to be isolated. V7 said COVID positive residents should be separated from COVID negative residents to prevent the spread of COVID-19 in the facility. R1, R2 and R14's COVID-19 test results dated 12/1/2020 show that R1, R2 and R14 are positive for COVID-19. R1 and R2's rooms were located in the beginning of the B wing hallway while R14's room was located in the middle of the B wing. R3, R11-R13, R15 and R16 test results dated 12/1/2020 show that R3, R11-R13, R15 and R16 are negative for COVID-19. The rooms of these COVID negative residents were located across the hall from COVID positive residents on B wing. R4-R10's COVID-19 test results dated 12/1/2020 show that R4-R10 are positive for COVID-19. R4 and R5's rooms were in the middle of the C wing. R6- R10's rooms were in the middle and at the end of the hallway of C wing. R17-R21's test results dated 12/1/2020 show that R17-R21 are negative for COVID-19. All of these resident rooms were in the beginning and middle of C wing in between the rooms of the COVID positive residents. On 12/7/2020 at 11:32 AM, V4 (Infection Preventionist Nurse) said on 12/1/2020 was when they received the test results on 2nd floor residents who were positive for COVID-19 (10 residents). V4 said the residents on 2nd floor who were COVID-19 positive were kept where they were and did not move these positive residents to the COVID Unit on 1st floor. V4 said all residents on 2nd floor have been exposed. On 12/7/2020 at 12:30 PM, V2 (Director of Nursing) said all residents on 2nd floor were already exposed, the positive residents on 2nd floor were kept on 2nd floor. V2 said the COVID unit on 1st floor could have been able to accommodate the residents who were positive on 2nd floor. On 12/7/2020 at 3:24 PM, V13 (Local Health Department) said that V2 had sent him list of positive residents in the facility. V13 said it was his understanding that the facility has a designated COVID unit for positive residents and not mix these COVID positive residents with COVID negative residents. And the facility had dedicated staff to primarily provide care to the COVID-19 positive residents. V13 said this was the expectation since day 1 of this pandemic, to have dedicated staff for COVID-19 positive residents. The facility's COVID Response Policy reviewed on 8/19/20 shows h. consider designating a certain area of the facility for residents with suspected or confirmed cases of COVID-19. The Centers for Disease Control and Prevention (CDC) website entitled Responding to COVID-19 Considerations for the Public Health Response to COVID-19 in Nursing Homes states, If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Assign a dedicated HCP (Health Care Professional) to work only on the COVID-19 care unit. Assign environmental services (housekeeping) to work only on the unit. The Immediate Jeopardy that began on 12/1/2020 was removed on 12/9/2020 when the facility took the following actions to remove the immediacy. 12/9/20 All positive residents were separated from negative residents. 12/9/20 Coordinated with Housekeeping Manager to assign 1 housekeeper to COVID positive rooms only. 12/9/20 Education initiated for all nursing and environmental staff that they cannot work with both positive and negative residents. 12/9/20 Education initiated for all nursing and environmental staff that all negative and positive residents cannot be mixed in one area or same hall (cohort staff and residents) 12/9/20 Start conducting daily IDT/QA meetings to review positive cases to ensure appropriate separation of our negative and positive resident cases. 12/9/20 Daily review of our staffing and scheduling to eliminate staff cross over between those negative and positive residents.

Based on observation, interview and record review the facility failed to safely reposition a resident during personal care. This failure resulted in R4 falling out of bed and sustaining a right leg femur fracture. This applies to 1 of 3 residents (R4) reviewed for falls in the sample of 5. The findings include: R4's Minimum Data (MDS) set dated (MONTH) 13, (YEAR) shows R4 has [DIAGNOSES REDACTED]. The same MDS shows R4 is cognitively intact, requires extensive assist of two people for bed mobility, and has upper and lower extremity impairment to one side. The facility's Incident Report dated (MONTH) 2, (YEAR) shows On (MONTH) 2, (YEAR) at 1:10 PM, while Certified Nursing Assistant (CNA) was doing pericare on R4 in bed, CNA turned resident to her right side using a bed pad when resident's legs started to fall. CNA was not able to get control of the legs falling. R4's Nurses Notes dated (MONTH) 2, (YEAR) at 10:45 PM, shows spoke with emergency room , patient admitted to hospital with fracture to right femur. On (MONTH) 15, (YEAR) at 12:45 PM, V12 Nurse Practitioner said R4 was in the hospital for a right femur fracture due to a fall. On (MONTH) 15, (YEAR) at 10:02 AM, R4 was in bed with her right leg in an immobilizer brace. R4 said she fell out of bed recently when the CNA rolled her. R4 stated I slipped out of bed and ended up on the floor. She was a new CNA. It hurt terribly. On (MONTH) 15, (YEAR) at 10:07 AM, V3 (R4's husband) stated They are saying R4 fell out of bed, but I have doubts on how it happened because she can't roll around well. R4 had an aide that day that I had never seen before and I'm here every day. V3 said R4 broke her leg and just had surgery a few days ago. On (MONTH) 15, (YEAR) at 12:07 PM, V2 CNA said she worked at the facility on an as needed basis and usually worked in the assisted living building. V2 said she had been working in the skilled area some this summer, but (MONTH) 2, (YEAR) was the first time working in R4's section. V2 said she was not familiar with any of the residents in that wing and only received in report from the night CNA that R4 was a mechanical lift with two assist for transfers. V2 said she was never told R4 couldn't roll well, or was weak on the left side. V2 stated To be honest, I was so busy that day, I didn't look at the residents' activities of daily living in the computer until the end of my shift. V2 stated when R4's fall occurred, she was alone, without anyone else helping her. R4 was in bed and she was providing incontinence care. V2 stated she rolled R4 onto R4's right side (toward the door) to put the incontinence brief underneath her and R4's legs fell out of the bed. V2 stated that R4 was so heavy for V2 and was falling out of the bed, so V2 climbed onto the bed and grabbed underneath R4's arms to lower her to the floor so R4's head didn't hit the floor. V2 said R4 ended up on the floor with her head at the foot of the bed and her feet by the head of the bed. On (MONTH) 15, (YEAR) at 10:25 AM, V5 CNA said she was working the day R4 fell . V5 said it was the first time V2 was taking care of R4. V5 said she was in the hall when V2 called for help. V5 said when she went into the room R4 was on the floor next to the bed with her head at the foot of the bed and her feet at the head of the bed. V5 stated I couldn't understand how R4 was turned around and fell with her head at the end of the bed. V5 said, R4 has left side weakness and can't grasp anything with her left hand. It can be difficult to roll R4 due to her weakness. On (MONTH) 15, (YEAR) at 10:36 AM, V10 Registered Nurse (RN) said she went to R4's room when the aid called for help and found R4 on the floor with her head at the foot of the bed. V10 said R4 kept saying It's my leg, my leg when asked if anything hurt. V10 said V2 explained that she was rolling R4 in the bed to change her and R4 legs swung out of the bed and R4 went down. V10 said she could understand how this could happen since R4 is weak on one side and can't hold on. On (MONTH) 15, (YEAR) at 11:10 AM, V11 Restorative CNA said R4 has left side weakness from a stroke and sometimes doesn't hold on to the bed rail with her left hand well when being changed. V11 said R4 can hold on with her right hand if she's turned to the left. On (MONTH) 15, (YEAR) at 12:55 PM, V4 CNA said R4 is only able to help you if you roll her to her left side. V4 stated, I don't think V2 knew you can't turn R4 toward the door. On (MONTH) 15, (YEAR) at 1:08 PM, V7 Physical Therapy Director said R4 is dependent on staff for activities of daily living. V7 said for bed mobility, R4 can only hold on to the bed rail with her right hand if rolled to the left. V7 said R4 would be unsteady if rolled to the right side and would need another person on that side of the bed for safety. On (MONTH) 15, (YEAR) at 1:09 PM, V8 Occupational Therapist said R4 has no movement on her left side from a stroke. On (MONTH) 15, (YEAR) at 12:50 PM, V5 CNA said V2 should have asked for help with R4 to prevent her from falling. On (MONTH) 15, (YEAR) at 2:15 PM, V1 Director of Nursing stated, R4's MDS is coded as two person extensive assist for bed mobility because she sometimes needs two assist. V1 stated, After R4's fall, we reviewed R4's needs and decided to make sure for safety to have two staff for bed mobility. V1 said if staff is unsure how to care for a resident the staff should ask for help. R4's Care Plan dated (MONTH) 13, (YEAR) shows R4 needs assistance from staff for activities of daily living due to functional deficit related to history of [MEDICAL CONDITION] with left sided [MEDICAL CONDITION]. R4 has minimal function to left arm and leg and is a fall risk. The same Care Plan shows Bed Mobility: Extensive assist of two. The facility's Falls and Fall Risk Policy dated (MONTH) 1, 2012 shows based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling.

Based on observation, interview and record review, the facility failed to analyze the root cause for the development of facility acquired pressure ulcers for three residents, R1, R 9 and R10. The facility also failed to develop and consistently implement specific and individualized interventions to promote healing and to prevent the development and worsening of existing pressure ulcers. The facility failed to turn and reposition R1 and R10 for more than two hours. These failures contributed to the development of R1, R 9 and R10 facility acquired pressure ulcer. (a) R1 acquired a Stage II pressure ulcer on the sacrum that progressed to an infected Stage IV. (b) R10 developed (b1) maceration on the sacrum that progressed to infected Stage IV and (b2) an Unstageable pressure ulcer on the right heel and (b3) a Stage II on R10 s right ear lobe that progressed to Stage IV. (c) R9 acquired Stage IV pressure ulcer on the sacrum and on the left hip. This applies to three of three residents (R1, R9 and R10) of five residents reviewed for the development of facility acquired pressure ulcers in the sample of 21. The findings include: I. On 01-16-14 at 10:05 AM, R10 was sleeping flat on the bed. E11/Charge Nurse stated, "She (R10) is in isolation for an infected wound ([MEDICAL CONDITION] resistant staphylococcus aureus), we do not get her up." On 01-16-14 at 3:25 PM, Z3 (family member) during interview said, "They have not been getting her up for a while now. She has multiple pressure ulcers that developed here, maybe because she has not repositioned enough. I was here since 10:00 AM and she (R10) has not repositioned since I came in (five hours and twenty-five minutes)." During the treatment observation on 01-16-14 at 3:30 PM, R10 was flat in bed wearing an adult disposable brief and a cloth pad underneath. R10's heels were resting directly on a pillow. E12 /Treatment Nurse removed R10's dressings and described the wound as follows: "The wound is in (1) the sacrum with a very foul (smelling) odor and with moderate amount of thick brownish yellow drainage. The measurements are 7.8 cm X 5.0 cm X 4.0 cm with undermining of 6.0 cm. at 10 o ' clock. The wound bed is necrotic- black, this was a Stage IV but now it is Unstageable (UST). It has 60% necrotic area and with palpable bone. (2) The right heel measurement is 4.5 cm X 3.0 cm with eschar, this is an unstageable pressure ulcer." E12 did not identify R10's right ear lobe which also has a pressure ulcer. E12 identified R10's sacral wound as infected ([MEDICAL CONDITION]). E 12 was observed to not wash her hands during the entire procedure, from removing the old dressing to applying a new and clean dressing, from the infected wound to non-infected wound. This observation was discussed with E12, E12 asked, "Could I leave the patient with the Aide to wash my hands? " On 01-16-14 at 12:00 PM, E12 gave the following explanations regarding R10's three major pressure ulcers: (1) The sacrum/coccyx that started as maceration on 07-02-13, E12 stated, " This is due to her being incontinent." The wound/skin healing record showed on 08-02-13, this maceration progressed to a Stage IV pressure ulcer and developed a wound infection on 11-12-13. E2/Director of Nursing presented a copy of R10's Physician order [REDACTED]. On 01-17-14 at 2:20 PM, E2 stated, "the patient (R10) is still in isolation for her wound, there was no re-culture that was done yet." (2) The right heel initially noted on 12-05-13 as a Deep Tissue Injury /Unstageable pressure ulcer measured at 3.0 cm X 5.0 cm. with eschar. (3) The right ear lobe is a Stage IV; initially noted on 12-10-13 as a Stage II that progressed to Stage IV. The recorded measurement for 01-10-14 on the wound/skin healing record showed a measurement of 1.0 cm X 0.3 cm X 0.2 cm. There was no pressure ulcer care plan found in R10's clinical record. On 01-16-14 at 3:15 PM. The Assistant Director of Nursing reviewed the 24 pages of R10's care plan and stated, "I cannot find any pressure ulcer care plan only the skin tears were addressed and the shear wound to the sacrum on page 24 but none for the pressure ulcers. " II. On 01-16-14 at 11:20 AM, R9 was in bed sitting at a 90-degree angle, with an adult disposable brief and with cloth pad on top of the mattress. R9 was verbally responsive but with periods of confusion. At 11:40 AM E13/Certified Nursing Assistant (CNA) stated, "She's (R9) totally dependent on staff for activities of daily living, including turning and repositioning. She usually gets up (from bed to wheelchair) at around 11:00 AM because her husband comes and visits. I do not put her back to bed; I leave at 2:30 PM. I don't know what time the afternoon shift put her back to bed. " On 01-16-14 at 10:55 AM, E12 reviewed the wound/skin healing record and stated, " She (R9) acquired the pressure ulcer on the sacrum on 06-01-13, it was initially noted with slough and with black eschar and the left hip was noted on 07-14-13 as redness/Unstageable/Deep Tissue Injury, with no open areas noted." During treatment observation on 01-16-14 at 11:55 AM, E12 identified and explained the status of R 9 ' s two areas of pressure ulcers as follows: (1) "The left hip is a Stage IV it has 80% yellow slough and 20 % black eschar, the measurement are 1.8 cm X 1.8 cm X 0.8 cm with no granulation noted. (R9's wound/skin healing record dated 1-2-14 showed a smaller measurement of 1.8 cm X 1.7 cm X 0.3 cm, comments reads: improved- decreased in necrosis, increased in granulation.) (2) "This is the sacrum, it's a Stage IV. The measurements are 6.0 cm X 6.2 cm X 1.0 cm with 2.5 cm undermining at 11 o'clock, the bone is visible at 3 o'clock. " During the entire treatment observation, E12 did not wash her hands. R9 pressure ulcer plan of care was not individualized and specific based on R9's identified problems and needs. There were no revision noted, the interventions for the sacral wound and R9's left hips are identical. III. On 01/14/2014 at 12:25 PM, R1 was in bed with a strong BM odor. At 12:30 pm an incontinence care was provided by E8 and E 9/Certified Nursing Assistants. R1 adult disposable brief was soiled with moderate amount of black semi liquid stool that penetrated inside R1's wound. On 01/16/2014 at 1:15 pm, R1 was in a wheelchair in the dining room. E6/Nurse stated she had not yet changed R1's dressing because she has been up since she started today. E6 stated R1 was brought to the dining room around 7 am and will be brought back to bed after lunch. E6 stated she has a cushion on her wheelchair and they try to have all residents out in the dining room to be visualized during the day. On 01/16/2014 at 1:45 pm, E 7 (treatment nurse) during interview stated R1 has a stage 2 pressure sore noted on 11/15/13. E7 stated it was likely from moisture and pressure and resident non-compliance. The facility policy dated October 1, 2012 stated. " ...If the resident is non-compliant with care, an evaluation of the basis of refusal, and the identification and evaluation of potential alternatives is indicated." The facility failed to identify and document any indicated alternatives. E7 stated 7 days after treatment began wound worsened from Stage II to an Unstageable on 11/22/13. E7 performed wound care and described the wound as Unstageable with 100 % necrosis measuring at 4.0 x 3.6 x 2.8 cm with foul odor, slight exudates, and with surrounding skin grey/pallor. E7 stated R1 just completed oral antibiotic for this wound being infected. E7 stated Z2 (wound doctor) did not perform a wound culture but diagnosed the infection by the deterioration of the wound and the progressing foul odor of the wound. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Z2 assessed R 1's wound on 01/10/2014 as 4.0 x 3.5 x 2.5 cm with moderate drainage, 80% necrotic and 20% slough. Z2 stated in wound notes: stage 4-pressure wound of the sacrum deteriorated due to infection. The facility did not develop a comprehensive care plan for R1 s pressure ulcer and did not revise the interventions when the pressure ulcer advanced. The intervention for R1's stage 2 ulcer are the same as the interventions for her unstageable ulcer and were not individualized to meet the progressing wound.

Based on interview and record review facility failed to prevent 1 of 7 sampled residents (R1), from being physically, verbally and mentally abused by E5 (nurse aide), on 9/11/13 and E3 (charge nurse), on approximately 9/01/13. Facility also placed 19 of 19 cognitively impaired residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20 and R21), residing on the facilities "Memory Care Unit," at risk for being abused 9/01 - 10/01/13 and all 98 facility residents were at risk 10/03/13 -10/11/13. E3 and E5 were terminated 10/11/13. On 9/11/13, E5 approached R1, without verbally communicating with the resident and proceeded to physically restrain R1 in tightly wrapped sheets, securing both arms against the sides of the body, rendering R1 unable to move, causing increased agitation and mental distress. On "approximately 9/01/13", E3 responded inappropriately with R1 while the resident was displaying behaviors of screaming out. E3 roughly transferred R1 from a recliner to a wheelchair, yelled and screamed at the resident, involuntarily secluded the resident behind a closed door in a dark office, physically mishandling R1 by "grabbing the resident by the shoulders and shaking R1, loudly telling the resident to stop screaming." While R1 continued to scream, E3 started mimicking and screaming at R1. The facility staff failed to report the above witnessed abuse incidents from dates of incidents 9/01/13 and 09/11/13 until 09/26/13. After facility administration found abuse allegations about E5 and E3 to be valid, E5 and E3 were allowed to continue providing hands on care to facility residents 10/02 - 10/11/13. These failures resulted in R1 experiencing mental and psychological harm. These failures also placed 19 of 19 cognitively impaired residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20 and R21), residing on the facilities "Memory Care Unit," to be at risk for being abused 9/01 - 10/01/13 and all 98 facility residents at risk 10/02 - 10/11/13. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy situation was identified on 10/18/13. The Immediate Jeopardy began on 9/01/13. The immediacy was removed 10/11/13. The facility remains out of compliance at a level 2 due to the need to evaluate staff response to abusive situations and changes in facility policy and procedures. The Findings include; According to the face sheet in the medical record R1 is a [AGE] year old female with [DIAGNOSES REDACTED]. According to the MDS (Minimum Data Set) completed 08/2013 R1 is rarely/never able to make herself understood and is rarely/never able to understand others. R1's cognitive skills are severely impaired and she is completely dependent upon staff for all ADLs (activities of daily living). 1) On 10/17/13 at approximately 2:00pm E6, CNA (Certified Nurses Aid) stated curing interview that she was hired at the facility on 09/04/13. E6 started on the memory care unit on 09/11/13 and was assigned to train with E5, CNA. This was the first and last time E6 worked with E5. E6 stated, I introduced myself to E5 at 2:30pm. E5 said we have to toilet residents. We entered R1's room. R1 was sitting in a recliner and she (E5) said (in Spanish) we are gonna transfer her. E6 asked E5 if she was going to explain to R1 what she was about to do. E5 said no, it will only agitate her. E5 further stated that the residents are just filthy barn animals. E5 continued to converse in Spanish which seemed to increase R1's agitation. At bed time we toileted R1 and E5 again did not explain to R1 what she was going to do. R1 was biting and scratching at us. E6 tried to calm R1 down and E5 said, What do you care? It doesn ' t matter, we have to get this done. When we put her to bed E5 asked E6 to get an extra sheet. E5 said she was gonna show E6 how we wrap R1 because she tears off her diaper and rips it up. E5 folded the sheet, put R1's arms to her sides, rolled R1 from side to side in the bed and proceeded to tightly wrap R1's body like a mummy. R1 could not move and began to scream loudly, " I hate you! I ' m gonna kill you." R1 continued to be very upset. E6 went back to R1's room about an hour later to check on her because she was wrapped so tightly she wanted to make sure R1 could breathe. E6 further stated that she has found R1 to be compliant with care if you just explain what you are going to do. E6 said she did not report the incident right away because she felt intimidated by E5 and E5 had been working there for a long time. But this was so bad, it was just not right. About 2 weeks later I told the nurse what happened. E2, DON (Director of Nursing and Abuse Coordinator) submitted a report of abuse and neglect with a completion date of 10/02/13. In the report E2 interviewed staff members including E5 and E6. E2 documented her interview with E6 who relayed the same information regarding the mistreatment of [REDACTED]. E5 denied the allegations in her statement. E2 stated on 10/17/13 she sent an initial report to the Department of Public Health and sent a letter to E5 (who was on vacation) to not return to work while the investigation was in process. However on 10/02/13 E2 concluded in her investigation that the information provided is inconclusive of verbal, physical abuse and neglect. The report also notes that E5 was returned to work, however to different, more visible unit. During a meeting with facility staff in the conference room on 10/17/13 E2 stated, that the reason she wrote on the investigation that the information provided was inconclusive was because she was directed to by HR (corporate human resource person, E12). E2 further stated that she felt the abuse had occurred and E5 should have been fired but we couldn't. E12 directed us to do this, we were all shocked. E10, RN (1st floor manager) stated during interview on 10/17/13 that she also helped with the abuse investigation involving R1. E10 said that while interviewing E4 (CNA), E4 told E10 about another situation that had occurred recently on the memory care unit. E4 said that a couple weeks ago, not sure of the exact date at dinner time around 5:30pm R1 was in the dayroom in a recliner. R1 was screaming and E3, (LPN) put R1 in a wheelchair and brought her into the nursing office. R1 was still screaming and E3 was screaming back at her and shaking her. On 10/17/13 E1, ( Administrator) was asked about the abuse allegations against E5 and E3. E1's reply was " We should have termed them. " Timekeeping reports were reviewed and it was determined that after the incident occurred on 09/11/13 E5 worked with residents for 8 more days, 09/12/13, 09/14/13, 09/15/13, 09/16/13, 09/18/13, 09/19/13 and 09/20/13. E5 was on vacation from 09/21/13/ thru 10/01/13. E5 worked again on 10/04/14 and 10/07/13 on a different resident floor, (after the facility became aware that abuse had occurred.) E3's timekeeping report notes that after the abuse incident of approximately 09/01/13, E3 worked directly with residents on 09/03/13, 09/04/13, 09/05/13, 09/07/13, 09/08/13, 09/10/13, 09/11/13, 09/12/13, 09/13/13, 09/19/13, 09/21/13, 09/22/13, 09/24/13, 09/25/13, 09/26/13, 09/27/13, 09/30/13, 10/01/13, 10/02/13, 10/03/13 and 10/05/13. E3 was not terminated until 10/11/13. 2) On 10/17/13 at 10:10AM, E2 (DON), during interview stated "on 10/01/13, E4 (nurse aide), reported that on approximately 9/01/13 during the dinner meal on Memory Care unit, E4 witnessed the following: R1 was sitting in a recliner in the dining room, agitated and screaming out loud. E3 grabbed R1 out of the recliner and put her in a wheel chair, then took R1 into a darkened nursing station office and closed the door behind them. R1 continued to scream in the office and E3 yelled back at R1, mimicking her. E4 also said that E3 grabbed R1's shoulders and started shaking the resident while telling R1 to stop screaming." E4 said, 30 minutes later, E3 brought R1 back to the dining room and served R1 her dinner tray but the other residents had already finished eating. After returning R1 to the dining room, E3 said out loud; "Let me know if any other residents need to be taken into the office." E2 said that E9 and E11 (nurse aide), were also present during this incident. E2 said that E3 denied ever putting R1 in the nursing office for screaming. E2 said the exact date of this incident is not known. On 10/17/13 at 4:29PM, during a telephone interview, E11 (nurse aide), stated that she witnessed E3 take R1 into the nursing station office during a dinner meal for screaming and spitting at her. E11 said that R1 was very agitated during the transfer from recliner to wheel chair. E11 observed E3 holding R1 with open hands to keep R1 from hitting her. E11 validated contents of her 10/01/13 written statement. On 10/17/13 at 10:30AM, E1 (Administrator), during interview stated " About 2 weeks prior to 9/11/13, exact date unknown, E3 was observed grabbing R1 by the shoulders, placing R1 in a locked office with the lights turned off. E1 said there were several witnesses to this incident and could see and hear E3 mocking R1 through the office window. E1 said that "we should have terminated E3 but facilities home office said we could not terminate her because we did not have enough evidence." E1 also said E3 was allowed to come back to work after 10/02/13. E1 said E3 denied doing anything wrong to R1. 10/18/13 at 11:15AM, during a telephone interview, E9 (nurse aide), stated that she witnessed E3 remove R1 from the dining room one evening (date unsure), and place R1 in the nursing station office due to screaming behaviors. E9's written statement in facilities 10/01/13 abuse investigation validates the above interview. E3's 10/02/13 written statement and E2 and E1's 10/17/13 interviews conclude that E3 denied ever taking R1 into the nursing station office due to screaming behaviors during a meal. Facilities abuse investigation related to R1 and E3, validated the above information obtained in staff interviews. The investigation documented the results were inconclusive for verbal, physical and restraint use and the " staff member returning to work 10/04/13." E1, Administrator was notified of the Immediate Jeopardy on 10/18/13 at 11:15AM related to the facility ' s failure to protect R1 from physical, verbal and mental abuse by E5 (nurse aide), on 9/11/13 and E3 (charge nurse), on approximately 9/01/13. The surveyor confirmed that the facility took the following steps to remove the immediacy of the situation. 1. On 10/11/13 the facility terminated E3 and E5 from employment at the facility. 2. The facility ' s abuse policy has been reviewed and revised to ensure that any employee accused of involvement in an incident of potential abuse is immediately suspended and is not allowed to return to work until a comprehensive investigation has been completed and it is confirmed that the allegation could not be substantiated. If, in fact the allegation is substantiated, the employee will terminated and reported to the police, IDPH and the Illinois Department of Professional Regulations or their licensing authority. 3. A new bullying policy has been developed to complement the facility 's abuse policy. This policy stresses the importance of immediately reporting any allegations or incidents. The policy also makes it clear that any staff member alleged to be involved in an incident will be immediately suspended. 4. All staff are being in-serviced on the abuse policy as well as the new policy on bullying. Special emphasis has been placed on each individual ' s reporting obligations. Staff are also being in-serviced on dealing with stressful situations and recommended approaches for dealing with stress or intervening to assist other staff in such situations. No staff will be allowed to work until they have received the in-service training. 5. All staff were queried regarding any other potential incidents. No additional incidents were identified. 6. The Administrator and /or designee shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of the Plan of Abatement. This will include reviewing these issues during daily stand up meetings. The Administrator will review all allegations and complaints of abuse/bullying to ensure that the facility ' s policies and procedures are being properly followed with special emphasis on reporting and the immediate suspension of staff. 7. Effective immediately, there will be a staff nurse assigned to the Memory Support Unit 24/7.

Based on interview and record review facility failed to ensure that 2 alleged violations involving mistreatment and abuse of a resident (R1) were immediately reported to facility administrator and to other officials in accordance with State law. Facility also failed to take corrective action when these alleged violations were verified during facility's abuse investigations. R1 was physically, verbally and mentally abused by E5 (nurse aide), on 9/11/13 and E3 (charge nurse), on approximately 9/01/13. On 9/11/13, E5 approached R1, without verbally communicating with the resident and proceeded to physically restrain R1 in tightly wrapped sheets, securing both arms against the sides of the body, rendering R1 unable to move, causing increased agitation and mental distress. This incident was witnesed by E6 who failed to immediately report it. On "approximately 9/01/13", E3 responded inappropriately with R1 while the resident was displaying behaviors of screaming out. E3 roughly transferred R1 from a recliner to a wheelchair, yelled and screamed at the resident, involuntarily secluded the resident behind a closed door in a dark office, physically mishandling R1 by "grabbing the resident by the shoulders and shaking R1, loudly telling the resident to stop screaming." While R1 continued to scream, E3 started mimicking and screaming at R1. The incident was witnessed by several facility staff who failed to immediately report the above witnessed abuse to their immediate supervisor. Both of the incidents (9/01/13 and 09/11/13) were not initially reported to IDPH until 09/26/13. After facility administration found abuse allegations about E5 and E3 to be valid, E5 and E3 were allowed to continue providing hands on care to facility residents 10/02 - 10/11/13. These failures placed 19 of 19 cognitively impaired residents (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20 and R21), residing on the facilities "Memory Care Unit," at risk for being abused 9/01 - 10/01/13 and all 98 facility residents at risk 10/02 - 10/11/13. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy situation was identified on 10/18/13. The Immediate Jeopardy began on 9/01/13. The immediacy was removed 10/11/13. The facility remains out of compliance at a level 2 due to the need to evaluate staff response to abusive situations and changes in facility policy and procedures. The Findings include: 1) On 10/17/13 at approximately 2:00pm E6, CNA (Certified Nurses Aid) stated during interview that she was hired at the facility on 09/04/13. E6 started on the memory care unit on 09/11/13 and was assigned to train with E5, CNA. E6 stated, I introduced myself to E5 at 2:30pm. E5 said we have to toilet residents. We entered R1's room. R1 was sitting in a recliner and E5 said (in Spanish) we are gonna transfer her. E6 asked E5 if she was going to explain to R1 what she was about to do. E5 said no, it will only agitate her. E5 further stated that the residents are just filthy barn animals. E5 continued to converse in Spanish which seemed to increase R1 ' s agitation. At bed time we toileted R1 and E5 again did not explain to R1 what she was going to do. R1 was biting and scratching at us. E6 tried to calm R1 down and E5 said, What do you care? It doesn ' t matter, we have to get this done. When we put her to bed E5 asked E6 to get an extra sheet. E5 said she was gonna show E6 how we wrap R1 because she tears off her diaper and rips it up. E5 folded the sheet, put R1's arms to her sides, rolled R1 from side to side in the bed and proceeded to tightly wrap R1 ' s body like a mummy. R1 could not move and began to scream loudly, " I hate you! I ' m gonna kill you." R1 continued to be very upset. E6 went back to R1 ' s room about an hour later to check on her because she was wrapped so tightly she wanted to make sure R1 could breathe. E6 further stated that she has found R1 to be compliant with care if you just explain what you are going to do. E6 said she did not report the incident right away because she felt intimidated by E5 and E5 had been working there for a long time. But this was so bad, it was just not right. About 2 weeks later I told the nurse what happened. E2, DON (Director of Nursing and Abuse Coordinator) submitted an initial report to IDPH on 09/26/13. A final report of abuse and neglect was completed by E2 on 10/02/13. In the report E2 interviewed staff members including E5 and E6. E2 documented her interview with E6 who relayed the same information regarding the mistreatment of [REDACTED]. E5 denied the allegations in her statement. E2 stated on 10/17/13 she sent an initial report to the Department of Public Health and sent a letter to E5 (who was on vacation) to not return to work while the investigation was in process. However on 10/02/13 E2 concluded in her investigation that the information provided is inconclusive of verbal, physical abuse and neglect. The report also notes that E5 was returned to work, however to different, more visible unit. During a meeting with facility staff in the conference room on 10/17/13 E2 stated, that the reason she wrote on the investigation that the information provided was inconclusive was because she was directed to by HR (corporate human resource person, E12). E2 further stated that she felt the abuse had occurred and E5 should have been fired but we couldn ' t. E12 directed us to do this, we were all shocked. E10, RN (1st floor manager) stated on 10/17/13 that she also helped with the abuse investigation involving R1. E10 said that while interviewing E4 (CNA), E4 told E10 about another situation that had occurred recently on the memory care unit. E4 said that a couple weeks ago, not sure of the exact date at dinner time around 5:30pm R1 was in the dayroom in a recliner. R1 was screaming and E3, ( LPN) put R1 in a wheelchair and brought her into the nursing office. R1 was still screaming and E3 was screaming back at her and shook her. On 10/17/13 E1,( Administrator) was asked about the abuse allegations against E5 and E3. E1's reply was " We should have termed them. " Timekeeping reports were reviewed and it was determined that after the incident occurred on 09/11/13 E5 worked with residents for 8 more days, 09/12/13, 09/14/13, 09/15/13, 09/16/13, 09/18/13, 09/19/13 and 09/20/13. E5 was on vacation from 09/21/13/ thru 10/01/13. E5 worked again on 10/04/14 and 10/07/13 on a different resident floor, (after the facility became aware that abuse had occurred.) E3's timekeeping report notes that after the abuse incident of approximately 09/01/13, E3 worked directly with residents on 09/03/13, 09/04/13, 09/05/13, 09/07/13, 09/08/13, 09/10/13, 09/11/13, 09/12/13, 09/13/13, 09/19/13, 09/21/13, 09/22/13, 09/24/13, 09/25/13, 09/26/13, 09/27/13, 09/30/13, 10/01/13, 10/02/13, 10/03/13 and 10/05/13. E3 was not terminated until 10/11/13. On 10/17/13 at 10:10AM, E2 (DON), stated during interview that "on 10/01/13, E4 (nurse aide), reported that on approximately 9/01/13 during the dinner meal on Memory Care unit, E4 witnessed the following: R1 was sitting in a recliner in the dining room, agitated and screaming out loud. E3 grabbed R1 out of the recliner and put her in a wheel chair, then took R1 into a darkened nursing station office and closed the door behind them. R1 continued to scream in the office and E3 yelled back at R1, mimicking her. E4 also said that E3 grabbed R1's shoulders and started shaking the resident while telling R1 to stop screaming." E4 said, 30 minutes later, E3 brought R1 back to the dining room and served R1 her dinner tray but the other residents had already finished eating. After returning R1 to the dining room, E3 said out loud; "Let me know if any other residents need to be taken into the office." E2 said that E9 and E11 (nurse aide), were also present during this incident. E2 said that E3 denied ever putting R1 in a office for screaming. E2 said the exact date of this incident is not known. On 10/17/13 at 4:29PM, during a telephone interview, E11 (nurse aide), stated that she witnessed E3 take R1 into the nursing station office during a dinner meal for screaming and spitting at her. E11 said that R1 was very agitated during the transfer from recliner to wheel chair. E11 observed E3 holding R1 with open hands to keep R1 from hitting her. E11 validated contents of her 10/01/13 written statement. E11 also stated that this incident occurred a couple months ago on the evening shift but exact date uncertain. On 10/17/13 at 10:30AM, E1 (Administrator), stated " About 2 weeks prior to 9/11/13, exact date unknown, E3 was observed grabbing R1 by the shoulders, placing R1 in a locked office with the lights turned off. E1 said there were several witnesses to this incident and could see E3 mocking R1 through the office window. E1 said that "we should have terminated E3 but facilities home office said we could not terminate her because we did not have enough evidence. E1 also said that E3 was allowed to come back to work after 10/02/13. E1 said that E3 denied doing anything wrong to R1. 10/18/13 at 11:15AM, during a telephone interview, E9 (nurse aide), stated that she witnessed E3 remove R1 from the dining room one evening (date unsure), and place R1 in the nursing station office due to screaming behaviors. E9's written statement in facilities 10/01/13 abuse investigation validates the above interview. On 10/17/13, during individual interviews, E2 at 10:20AM, E1 (Administrator) at 10:30AM and E10 at 1:30PM , all stated that on 10/01/13, E1, E2 and E10 all agreed that the alleged abuse incidents to R1 on 9/01/13 by E3 (nurse) and on 9/11/13 by E5 (nurse aide), were validated and they agreed to terminate E3 and E5. E1, E2 and E10 also said that as a final determination by facilities "Home Office", E3 and E5 were not terminated and allowed to return to work in same positions, providing hands on patient care. On 10/17/13 at 5:00PM, E7 (executive director), stated "We have set protocol to follow before terminating an employee. E3 and E5 have had very good performance appraisals up to these incidents. So they were allowed to return to work." Facilities abuse investigation related to R1 and E3, validated the above information obtained in staff interviews. The investigation documented the results were inconclusive for verbal, physical and restraint use and the " staff member returning to work 10/04/13." E1, Administrator was notified of the Immediate Jeopardy on 10/18/13 at 11:15AM related to the facility ' s failure to protect R1 from physical, verbal and mental abuse by E5 (nurse aide), on 9/11/13 and E3 (charge nurse), on approximately 9/01/13. The surveyor confirmed that the facility took the following steps to remove the immediacy of the situation. 1. On 10/11/13 the facility terminated E3 and E5 from employment at the facility. 2. The facility 's abuse policy has been reviewed and revised to ensure that any employee accused of involvement in an incident of potential abuse is immediately suspended and is not allowed to return to work until a comprehensive investigation has been completed and it is confirmed that the allegation could not be substantiated. If, in fact the allegation is substantiated, the employee will terminated and reported to the police, IDPH and the Illinois Department of Professional Regulations or their licensing authority. 3. A new bullying policy has been developed to complement the facility 's abuse policy. This policy stresses the importance of immediately reporting any allegations or incidents. The policy also makes it clear that any staff member alleged to be involved in an incident will be immediately suspended. 4. All staff are being in-serviced on the abuse policy as well as the new policy on bullying. Special emphasis has been placed on each individual ' s reporting obligations. Staff are also being in-serviced on dealing with stressful situations and recommended approaches for dealing with stress or intervening to assist other staff in such situations. No staff will be allowed to work until they have received the in-service training. 5. All staff were queried regarding any other potential incidents. No additional incidents were identified. 6. The Administrator and /or designee shall be responsible for ensuring continued compliance and will be responsible for overseeing the implementation of the Plan of Abatement. This will include reviewing these issues during daily stand up meetings. The Administrator will review all allegations and complaints of abuse/bullying to ensure that the facility ' s policies and procedures are being properly followed with special emphasis on reporting and the immediate suspension of staff.

Based on observation, interview and record review, the facility failed to provide resident specific interventions, reevaluate the effectiveness of interventions and provide adequate supervision and assistance to prevent reoccurring falls. This applies to 2 of 9 residents ( R14 and R15) reviewed for falls in the sample of 18. This failure resulted in R14 sustaining a left hip fracture, after a fall on 10/17/12. The facility also failed to ensure that emergency exit door was not blocked and that potentially hazardous materials were kept locked and are not accessible to cognitively impaired residents. This was observed in 1 (first floor) of 2 nursing floors. Findings include: 1. R14 has multiple [DIAGNOSES REDACTED]. On 1/30/13 at 1:30 PM, R14 was observed ambulating with assistance from the staff using a gait belt and a rolling walker. R14's annual MDS (Minimum Data Set) dated 7/24/12 was coded to reflect that the resident has orientation problem and required limited assistance x 1 person physical assist with transfers and ambulation. The same MDS indicated that R14 required extensive assistance x 1 person physical assist with toilet use (how resident uses the toilet room, transfer on/off toilet). R14's fall risk screening tools dated 4/6/12, 10/24/12 and 10/31/12 all indicated that the resident is high risk for fall. R14's electronic incident report dated 10/17/12 (4:40 PM) indicated that the resident fell in the bathroom, "Aid was by the door her back against the resident and trying to grab some gloves and when she turned the resident is calling and sitting on the floor." The incident report also stated that R14 was trying to stand up, her pants were halfway through her knees. Upon assessment, R14 was complaining of left leg pain upon movement and left foot was noted to be externally rotated. MD called and ordered to send R14 to hospital ER for evaluation. 911 was called and transported resident to hospital ER for evaluation. The incident report indicated that R14 was admitted to the hospital with [REDACTED]. In an interview held on 1/31/13 at 1:47 PM, E3 (Certified Nursing Assistant, CNA) stated that on 10/17/12 before supper time, she took R14 to the toilet. Per E3 she left R14 on the toilet to get gloves. While she was outside the washroom door, she heard a "thump" and when she went back inside the washroom she saw R14 on the floor, with her (R14) pants and brief halfway down her legs. According to E3, she was not aware that R14 was assessed to be a high risk for fall. E3 stated that, if she was aware that R14 is a high risk for fall, "I would have hollered for another staff to bring in gloves, because I will not leave R14 alone in the washroom." Per E3, R14 is confused and prior to the resident's fall incident on 10/17/12, resident had a behavior of "just getting up/jumps up" without assistance and would fall. E3 stated that R14 had fallen before. E3 also added that at the time of the incident on 10/17/12, R14 did not have an alarm in place. Review of R14's records reflected history of fall on 6/7/11 at 5:45 PM. The resident was found lying on the floor inside the bathroom. R14 complained of pain at the back of the head, left arm, knees and back. R14 was also noted with swelling and redness on the left arm and two pinpoint redness at the left side of the back of the head. Further review of R14's fall history reflected a fall on 7/13/11 at 10:35 PM. R14 got out of bed without assistance to go to the bathroom. While ambulating to the bathroom R14 began urinating and slipped on the floor, hitting her back and left side of the head on the dresser. R14 complained of back pain and was noted to have bruising on the back measuring 10 x 10 cm. R14 was noted with bump on the left side of the head. R14 has history of falls with injury and was identified by the facility as high risk for fall. However, no fall care plan was in place during the fall incident of 10/17/12. 2) R15 is a [AGE] year old resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of MDS (Minimum Data Set) dated 11/14/2012 and 12/26/2012 identified R15 requiring extensive assistance with 1 person physical assist for transfers and mobility. Review of the "Fall Risk Assessment" dated 8/8/2012 and 11/9/2012 showed that R15 is a high risk for fall. R15 was observed on 1/28/13 at 11:45 A.M. and 1/29/2013 at 1:30 P.M. R15 was sitting in his wheelchair in the dining room. R15's upper body was leaning forward and had poor trunk control. A review of the facility's incident reports showed that R15 sustained 9 fall incidents for a period of 7 months (6/2012 to 1/2013). The incident reports documented R15's fall episodes: 1) 6/24/2012 at 11:35 A.M. "found on the floor (R15's room) , sustained cut , frontal lobe measures 1 and 1/4 (centimeter) cm and 3 cm. bleeding noted." 2) 8/10/2012 at 4:45 A.M., "bed alarm going off, (R15) found on the floor (R15's room)" 3) 10/13/2012 at 7:15 P.M., "(R15) found on the floor (in his room)" 4) 11/26/2012 at 3 P.M."heard calling, (R15) found on the floor (in his room) " 5) 12/5/2012 at 9:55 P.M., "heard alarm, (R15) fell out of bed while trying to go bathroom" 6) 12/7/2012 at 3:20 A.M., "found sitting on the floor (in his room), unable to relate what happened" 7) 12/17/2012 at 2:25 A.M. "alarm going off, (R15) found kneeling on the floor" 8) 12/26/2012 at 4:30 P.M. "alarm going off, (R15) found on the floor (in his room) " 9) 1/19/2013 at 10:40 P.M., "heard bed alarm, (R15) found sitting on bedside floor mat " R15's current care plan did not include revised specific interventions after each fall. There were no adjustments in approaches or goals specific to R15's specific needs in order to prevent further fall. R15's incident report investigations showed that the falls were not analyzed to find the root cause in an attempt to prevent further falls. 3. During the lunch observation made on 1/29/13 at 2:10 PM inside the first floor main dining room, Table #22 was blocking the emergency exit door. There were two residents occupying this table. 4. During the environmental tour held on 1/30/13 at 11:15 AM inside the C-wing (Alzheimer's unit), 1 bottle of glue, 1 bottle of fabric paint and 1 bottle of glittered acrylic paint were observed stored inside an unlocked top cabinet by the open resident lounge area.

A. Based on interview and record review the facility failed to obtain a Physician order [REDACTED]. As a result of this facility failure, R15 sustained a burn requiring 21 days of daily dressing changes and antibacterial ointment application. Findings Include: A. The September 2011 Physician order [REDACTED]. Additionally this same Physician order [REDACTED]. (According to the Physician's Desk Reference, 64th Edition, Lidoderm Patch is a local anesthetic agent that reduces sensation). On 3-21-2012 at 9:05am., E2, (DON/Director of Nursing) stated, "I'll check to see if we have a Policy for heating pads/hot packs in resident rooms. I don't think we allow heating pads/hot packs." The undated Facility Admissions Forms/Items Not Allowed is, "The following items are not allowed to be kept by residents in their rooms, per Illinois Department of Public Health Regulations: Electrical appliances that produce heat.....heating pads." R15's resident file does not contain a Physician order [REDACTED]. On 3-21-2012 at 3:15pm., E2, (DON) verified R15 did not have a physician's orders [REDACTED]. E2 provided the following information: Therapy had applied the hot pack to R15 and left the hot pack with R15, in R15's room. R15 asked the CNA, (Certified Nursing Assistant), (E16), to heat the hot pack. Another CNA, (E17), while assisting R15's roommate saw the burn on R15's back, around 8:00pm. Z2, (Physical Therapy Assistant) on 3-21-2012 at 2:05pm., stated, "There was no need for (R15) to have a hot pack. No, there wasn't an order for [REDACTED]. We, (therapy) do not allow staff to use our hot packs for residents. Our Policy is to only allow hot pack application in the therapy room, because residents need constant supervision." E17, (CNA)'s 9-15-2011 CNA Statement Regarding Resident's Accident/Incident is, "Was in the room helping (R15's) roommate. (R15) was undressing for bed. I saw (R15's) back, red, and blisters. Huge red area and blisters. (R15) said heat pad was not hot. (R15) said she was not aware of redness or blisters on her back until I mentioned it." The 9-15-2011 at 8:15pm., Incident Report Summary is, "(R15) found redness with some blister to lower back, patient stated that it is from hot pack. Hot packs removed from service area. Only therapy to use at this time. (R15) was noted with redness and some blister to the lower back. (R15) is alert and oriented and claimed that she asked the CNA, to heat the hot pack from therapy for her back pain. (E16/CNA) heated the hot pack according to instruction and wrapped the hot pack with towel before giving to (R15)." Physician order [REDACTED]." The 9-16-2011 Physician order [REDACTED]. Apply Silvadene cream to right lower flank until healed, every day, cover with gauze and tape." Physician order [REDACTED]. Wash right flank/back with normal saline solution, pat to dry and cover with dry dressing daily, until healed. Discontinue wound consult." Z6, (Physician)'s 9-16-2011 Progress Note is, "(R15) Blister to right lower back, big blister and one small blister with redness, wound care, silver sulfadiazine ointment." (According to the Nursing 2012 Drug Handbook, 32nd. Edition, Walters, Flumer, Lippincott and Williams page 1230 Silver Sulfadiazine ointment is an "Antibacterial ointment used to prevent or treat wound infection, in second or third degree burns.") R15's Non-Pressure Skin Condition Report is, "9-15-2011, Lower back, burn from hot pack with blister, 18 x 7cm.,(Centimeters). 9-17-2011, Blisters present, fluid filled, surrounding skin slightly reddened. 9-24-2011, Burn healing, no blister, covered with antibiotic ointment and sterile dressing - looks much better. 10-1-2011, Healing, slightly reddened. 10-7-2011, Healing, slight redness." Nursing Notes and Treatment Records from 9-15-2011 through 10-6-2011 contain documentation that R15 required daily dressing changes with application of antibiotic ointment and/or burn ointment for her lower back burn, from the application of the hot pack. Medication Administration Sheet of 9-15-2011 contains documentation that R15's pain patch was applied, when R15 sustained the burn to her lower back. B. Based on record review and interview, the facility failed to adequately supervise and monitor one resident (R18) from leaving the facility without the staff knowledge in a sample of 20. Findings include: R18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical report dated 11/17/11 indicated that R18 was alert with dementia. The Incident Report dated 11/27/11 indicated that R18 eloped from the facility on 11/27/11 without the staff knowledge between 9:00 PM and 10:00 PM. E19 (Night Certified Nursing Assistant - CNA) observed R18 sitting in the wheelchair at the stop sign of Grand Avenue and Deep Lake Road at 10:00 PM. R18 was alert with confusion and forgetfulness. When E19 asked R18 where he was going, the resident pointed to the stop light and stated that he was going home. The temperature was cool and R18 was not wearing a coat. E19 called the nursing station and informed the staff to meet them at the stop sign to retrieve the wheelchair. Incident report summary dated 11/27/11 indicate that R18 was alert with period of confusion and lacks cognitive skills for poor safety awareness. R18 traveled on a wheelchair from the 2nd floor via elevator thru two double doors of the front entrance into the winding, slightly downhill street which was approximately 0.2 mile. No staff was at the entrance door after 8:00 PM. The door of the front entrance was not locked to go out. It can be accessed by phone and the staff on the 1st floor had to release the alarm. The Minimum Data Sheet (MDS) with Assessment Reference Date (ARD) of 11/26/11 indicated under Section E: Behavior - Wandering - Presence & Frequency, R18 wandered 4 - 6 days. Wandering Impact - R18 was at significant risk to wander to potentially dangerous place. On 03/22/12 at 9:55 AM, E18 CNA (Certified Nursing Assistant) was interviewed via telephone and stated " around 9:30 am R18 bed alarm was going off. R18 usually moves around his bed. I saw R18 up in wheel chair already. I turned off the alarm and asked R18 if he needed help. R18 said No. I left R18 in his room and went to help another resident. E19 night CNA called the unit and said that resident was found outside near the stop sign in front of the care center downhill past the parking lot. When I heard that resident was out, E21 ( nurse) and I (E18) went downstairs. We first asked the first floor nurse's aide who was sitting at the nurse's station if she heard an alarm because when people go out, first floor will hear the alarm sound. They said they did not hear anything. E21 and I ran outside to the stop sign but we found the resident down by the Grand Avenue road stop sign. E19 was getting resident in her car. We took the wheelchair and met them at the front entrance. We put R18 in a wheelchair and brought him up to second floor and filled out an incident report and put R18 in bed. R18 has coat and hat. We were short of staff that night. 4 CNA's and 3-4 nurses. The weather was a little bit chilly. We were cold. That evening, he was kind of upset and feisty because of the news that his wife was leaving him. R18 was asked why he went out, he indicated that he wanted to go just because." On 03/22/12 at 10:55 AM E19 CNA was interviewed via telephone and stated " I was coming to work around 10 PM and saw R18 in a wheelchair by Grand avenue off the street by stop sign. I asked R18 where he was going and R18 said he was going to the gas station. I told R18 that he was not supposed to be there because it was cold that night. I put R18 in the car and called the nurse's station on the second floor. I saw E18 and a nurse coming toward me so I told them to meet us at the facility entrance. They took the resident in and I waited for my shift." E19 also indicated that R18 was wearing a sweat suit and the temperature was around 40 degrees that night. Weather report dated 11/27/11 indicated that the temperature was 40 degrees Fahrenheit. E1 (Facility Administrator) stated on 3/21/12 at 11:00 AM, the front door access is closed to people coming in but would sound an alarm when somebody exits from the facility after eight PM. On 03/22/12 at 12:20 PM with E20 (Plant Operation technician), it was verified the distance that R18 traveled from the facility entrance around the parking lot on a downhill slope to the main road (Grand Avenue) was 0.2 mile.