Every finding on record at Warren Barr Lieberman

Based on record review and interview, the facility failed to return resident trust fund balances for 6 residents (R5-R10)reviewed for trust fund balances after being discharged /expired within 30 days reviewed for resident's rights in a sample of 10. On [DATE] at 12:21 PM, V7 (Business office manager/BOM) stated V7 is the person who closes residents RFMS account when a resident discharges from the facility or expires. V7 residents RFMS (Resident Fund Management Service) account should have been closed when the resident is discharged or expires and notifies cooperate Account Receivable (AR) so the residents, if expired residents appointed person or the state could have received a check of the residents closed balance from the residents RFMS account within 30 days. V7 stated she did not do so for the sampled residents R5, R6, R7, R8, R9, and R10 and has been more than 30 days for each sampled resident. On [DATE] at 2:48PM, V9 stated when a residents RFMS account is closed, V9 distributes the trust fund checks when V9 knows the address of the person the check is going out to, this information is given to V9 by V7. V9 states V9 has not distributed checks for R5, R6, R7, R8, R9, and R10 because V9 was just notified [DATE] by V7. Record Review for R5, reviewed document titled: Resident Statement Landscape [NAME] Skilled Nursing for resident R5 documents admission date [DATE], R5 expired [DATE]. R5s [DATE] balance $3,432.40.Record Review of R6s document titled RFMS (Resident Fund Management Service) Trial Balance list, balance as of [DATE], R6 current balance $1274.48. Resident Statement Landscape [NAME] Skilled Nursing RFMS (Resident Fund Management Service) admission date [DATE] Status Reason: R6 Expired [DATE]. R6s [DATE] balance closing interest balance $1,274.66.Record Review of R7s document titled RFMS (Resident Fund Management Service) Trial Balance list, balance as of [DATE] R7 current balance $969.19, R7 expired [DATE]. Resident Statement Landscape [NAME] Skilled Nursing RFMS (Resident Fund Management Service) admission date [DATE], Expired [DATE]. R7s [DATE] balance closing interest balance $969.33.Record review of R8s document titled document RFMS (Resident Fund Management Service) Trial Balance list, balance as of [DATE] R8s current balance $7,723.55. Resident Statement Landscape [NAME] Skilled Nursing RFMS (Resident Fund Management Service) admission date [DATE] discharge date [DATE]. R8s [DATE] closing interest balance $7,724.64.Record Review of R9s document titled RFMS (Resident Fund Management Service) Trial Balance list, balance as of [DATE] R9s current balance $1538.46, expired [DATE]. Resident Statement Landscape [NAME] Skilled Nursing RFMS (Resident Fund Management Service) admission date [DATE], expired [DATE]. R9s [DATE] closing interest balance $1,538.68.Record Review of R10s document titled RFMS (Resident Fund Management Service) Trial Balance list, balance as of [DATE], R10s current balance $1,904.06. Resident Statement Landscape [NAME] Skilled Nursing RFMS (Resident Fund Management Service) admission date [DATE], expired [DATE]. R9s [DATE] closing interest balance $1,904.33.Facilities Trust Fund Policy Revised [DATE].Purpose The facility will comply with the federal regulations in regards to resident's trust fund.Procedure: 5) Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days of the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate.

Based on observation, interview, and record review, the facility failed to obtain orders from the physician to have residentmedication at the bedside. The facility also failed to complete self-administration of medication assessments. This applies to 1 (R3) of3 residents (R2 and R4) reviewed for medications in a sample of 3.On 7/21/2026 at 11:12AM, During observation and resident interview with R3 for resident rights, surveyor observed in R3s room, a medication cup with multiple pills inside.On 7/21/2026 at 11:16AM, V5 entered R3s room while surveyor was in room with R3. V5 stated she was R3s nurse and left the medication cup in R3s room but is not supposed to leave the medication in R3s room. V5 stated V5 should have waited and watched R3 swallow R3s medication but did not stay in the room and assumed R3 would take R3s medicine. During observation V5 and nurse surveyor counted 11 pills in the medication cup on R3s bedside table. On 7/21/2026 at 11:19 AM, V5 showed surveyor R3s electronic medication Administration record color green on the computer. V5 stated green means R3s medications were signed off as given. V5 stated she did not watch R3 take her pills and still documented on the electronic MAR as given but should not have marked it off until she observed R3 swallow R3s pills.On 7/21/2026 at 11:29 AM V2 stated nurses should not leave medications in residents' room, and it is expected for nurses to stay with the resident until the resident swallows their medication. V2 stated R3 did not have self-administer orders or assessments in place for self-administer medications.Reviewed facilities Nurse Medication Pass Competency dated 7/8/2026 reads observes each resident after administering meds to ensure medications are fully swallowed/consumed.Facilities Medication Pass Policy and Procedure revised 7/7/2026.Policy statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures.Procedures: 7. PO meds: E. After medications is administered to each resident, sign MAR that it was given.

Based on observation, interview, and record review the facility failed to use appropriate infection control practices during resident care on contact isolation precaution and during taking resident's vital signs. The facility failed to provide disposable vitals equipment inside the room of resident with COVID infection. This deficiency affects all four (R48, R70, R187 and R427) residents in the sample of 35 reviewed for Infection Prevention and Control Program. Findings include: On 5/6/25 11:39AM, Observed V18 CNA (Certified Nurse Assistant) entered R70's room who is on contact isolation precaution without appropriate Protective personal equipment (PPE) to bring the lunch tray. V18 is only wearing mask. Showed observation to V16 LPN (Licensed Practical Nurse). V16 said that V18 should wear appropriate PPE such as gown and gloves in addition to mask when entering R70's room to give her lunch tray because she is on contact isolation. V18 said that she forgot to wear gown and gloves when entering R70's room. On 5/6/25 at 12:39PM, Informed V4 Infection Preventionist/4th floor unit manager of above observation. V4 said that staff should wear appropriate PPE when entering R70's room to provide lunch tray. On 5/6/25 at 12:51PM, Observed V17 LPN prepared medication for R48. V17 said that will take her blood pressure before giving her medication. V17 took the Blood pressure (BP) portable machine from the hallway and wheeled it to R48's room. V17 did not disinfect the BP cuff prior using it. V17 applied the BP cuff to R48's right arm and obtained BP reading of 107/52mmhg. V17 said she will hold the BP medication. V17 removed the BP cuff without disinfecting after using it. V17 wheeled the BP machine back to the hallway and plugged it. V17 proceed to another resident to administer medication. Informed V17 of above observation made that she did not disinfect the medical equipment before and after using it. V17 said that she forgot, she should disinfect the BP cuff before and after using it. On 5/6/25 at 1:28PM, Informed V4 Infection Preventionist/4th floor unit manager of above observation and concern. On 5/6/25 at 2:13PM, Informed V2 DON (Director of Nursing) of above concerns with implementation of infection prevention control protocol. V2 said that staff should wear appropriate PPE when entering resident's room on contact isolation precaution. V2 said that medical equipment for taking vital signs should be disinfected before and after using it. On 5/7/25 at 8:54AM, Observed V22 RN (Registered Nurse) preparing medication for R187. V22 said that she will take the vital signs first. V22 took the BP machine from the hallway without disinfecting it prior using it and wheeled to R187's room. R187 is sitting in his chair. V22 placed the BP cuff on R187's left arm and pulse oximetry on index finger. V22 obtained BP 86/56 mm hg, HR 71, and Oxygen saturation 96%. V22 said that she will hold R187's BP medication. After taking the vital signs she wheeled the medical equipment back to the hallway. V22 did not disinfect the medical equipment. V22 administered prepared medications to R187 and proceed to another resident. On 5/7/25 at 9:27AM, Informed V3 ADON (Assistant Director of Nursing) of above concerns. V3 said that staff should disinfect the medical equipment for vital signs before and after using it. Facility's policy on Infection Prevention and Control revised 2/10/25 indicated: Policy statement: The facility has established a policy to identify, record, investigate, control, test and prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection. Precautions to prevent transmission of infectious agents and transmission-based precaution: 2. Contact precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. b. Use of gown and gloves is necessary prior to room entry. Face protection may be necessary if performing with risk of splashing or spraying (Standard precaution). Facility's policy on medical equipment, instruments and health IT devices infection plan revised 8/16/24 indicated: Policy statement: it is the policy of this facility to prevent infection control and create/maintain a safe environment for the residents, their visitors and staff thru proper handling, cleaning, and sanitizing of medical care equipment, instruments, and other related health IT devices. Procedures: 7. Nursing personnel shall wipe down/clean/disinfect care equipment between residents using a facility approved cleaner/disinfect. 49871 On 5/6/2025 at 11:05 AM during facility rounds, V21 (Licensed Practical Nurse) walking in the hallway with ziplock bag on her hand containing vital sign equipment. V21 claimed bag belongs to R427 and she was cleaning the equipment. On 5/6/2025 at 11:06 AM, V4 (Infection Preventionist) said R427 should have his own dedicated vital sign equipment and should not be taken out of the room until isolation precaution ended. V4 said R427 is on isolation for positive Covid19. On 5/7/2025 at 9:29 AM, V2 (Director of Nursing) stated transmission-based precaution/isolation room should have their own dedicated equipment that would stay in the room until isolation is discontinued to avoid cross- contamination of other residents. Review of R427 medical records read: admitted : 4/22/2025, Diagnosis Information: Covid-19; Order Summary, start date 5/5/2025 Maintain at all times: Strict contact/droplet isolation precautions due to an active infection; Care Plan, 5/5/2025 R427 requires strict droplet/contact precautions related to Covid. Interventions: Use appropriate protective equipment Policy and Procedure Name: Infection Prevention and Control, Revised 2/10/25 Policy Statement The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for identified infection. Procedures 10. A disposable thermometer, BP cuff, and stethoscope will be provided inside the room to provide personal equipment for residents who are on transmission-based precaution or quarantine.

Based on observation, interview, and record review the facility failed to ensure an accurate count of controlled medication in the controlled drug administration record sheet. This deficiency affects 2 of 5 medication carts reviewed for Controlled Medication count Management. The facility also failed to follow physician order in administration of medication. This deficiency affects two (R121 and R132) of three residents reviewed for administration of medication. Findings include: On 5/6/25 at 9:59AM, Checked controlled drug administration record sheet binder with V15 RN (Registered Nurse). Observed R121's controlled drug administration record indicated hydrocodone APAP 5-325mg give 1 tab daily every 12 hours as need for pain however the nurses are giving 1/2 tab as indicated in the administration record. V15 said that resident is alert, oriented x 3 and able to verbalize needs to staff. V15 said that R121 will request if she needs 1/2 or 1 tablet when she is pain. V15 said that they should follow physician order in medication administration. V15 said that they should call the physician to verify and change the order. On 5/6/25 at 10:10AM, Informed V10 Restorative Nurse /3rd floor unit manager of above concern. V10 said that they should follow physician order in medication administration. On 5/6/25 at 10:45AM, Informed V2 DON (Director of Nursing) of above concern. V2 said that they should follow physician order in medication administration. On 5/6/25 at 12:04PM, Checked controlled drug administration record sheet binder with V17 LPN. Observed R116's controlled drug medications - Oxycodone-APAP 10-325mg tablet, Pregabalin 25mg capsule and Tramadol 50mg tablet did not have accurate count. All medications are missing 1 count each. V16 said that she gave the medications this morning but forgot to sign them out in the controlled drug administration record sheet. On 5/6/25 at 12:20PM, Informed V4 Unit floor manager/Infection Preventionist of above concern. V4 said that the nurse should document the dated, time and amount of controlled medication taken in the controlled drug administration record sheet. On 5/6/25 at 12:37PM, Observed V17 LPN (Licensed Practical Nurse) preparing medication for R132. Medication administration record indicated Cranberry tablet 300mg give 1 tablet by mouth three ties a day for supplement. V17 said that they have been giving the house stock of Cranberry tablet 400mg because they don't have 300mg. Observed V17 administered medication to R132. On 5/6/25 at 2:13PM, Informed V2 DON (Director of Nursing) of above concerns. On 5/7/25 at 8:45AM, Observed medication cart unlocked, with keys left on top of the cart and computer open showing MAR (Medication administration record) screen. V22 RN came from resident's room (2 doors away from the medication cart). Showed observation made to V22. V22 said she that she should not leave the medication cart unlocked, leave the medication keys on top of the cart, and leave the MAR computer screen open. On 5/7/25 at 8:59AM, Checked controlled drug administration record sheet binder with V22 RN. Observed R17's Pregabalin 75mg capsule and R169 's Tramadol 50mg tablet did not have accurate count. Both medications are missing 1 count each. V22 said that she gave them both medications at 8:00AM and forgot to sign it in the controlled drug administration record. On 5/7/25 at 9:15AM, Informed V3 ADON (Assistant Director of Nursing) of above concern. V3 said that the nurse should sign off in the controlled drug administration record indicating the medication taken right after taking medication from the bingo card. Facility's policy on Controlled Medication Count revised on 7/26/24 indicated: Policy statement: It is the policy of the facility to maintain an accurate count of scheduled II controlled medications. Procedure: 1. After removing the controlled medication from the bingo card or individual packet the nurse will sign off the accompanying controlled medication sheets indicating the medication is taken. Facility's policy on Physician orders revised 8/16/2 indicated: Policy statement: it is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS.

Based on observation, interview, and record review the facility failed to ensure that no medication should be left at resident's bedside without physician order. The facility also failed to follow its policy in resident self-administration of medication. This deficiency affects all four (R71, R103, R116 and R177) residents in the sample of 35 reviewed for Medication Safety. Findings include: On 5/6/25 at 12:43PM, Observed V17 LPN (Licensed Practical Nurse) preparing medication for R116. V17 said that R116's eye drop medication is at bedside. V17 said that R116 is alert and oriented x 3. V17 said that she usually keeps the eye drops and take it by herself. Observed Refresh eye drop 1 vial (individual dosage) and 1 bottle of Calcium chewable extra strength 750mg on top of R116's bedside tray table. R116 said that her family bought these medications, and she keeps at bedside because the nurses are forgetting to give her medications. She took her eye drops and calcium this morning around 9am because the nurse did not give her medications. V17 LPN is at the bedside and did not response to R116. V17 administered prepared medication including the refresh eye medication at bedside. On 5/6/25 at 12:55PM, V17 LPN said that R116 does not have physician order to keep medications at bedside. On 5/6/25 at 12:58PM, V28 Wound care nurse opened the treatment cart and gave the Voltaren gel house stock to V17 LPN that they use for residents on 4th floor. V17 said that they use the Voltaren house stock and shared it with residents on the 4th floor. Surveyor and V17 went to R177's room to administer Voltaren cream medication but R177 refused. Observed 2 bottle of artificial tears and 3 opened albuterol sulfate inhalers, I box of unopened albuterol sulfate inhaler, 1 Vicks vapor rub. R177 said that she has been keeping these medications at bedside. R177 said that she uses all these medications as needed. R177 said that she uses the Vicks frequently at night. On 5/6/25 at 1:02PM, V9 Nurse Supervisor said that they can keep medication at bedside if there is an order from physician. V17 LPN said that R177 has no physician order to keep medications at bedside. On 5/6/25 at 2:13pm Informed above concerns with V2 DON. V2 said that medication cannot be left at bedside without physician order. If resident wants to self-administer her medications, the IDT (Interdisciplinary team) team will assess resident for self-medication administration and will develop care plan. V2 said that the Voltaren cream house stock should not be shared by residents on the 4th floor. Each resident should have each own medication cream. On 5/7/25 at 9:09AM, V22 RN tried to administer the prepared medication to R71. R71 said that she likes her tums at bedside. She asked V22 to get her tums placed in plastic food container with no label. R71 is alert and oriented x 3. R71 said that she has been taking her tums at bedside daily after breakfast. R71 said that she asked them to place her tums in the plastic container so it's easy for her to get the medication. R71 said that the empty bottle of tums is in the bedside drawer. V22 took the empty bottle of tums indicated Tums chewy bites extra strength 750mg. While conversing with R71 and V22, V23 CNA came into the room without knocking and announcement, she slammed the tums bottle in R71's bedside tray table and walked out of the door. Surveyor tried to stop the CNA for interview, but she refused and left saying she has to attend to her residents. Surveyor called for DON. Surveyor asked V22 where V23 CNA got the tums medication. V22 said that V23 took the medication from R71's closet. R71 said that she keeps her stock of medications in her closet and bedside dresser. Observed the Tums, Advil, Deep Sea nasal spray, Advil, and Aspercreme lidocaine inside the closet top shelf. V22 took all medications and placed it on R71's bedside tray table. R71 described how she uses the following medications: She uses the Tums daily after breakfast for indigestion. She uses the Advil as needed for pain and last time she used it was 2 days ago. She uses the nasal spray as needed for nose bleeding due to dryness. She uses the Aspercreme lidocaine cream for her shoulder pain. She said that she has more medications in the black plastic bag inside the bedside dresser. V22 took the plastic bag and observed 4 different brands of analgesic cream. R71 said that she asked the CNA to give her bedside medications so she can take it. R71 said that the nurses are busy so she keeps her medications at bedside so she can take it when she needs it. On 5/7/25 at 9:27AM, Informed V3 ADON of above concerns and showed R71's medications at bedside. V3 said that they don't allow medications at bedside without physician orders. V3 said that the staff should report to DON and called the physician if they observed medication at bedside. On 5/8/25 at 10:00AM V2 DON said that they don't have policy on Medication safety, it is incorporated in medication storage. Facility's policy on Self administration of Medication revised 6/6/24 indicated: Policy statement: it is the policy of the facility to ensure that resident's right to self-administer medications is observed. A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-medicate. Procedure: 1. The IDT (Interdisciplinary Team) will assign a staff to evaluate resident's ability to safely administer medication. A self-administration evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. 3. The nurse on duty will document administration of medication in the MAR. 4. The medication will be administered by the resident. 5. The resident's ability to self-administer medication will be assessed regularly by the facility to coincide with the MDS assessment or nay notable change in status. Facility's policy on Medication Storage, Labeling and disposal revised 8/16/24 indicated: Procedures: 3. Medications will be stored safely under appropriate environmental controls. 49871 On 5/6/2025 at 11:52 AM, R103 in bed. Observed bottles of medication, Metoprolol Succinate ER, Ranolazine ER, Ropinirole HCl, and Nifedipine on top of his bedside table. R103 said he keeps these medications in case facility does not give it to him because it's not available. R103 stated he thinks facility is aware he has medications a bedside. On 5/6/2025 at 11:56 AM, V21 (Licensed Practical Nurse) said medications should not be left at bedside. V21 stated R103's medications found at bedside is available in facility. On 5/7/2025 at 9:30 AM, V2 (Director of Nursing) stated no medication should be left at bedside. If resident want to self-administer, assessment and care plan needs to be in place. V2 said R103 do not have an assessment and care plan for self-administration. Review of R103 medical records: admitted : 3/4/2025; Order Summary, order date: 4/3/2025 Metoprolol Tartrate, Ranolazine ER [DATE]), Ropinirole HCl (3/4/2025); MDS section C, BIMS Summary Score 15.

Based on observation, interview, and record review the facility failed to ensure that the facial hair of a female resident who needs assistance with Activity of Daily Living (ADL) is shaved. This deficiency affects one (R9) of three residents in the sample of 35 reviewed for ADL care program. Findings include: On 5/6/25 at 11:44AM, Observed R9 sitting in her chair. She is alert, oriented and able to verbalize needs to staff. R9 has visible facial hair over her jaw line and chin area. R9 said that they don't shave her facial hair. R9 said, she cannot do it by herself and needs assistance from staff. Showed observation to V16 LPN (Licensed Practical Nurse). V16 said that CNA should remove /shave facial hair when providing ADLs (Activity of daily living) to R9. On 5/6/25 at 11:50AM, Informed V4 4th floor unit manager/Infection Preventionist of above concern. V4 said that the CNA is responsible for shaving/removing facial hair. On 5/7/25 at 10:05AM, Observed R9 sitting in her chair. Observed that R9 still have facial hair. R9 said that they still have not shaved her facial hair, as she touches her face. Showed observation to V26 LPN. Informed V26 that R9 complaint yesterday with V16 LPN that her facial hair not being shaved. V26 said that she will take care of it today. On 5/8/25 at 1:13PM, Informed V2 DON (Director of Nursing) of above concern. Review R9's medical records with V2. R9 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus, Morbid Obesity, Glaucoma, Osteoarthritis. MDS/Resident assessment dated [DATE] Section C Cognitive patterns C0500 BIMS (Brief Interview for Mental Status) score indicated score of 12. Section GG Functional abilities GG0130 Self-care Personal hygiene coded 4 indicated needs supervision or touching assistance. Comprehensive care plan indicated R9 has an ADL self-care performance deficit and impaired mobility. Informed V2 DON that no intervention indicated for personal hygiene and grooming in care plan for ADLs. Facility's policy on ADL (Activity of daily Living) care revised 8/6/24 indicated: ADL care is provided for each resident in the facility in accordance with the resident's comprehensive assessment and care plan to identify, evaluate and intervene to maintain, improve, or prevent an avoidable decline in ADLs. Interpretation and implementation: 2. Nurses and CNAs are trained in providing general/routine ADL care to the residents. 4. ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders as well as ADL documentation on various shifts. Such care may include as appropriate but is not limited to: h. Daily assistance in eating, grooming/hygiene, transfer, locomotion, and mobility. Facility's policy on General Care revised on 7/30/24 indicated: Policy statement: It is the facility's policy to provide care for every resident to meet their needs. AROM Program fatigue, impaired balance, physical inactivity

Based on observation, interview, and record review the facility failed to ensure enteral feeding bag is properly labeled before administration affecting 1 of 2 residents (R111) reviewed for enteral feeding care in a total sample of 35. Findings Include: On 5/6/2025 at 11:40 AM, R111's enteral (tube) feeding (TF) infusing. TF bag labeled with 5/6/25 date and time 7:00AM. On 5/6/2025 at 11:50 AM, V19 (MDS/CP Coordinator) said TF bag should be labeled with resident's name, formula name and nurse initial. On 5/7/2025 at 9:29 AM, V2 (Director of Nursing) said TF bag should be labeled with resident name, feeding formula, rate, and start date and time. V2 also said TF bag label should be initialed by the nurse that initially hung the feeding. Review of records read: Admission Record/Date: 4/27/2025, Diagnosis Information: Gastrostomy Status; Dysphagia following Cerebral Infarction; Order Review Report/ Order Summary- Enteral Feed order every shift Enteral feeding- Tube type: Gastrostomy Tube, [NAME] Farms 1.4, 40cc/hr, start date: 4/29/2025; Care Plan, 5/2/2023 Focus: R111 has risk for infection related to presence of enteral tube. Interventions: Give medications and treatments as ordered Policy and Procedure Name: Enteral Tube Feeding Care, Revised 7/26/24 Policy Statement Enteral Tube- is an avenue of feeding and hydration nutritional support via gastrostomy route. Procedure 3. Check that Feeding bag is properly labeled to include: a. Resident's name b. Formula (if it is not a closed system) and rate of feeding administration. c. Date and time feeding was started.

Based on observation, interview, and record review the facility failed to ensure Medication refrigerator with controlled medication is locked in the medication room. This deficiency affects one of three medication rooms reviewed for Safe medication storage. Findings include: On 5/6/25 at 9:56AM, Checked Medication storage room with V14 LPN (Licensed Practical Nurse). V14 said that they have controlled medications in the refrigerator. Observed Medication refrigerator is unlocked. V14 said that it should be kept always locked. V14 said that the other nurse left is opened. On 5/6/25 at 10:45AM, Informed V2 DON (Director of Nursing) of above concerns. V2 said that the medication refrigerator should be locked. Facility's policy on Medication storage, Labeling and Disposal revised 8/16/24 indicated: Policy statement: it is the facility's policy to comply with federal regulations in storage, labeling and disposal of medications. Procedures: 4. Medications will be secured in locked storage area. 5. Scheduled 2 medications will be double-locked (example placed in a locked medication cart inside a locked controlled medication box, placed in a refrigerator with 2 separate locks if the medication requires refrigeration or placed in a locked medication room inside a locked refrigerator if the scheduled 2 medication requires refrigeration).

Based on interview and record review, the facility failed to protect and secure the confidential personal medical records of a resident by allowing an unauthorized individual to obtain resident medical records. This failure applied to one of one (R72) residents reviewed for medical records. Findings include: R72 is a cognitively impaired [AGE] year-old resident with diagnoses listed in part, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, occlusion or stenosis of unspecified cerebral artery, vascular dementia, and type II diabetes mellitus. On 03/25/2024 at 12:00pm, V4 (Family Member) said about two months ago, the facility gave confidential records belonging to R72 to an unauthorized family relative. V4 further said the relative posed as V4 and convinced facility staff to hand over the personal medical documents. On 03/27/2024 at 1:45pm, V3 (Assistant Administrator) said on 02/03/2024, a person impersonated V4 at the facility and an agency nurse gave R72's medical information, specifically, R72's progress notes and care plan, to him. V3 said there were family dynamics within R72's family. V3 said after the breach occurred, R72's power of attorney and V4 were notified, and the family member that posed as V4 was banned from the facility. V3 said the agency nurse that gave R72's medical information to the unauthorized family member failed to fill out a medical release form needed to request the information, and added that it happened on a weekend when the weekend manager was on duty. V3 said the assistant director of nursing was notified, as well as the responsible nurse's agency, and in-service education was provided to staff. V3 lastly said attempts were made to try to get the released medical documents back from the relative but he did not return them. Facility provided a Concern Response Form dated 02/03/2024 and filled out by V3, which read: reported that his cousin pretended to be him and requested medical records from the nurse on duty. The form further states the assistant director of nursing told the administration team who told V4 they would, follow compliance process and submit breach to OCR (Office for Civil Rights) and AG (Attorney General). The facility's, Medical Records Request and Access policy dated 10/17/2018, states in part, the resident or legal representative of the resident will be allowed access to inspect resident's medical records within 24 hours of a valid oral or written request to the Administrator excluding weekends or holidays.

Based on observation, interviews, and record reviews, the facility failed to administer medications as ordered; and failed to follow policy and manufacturer's instructions for use in the administration of inhalers. There were 25 opportunities with four errors resulting in a 16% medication error rate. The errors involved two (R30 and R138) of nine residents in the sample of 74 reviewed for medication administration. Findings include: On 03/25/24 at 4:45 PM, V8 (Licensed Practical Nurse, LPN) was observed preparing medications of R30. According to POS (Physician Order Sheet) dated 06/08/22, R30 has an order for Nabumetone tablet 500mg (milligrams) give 0.5 tablet by mouth two times a day. Also, POS dated 03/24/24 documented: Tylenol oral capsule 325mg give 2 tablets by mouth every 4 hours as needed for pain AND give 2 tablets by mouth two times a day for arthritis on shoulder. During medication pass observation, V8 asked R30 if she was experiencing pain. R30 stated no. V8 did not give Tylenol and Nabumetone. V8 was asked why she did not administer the two medications on R30. V8 stated, She is not in pain. I am not sure if I should give it or not. I am not familiar with Nabumetone so I have to ask the doctor. At 5:10 PM, V9 (Registered Nurse, RN) was observed preparing R138's inhalers. R138 has the following orders: POS dated 07/29/21 documented: Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg/act (microgram per actuation) 2 puffs inhale orally two times a day POS dated POS 09/14/22: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg/dose (microgram per dose) 1 puff inhale orally two times a day During medication pass, V9 stated that R138 knows how to administer the inhalers with her supervision. V9 took the Albuterol, did shake it and gave it to R138. R138 administered himself with 2 consecutive puffs. When R138 finished giving himself the puffs, he opened his mouth and a white smoke was observed coming out. Subsequently, V9 took the Advair Diskus, did shake it and handed it to R138. R138 administered himself with 2 consecutive puffs. Then, he took a cup of water, took it all in, did not gurgle. There were no instructions provided on R138 prior to administering the inhalers. Also, R138 gave himself two puffs of Advair when the order stated one puff only. Per manufacturer's guidelines, the following instructions were documented in part but not limited to the following: Instructions for Use Ventolin HFA (Albuterol Sulfate Inhalation Aerosol for Oral Inhalation Use): Step 5 - After the spray comes out, take your finger off the metal canister. After you have breathed in all the way, take the inhaler out of your mouth and close your mouth. Step 6 - Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Instructions for Use Advair Diskus: Step 5 - Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow. On 03/27/24 at 10:28 AM, V2 (Director of Nursing) was interviewed regarding medication administration on R30 and R138. V2 replied, The Nabumetone and Tylenol should be given to R30 because it is a standing order. For R138's inhalers, we have to follow the manufacturer's guidelines and policy in administering inhalers. Facility's policy titled, Medication Pass dated 07/28/23 documented in part but not limited to the following: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Procedures: 3. Inhalers b. Shake inhaler first. Powder inhaler such as Advair does not need to be shaken first. c. Rinse mouth with water afterwards. Some inhalers do not need to be rinsed with water after administration. d. If there are 2 different inhalers to be given at the same time, make sure there is at least 30-60 seconds interval in between inhalers. Facility's policy titled Physician Orders dated 07/28/23 stated in part but not limited to the following: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS.

Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed and implemented to prevent the spread and transmission of COVID-19 within the facility during a COVID outbreak. Facility staff failed to conduct proper hand hygiene, gowning and doffing, and proper wearing of PPE (Personal Protective Equipment) to contain the spread of infectious disease. This failure has the potential to affect all 231 residents currently residing in the facility. Findings include: At time of entrance, facility provided census indicating 231 residents currently in the facility. On 12/16/23 at 9:50 AM, surveyor entered the facility and asked V4 receptionist if there was any COVID-19 in the facility whereupon V4 indicated that she was uncertain if there was any at all because she only worked part time on Saturdays and Sundays and was not informed of any. Surveyor asked who the person in charge was for the weekend, V4 stated that V3 (Social Service Director) was the manager on duty. V4 was asked if there were any COVID in the facility and indicated that there was but was not certain the number of residents affected. V4 was asked by surveyor how as the manager on duty for the day, how she could contain the spread of COVID-19 within the facility, if she did not know which floors were affected by the outbreak, V4 stated, I can find out for you. Observations on 12/16/23 upon entrance to the facility showed no warning signs for visitors that the facility was under current COVID-19 outbreak status. On 12/116/23 at 10:40 AM, V3 (director of nursing) upon arrival to the facility later provided the accurate number of residents to the surveyor which were a total of 231 current residents and confirmed that there was a COVID-19 outbreak in the facility which included 15 COVID positive residents that resided on the 4th and 5th floors. On 12/16/23 at 10:10 AM, surveyor entered the 5th floor and approached V5 (LPN- licensed practical nurse) who offered surveyor an N95 mask and face shield. V5 stated, I'm sorry sir, they should have told you that it is required to have an N95 mask up here and also a face shield since we are on COVID outbreak status. V5 indicated that there were COVID positive residents on the floor and that staff were required to wear the appropriate PPE (personal protective equipment) such as gloves, gown, mask and faceshield when having any contact with the resident in the isolation room. Surveyor clarified if masks were required to be worn on the floor and which residents were on isolation, V5 stated, Yes all staff should wear their masks at all times especially when on this floor since this is where our COVID outbreak is, Rooms with red zone sign are on isolation and you'll see signs on the door and isolation cart outside the door. On 12/16/23 at 10:15 AM, V9 (Agency CNA- Certified Nursing Assistant) was observed going in and out of R3's room which had a red zone sign outside her room and isolation bins immediately outside indicating that the resident was on strict isolation. V9 was wearing gloves and a mask but did not wear a gown or face shield as she proceeded to conduct patient care on R3. V9 did not wash her hands prior to wearing gloves nor changed her gloves as she emptied the garbage and collect linens. V9 took the dirty and soiled linens, placed them in the bag and walked out of the room to throw the bag of linens in the linen room and returned back to R3's room without replacing her soiled gloves. Surveyor asked V9 if she was supposed to be washing her hands in between patient care and emptying the garbage and changing linens, V9 stated, I guess so but I'm usually on the 4th floor and this is my first time up here. I'm agency so they didn't tell me anything about that. Surveyor asked if there were COVID patients on the 4th floor she had worked on, V9 stated, Yes I think so. I saw a lot of residents on isolation but they (referring to nurses) don't tell us if they're on isolation or for what. Surveyor clarified what floors she worked on, V9 stated, I've worked everywhere in this building and no one has told me anything about that because I'm agency. At 10:30 AM V10 (LPN) was standing in the hall by her medication cart and was asked about R3 and stated, I just got here and nobody told me anything about her. Surveyor asked if R3 was on any isolation precautions, V10 stated, I think so but I would have to check. Review of records showed R3 to be on strict isolation due to COVID-19 infection and readmission from the hospital. Surveyor asked if the 5th floor was her regular floor, V10 stated, No I'm not a regular here and I float (meaning can and have worked all floors). At 11:15 AM, R6 was observed in bed with V17 (Agency CNA) observed with a mask but no face visor as per the facility policy when working on a floor with active COVID. V17 was using a gloved hand to clean R6 and wiping the residents feces and throwing the dirty wipes in to a bag that was strewed on to the floor. Outside the residents room was also a dirty bag filled with linen and soiled cloths that was in the center of the common area. Surveyor asked V17 if the bag was his, V17 stated, Yes, I put it there because I'm going to throw it away once I'm done cleaning up (R6). Surveyor asked what was in the bag and if it should be on the ground in the middle of the hall, V17 stated, Sorry its soiled clothes and linens from another resident I cleaned so I put it there but I'll get rid of it as soon as I'm done here. V5 (LPN) was shown the bag in the hall and also a bag on the ground in the resident's room, V5 stated, No that should not be there. Surveyor asked if that was proper to maintain good infection control, V5 stated, No it is not. I will have him remove it immediately. Surveyor asked where V17 normally works, V5 stated, (V17's) agency so he works anywhere we are short-staffed. Revised policy dated 11/7/22 titled COVID 19 Guidelines and Emergency Preparedness Plan reads in part but not limited to: Inservice all staff on infection control procedures to prevent COVID 19 including but not limited to, risk of transmission, infection control practices including frequent handwashing x at least 20 seconds or use of alcohol gel, avoiding touching of face, nose, and mouth, and avoidance of crowded places or events, keeping a distance of 6 feet from individuals with respiratory illness, use of PPE, Standard, Contact, and Droplet Precautions, Proper Donning and Doffing of PPEs, Extended Use and Reuse of PPEs per CDC, staff and resident screening for COVID 19 and respiratory illness, Cough Etiquette, and Vaccination.

Based on observation, interview, and record review, the facility failed to provide assistance to dependent residents requiring assistance with ADL (activities of daily living ) such as basic grooming hygiene, and toileting assistance for three (R1, R5, R6) of six residents reviewed for ADL care. Findings include: 1. R1 is a [AGE] year old with diagnosis of dementia, functional quadriplegia, obstructive uropathy and history of falls. MDS (Minimum Data Set) dated 10/3/23 shows R1 as totally dependent on staff for almost all activities of daily living including toileting, personal hygiene, and bathing. Care plan showed resident has an ADL Self Care Performance Deficit related to generalized weakness, impaired range of motion, decrease activity tolerance, easy fatigability, and impaired mobility. Interventions: Bed mobility: requires total assist x 2 staff participation to reposition and turn in bed. Eating: requires extensive assist x 1 staff participation to eat. Toilet use: requires total assist x 2 staff with all toileting needs. Hygiene: requires 1 total assistance with personal hygiene care. Call light: place call light within accessible reach. On 12/16/23 at 10:10 AM, R1 was observed in bed atop an air mattress with a pump that dangled on one hook at the foot of the bed. There was a foul sharp odor of feces upon entering the room and R1 appeared confused and could not follow any line of questioning from the surveyor but appeared to need nursing assistance although his call light was dangling on the floor away from the resident's reach. R1's hair was matted and face appeared to have food remnants on his mouth and on R1's chest and hospital gown that was soiled, wrinkled and appeared moist with sweat. On 12/16/23 at 10:15 AM, surveyor asked V7 (CNA) when R1 was given incontinence care, V7 stated, I did it earlier when I got in. Surveyor asked if anyone assisted her in turning and repositioning the resident in order to perform incontinence care, V7 stated, No I did it myself. Surveyor asked if the resident ate breakfast, V7 stated, Yes, he eats on his own. We just get him up and he can eat by himself. On 12/17/23 at 10:45 AM, V13 agency CNA was asked whether R1 was given breakfast or if he had eaten his breakfast, V13 stated, Yes. He ate his breakfast and he can eat on his own. Interview with V5 (LPN) at 10:50 AM disputes V13's statement that R1 is capable of eating on his own and requires 1 person assist to eat and as per care plan. Surveyor asked who would be responsible to assist in feeding the resident, V5 stated, It would be the CNA assigned to that particular section and today that would be V13. 2. R5 is a [AGE] year old with diagnosis of dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Care plan for ADLs dated 10/6/23 showed (R5) has ADL self care performance deficit and impaired mobility related to generalized weakness, decreased range of motion, easy fatigability, poor endurance, limited activity tolerance and impaired mobility. Interventions: Bed Mobility: requires substantial assistance with repositioning and turning in bed. Transfer: requires substantial assistance with transferring. Eating: requires partial assistance with eating: requires substantial assistance toileting. Personal hygiene/oral care: requires substantial personal hygiene and oral care assistance. Bathing: (R5) requires substantial assistance with bathing. On 12/17/23 at 10:55 AM, R5 was observed naked in bed, breasts exposed, and wearing only an incontinence brief. Her call light was placed behind the bed away from R5's reach in order to get assistance. R5 appeared confused and was heard mumbling words. V15 was asked about R5's current condition, V15 stated, I was just going to change her. I went to get supplies so I can change her linens. Surveyor asked if she normally would leave the resident naked in bed alone to get supplies, V15 stated, No but I just changed her diaper and I went to get new sheets. After V15 was changing the linens on the bed, V15 started putting a clean gown on the resident to cover up her body, surveyor asked the aide to stop and requested to check the incontinence pad on the resident. V15 stated, I already changed that. Surveyor asked to see the under the incontinence pad to verify check her skin. V15 removed the incontinence brief and revealed a large amount of feces that spread up toward the residents vaginal area. V15 stated, She must have done that while I went to get linens because I had just changed her. 3. R6 is [AGE] year old with diagnosis of vascular dementia, hemiplegia, diabetes, and history of falling. Care plan dated 1/6/23 reads in part, R6 has an ADL self care performance deficit related to generalized weakness, impaired mobility, decreased activity tolerance secondary to multiple complex diagnosis. Goal: Resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review. Interventions: Bed Mobility: resident require extensive (2) staff participation to reposition and turn in bed. Transfer: resident requires total (2) staff participation with transfers Dressing: resident require(s) extensive (1) staff participation to dress. Toileting: require(s) extensive (2) staff participation to use toilet. Personal hygiene/oral care: requires extensive(1) staff participation with personal hygiene and oral care. Bathing: resident requires extensive(2) staff participation with bathing. On 12/17/23 at 11:15 AM, R6 was observed in bed fully naked with V17 (agency CNA) cleaning the resident with feces being wiped away from the resident's genitals. Surveyor asked how long R6 was in bed with the amount of feces that were on the resident, V17 stated, I have no idea. I'm agency and I don't really know this resident. I saw him earlier and he was asleep but I didn't check if he was dirty or anything like that if that is what you're asking. Surveyor asked if providing a bath for the resident was warranted, V17 stated, No. I can clean him up good. Surveyor asked if he was going to ask for assistance to reposition the resident so he could clean R6's underside, V17 stated, I have this section and I wouldn't be able to get someone to help me anyway. R6 appeared disheveled with long matted gray hair, full gray beard, and both legs that were severely dry and cracked. The air mattress the resident was on had remnants of food and dry skin and other bodily stains. Policy dated August 5, 2023 titled ADL care reads in part, ADL care is provided for each resident in the facility in accordance to the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent an avoidable decline in ADLs' ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders. Such care may include as appropriate: maintaining good body alignment and proper positioning. Recognizing and assessing an inability to perform ADL's or at risk for decline. Encouraging and assisting bedfast residents to change positions at least every two hours. Making every effort to keep residents active and out of bed for reasonable periods of time. Incontinent care and bowel and bladder training as indicated. Daily assistance in eating, grooming and hygiene, transfer, locomotion and mobility. Policy dated 7/28/23 titled Incontinent and perineal care reads in part, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on interview and record review, the facility failed to keep residents free from physical abuse. This failure applied to four of four (R1, R2, R3, and R4) residents reviewed for abuse. Findings include: R1 is a [AGE] year-old resident admitted on [DATE]. R1 has medical diagnoses that include: Cerebral Infarction, Type 2 diabetes, Dementia with agitation, and history of falling. R1's primary language is Russian and does not speak English. MDS (Minimum Data Set) assessment dated [DATE], documents that R1 has a BIMS (Brief Interview of Mental Status) score of 04 (severe cognitive impairment). R1's abuse assessment upon admission, dated 12/15/22, narrative section documents that R1 is at risk of abuse due to diagnosis of dementia. R2 is a [AGE] year-old resident admitted on [DATE]. R2 has medical diagnoses that include: Alzheimer's Disease, Major Depressive Disorder, and Adult Failure to Thrive. R1's primary language is Russian and does not speak English. MDS (Minimum Data Set) assessment dated [DATE], under Section C (Cognition), documents that R1 rarely/never understood; BIMS (Brief Interview of Mental Status) could not be determined. Facility incident report dated 2/22/2023, submitted by V3 (Executive Director) documents: On 2/22/23 V23 (RN) notified to Administrator at approximately 5:37pm that R1 reported that another resident, R2, threw his plate cover and it accidentally hit her in the head. Both residents were separated, and R2 was placed on 1:1. Skin assessment and pain assessment were done for R1 and there was no redness or swelling. Resident denied any pain. Nurse on duty, V23, notified both resident's attending physicians and both resident's HCPOA, were made aware. After further interview with the staff and the other residents on the 5th floor, it was concluded that the abuse is unsubstantiated. R2, who has a diagnosis of Dementia, stood up after he was finished with his meal in the dining room. He was trying to alert staff that he was finished with his meal and threw the lid of his plate which is when this incident occurred. When he threw the top of the plate, it accidentally hit R1's right cheekbone. An icepack was immediately applied to R1's face. There was no swelling, redness, or injury. Resident, R2, was interviewed and did not report any intention of hitting another resident in the face. R1 reports that she did not feel that the resident threw the top of the plate at her intentionally. Skin assessment was done on R1 and there was not skin alteration found. Both resident care plans were reviewed an updated. Additional interviews revealed that no other staff members witnessed this incident and reported that all residents are treated with dignity and respect. Other staff members reported that both residents received ADL's care, assistance with meals and were frequently checked on throughout their shifts. No other residents and staff reported any sign of mistreatment or abuse from the staff and treats all residents with dignity and respect. The facility has taken steps to ensure resident safety such as increased supervision, providing residents with activities to a occupy their time, frequently round on both resident's, maintaining a calm, environment for the resident, etc. This allegation of abuse is unsubstantiated. V3 (Executive Director) provided a copy of interviews that were conducted during the facility abuse investigation of the incident on 2/22/23 between R1 and R2. Of the staff working on the 5th floor at the time of the incident, V23 (RN), V27 (CNA), and V30 (CNA), were interviewed; all three staff stated that they did not witness the incident in question. On 3/11/2023 at 2:58PM, V3 (Executive Director) was asked, why weren't staff who were present during the incident interviewed. V3 responded that she interviewed who she could at the time; she wanted to get the investigation done on time. Review of Daily Schedule on date of incident, 2/22/23 documents that the following staff were assigned to work on the 5th floor (dementia unit): V23 (RN), V27 (LPN), V28 (CNA), V29 (CNA), V30 (CNA), and V31 (CNA). 3/11/23 at 3:07PM, V23 (RN) stated, as far as I can remember, I was not there during the incident because I always come in and out of the dining room. R1 and R2 were in the dining room doing activities around 3pm. When I came back, dinner was already served. I asked what happened. R2 didn't seem agitated or have any behaviors. After the incident I walked him back to his room. He was not having behaviors that afternoon as far as I remember. He refuses showers but he is compliant with me for other cares. I don't know about how he is with others. We have bx monitoring for him if he is showing behaviors. I follow him because when he comes out of his room, it's usually because he's hungry. If behaviors are observed, we should complete the behavior monitoring and a progress note with interventions and if they are effective. I worked here like a year. He chooses who he likes to work with. Review of behavior monitoring and progress notes for R2 on 2/22/23 do not include any documentation of the incident in the dining room or that R2 was exhibiting any behaviors. 3/10/2023 at 3:50PM, V28 (CNA) was interviewed and stated, I was in the dining room (at the time of the incident), but I was at a different table. It was my time to supervise the dining room. I immediately reported it to the nurse (V23, RN). There were about 10 or 11 residents in there. R1 screamed and she pointed to R2. R2 is very combative. At times, even with staff, he will try to swing at you. V28 was asked if she remembers what other staff were in the dining room at the time, V28 stated, there were other agency CNA's but I don't remember. At that time, the residents are very active because it's dinnertime. They were talking Russian. I don't know what they were saying. Review of R1's current care plans provided by the facility document as a Focus - resident is at risk for alteration in nutritional status related to: modified texture diet, 1:1 feeding assist, pressure ulcers [Date Initiated: 12/19/2022] 3/10/23 at 1:05PM V9 (CNA) was interviewed and stated that he has worked at the facility over a year and is very familiar with R2. V9 stated, R2 is aggressive with residents and staff. Maybe it is because of the language barrier. He will hit you if there is something in his hand. I have moved things out of his room because he can hit you in the back of the head. He's had these behaviors for a long time. The family provides two caregivers, especially on bath days because she does a lot of convincing him because he resists care often. If he is not familiar with you, he will definitely act that way. His behavior is not predictable, so you have to really watch him. Reviewed medical record for R2 - Nursing Progress Notes on 2/1/2023 04:32 Behavior Note - Behavior: Resident wandering into other residents rooms and taking stuff. Resident becomes physically combative towards staff when trying to assist out of residents room. Non Pharmacological Interventions: Redirection, Pharmacological Interventions: (blank), Summary/Outcomes: Fair Surveyor reviewed current care plans and noted that there was an abuse/trauma care plan specific to being a holocaust survivor, but no general abuse care plan for R1 and R2. Surveyor interviewed staff regarding this concern and was told the following: 3/11/23 at 1:29PM, V2 (Assistant Director of Nursing) stated, R2's combativeness has been since admission so it may not be in the progress notes. There have been a lot of changes. I will find out if documenting in the incident report is sufficient; they may not document in both the incident and progress notes. At 1:55 PM, V2 stated, the nurses communicate with social work, and they keep track of the behaviors for five days (after an incident). 3/11/23 at 2:52PM, V18 (MDS / Care plan Nurse) stated that social services typically creates the abuse care plans. 3/11/2023 at 2:54PM, V7 (Social Services Designee) stated, social services does the abuse care plans. There is a care plan for holocaust and that is separate from the general abuse care plan. They should have both care plans if both situations apply. R1 has care plan with Focus - Abuse/Neglect/Trauma Factors Holocaust Survivor [Date Initiated: 12/17/2022] R2's care plan with Focus - Stress r/t Trauma/Anxiety USSR Holocaust Survivor I may become paranoid, hostile, and defensive secondary to reliving trauma from my youth when my country (Ukraine) was invaded by Nazi [NAME] . Interventions [Date Initiated: 5/10/2022] include but not limited to: Staff should be mindful of the potential presence of the following symptoms often associated with PTSD - Avoiding - avoiding people, places, things, or memories that remind the person of the trauma - Hyperarousal - increased alertness, anger, fits of rage, irritability, or hatred . R2's care plan with Focus - Abuse/Neglect/Trauma Factors [Date Initiated: 08/02/2021] R2 presents with significant medical problems and a mental health hx. He is a Holocaust survivor and may have experienced unspeakable horror. His behavior is such that he may present with some risk for engaging in untoward physical behavior, often reacting to the behavior of others. He is living with Alzheimer's disease. On 5.5.2022 another resident went into R2's room. It was alleged that he pushed the resident, causing her to fall down. This was not a witnessed incident. Protocol followed. On 7/13/22 residents care taker took pictures of residents room and send it to the POA, and POA alleged that resident has been neglected. Care Plan Interventions (include, but not limited to) - Conduct appropriate assessments to promote knowledge and understanding of the resident's past. [Date Initiated: 08/02/2021] Identify if there are behaviors or factors from the past that should be considered in treatment planning. [Date Initiated: 08/02/2021] Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. [Date Initiated: 08/02/2021] 3/11/2023 at 11:45AM, V3 (Executive Director) stated that abuse assessments are done upon admission, quarterly, and annually. 3/11/2023 at 2:10PM, V7 (Social Services Designee) was asked if care plans were updated to reflect changes from abuse assessments and V7 commented that care plans should be updated quarterly but sometimes we don't. Facility provided Abuse and Neglect Policy (Effective Date: 10/24/22), reads: Policy Statement: It is the policy of the facility to provide professional care and services, in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to, prevention of abuse, and, timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention, and investigation. Definitions of Abuse, Neglect, Exploitation, & Abuse Coordinator Abuse Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse . Types of Abuse and Examples 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling . III. Prevention . - Deployment of sufficient and trained staff to deal with behaviors in the units - Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect - The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who toileting assistance to urinate or defecate in their beds 41692 Findings include: R3 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: dementia with severe agitation, bipolar disorder, suicidal ideations and benign prostatic hyperplasia. Minimun Data Set (MDS) dated : 12-20-2022, Brief Interview for Mental Status (BIMS) score is 3/15, score suggests a severe cognitive impairment. R4 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis that include and are not limited to: dementia, cerebral infarction and hypertension. Minimun Data Set (MDS) dated : 1-16-2023 Brief Interview for Mental Status (BIMS) score is 9/15, score suggests a moderately cognitive impairment. According to facility reported incient dated 1-28-2023 at 1:00pm reads: V2 (Assistant Director of Nursing) notified V13 (Assitant Admininistrator that R3, became agitated trying to exit the dining room and was wailing his hands around, R3 accidendently came in contact with R4. On 3-10-2023 at1:00pm R3 observed in his room. R3 said in Spanish, I am ok. writer asked R3 if R3 had any altercation or any problem with any other resident and R3 said I am ok. On 3-11-2023 at 11:20am R4 observed sitting at the edge of the bed in his room, said, I was hit by another crazy man that is not longer in the floor. I know I am in the dementia floor but I still remember things, one day a crazy man hit me in my left eye, I demanded to have an x-ray done and that person to be taken out of the floor, and they did both things, I do not like the aggressive people like the one that hit me in my left eye, here, R4 was pointing to the left eye orbital area. On 3-12-2023 at 10:50 am V25 (Licensed Practical Nurse) said, On 1-28-2023, Saturday, I was in the dinning room about 50 feet away from where R3 and R4 incident happened. R3 was agitated because R3 wanted to passed by were R4 ' s walker was and R3 was not able to. The next thing I heard was R4 creaming, yelling and crying he hit me in my face. I reacted to the yelling and screaming and called the patients nurse to come and assessed, Ice was applied to R4 ' s face and the residents were separated. On 3-11-2023 at 8:45am V14 (Licensed Practical Nurse) said, I was working on 1-28-2023 during 7-3 shift. I was passing medications when V25 (Licensed Practical Nurse) told me that she was the only one in the dinning room and was in the opposite side of the dinning room. (I cannot showed you because there is construction going on and the area is blocked). V25 said, R3 was sitting in his wheelchair and when passing by next to R4, the area was narrow and R3 bumped R4's walker and R3's hand came in contact with R4's face left eyebrow. I assessed both R3 and R4. R3 was fine, no complaints. R4 was complaining of pain to the left eyebrow, I applied an ice packed and contact the doctor, family and administration. Per R4's medical record, V14 (licensed Practial Nurse) documented: 1/28/2023 at 12:09pm (R4) was sitting in the dining room watching TV when (R3) came into contact with (R4's) face-specifically (R4) left eyebrow. Upon assessment, (R4) left eyebrow is red, but no open wounds nor discoloration is noted. (R4) is verbalizing an immediate 9/10 pain. medication has been offered, but resident refused. Other non-pharm treatments- applying an ice-pack for about 10-15 min. On 3-11-2023 at 9:10am V15 (Certified Nurse Assistant) said. R3 was in my assignment before he was transfer to another floor. R3 was very impulsive, does not like to be disturbed, he is aggressive, that is the reason that all the dressers and all furniture were taken out of his room because he will [NAME] things down when he was upset. They put two plastic containers, similar to the isolation bins for his personal items. R3 is always in the defensive I always was careful when taking care of R3 because R3 is Hard of Hearing and speaks Spanish only. I did not witness the incident between R3 and R4. I was assigned to R3 on that day. I was in A wing On 3-11-2023 at 9:30am V17 (Certified Nurse Assistant) said, R3 can be aggressive at times, he does not like to be redirected and likes to be in his room. On 3-11-2023 at 11:20 am V24 (Medical Doctor) said, I do remember R3, the patient has aggressive behaviors, R3 was sent out to the hospital for treatment. 3-11-2023 at 12:10pm V21 ( Psycotropic/ fall nurse) said, R3 is a very hard of hearing, speaks Spanish, R3 does not like to be confined, R3 does not like to have any one in his personal space. I know the Psychiatrist saw R3 after the incident with R4. V21 presented V26 (Medical Doctor), This is the psychiatric evaluation done after the incident on 1-28-2023. R3 record reviewed reads: According to V26 (Medical Doctor) progress note dated: 1-30-2023 reads: Patient (R3) seen and interviewed, R3 was involved in an incident with another resident (R4) over the weekend. R3 became upset when he was not able to get through in his wheelchair and struck out. On 3-11-2023 at 2:30-pm V7 (Social Service Designee) said, we removed all the furniture from R3 and we blocked the window for R3's room for R3's safety, because R3 was trowing things in his room, like the cabinets, the television, we even blocked his window. and we put the plastic containers for R3 to put R3's clothing and any other personal items. R3 has a diagnosis of dementia with agitation. I was not here when the incident happened between R3 and R4. According to R3's social service abuse, neglect, explotation and trauma assessment dated : 12-14-2022 reads; under question 8: Does the resident have a history or presence of behaviors, such as provoking, aggresive manner, manipulative, disrespectful, insensitive, attention seeking and/or otherwise abrasive/ innapropiate behavior? Answer : Yes, at risk for abuse. R3 has a diagnosis of dementia, R3 is at risk for abuse and neglect.

Based on interview and record review, the facility failed to have current, resident-centered care plans in place to meet the needs of residents with dementia and at-risk of abuse. This failure applied to two of two (R1 and R2) residents reviewed for care planning. Findings include: R1 is a [AGE] year-old resident admitted on [DATE]. R1 has medical diagnoses that include: Cerebral Infarction, Type 2 diabetes, Dementia with agitation, and history of falling. R1's primary language is Russian and does not speak English. MDS (Minimum Data Set) assessment dated [DATE], documents that R1 has a BIMS (Brief Interview of Mental Status) score of 04 (severe cognitive impairment). R1's abuse assessment upon admission, dated 12/15/22, narrative section documents that R1 is at risk of abuse due to diagnosis of dementia, however, score is 0 Low Risk. R2 is a [AGE] year-old resident admitted on [DATE]. R2 has medical diagnoses that include: Alzheimer's Disease, Major Depressive Disorder, and Adult Failure to Thrive. R2's primary language is Russian and does not speak English. MDS (Minimum Data Set) assessment dated [DATE], under Section C (Cognition), documents that R2 is rarely/never understood; BIMS (Brief Interview of Mental Status) could not be determined. R2's abuse assessment upon re-admission, dated 12/2/22, narrative section documents that R2 is at risk of abuse due to diagnosis of dementia, score is 6 At Risk. Facility submitted an incident report dated 2/22/2023, by V3 (Executive Director), which documents: On 2/22/23 V23 (RN) notified to Administrator at approximately 5:37pm that R1 reported that another resident, R2, threw his plate cover and it accidentally hit her in the head. Both residents were separated, and R2 was placed on 1:1. Skin assessment and pain assessment were done for R1 and there was no redness or swelling. Resident denied any pain. Nurse on duty, V23, notified both resident's attending physicians and both resident's HCPOA, were made aware. After further interview with the staff and the other residents on the 5th floor, it was concluded that the abuse is unsubstantiated. R2, who has a diagnosis of Dementia, stood up after he was finished with his meal in the dining room. He was trying to alert staff that he was finished with his meal and threw the lid of his plate which is when this incident occurred. When he threw the top of the plate, it accidentally hit R1's right cheekbone. An icepack was immediately applied to R1's face. There was no swelling, redness, or injury. Resident, R2, was interviewed and did not report any intention of hitting another resident in the face. R1 reports that she did not feel that the resident threw the top of the plate at her intentionally. Skin assessment was done on R1 and there was not skin alteration found. Both resident care plans were reviewed an updated . 3/10/23 at 1:05PM V9 (CNA) was interviewed and stated that he has worked at the facility over a year and is very familiar with R2. V9 stated, R2 is aggressive with residents and staff. Maybe it is because of the language barrier. He will hit you if there is something in his hand. I have moved things out of his room because he can hit you in the back of the head. He's had these behaviors for a long time. The family provides two caregivers, especially on bath days because she does a lot of convincing him because he resists care often. If he is not familiar with you, he will definitely act that way. His behavior is not predictable, so you have to really watch him. Reviewed medical record for R2 - Nursing Progress Notes on 2/1/2023 04:32 Behavior Note - Behavior: Resident wandering into other residents rooms and taking stuff. Resident becomes physically combative towards staff when trying to assist out of residents room. Non Pharmacological Interventions: Redirection, Pharmacological Interventions: (blank), Summary/Outcomes: Fair Surveyor reviewed current care plans and noted that there was an abuse/trauma care plan specific to being a holocaust survivor, but no general abuse care plan for R1 and R2. Care plans did not indicate that there had been any updates since the incident on 2/22/2023. Surveyor interviewed staff regarding this concern and was told the following: 3/11/23 at 1:29PM, V2 (Assistant Director of Nursing) stated, R2's combativeness has been since admission so it may not be in the progress notes. There have been a lot of changes. I will find out if documenting in the incident report is sufficient; they may not document in both the incident and progress notes. At 1:55 PM, V2 stated, the nurses communicate with social work, and they keep track of the behaviors for five days (after an incident). 3/11/23 at 2:52PM, V18 (MDS/Care plan Nurse) stated that social services typically creates the abuse care plans. 3/11/2023 at 2:54PM, V7 (Social Services Designee) stated, social services does the abuse care plans. There is a care plan for holocaust and that is separate from the general abuse care plan. They should have both care plans if both situations apply. Reviewed abuse assessments for R1 and R2. R1's abuse assessment upon admission, dated 12/15/22, documents the following: SECTION VI. Abuse, Neglect, Exploitation & Trauma 1. Per resident interview, is the resident a victim of abuse, neglect and/or exploitation (e.g., physical, sexual, verbal, emotional and financial) and/or injury of unknown origin prior to admissions including self-neglect? - Response provided is No 1a. Per family information and medical record information, is the resident a victim of abuse, neglect and/or exploitation (e.g., physical, sexual, verbal, emotional and financial) and/or injury of unknown origin in the past? - Response provided is No 2. Per resident interview, is the resident a victim of trauma including violence (example: torture, assault), war (example: Holocaust survivor, Combat veteran, Korean War, Vietnam War, Afghanistan War), natural disaster (Desert Storm), man-made disaster (example: fire), terrorism, and catastrophic accident? - Response provided is No 2a. Per family information and medical record information, is the resident a victim of trauma including violence (example: torture, assault), war (example: Holocaust survivor), natural disaster, man-made disaster (example: fire), terrorism, and catastrophic accident? - Response provided is No R1's care plan with Focus - Abuse/Neglect/Trauma Factors Holocaust Survivor, reads: I present with medical, mental health and cognitive problems. I am not a good historian, and may not have clear memories of my past growing up in Russia pre-WWII and during the war with Nazi [NAME] (and their well-documented atrocities) and then following the war with the [NAME] of Stalin's dictatorship and human rights/civil rights abuses. My history includes witnessing depravation and likely violence. At this time, I may not view myself as someone who was victimized during early life. I do not present with any unusual risk for becoming a recipient or perpetrator of abuse and/or neglect. [Date Initiated: 12/17/2022] Interventions with Date Initiated: 12/17/2022 - Focus on trauma informed approaches acknowledging the type of ACT and the mistreatment/maltreatment that the resident experienced and take steps to avoid re- triggering negative memories. Provide psychiatric management [evaluation, treatment recommendation, med management and counseling sessions] as well as referral for psychological therapy to support stabilization, facilitate return to baseline functioning, monitor psychiatric symptoms and support/monitor psycho-active medications. - Provide culturally competent, sensitive trauma-informed care in accordance with professional standards accounting for the person's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. - Reinforce with the caregiving team that trauma refers to experiences that cause intense physical and psychological stress reactions. Staff should be knowledgeable about the resident's past. R2's abuse assessment upon re-admission, dated 12/2/22, documents the following: SECTION VI. Abuse, Neglect, Exploitation & Trauma 1. Per resident interview, is the resident a victim of abuse, neglect and/or exploitation (e.g., physical, sexual, verbal, emotional and financial) and/or injury of unknown origin prior to admissions including self-neglect? - Response provided is No 1a. Per family information and medical record information, is the resident a victim of abuse, neglect and/or exploitation (e.g., physical, sexual, verbal, emotional and financial) and/or injury of unknown origin in the past? - Response provided is No 2. Per resident interview, is the resident a victim of trauma including violence (example: torture, assault), war (example: Holocaust survivor, Combat veteran, Korean War, Vietnam War, Afghanistan War), natural disaster (Desert Storm), man-made disaster (example: fire), terrorism, and catastrophic accident? - Response provided is No 2a. Per family information and medical record information, is the resident a victim of trauma including violence (example: torture, assault), war (example: Holocaust survivor), natural disaster, man-made disaster (example: fire), terrorism, and catastrophic accident? - Response provided is No R2's care plan with Focus - Stress r/t Trauma/Anxiety USSR Holocaust Survivor I may become paranoid, hostile and defensive secondary to reliving trauma from my youth when my country (Ukraine) was invaded by Nazi [NAME] . Interventions [Date Initiated: 5/10/2022] include but not limited to: Staff should be mindful of the potential presence of the following symptoms often associated with PTSD - Avoiding - avoiding people, places, things, or memories that remind the person of the trauma - Hyperarousal - increased alertness, anger, fits of rage, irritability, or hatred . R2's care plan with Focus - Abuse/Neglect/Trauma Factors [Date Initiated: 08/02/2021] R2 presents with significant medical problems and a mental health hx. He is a Holocaust survivor and may have experienced unspeakable horror. His behavior is such that he may present with some risk for engaging in untoward physical behavior, often reacting to the behavior of others. He is living with Alzheimer's disease. On 5.5.2022 another resident went into R2's room. It was alleged that he pushed the resident, causing her to fall down. This was not a witnessed incident. Protocol followed. On 7/13/22 residents care taker took pictures of residents room and send it to the POA, and POA alleged that resident has been neglected. Interventions (include, but not limited to) - Conduct appropriate assessments to promote knowledge and understanding of the resident's past. [Date Initiated: 08/02/2021] Identify if there are behaviors or factors from the past that should be considered in treatment planning. [Date Initiated: 08/02/2021] Observe the resident for signs of fear and insecurity during delivery of care. Take steps to calm the resident and help him/her feel safe. [Date Initiated: 08/02/2021] 3/11/2023 at 1:57PM, surveyor interviewed V7 (Social Services Designee) regarding discrepancy between answers on abuse assessment and care plan - abuse assessment says resident does not have a history of trauma/war/holocaust; however, care plan is specific to being a holocaust survivor. Surveyor also asked why R1's care plan score is low risk, although note says that residents is at risk for abuse. V7 stated, I am not sure why it says Low Risk on the score, but she is at risk based on her diagnosis of depression and dementia. It may be giving a total score off the other areas of the assessment. I put in the care plan for holocaust survivor for everyone from that part of the World. At 2:10PM, V7 added, the reason it's not triggered is because it's based off the full assessment (low risk score). When R1 first came in and was assessed, the family did not tell us that information about the holocaust - we found out after. The same thing happened with R2. The care plan was updated before we had that information. Honestly, we should be updating quarterly but sometimes we don't. Review of current care plans for R1 and R2 did not reflect that care plans had been updated after the incident on 2/22/2023. Facility was made aware of concerns related to lack of care planning for abuse and provided with the opportunity to present care plans during the course of the survey. Last care plans provided on 3/11/2023 at 4:02PM were the same as care plans previously provided during the survey. Facility provided Abuse and Neglect Policy (Effective Date: 10/24/22), reads: Policy Statement: It is the policy of the facility to provide professional care and services, in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to, prevention of abuse, and, timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention, and investigation . Abuse Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse . Types of Abuse and Examples 1. Physical: Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling . III. Prevention . - Deployment of sufficient and trained staff to deal with behaviors in the units - Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect - The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who toileting assistance to urinate or defecate in their beds

Based on observation, interview and record review the facility failed to provide an ongoing assessment, monitoring and reporting on skin/wound of resident who are at risk for skin impairment . This failure resulted to ( R1) worsening of current skin impairment (MASD- Moisture associated skin disorder) and developed new wound that the facility is not aware of; and to (R7) for developing necrotic tissues on right lower leg that facility is not aware of. The facility also failed to follow manufacturer recommendation regarding using of low air loss mattress avoiding multilayer linens over the mattress. The facility failed to implement care plan to enhance wound healing and prevent development of new skin impairment. This deficiency affects all four residents (R1, R4, R6 and R7) reviewed for Wound Care Management and Prevention. Findings include: R1 On 2/21/23 at 9:15am, V22 Family member said that R1 has developed sacral wounds last month. On 2/21/23 at 10:58am, Observed R1 transferred to bed from Broda chair using mechanical lift by V9 CNA and V11 CNA. R1 is on special mattress covered with flat sheet with cloth pad on top. V9 CNA repositioned R1 to her right side, opened her disposable adult brief. Observed blood stained at the disposable brief from the open wound on sacral area and soiled with urine. R1 does not have wound covering for open wound. V9 CNA said that R1 has on and off wounds on her sacral area for a while. V9 said that her wound today is worse that the last time he saw it. V9 said that they usually report to the floor nurse if they observed resident does not have dressing for open wound. On 2/21/23 at 11:15am, V6 Wound care Nurse (WCN) preparing wound care for R1. V12 CNA assisted V6 and kept R1 in left side lying position. Sacral area (right and left buttocks) has inflamed excoriation open wounds. V6 cleansed the left buttocks with Normal Saline Solution (NSS). Asked V6 WCN of wound status. V6 said he does not know. V6 said that he measures and took pictures of R1's wound report weekly, he needs to compare it. V6 took picture of R1's left buttocks and measures the wound. V6 said that R1 has MASD measures 7cm x 5.5cmx 0.1cm with 6 superficial open wounds. V6 said 50% Epithelial tissues (open wound) and 50% intact skin. V6 said this is an improvement from last week. Then he took picture of the left posterior thigh without cleaning it. V6 said it does need to be cleaned because it healed now. Then V6 is about to take picture of the right buttocks with open wound. Surveyor asked him if he could clean the wound before taking the picture and measurements. After V6 cleansed with NSS, he took picture and measured it. V6 said that R1's right buttock has MASD 4.7cm x 4.5cm x 0.1cm with 4 open wounds. 25% Epithelial tissues and Intact skin 75%. V6 said that R1's treatment is skin prep to both left and right sacral area and applied Hydrocolloid/duoderm dressing. He said he changes R1's dressing 3x/week. If the dressing falls off or become soiled the floor nurse will do the wound dressing. Informed V6 that R1 does not have wound dressing when V9 CNA provided incontinence care before he did the wound care. V6 is updating R1's wound records via cellphone while doing treatment. On 2/21/23 at 11:45am, After wound treatment, V6 WCN realized that the left buttock is new to him, and this is the first time he will be documenting it. V6 said he is not aware, and nobody told him until now that he is being observed for wound care. V6 said that that last time he did wound dressing for R1 was last Thursday (2/16/23) and it's only the right buttocks and left posterior thigh. V6 said R2 is not seen by wound care physician. V12 CNA said that she cannot recall if R1 has left buttocks open wound when she assisted V6 with wound care last week. On 2/21/23 at 11:50am, V13 LPN said that she is the regular nurse for R1. V13 is not aware that R1 has open wound on her both sacral areas. V13 said that she did not receive report from the night shift that R1 has new wound on left buttocks and does not have wound dressing. On 2/21/23 at 12:02pm, Informed V3 ADON of above observation. On 2/21/23 at 1:06pm, V5 WCN said that she used to be the Wound care coordinator and she stepped down as WCN and Floor nurse. V5 said that any skin alteration observed by CNA or no wound dressing for open wound should be reported to the nurse. On 2/21/23 at 3:02pm, V5 WCN said that R1 was admitted on [DATE]. They have new management since last year and that she can only access the following Braden scale/skin assessment: 8/31/21, 12/8/22, 1/8/23, and 2/6/23- all indicated high risk score of 10. On 2/22/23 at 2:12pm, Review R1's wound record with V6 WCN. V6 said that R1 has facility acquired MASD on right buttock dated 1/26/23, measures 2cm x 4.5cm x0.10cm, 50% Epithelial tissues ( pink/red) and 50% Non-granulating tissues, scant serous exudate. V6 said that the right buttock MASD is worsened most recent measurement on 2/21/23, 4.7cm x 4.5cm x0.10cm, 50% Epithelial tissues (pink/red) and intact skin 50%, scant serous exudate. Informed V6 WCN of concerns on ongoing assessment, monitoring and reporting of R1's sacral wound/MASD. R1 has treatment on right buttocks and left posterior thigh every Tuesday, Thursday and Saturday and as needed (PRN) if dressing/Hydrocolloid is soiled or loosen. R1 is also incontinent of bladder and bowel. R1 has ordered for skin checks every shift and head to toe skin assessment for any skin alteration. No nurses or CNAs reported to the wound care team of changes in R1's left buttocks (new wound) and worsening of right buttocks. R1 is admitted on [DATE] with diagnosis listed in part but not limited to Vascular Dementia, Diabetes Mellitus type 2, Obesity, Polyneuropathy, Fibromyalgia, Major Depression, Anxiety. Physician Order Sheet (POS) indicated: Apply barrier cream on perineal area every shift and PRN, CNA may apply and leave at bedside. May use low air loss (LAL) mattress every shift for preventative care. Skin checks every shift for preventative. Please check from head to toe for any skin alteration. Skin: Turn and reposition at no longer than 2 hours interval and PRN every shift. Treatment: Left posterior thigh and right buttock: cleanse with normal saline, pat dry. Apply skin prep peri-wound and cover with hydrocolloid every T/Th/S and PRN if loose /soiled and PRN dated ordered 1/26/23. Care plan indicated: R1 requires 2 total assist with 2 staff using hoyer lift with transfers ( to/from: bed to broda) due to generalized weakness and poor we bearing tolerance. R1 has an ADL self-care performance deficit r/t limited ROM, impaired mobility, decreased endurance/activity tolerance and cognitive impairment. R1 has an actual skin impairment to skin integrity and was assessed to be at high risk for further skin breakdown related to age fragile skin, incontinent of bladder and bowel, impaired physical mobility, decreased ADLs functional ability, Braden scale 10 and secondary disease process. Wound report dated 2/21/23 indicated: Left buttock- active MASD, incontinence, Facility acquired, identified on 2/21/23 by V6 WCN. Measures- 7cm x 5.5cm x 0.10cm. Intact skin -50%, epithelial pink/red tissue- 50%, scant serous exudate, erythema/maceration on peri wound. Wound summary Right buttock indicated: Active MASD, incontinence, facility acquired dated 1/26/23 identified by V5 WCC. Measures 2cm x4.5cm x 0.10cm, 50% epithelial tissues, 50% non-granulating tissues. 2/21/23 measures 4.7cm x 4.5cm x 0.10cm. 50% intact skin, 50% epithelial tissues red/pink. R4 On 2/21/23 at 12:56pm, V16 RN said that R4 has pressure ulcer. R4 is on enhanced isolation precaution. Observed R4 with V16 RN on special mattress covered with flat sheet, with folded linen in quarter underneath R4. V16 said that R4 should only be on flat sheet over LAL mattress, no folded linen on top of the flat sheet/over the LAL mattress. On 2/22/23 at 10:55am, Observed V6 WCN and V12 CNA preformed wound care to R4. Observed R4's sacrum wound dressing soaked with serous sanguineous with brownish greenish drainage. V6 cleansed the sacrum with NSS. V6 said that R4 has unstageable pressure ulcer which is facility acquired, measures 5.2cm x 4.9cm x 0.70cm, 30% greenish slough attached to wound base, 70% non-granulating tissues. On 2/22/23 at 2:12pm, Review R4's wound record with V6 WCN. Informed V6 of above observation. V6 said that R4 should only have flat sheet over the LAL mattress. V6 said that R4 is admitted on [DATE]. R4 has facility acquired MASD on sacrum on 11/1/22 that progress to unstageable pressure ulcer on 12/29/22 until present. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Metabolic encephalopathy, Acute pulmonary edema, Malignant neoplasm of uterus, Severe protein calorie malnutrition, Palliative care. POS indicated: Low air loss mattress and check if functioning properly. Care plan indicated: R4 has actual skin impairment and was assessed to be at high risk for further skin breakdown related to age, fragile skin, incontinence of Bladder and bowel, impaired physical mobility, decreased ADLs functional ability, poor appetite, Braden score of 10 and underlying disease process. Wound summary: Sacrum Pressure ulcer. Facility acquired. Date identified 11/1/22. Denuded/MASD. 3cmx3.5cmx0.10cm. Epithelial tissues (pink/red) 50%, Non- granulating tissues ( pink /red) 50%. Scant serous exudate. 2/16/23 Unstageable pressure ulcer. 4.70cmx4.50cmx not measurable. Slough white fibrinous 30%, Non granulating tissue (pink/red) 70%. Moderate serous exudate. R6 On 2/21/23 at 1:25pm, V19 LPN said that R6 has pressure ulcer and is on hospice care. Observed R6 with V19 lying in bed on LAL mattress covered with flat sheet, folded sheet in quarter underneath him. V19 said that R6 should only be on a flat sheet over the LAL mattress, no folded sheet underneath over the mattress. On 2/22/23 at 11:03am, Observed V5 WCN, V6 WCN and V12 CNA provided wound care to R6. Observed R6 on LAL mattress covered with flat sheet and folded linen in quarter underneath R6. Showed observation to V6 and he removed it. V6 said that R6 should only be only flat sheet over the LAL mattress. V6 measures and describes the following wounds: Left back pressure ulcer ( with 2 wounds) - 19cmx 8.2cm x not measure due unstageable, 20% necrotic tissue, 10% slough and 10% non-granulating tissue; Midback pressure ulcer ( with 3 wounds)- 17cm x2.8cm x not measure due to unstageable, 20% necrotic, 20% slough, 60% intact skin, erythema on peri wound; Right lower back ( with 4 wounds)- 6cm x 10cm x 1.9cm undermining 12 to 2 o'clock, 15% slough, 15% necrotic tissue, 20% intact skin and 50% red/pink tissue; Sacrum- MASD, 10cm x 11cm. with open wound measures 1.6cm x1.5cm x0.1cm. On 2/22/23 at 2:12pm, Review R6's wound record with V6 WCN. Informed V6 of above observation. V6 said that R4 should only have flat sheet over the LAL mattress. V6 said that R6 is admitted on readmitted on [DATE]. V6 said all R6's wounds are facility acquired. Left back pressure ulcer is facility acquired on 1/2/23 as stage 3, 15cm x 6cm x 0.2cm, 10% non-blanchable erythema, 20% slough white fibrinous, 20% non-granulating tissue and 50% intact skin, light serous exudate. Left back stage 3 progressed to unstageable pressure ulcer on 1/19/23 until present. Left buttocks deteriorated. Midback pressure ulcer is facility acquired on 1/5/23 as stage 3 pressure ulcer, 15cm x 6cm x 0.20cm, 10% on-blanchable erythema, 20% non- granulating tissue, 20% slough white fibrinous and 50% intact skin, light serous exudate, Mid back pressure ulcer remains stage 3 but increased in wound size; Right lower back pressure is facility acquired on 1/2/23 as unstageable pressure ulcer, 5cm x 5cm x unknown, 20% non-granulating tissue and 80% slough white fibrinous, light serous exudate. Right lower back pressure ulcer remains unstageable but with undermining; Sacrum MASD is facility acquired on 1/2/23, 4cm x 5cm x 0.10cm, 50% epithelial tissue and 50% non-granulating tissue. Sacrum MASD remains but increased in size. R6 is admitted with diagnosis listed in part but not limited to Parkinson's disease, Chronic embolism and thrombosis of deep veins of lower extremities, Neuromuscular dysfunction of bladder, Metabolic encephalopathy, Alzheimer's disease, Cerebral atherosclerosis, Acute kidney failure. POS indicated: Low air loss mattress and check if functioning properly. Care plan indicated: R6 has actual skin impairment and was assessed to be high risk for further skin breakdown related to factors such as age, incontinence of bladder and bowel, impaired mobility, decreased ADLs functional ability, Braden score of 9 and secondary to disease process. R7 On 2/23/23 at 10:37am, Observed R7 up in wheelchair in her room by her bedside dresser with no pants, wearing shorts and blouse. Clothes scattered on the floor. Observed right leg redness and swollen with necrotic/black tissue at the back of her leg. The entire right lower leg is swollen that causing visible skin tightness. Left leg has purplish discoloration, no swelling. Bilateral lower leg has dry skin. Called V24 Agency CNA sitting by the hallway and showed observation. V24 said that she is the CNA taking care of R7, but this is the first time she is assigned to her. V24 does not know about the necrotic wound on her right leg. R7 is dressed up by the night shift. R7 is in the dining room for breakfast and probably came back to her room and undressed herself. V24 called V25 LPN. On 2/23/23 at 10:43am, V25 LPN said that she is regular nurse who works with R7 but she has not taken care of R7 for the last 3 weeks. V25 said that the night shift nurse just endorsed to her this morning about R7's necrotic wound with redness and swelling of on her right leg. R25 said that she just waiting for the nurse Practitioner to come and see R7. Review R7's e-POS with V25. No treatment order for necrotic wound on right lower leg. R7 has ordered for ace wrap to bilateral lower leg in the morning, remove at bedtime dated 10/6/22. On 2/23/23 at 10:45am, V26 Restorative aide said that she has been treating R7 for daily Restorative program but is not aware of the necrotic/black wound on her right leg. R7 is wearing pants so she did not notice it and R7 did not complaint about it. On 2/23/23 at 11:04am, V6 WCN said that he is not aware of R7's has necrotic wound with redness and swollen right lower leg. No one informed him until now. The last time that he treated R7 was last 10/27/21 when he healed her skin tear on right lower leg. V6 cleansed R7's necrotic wound on right posterior leg. V6 measured necrotic wound, 7cm x 4cm x not measurable due to necrotic tissue, entire right lower leg/foot swollen. R7's left leg has purplish brown discoloration. V6 applied Betadine paint and left open to air. On 2/23/23 at 11:22am, V27 Wound Care Coordinator (WCC),V5 WCN came to R7's room and observed her wound. Informed V5, V6 and V27 of concerns on ongoing assessment, monitoring and reporting of R7's right leg or bilateral legs. R7 has treatment ordered of ace wrap to both lower leg in the morning, remove at bedtime since 10/5/22. No nurses or CNAs reported to the wound care team of necrotic wound with redness and swelling that causing tightness of the skin. V27 said that she already contacted V28 Wound care Physician for consultation. On 2/23/23 at 1:30pm Informed V1 Administrator, V2 DON, and V3 ADON of above observation. R7 is admitted on [DATE] with diagnosis listed in part but not limited to Metabolic encephalopathy, Alzheimer's disease, Urinary tract Infection, Anxiety disorder, Obsessive compulsive disorder, Age related osteoporosis, Peripheral Vascular disease. POS indicated: Apply ace wrap to both lower leg in the morning, remove at bedtime dated 10/5/22. Care plan indicated: Potential for skin impairment and is at risk for further skin breakdown related to factors such as age, fragile skin, impaired mobility, decreased ADLs functional ability, Braden score 16 and secondary to disease process/diagnosis. Interventions: Skin checks every evening shift. Report abnormalities to the nurse. Notify nurse immediately of any of skin breakdown, such as redness, blister, bruises, skin tears, discoloration noted during bath or daily care. On 2/24/23 at 12:11pm, V28 Wound Care Physician said that minimal layer is recommended over LAL mattress like using flat sheet. Placing folded linens created multi layers could inhibits the effectiveness of the LAL mattress overall. Facility's policy on Skin Care Treatment Regimen indicated: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for resident with skin breakdown. Procedures: 1. Charge nurses must document in the nurse's notes and or the wound report form any skin breakdown upon assessment and identification. 5. Refer any skin breakdown to the skin care coordinator for further review and management as indicated. Facility's guidelines on Low Air Loss (LAL) Mattress Purpose: LAL have tiny laser made air holes in the mattress top surface that continually blow out air causing a reduction in humidity and heat between the skin and mattress surface (Microclimate). A blower will typically output around 100-150liters of air into the mattress, drying the skin and preventing skin breakdown. Procedure: 3. Provide a breathable sheet on top of the LAL mattress and provide incontinence pad and or brief as necessary only. If the resident is continent, then an incontinence pad or brief is not needed. Please see Specialized Mattress and appropriate Layers of padding policy for more details. Facility's policy on Specialized Mattress and Appropriate Layers of Padding: Procedure: 1. Limit the amount of layers on top of specialized air mattress such as LAL mattress according to the resident's needs and individual's condition in order to manage comfort, positioning and moisture. For LAL mattress, consider 1 fitted or flat sheet on top of the bed for dignity, 1 cloth incontinence pad and 1 absorbent brief to absorb fecal or urinary incontinence and help with repositioning, prevent fecal urinary soiling of the entire bed and resident's skin, if the resident is incontinent.

Based on observation, interview and record review the facility failed to ensure that resident with pacemakers is provided necessary follow up as indicated in resident's care plan to ensure that the pacemakers are in good working condition. This deficiency affects all six (R1, R8, R9, R10, R11, R12) residents with pacemaker in the facility reviewed for pacemaker follow up and monitoring. Findings include: R1 On 2/21/23 at 9:15am, V22 Family member said that facility is not transmitting R1's pacemaker information as ordered. R1 pacemaker to be transmitted out every three months. Facility is not aware of transmitting information. R1 is admitted on [DATE] with diagnosis listed in part not limited to Hypertension, Presence of Cardiac Pacemaker, Angina Pectoris, Complete atrioventricular block. Care plan indicated: R1 has pacemaker related to complete heart block. Intervention: Pacemaker checks every 3 months and document in chart heart rate, rhythm, battery check. No ordered written in POS ( Physician order sheet) on how often the pacemaker is to be checked and by whom ( physician office, cardiology clinic by telephone) as indicated in facility's policy in Pacemaker management. On 2/21/23 at 10:47am, Presented complaint allegation of V22 Family member regarding not transmitting /checking the pacemaker every three months to V3 ADON. He said that he spoke with V22 last month regarding her concerns of pacemaker check/follow up and acted on it. V3 did not complete a grievance/ concern log. V3 did not make a follow up call with V22. V3 did not inform V2 DON of her concerns because he acted already on it. V3 is not aware that V22 expected a follow up call. Review R1's pacemaker medical record with V3 ADON indicated R1 pacemaker was done on 4/19/22. V3 said that last record of pacemaker check is recorded in his pacemaker machine transmitter. Found R1's pacemaker machine transmitter by the window (sic). V3 plugged it in and, showed indication that last pacemaker checked was done on 1/18/23. V3 said he does not know the frequency of pacemaker check and will check on their policy. No record of pacemaker check indicated in chart that was done on 1/18/23. V3 ADON said that he will call the company to fax the record of transmission. On 2/22/23 at 12:25pm V3 ADON provided list of residents in the facility with pacemakers. Rounds made to all residents with pacemakers. Review the following residents with V3 ADON. Informed V3 ADON that concern identified in not ensuring follow up made for pacemaker check after admission of all residents. R8 R8 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic combined systolic and diastolic heart failure, Atherosclerotic heart disease, Sick sinus syndrome, Presence of cardiac pacemaker. No order in POS for how often the pacemaker is to be check and by whom. Care plan indicated that R8's pacemaker care plan is initiated on 2/22/23 by V29 Care Plan Coordinator. R8 has a pacemaker related to Sick sinus syndrome. Intervention: Pacemaker checks and document in chart: heart rate, rhythm, battery check. Pacemaker check done on 2/8/23. Pacemaker report does not indicated date and insertion, make model and serial number of the pacemaker. R9 R9 is admitted on [DATE] with diagnosis listed in part but not limited to Atherosclerotic heart disease, Atrioventricular block second degree, Heart Failure, Presence of Pacemaker. No order in POS for how often the pacemaker is to be check and by whom. Care plan indicated that R9's pacemaker care plan is initiated on 2/22/23 by V29 Care Plan Coordinator. R9 has a pacemaker related to Sick sinus syndrome. Intervention: Pacemaker checks and document in chart: heart rate, rhythm, battery check. Pacemaker check done on 7/8/22. R10 R10 is admitted on [DATE] with diagnosis listed in part but not limited to Atherosclerotic heart disease, Sick sinus syndrome, Presence of cardiac pacemaker. No order in POS for how often the pacemaker is to be check and by whom. Care plan indicated he has pacemaker related to Sick sinus syndrome. Interventions: Pacemaker checks every 3 months and documents in chart: heart rate, rhythm, battery check. Pacemaker check done on 4/13/22. R11 R11 is admitted on [DATE] with diagnosis listed in part but not limited to Atherosclerotic heart disease, Paroxysmal Atrial Fibrillation, Presence of cardiac pacemaker. No order in POS for how often the pacemaker is to be check and by whom. Care plan indicated he has pacemaker related to Atrial Fibrillation. Interventions: Pacemaker checks every 3 months and documents in chart: heart rate, rhythm, battery check. Pacemaker check done on 8/28/22. R12 R12 is admitted on [DATE] with diagnosis listed in part but not limited to Atherosclerotic heart disease, Nonrheumatic mitral valve stenosis, Atrioventricular Block complete, Chronic diastolic congestive heart failure, Presence of cardiac pacemaker, Presence of prosthetic heart valve. No order in POS for how often the pacemaker is to be check and by whom. Care plan indicated he has pacemaker related to Atrioventricular Block 3rd degree. Interventions: Pacemaker checks every 3 months and documents in chart: heart rate, rhythm, battery check. Pacemaker check done on 4/13/22. On 2/22/23 at 3:02pm, Informed V2 DON of concerns in ensuring all residents in the facility with pacemakers are being monitored and followed up. V2 admitted that they have not follow up pacemaker checks for their residents because since they have the new management last year, the cardiac company who comes to monitor their pacemakers resident stop coming. V2 said that they are addressing these concerns and having contract with another cardiac monitoring company for their resident's with pacemakers who will come to the facility. Facility's policy on Pacemakers indicated: it is the policy of the facility to ensure that the care for residents with pacemakers is provided in each facility according to current standards of practice. The facility shall also ensure that the necessary follow up id done to ensure that the pacemakers are on good working condition. Pacemakers check and interrogation can be done at the cardiologist's office, or it can be done remotely at the facility. Procedures: 1. Residents who have pacemakers must have the following documented in their medical record: a. The date of insertion, physician who inserted it, and the place where it was inserted. b. Make model and serial number of the pacemaker c. Orders in POS ( physician order sheet) for how often the pacemaker is to be checked and by whom ( physician office, cardiology clinic by telephone, etc).

Based on observation, interview and record review the facility failed to implement fall prevention intervention to resident on high risk for fall and has history of falls. This deficiency affects all three (R4, R5 and R13) of three residents reviewed for fall prevention management program. Findings include: R4 On 2/21/23 at 12:56pm, Observed with V16 RN, R4 lying in bed with no floor mats on the floor. No floor mat found in resident room. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Repeated falls, Dizziness and Giddiness, Syncope and Collapse, Metabolic Encephalopathy. R4's care plan indicated that she is at high risk for fall related to generalized weakness, impaired cognition, medication side effects, impaired mobility, incontinence, impaired vision, history of falls. Intervention: floor mats/floor pads placed at bedside. R5 On 2/21/23 at 1:14pm, Observed with V13 LPN, R5 lying in bed with no floor mats on the floor. He is on low bed but not in the lowest position. The bed is about 28 inches from the floor. R5 is admitted on [DATE] with diagnosis listed in part but not limited to History of falling, Wedge compression fracture of lumbar vertebra, Senile degeneration of the brain, Dementia. R5's care plan indicated that he is high risk for falls related to current medication use, Poor safety awareness, Unsteady gait, Disease process, History of falling, Acute encephalopathy, Urinary Tract Infection, Hypertension, Lumbar compression fracture and Meningioma. Interventions: Floor mat in place adjacent to bed. Place bed to the lowest position. R13 On 2/21/23 at 1:42pm, Observed R13 with lying in bed, in high position. Showed to V21 LPN R13's bed position. V21 said that the bed should be in the lowest position. V21 took the bed control and adjust the bed to its lowest position. On 2/21/23 at 1:49pm, V14 LPN said that she is the nurse assigned for R13. She does not know if she is on fall precaution, she has to check her care plan if she is at risk for falls. V14 reviewed R13's care plan and said that she is at high risk for fall. V14 said that R13's bed should be on the lowest position. Informed her that round made with V21 LPN and found R13's bed in high position. V14 said that the CNA probably forgot to place the bed to its lowest position. R13 is admitted on [DATE] with diagnosis listed in part but not limited to Aftercare following joint replacement surgery, History of falling, Displaced spiral fracture of shaft or right femur, subsequent encounter for closed fracture with routine healing, Amyloidosis, Rheumatoid Arthritis, Systemic involvement of connective tissue, Disorders of bone density and structure. Care plan indicated: At high risk for falls related to the following contributing factors: Generalized weakness, Cognitive deficit Medication side effects, Impaired mobility and Incontinence. Intervention: Keep the bed in the low position for safety. R13 had 3 unwitnessed Fall incident reports dated 1/13/23, 12/12/22 and 11/10/22. On 2/22/23 at 2:30pm, Informed V2 DON and V3 ADON of above observation made. V3 said that they are expected to implement the fall care plan intervention for resident who are at risk for fall. The bed should be on the lowest position for safety with floor mats on the floor. On 2/23/23 at 12:35pm, V5 Fall coordinator said that she is aware of floor mat is not implemented it for R4 but she corrected it the following day. V5 said that the order for placing the bed to lowest position for R5 and R13 are depending on their height and how they sit on the bed. Facility's policy on Fall occurrence: it is the policy of this facility to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are re-evaluated and revised as necessary. Procedure: 2. Those identified as high risk for falls will be provided fall interventions.

Based on observation, interview and record review, the facility failed to monitor the resident's refrigerator temperature for five (R128, R171, R184, R134, R82) of seven residents observed for food safety in a sample of 36. Findings include: On 01/24/2023 at 10:21AM during observation with V24 (Licensed Practical Nurse - LPN), R128's refrigerator was observed with last temperature check on July 22, 2022. On 01/24/2023 at 10:23AM during observation with V24, R171's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:26AM during observation with V24, R184's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:29AM during observation with V24, R134's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:32AM during observation with V24, R82's refrigerator was observed with last temperature check on May 16, 2022. On 01/24/2023 at 10:30AM, V24 said that the refrigerator temperature should be monitored daily. On 01/25/2023 at 2:59PM, V2 (Director of Nursing) stated that all refrigerator temperatures should be monitored daily by housekeeping. R128's Order Review Report dated 01/06/2023 indicated admitted [DATE] and diagnosis of but not limited to essential hypertension. R171's Order Review Report dated 01/06/2023 indicated admitted [DATE] and diagnosis of but not limited to essential hypertension. R184's Order Review Report dated 01/06/2023 indicated admitted [DATE] and diagnosis of but not limited to type 2 diabetes mellitus. R134's Order Review Report dated 01/06/2023 indicated admitted [DATE] and diagnosis of but not limited to hyperglyceridemia. R82's Order Review Report dated 01/06/2023 indicated admitted [DATE] and diagnosis of but not limited to secondary hypertension. Facility Policy: Title: Refrigerator and Resident Appliance Maintenance Service Reviewed: 07/28/2022 Policy Statement: It is the policy of this facility to provide maintenance services for refrigerator units in resident rooms, common areas/dining rooms and nurses station. Procedures: 2. The facility will perform the following refrigerator checks: c. Temperature is maintained below 41F and above 32F using a thermometer with +-3 degrees temperature variance. 40001 Based on observation, interview and record review, the facility failed to follow their policy on storing and dating opened food Items in the refrigerator cooler for 94 of 95 residents eating in the facility. Findings include: On 1 /24/2023 at 10:00am during an initial tour of the kitchen, the surveyor observed in the refrigerated cooler had 9 large pans of prepared raw beef with out a covering or a date, 2 large containers without a covering of raw white potatoes cut and peeled in water no date. On 1/24/2023 at 9:50am V10(Food Service Director) said all food that is prepared or open should be covered and dated. Facility Policy: Kitchen Revised 7/28/2022 Policy Statement The facility will comply with state and federal regulations in operating facility's kitchen. Procedures: 1.Food Storage e. Refrigerated food should be covered, dated, labeled, and shelved to allow air circulation. h. Open containers or potentially hazardous food or leftover should be dated and used within 3-5 days in the refrigerator.

Based on observation, interview and record review, the facility failed to post visual alert signs at the entrance of the facility notifying visitors entering the building about facility's COVID-19 status. They also failed to sanitize the glucometer in between resident's use and post the transmission-based precaution sign on R1's door affecting three of eight residents reviewed for infection control in a sample of 36. Findings include: 1. On 1/24/23 at 9:30 am, the entrance of the facility was observed with no sign notifying visitors of the facility's COVID-19 status. During an interview on 1/24/22 at 9:30 am, V2 (Director of Nursing) stated that the facility currently has four COVD-19 residents. On 1/26/23 at 9:30 am, V15 (Infection Retentionist) stated that a sign should be posted with the facility's COVID-19 status at the facility's entrance. Facility's policy titled: COVID 19 Testing Plan and Response Strategy revised 1/6/22 reads. Infection Prevention and Control Interventions. 4. Screening: Instead the facility must establish a process to inform HCP, residents, and visitors of recommended actions to prevent the transmission of COVID-19 by posting visual alerts (e.g sings, posters) at the entrance and other strategic places. These alerts should include instructions about current infection prevention control recommendations (e. g, when to use source control and perform hand hygiene). 46560 2. On 01/24/2023 at 10:25AM during observation, R1's door was not observed with any transmission-based precaution (TBP) sign and cart. On 01/25/2023 at 9:05AM during observation, R1's door was again observed without any TBP sign and cart. On 01/25/2023 at 10:49PM during observation, V19 (Licensed Practical Nurse - LPN) was observed checking blood sugars of R136 then immediately proceeded to checking blood sugar of R10 without disinfecting the blood glucose machine. On 01/25/2023 at 2:00PM during observation, V19 observed the order for isolation - contact precautions for R1. R1's room was also observed with V19 and V26 (LPN) and noted without any TBP sign and cart at the door. On 01/25/2023 at 10:55AM, V19 stated that he is not sure if he needs to disinfect the blood glucose machine in between residents. On 01/25/2023 at 2:00PM, V26 said that the isolation has been discontinued. When the order was presented to her, she said she will call the Infectious Disease and ask if it needs to be discontinued. On 01/25/2023 at 3:45PM, V3 (Wound Care Director) said that R1 is not on any contact precaution but he is on Enhanced Based Precaution (EBP) due to his wounds. She said that EBP does not need a physician order, but TBP cart and sign should be placed on the door. R1's Order Review Report dated 01/06/2023 indicated admitted [DATE] and diagnosis of but not limited to protein-calorie malnutrition. Facility Policy: Title: Glucose Meter Cleaning Reviewed: 7/28/22 Policy Statement: To ensure safe, convenient and proper cleaning and disinfection of Blood Glucose Meters in accordance to CDC (Center for Disease Control and Prevention) guidelines and manufacturer's instructions to help prevent device exposure to bloodborne pathogens. Procedures: 4. Clean and disinfect glucose meter with Clorox Healthcare Bleach Germicidal Wipes/Microkill Wipes/Microdot Wipes/Avert Wipes before after each resident use. Title: Observational Competency: Blood Glucose Monitoring Task: 6. After checking the blood sugar of the resident, the nurse cleaned the accu-check machine using the disinfectant solution as per facility's policy.

Based on observation, interview and record review, the facility failed to label and store medications properly for five of five medication carts and one of three medication room refrigerators reviewed for medication storage. Findings include: On 01/24/2023 at 3:17PM during observation with V20 (Registered Nurse - RN), 6th floor unit C and D medication carts were observed with the following: 1. R22's Calcitonin 200 units/actuation (act) nasal spray - no open date; label indicates discard after 30 days 2. R132's Calcitonin 200 units/act nasal spray - no open date; label indicates discard 3. R77's Tiotropium bromide 2.5micrograms (mcg)/act (3 sprays) - no open date; label indicates discard 3 months after 4. R77's Ipratropium bromide and albuterol 20mcg/100mcg/act inhalation spray (2 sprays) - no open date; label indicates discard 3 months after On 01/24/2023 at 3:42PM during observation with V21 (RN), 7th floor unit C and D medication cart was observed with the following: 1. House stock Diphenhydramine 25 milligrams (mg) caplets - manufacturer's expiration date 08/2021 2. Glucosamine & Chondroitin 500mg/400mg tablets - manufacturer's expiration date 09/2022 3. 2 opened bottles of clear emollient lubricant gel drops - manufacturer's expiration date 10/2020 4. R4's Insulin glargine 100 units/milliliter (mL) - no open date; label indicates once opened refrigerated or not discard after 28 days 5. R53's Insulin glargine 100 units/mL - no open date; label indicates once opened refrigerated or not discard after 28 days On 01/25/2023 at 9:38AM during observation with V22 (RN), 4th floor unit C and D medication cart was observed with the following: 1. R39's Budesonide 0.25mg/2mL nebulization suspension - one open foil pack noted inside the box with no open date; label indicated once foil pack opened use vials within 2 weeks 2. Opened Calcitonin 200 units/act nasal spray - not in a labeled bag, no open date 3. Opened and unlabeled lubricant eye drops - manufacturer's expiration date 11/2022 On 01/25/2023 at 10:08AM during observation with V19 (Licensed Practical Nurse - LPN), 5th floor unit C and D medication cart was observed with the following: 1. Resealable bag labeled with R141's name with opened without box umeclidinium and vilanterol 62.5mcg/25mcg inhalation powder with open date 11/20/2022. Inhaler indicated discard 6 weeks after. 2. Resealable bag labeled with R33's name with opened without box fluticasone furoate and vilanterol 200mcg/25mcg inhalation powder without open date and indicated discard 6 weeks after. On 01/25/2023 at 11:00AM during observation with V4 (LPN), 3rd floor unit A and B medication cart was observed with the following: 1. R146's umeclidinium 62.5mcg inhalation powder without foil tray - no open date; label reads discard 6 weeks after foil tray opened 2. R177's ipratropium bromide and albuterol 20mcg/100mcg/actuation inhalation spray with open date 01/21/2022 - label reads discard 3 months after opening 3. Two of R2's fluticasone furoate and vilanterol 200mcg/25mcg inhalation powder - no open date; label reads discard 6 weeks after opening On 01/25/2023 at 11:26AM during observation with V4 (LPN), 3rd floor medication room refrigerator was observed with last temperature check on September 6, 2022. On 01/24/2023 at 3:34PM, V20 stated that there should be an open date on the nasal sprays and inhalers. She also said that the expired medications should be removed from the cart immediately upon expiry. On 01/24/2023 at 4:05PM, V21 said that expired medications should be removed from the cart. She also said that insulins should have open dates on them. On 01/25/2023 at 10:00AM, V22 said that medications that are already expired should be discarded. She also added that nasal sprays and inhalers should have open dates. On 01/25/2023 at 10:35AM, V19 said that inhalers should have open date and discarded per manufacturer's guidelines. On 01/25/2023 at 11:23AM, V4 stated that the expired medications should have had opened dates and discarded after the manufacturer's recommended discard date. At 11:27AM, she said that the refrigerator temperature should have been checked by night shift daily. On 01/25/2023 at 2:59PM, V2 (Director of Nursing) said that she expects the nurses to remove and discard all expired medications, put open date on inhalers and nasal sprays, and check and monitor the medication refrigerator temperatures daily. Facility policies: Title: Medication Storage, Labeling, and Disposal Reviewed: 10/24/2022 Policy Statement: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. Procedures: 2.And the medication automatically expires based on the expiration date based on the manufacturer's guidelines. Title: Medication Pass Reviewed: 7/28/2022 Procedures: Medication Labeling 3. Follow pharmacy recommendation as to when the medication should be discarded after opening. Title: Refrigerator and Resident Appliance Maintenance Service Reviewed: 07/28/2022 Policy Statement: It is the policy of this facility to provide maintenance services for refrigerator units in resident rooms, common areas/dining rooms and nurses station. Procedures: 2. The facility will perform the following refrigerator checks: c. Temperature is maintained below 41F and above 32F using a thermometer with +-3 degrees temperature variance.

Based on interview and record review the facility failed to prevent an avoidable accident while allowing a resident identified to be a fall risk due to impaired mobility, to assist push another resident in a wheelchair on the nursing unit. This affected 1 of 3 residents reviewed for avoidable accidents. This failure resulted in R10 pushing R3 around the nursing unit where R3 fell from the wheelchair and went to the local hospital where R3 was diagnosed with comminuted sub capital fracture of the right femoral, and a minimally displacement of the left nasal bone inferiorly anteriorly, had a hemiarthroplasty to repair the right hip. Based on observations, interviews, and record reviews, the facility failed to provide a safe mechanical lift transfer by not following the Mechanical Lift Transfer Policy, and manufacter reccomendations, to include folding resident arms across the chest, bilateral siderails up during transfers, ensuring all extremities are clear of the mechanism while in operation. This affected 1 of 3 residents (R5) reviewed for safe mechanical transfers. This failure resulted in R5's right hand getting entangled in the mechanical lift causing a laceration to right middle finger and comminuted fracture in the distal phalanx of the 3rd digit. Based on interview and record review the facility failed to maintain safety for a resident assessed to be at high risk for falls while performing a staff assisted shower for 1 of 3 (R8) residents reviewed for falls. This failure resulted in R8 being involved in a fall incident while being showered by a certified nurse aide resulting in R8 falling to the floor sustaining a laceration to the forehead requiring sutures at the local hospital. Findings Include: Facility Reported Incident (dated 2/22/22) reviewed, and reads in part: Facility reportable dated 2/22/22 reads in part: Date of incident 2/22/22 at 12:20 pm (Time verified with V32, ADON on 4/22/22), location R3's room. CNA observed R3 fell forward on to the floor from R3's wheelchair while being wheeled out of her room by R10 (husband and resident on the 6th floor). CNA notified the nurse and the nurse immediately responded and observed the R3 laying on R3's right side in front of R3'sroom. Nurse noted swelling on the bridge of R3's nose and complaint of pain. R3 was sent to hospital. Final investigation dated 3/1/2022 reads in part: R10 (R3's husband) visiting the R3 when R10 decided to take R3 out from the room to the common area. The right wheelchair wheel hit the door frame and the wheelchair came to a sudden and complete stop. The stop forced the resident to move forward and fell on the floor face down. Hospital record reviewed. X-ray of the hip reveals comminuted sub capital fracture of the right femoral neck and resident had hemiarthroplasty on right hip. CT of maxillofacial without contrast [NAME] minimally displaced of the left nasal bone inferiorly anteriorly. R3 is with diagnosis of Dementia and resides in the Dementia Unit (5th floor). R3 was assesses on 2/8/22 to be high risk for fall. BIMS (Brief Interview for Mental Status) score of 3 out of 15 (severe cognitive impact). R3's Minimum Data Set (MDS), section G (Functional Status) shows Locomotion on unit as extensive assistance with one person assist. R3 is high risk for fall, assessed on 2/8/22 and the day of the incident 2/22/22. R10 resides on the 6th floor, care planned for RESTORATIVE TRANSFER PROGRAM: R10 has an ADL Self Care Performance Deficit related to Limited ROM, Impaired Mobility Decreased Endurance/Activity Tolerance (dated 10/28/21). Intervention: R10 requires Extensive Assist x 1 staff participation with transfers (dated 10/28/21). R10 is At Risk for fall related to the following contributing factors: 1) Generalized weakness related to Multiple complex/chronic medical diagnosis. 2) Inability to call for assist, decreased comprehension, impulsivity (dated 1/28/22).One of the care plan intervention for R10 fall care plan is: Provide R10 with staff assistance in areas of mobility, transfer, self-care as indicated (dated on 10/28/21). R10's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/19/22 section G (Functional Status) shows R10 Walk in room and walk in corridor as supervision with set up help only. R10 has a BIMS score of 14 out of 15. R3's hospital record reviewed and noted on 2/23/22 R3 had a Right Hip hemiarthroplasty. On 4/15/22 at 11:35am, interviewed 5th floor social service (V10) stated that R3 uses wheelchair and participates in activity. V10 reported that R10 visits R3 daily in the Dementia unit. R10 has a behavior of wheeling R3's wheelchair away from the hallway, however R10 is re-directable. I am not sure, how often R10 wheeled R3 back in R3's room, but there was an Activity Aide and CNA that could of redirected R10 not to wheel R3. I am not sure who put R3 in her room at the date of the incident. On 4/15/22 at 12:00pm, interviewed V12 (6th floor Social Service) stated that R10 visits R3 in the Dementia Unit. R10 has a BIMS score of 8 out of 10, which means R10 has cognitive impairment. R10 is aware of his safety and most of the time, R10 is aware of the safety of others. On 4/15/22 at 11:20am, interviewed V9 (CNA assigned to R3 on 2/22/22) and stated that V9 is an agency CNA. 9 stated that before the incident on 2/22/22, V9 already observed R10 wheeled R3 in and out of R3's room. Per V9, the first time V9 observed this behavior, V9 asked the regular staff in the unit and the staff told V9 that it is okay for R10 to wheel R3, and that R10 and R3 are husband and wife. V9 denied putting R3 in her room that day (2/2/22). Per V9, he was assisting another resident in their room and V9 heard a noise and when V9 came out of the room, I was coming out of another resident's room and I heard a noise, and then I saw R3 was on the floor, by R3's bed room doorway. The wheelchair was facing the outside of the room, so I guess that R10 was wheeling R3 outside her room. I called the nurse. V9 stated that the last time V9 saw R3 and R10 was in the dining room after lunch. V9 denied assisting R3 back to R3's room and does not know who placed R3 in R3's room. On 4/15/22 at 12:55pm, interviewed V8 (Nurse assigned to R3 on 2/22/22) stated that V8 did not witness the incident, V8 was just informed by staff. V8 stated V8 called 911 while other staff assisted with R3. On 4/19/22 at 20:10am, interviewed V21 (Fall Coordinator) stated that R10 alert times 3, came down to the unit (5th floor). R10 Par take activity with R3, wheeled her in the bedroom, and R10 routine was R10 would wheel R3 in the unit. On 4/19/22 at 2:40pm, V3 (Director of Nursing) stated R10 is alert and oriented x 3. BIMS score of 14, and able to verbalize his needs. We don't have any policy about resident to resident assistance with wheeling a wheelchair of another resident. On 4/20/22 at 2pm, V2 (Executive Director) stated that the facility does not have Supervision policy. Fall Prevention Program Guidelines policy with a revised date of 6/15/2019 reads in part: Fall prevention program shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence0based prevention intervention. Procedure: Safety interventions shall be initiated and implemented for each resident identified at risk for fall. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. Surveyor: [NAME], [NAME] R5 During the course of the survey, surveyor observed staff tending to residents. On 4-19-22 at 2:02 PM, surveyor observed CNA and Restorative Aide use mechanical lift to transfer R5 from reclining high back wheelchair to bed. Surveyor noted staff left R5's bilateral bed rails up during the mechanical lift transfer from wheelchair to bed. R5 is confused, nonverbal, and unable to carry conversation. On 4-15-22 at 11:00 AM, V3 (Director of Nursing/DON) is alert and oriented x 1. R5 has dementia and is un-directable. R5 has mood swings and be easily agitated and unpredictable. The guide for mechanical lift transfer is responsible for ensuring the resident is safe during transfer. The staff provided cues prior to mechanical lift transfer. The staff should have continued to provide verbal cues throughout the transfer and a hand to hold to assure resident is safe during transfer. R5's left side rail was up during this mechanical lift transfer which R5 hit her head. R5 siderail was up during mechanical lift transfer. The siderail should not be up during mechanical lift transfers. Due to R5's behavior, staff should be providing verbal and nonverbal cues to calm the resident and alleviate behaviors. On 4-21-22 at 10:34 AM, V32 (ADON) said during interviews with direct care staff, CNA and LPN said R5 was moving her head and hit her head on the side rail causing a laceration after being lowered into bed. V32 said, when transferring a resident using a mechanical lift, the siderails should be down to prevent bumping or resident injury. R13 was agitated, flailing her arms, and she touched the bar of the mechanical lift causing laceration and finger fracture. R13 was still agitated and moving her head side to side and hitting the side rail causing head laceration. On 4-15-22 at 10:06 AM, V5 (LPN) said R5 is alert oriented x 1. R5 had dementia, difficult to redirect, and unable to make her needs known. R5 has a history of her flailing arms and hitting staff when providing care. R5 has scratched and punched V5 when giving care. V5 and V7 (CNA) were going to transfer to the reclining high back wheelchair using mechanical lift. V5 and V7 were on left side of bed (bed was against wall). R5 suddenly hit her hand against the bar while attempting to lift up. V7 was using the controller and V5 was standing near R5 holding 1 hand near the pad. V7 and V5 saw R5 hit her hand on the bar. R5 made loud noise. R5 was cooperative during the transfer until she hit her hand. R5 is supposed to have her hands across her chest during the transfer. Hands are placed across the chest for safety and to prevent injury. R5 can act out suddenly. R5 can be aggressive and unpredictable. The staff are responsible for keeping residents safe during transfers. On 4-15-22 at 10:39 AM, V6 (LPN) said R5 is alert, oriented x 1. R5 is not conversational and nonsensical due to her dementia. R5 can get agitated and change instantly. R5 would flail her arms and could possibly hit staff. V6 has seen R5 change instantly and have behaviors. V5 would assist with mechanical lift transfers using 2-person assist. One staff uses the controller after placing resident in the sling. The other person is there to guide and protect the resident's head and arms. Arms are to be crossed against the chest or belly. The crossed arms are for safety and to prevent injury. The guide must keep eyes on the whole time. If V6 saw the R5's arms go up, V6 would immediately redirect R5 to keep arms crossed. R5 requires close supervision during transfers. On 4-19-22 at 2:10 PM, V6 said the side rails should be down when transferring a resident from chair to be with the use of a mechanical lift. After the transfer, the staff should raise the side rails. On 4-15-22 at 10:22 AM, V7 (CNA) said R5 is demented and not alert. R5 is not directable. R5 can be agitated and irritated. R5 will flail her flail her arms when refusing care. R5 can be unpredictable. V7 has to be extra cautious and alert when providing R5 care. The facility uses 2 persons for mechanical lift (1 to control to machine. the other is to guide the resident) to ensures sure R5 is always safe. R5's arms should be on the chest for safety. The guide is responsible for making sure the arms are on the chest. On 4-19-22 at 2:12 PM, V19 (restorative nurse) said siderails should be down when transferring a resident using the mechanical lift. The rails should be down to ensure a smooth transition or pathway from one surface to another surface. Progress Note dated 2-16-22 documents Incident Note Late Entry: Incident Summary: At approximately 5:30 am, this writer and another staff was using the mechanical lift with resident for transfer from bed to her wheelchair. During that process, resident became agitated and grabbed the mechanical lift bar and accidentally bumped her right hand on Hoyer lift bar sustaining a laceration to her right middle finger. Staff redirected resident, attempted to calm her down, and immediately lowered resident back in bed. Resident continued to be restless and moving around once in bed and accidentally bumped her left side of forehead against the side rail sustaining a laceration on her left forehead above the left eyebrow. Resident continued to be restless and pressure dressing applied to Left forehead laceration and Right middle finger to control bleeding. Paramedics called and transported resident to local hospital ER for evaluation and treatment. Nursing Supervisor notified. MD (Medical Doctor) on call for primary MD. POA(Power of Attorney/Daughter notified. Progress Note dated 2-16-22 documents Health Status Note Text: Resident transported to facility via stretcher from ER visit R/T to facial laceration and middle finger laceration. Arrived on the unit alert and awake, no change in LOC noted. Resident assessed noted with 4 sutures to left of forehead and swollen discolored right middle finger. Per discharge instruction sutures will dissolve over time. No facial grimacing or body guarding. NP (Nurse Practitioner) of primary MD assessed resident and order STAT X-Ray of right middle finger due x-ray was not done in ER (emergency room ). Order noted and carried out. POA notified of resident's return to facility and x-ray order. Progress Note dated 2-16-22 documents Health Status Note: X-Ray result of Right Middle finger concluded Comminuted fracture in the distal phalanx of the 3rd digit. Result review by NP of primary Dr. MD. NP (Nurse Practitioner) placed splint to resident's finger. Resident stated, 'I have pain there, there, PRN acetaminophen 650 mg PO (by mouth) offered, resident spitted medication from mouth. Initial State Reportable dated 2-16-22 documents R5 was transferred from her bed to her wheelchair by the nurse on duty and another staff using a mechanical lift. During transfer, R5 became agitated and grabbed the mechanical lift bar and accidentally bumped her right hand sustaining a laceration to her right middle finger. Staff immediately lowered R5 back to bed using mechanical lift. Staff redirected R5 and attempted multiple times to calm her down, but resident remained uncooperative and talking nonsensical. After R5 was transferred back to bed, R5 continued to move around and accidentally bumped her left side of forehead against the siderail sustaining a laceration on her left forehead. R5 had head to toe assessment and staff treated wounds. R5 was sent to local hospital for evaluation and returned with sutures to her left forehead and right middle finger covered with bandage. Final State Reportable dated 2-21-22 documents Conclusion: R5 grabbed the mechanical lift bar during transfer from bed to wheelchair and accidentally bumped her right hand sustaining a laceration to her right middle finger. R5 continued to move her head and accidentally bumped the left side of her forehead against the right siderail of the bed sustaining a laceration on her left forehead with minimal bleeding. Hospital Record dated 2-16-22 documents History: R5 presents with laceration to right middle finger and left eyebrow from nursing home, occurred on mechanical lift at the home. R5 is demented and unreliable historian. Triage: R5 presents with 2 CM laceration on the finger and 4 CM (centimeter) laceration on the left eyebrow. Number of sutures: 4 in face, 3 in finger. There is no documentation of x-rays taken or concerns of fracture in hospital record. Mechanical Lift Transfers Policy dated 7-28-21 documents prompt resident to fold arms on chest. Portable Patient Lift Owner's Guide documents keep all extremities (such as fingers and arms) clear of left mechanism while it is in operation. Care must be taken to avoid pinch points when the lift is being operated. Side Rail Care Plan (revised 2-16-22) documents Please lower my siderail before transfers. Side Rail Policy reviewed on 7-28-21 was reviewed. R5's MDS (ARD ((Assessment Reference Date) 2-4-22) documents BIMS ( Brief Interview for Mental Status)score: 3:15, Transfer: Self: total dependence, Support: 2+ person physical assistance, Diagnoses (not limited to): Alzheimer's Disease, Non-Alzheimer's Dementia, Depression, [CONDITION(S)]. R8 On 4-14-22 at 12:45 PM, R8 was up to her reclining high back wheelchair in the dining room. R8 is confused and unable to carry a meaningful conversation with surveyor. Surveyor noted scab to R8's forehead. On 4-19-22 at 11:45 AM, V3 (Director of Nursing/DON) said R8's nurse notified V3 of fall incident. V3 instructed to give 1st aid, immediate interventions, and call 911 due to head injury (noted bleed). R8 returned around 4:50 PM with stitches on forehead. Investigation findings document R8 is impulsive and suddenly stood up and resulted in a fall with head injury. CNA was present and unable to prevent fall. R8 is oriented x 1 with dementia. R8 has impulsive behavior and poor safety awareness. R8 requires 1-person direct supervision in shower. Prior to incident (1-28-22) and after incident (3-26-22) R8 is coded as high fall risk. On 4-19-22 at 10:52 AM, V6 (LPN) said is alert and oriented x 1. R8 is not able to make her needs known due to dementia. R8 requires supervision due to poor safety awareness. R8 is impulsive and would try to do things by herself. R8 will attempt to get up from wheelchair by herself and without asking. R8 requires 1 person assist for showers. Staff must guide and direct R8 during showers. CNA reported fall to V6. V6 went to assess R8 and R8 was up to the wheelchair with head bandaged and bleeding controlled. R8 complained of pain to her head. R8 grimaced and flinched when V6 was assessing her head. R8 was unable to say what happened. CNA said R8 was in shower chair and had an immediate bowel movement, CNA pivoted to get disposable brief, and observed R8 on the floor with immediate head injury. R8 requires 1:1 supervision and needs direct attention. On 4-19-22 at 11:09 AM, V24 (CNA) said R8 is verbal, nonsensical, and unable to make her needs known. R8 is a fall risk. R8 has dementia. R8 is impulsive and will try to get up. V24 took R8 to resident to shower. R8 had a bowel movement during the shower. V24 said he turned to his side to pick up a brief and R8 suddenly fell . R8 was facing down on the ground and V24 saw blood on R8's forehead. R8 requires 1:1 attention during showers. Initial Incident Report dated 3-26-22 documents CNA was giving R8 a shower. CNA turned to get R8's disposable brief, R8 suddenly got up and observed on the floor in the prone position. Nurse immediately responded and observed R8 with laceration on her forehead with minimal bleeding on forehead. MD updated and ordered to send to hospital via 911. Later that day, R8 arrived back at facility with stitches on forehead. Final Reportable dated 3-31-22 documents R8 has poor safety awareness related to vascular dementia with behavior disturbance, she suddenly stood up which resulted into fall. CNA was unable to stop the fall. Final Reportable dated 3-31-22 documents R8 has poor safety awareness related to vascular dementia with behavior disturbance, she suddenly stood up which resulted into fall. CNA was unable to stop the fall. Fall Risk Evaluation dated 1-28-22 documents score: 12 and Fall Risk Evaluation dated 3-26-22 documents score: 12 (8 and above = high risk), Fall Prevention Program Guidelines reviewed 8-5-21 documents residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. R8's MDS (ARD 4-4-22) documents BIMS Score 3, Diagnoses: Non-Alzheimer's dementia, [CONDITION(S)], Other Fracture, Need for assist with personal care. Fall Risk Evaluation dated 1-28-22 documents score: 12 and Fall Risk Evaluation dated 3-26-22 documents score: 12 (8 and above = high risk), R8's Fall Care Plan documents Fall Prevention Program Guidelines reviewed 8-5-21 documents residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. Hospital Record dated 3-26-22 documents History: Patient presents with FALL. History of Present Illness: Per report, patient with witnessed fall out of wheelchair this morning. Struck front of face. Procedure: Laceration Repair. Number of sutures: 6.

Based on interview and record review the facility failed to identify or have a treatment plan in place for a facility acquired venous stasis wound to right heel for 1 of 3 residents (R2) reviewed for skin assessments. This failure resulted in R2 being at the local hospital for a chronic treatment where the right heel ulcer was noted to be foul smelling with purulent drainage, and a black [CONDITION(S)] around it, R2 was diagnosed and treated with intravenous antibiotic for [CONDITION(S)] of the right heel at the local hospital. Based on interview and record review the facility failed to inform attending physician of resident's change in condition and failed to provide radiology services in a timely manner. This affected 1 resident (R13) of 3 residents reviewed for professional standards. Findings Include: R2 was sent out to hospital on 2/12/22 and returned to facility on 2/28/22. Documented in nurse's note that R2 was transported to local hospital at 4:20pm on 2/12/22. Emergency department documentation on 2/12/22 at 1800, reads in part: patient has bilateral lower leg [CONDITION(S)], with excoriation to bilateral shins, and several ulcers to right heel and left heel and ankle. Ulcer on right heel is black with [CONDITION(S)] around it and foul smelling. History and Physical documentation on 2/13/22 at 1039, reads in part: Right heel wound with foul smell and some purulence. May have infection on her chronic wounds, noted that some of them appear foul smelling in the ER. R2 admitted in ICU with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's hospital record dated 2/25/22 at 10:29am, reads in part: Vascular surgery consulted for perfusion to assist for wound healing. Podiatrist is seeing patient for her heel wound and recommended amputation. However family is not agreeable to amputation and would like antibiotics. R2 found to have [CONDITION(S)] in right heel wound. R2's Facility Treatment Administration Record (TAR) from January 2022 to February 2022 reviewed. Noted to have treatments for right first great toe, left leg and right leg. Treatment rendered for all three sites. There is no noted treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Facility wound doctors notes (with date of service on 1/20/22) addressed and documented right great toe, left leg, and right leg, all sites with etiology of venous. There is no noted documentation for Right heel wound. On 4/19/22 at 11am, V4 (Wound Nurse) stated that currently R2 has 2 wound sites. R2 is with left lower leg and right planter heel. Right plantar heel identified on 3/1/22 upon readmission to the facility from hospitalization . Prior to hospitalization of 2/12/22. Wounds were All Venous Stasis. Vascular. Left leg identified 11/3/21. Right first great toe identified 1/20/22 and the right leg shin identified 11/3/21. On 4/19/22 at 2:40pm, V3 (DON) stated that R2's right heel wound happened in the hospital and not in the facility because there is no documentation that R2 has right heel wound when R2 was in the facility. V3 reported to reviewed hospital record of R2 upon return to the facility and read that R2 has right heel wound, but V31 also reported that the nurse on duty (V31) at the time R2 was sent out on 2/12/22, documented no new skin issue on 2/12/22. On 4/20/22 at 12:40pm, V31 (Nurse) stated that R2's wound treatment are ordered daily dressing change and done during morning shift nurses or wound nurse. The only time I (V31) provided care on R2's wound was when the wound wrap was loose. I (V31) have not seen the wounds, I just have to rewrap the leg with gauze wrap. I (V31)was able to do body assessment for R2 prior to 911 transported R2 to local hospital. Before the family called 911, I already conducted the body assessment. I (V31) do not remember how many wounds R2 has, but I know I did skin assessment. I do not know the wound sites location. On 4/20/22 at 2:00pm, V30 (Wound Doctor) stated I am aware now of the right heel wound upon readmission of R2. It is unlikely for the wound of R2's to have signs of infection if the wound is newly acquired, but I am not really sure what was going on with R2 medically. What I know is that R2 has chronic disease with vascular compromise. I have never seen the wound develop in minutes or hours and be diagnosed with [CONDITION(S)] immediately. Wound could develop pretty quickly, my speculation with R2's right heel wound is that it would take hours and even days for R2's wound to show signs of infections. V30 also stated that V30 stopped seeing R2's wound January 2022 because it was improving and the sites that V30 was treating were right leg, left leg and right great toe. Denied treating any right heel wound for R2 before the hospitalization on [DATE], V30 stated since the returned of R2, right heel wound is now identified and classified as venous stasis. Facility R2's shower sheet reviewed from January to February 2022. R2 received showers on scheduled shower days. Shower sheets dated 1/3/22, 1/6/22, 1/10/22, 1/17/22, 1/20/22, 1/24/22, 1/27/22, 1/31/22, 2/3/22, 2/7/22 and 2/10/22 shows (x) mark on right leg and right great toe skin alteration. There is no documented right heel skin alteration on shower sheets on dates mentioned. Facility unable to provide of any documentation of right heel wound prior to R2's hospitalization on [DATE]. Hospital record 2/12/22 at 1702, White blood cell count (WBC) of 30K. Hospital record dated 2/13/22 reads in part: to continue with broad spectrum antibiotic for now, follow up blood culture and wound culture. Facility's Wound Care Program Care Guidelines with a revised date of July 3, 2019, reads in part: this facility adheres to the Federal and State Regulatory requirements for wound care management and the care guidelines for wound care established by the National Pressure Ulcer Advisory Panel. Timely identification of residents assessed to be at risk for skin breakdown. Wound assessments for pressur3e, diabetic, venous and arterial wounds: Wound assessment documentation shall include but are not limited to: type of wound and/or ulcer, location, date, stage (if applicable), length, width and depth; wound bed description, wound edge description and if present, exudates, undermining, tunneling and wound related pain. On 4-28-22 at 11:28 AM V2(Executive Director) said staff should immediately report new changes in condition to attending physician. The stat x-ray window should be within 4 hours. Routine x-ray should be within 24 hours or at scheduled time. X-ray was ordered on 4-7-22, the schedule date was 4-8-22, and service date fell on [DATE]. Staff is responsible for calling radiology if the scheduled date was not met. On 4-27-22 at 12:14 PM, V3 (DON) said R13 was seen by attending physician on 4-6-22. Attending physician noted 4-6-22 documents knee pain and not knee swelling. R13's medical records dated 4-5-22 documents onset of right knee swelling. A stat x-ray is with 4 hours and routine X-ray is done within 24 hours or schedule a time. The business is open 24 hours. The facility ordered x-ray on 4-7-22 and the radiology did x-ray on 4-9-22. This exceeds the window of 24-hour expectation. The nurse could have made a follow up call for status of radiology. On 4-27-22 at 12:35 PM, V43 ( Attending Physician) said he saw R13 on 4-6-22 for routine follow up visit. V43 does not recall being aware of new concerns of right knee swelling. V43 may not have seen right knee swelling because R13 is in bed and unable to talk. attending physiciandoes not recall being told of new right swelling and this is not documented in his progress note. On 4-29-22, V35 (RN) said she worked on 4-6-22 from 7:00 AM to 3:00 PM. RN noted swelling to right knee. RN may not have reported new right knee swelling to attending physician. On 4-22-22 at 10:08 AM, V36 (Nurse Practitioner) said on she does not remember facility calling on 4-5-22, to notify about onset of new right knee swelling. V36 said she would usually order x-ray for a new onset of swelling and new pain. V36 saw R13 on 4-7-22 and ordered right knee x-ray. V36 doesn't recall receiving page. In normal cases, V36 would have ordered x-ray. On 4-22-22 at 10:39 AM, V35 (RN) said she assessed swelling on R13's right knee (verified with cna) and worsened pain. R13 was taking scheduled pain medication and no further issues. Staff was monitoring R13. V35 paged NP, NP ordered X-ray for knee. V35 spoke to x-ray company because she had 2 x-rays to order (4-7-22). On 4-22-22 at 11:10 AM, V37 (Radiology VP of Operations) said staff called on 4-7-22 at 11:15 AM to order X-ray. X-ray done on 4-9-22 at 1:36 AM. Progress Note dated 4-5-22 documents while obtaining R13's urine specimen for UA/CS (Urinalysis/Culture and Sensitivity) via straight catheterization (nurse) noted some swelling of Right knee. Resident was only able to verbalize that she has generalized pain, displayed baseline limited ROM in all extremities, refused any offered pain medication. R13 has multiple PMH (Past Medical History) including unspecified dementia, pain unspecified knee, primary [CONDITION(S)]. left message for NP, coming shift nurse endorsed. Attending physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She is without new complaints at the time of visit, per nursing, she had urinary tract infection. On vitals, her blood pressure is 133/64, temperature 97, pulse 73, weight 123.8. Musculoskeletal: up with assist. Plan: 20. Knee pain, Continue as needed pain medicine. No documentation of onset of right knee swelling noted. NP Progress Note dated 4-7-22 documents Late Entry: Note Text: Subjective: Chief Complaints: Right knee pain HPI (History of Present Illness): An Interim history: Resident seen and examined, per request of daughter, for increased right knee pain; resident with known history of severe OA ([CONDITION(S)])to knees. Progress Note dated 4-9-22 documents: Chief Complaints: Right knee pain HPI: Resident seen and examined for a follow up visit and assessment of recent complaints of increased right knee pain; resident with history of significant OA of bilateral knees; on scheduled Tylenol; noted with increased pain to right knee with palpatation and movement; uric acid level wnl; recent x-ray shows right acute mildly displaced distal femoral diametaphyseal fracture and joint effusion. Radiology Report dated 4-9-22 documents acute mildly displaced distal femoral diametaphyseal fracture. Radiology Investigation Report dated 4-18-22 documents on 4-7-22 at 11:14 AM, staff nurse ordered routine x-ray exam. Routine service date of exam was scheduled for 4-8-22. On 4-9-22 at 1:26 AM, x-ray technologist completed the exam. Facility Agreement (Radiology) dated 8-1-21 documents provider shall provide services within 24 business hours or schedule a time for the service. The povider will promptly notify the facility if services time is unable to be met. Notification for Change in Condition Policy (reviewed 7-28-21) documents the facility must inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications).

Based on interview and record review the facility failed to monitor and provide supervision for a resident known to be at risk for falls. This affected 1 of 4 (R5) residents reviewed for fall. This failure resulted in R5 falling and hitting his head requiring treatment at the local hospital for forehead laceration and a subdural hematoma. Findings include: On 2-18-22 at 9:37 AM, V2 (DON) said R5 is alert and oriented x 1. Unable to make needs known due to advanced dementia and Alzheimer's. R5 has poor safety awareness. R5 is a high fall risk due to unsteady gait, history of fall at facility, and history of dementia without behaviors. R5 requires close supervision due to history of falls, unsteady on feet, and requires redirection. R5 had an observed fall by CNA. CNA was in 20 feet when R5 fell and CNA was unable to prevent the fall due to being 20 feet away. R5 fell and was noted with laceration to right forehead. R5 was sent 911 to local hospital and received diagnosis of subdural hematoma. On 2-18-22 at 11:01 AM, V9 (CNA) said R5 is not very alert. R5 is confused. R5 is unable to make his needs known. R5 is impulsive. R5 is a fall risk. V9 was not aware of previous falls at the facility. R5 does not requires assistance getting up. R5 does not require assistance with walking. V9 was assigned to observe R5 in common area when another resident called for help. V9 went to assist another resident when R5 got up by himself and fell . V9 could not prevent R5's fall. On 2-18-22 at 10:42 AM, V4 (RN) said R5 ambulates but need to be assisted due to unsteady gait. He wanders and needs to be supervised. R5 has poor safety awareness and is impulsive. R5 is a fall risk because of unsteady gait and bumps into things and needs redirection. R5's fall occurred in common area of D wing. R5 was supervised by CNA. CNA is responsible for watching and monitoring residents especially residents who are risk for falls. The CNA should be close to the resident to monitor and prevent falls. The CNA was unable to prevent R5's fall. When a CNA is assigned to a resident for monitoring the CNA should provide close supervision to prevent accident. If another resident needs assistance, CNA can call another staff member to watch specified resident or tend to other resident who needs assistance. On 2-18-22 at 9:16 AM, V8 (Restorative Nurse) said R5 has poor safety awareness, unable to make needs known, and requires redirection. R5 is high fall risk because of history of falls, advanced Alzheimer's, and [CONDITION(S)] medications. R5 is placed in common area for supervision due to high fall risk. R5 was walking in the common area and the CNA was approximately 20 ft away. R5 lost his balance and CNA was unable to prevent the fall. Shuffling gait would make him unsteady on his feet and would make his risk for falls. CNA was assigned to watch R5. The CNA was unable to prevent the fall due to not being close enough to R5. Restorative would actively engage resident this would be more of a safety measure. R5's MDS (ARD 1-14-22) documents BIMS Score: 00, Wandering behavior occurred 4-6 days, Self transfers require extensive assistance, Support transfers require 1 person, Self walking requires extensive assistance, Support walking requires 1 person, Surface to surface transfers require staff assistance, Diagnoses (not limited to): Alzheimer's Disease, Non-Alzheimer's Dementia, [CONDITION(S)], History of Falling, R5 had 1 fall since admission to facility. R5's Hospital Record (dated 2-9-22) documents reason for admission: subdural hematoma and Subarachnoid hematoma, without loss of consciousness.

Based on observation, interview and record review, the facility failed to prevent potential infection and transmission of COVID-19 by failing to ensure staff followed appropriate standard and transmission based infection control practices in the rooms for Persons Under Investigation (PUI) who were currently on contact and droplet precaution. This failure had a high likelihood of causing serious harm or death to the residents residing on the third and seventh floor units given their congregate nature, age, and underlying medical conditions. At the time of the survey, the facility had six residents who were positive for COVID19 and 11 residents who were classified as PUI. The facility was in a county that had sustained community transmission, especially in the nursing home setting. The Immediate Jeopardy began on 6/25/20 at approximately 3:15pm when NA1 entered R1's (a PUI) room without donning an isolation gown and face shield. NA1 took R1's vital signs while inside the room and exited the room without removing her used gloves. Furthermore, NA1 used the mobile vital signs machine (MVSM) when she took R1's vital signs instead of the dedicated medical monitoring equipment (BP machine, thermometer etc.) located inside R1's room. The MVSM was intended for the use of non- PUI residents only. NA1 was about to use the same MVSM to a non-PUI resident without first disinfecting the machine when she was stopped. The Administrator and the Director of Nursing (DON) were notified of the immediate jeopardy on 6/26/20 at approximately 12:35pm. The immediacy was removed on 7/1/20 at 3pm when the removal plan was verified as implemented. Findings include: Review of the CDC's Responding to Coronavirus (COVID-19) in Nursing Homes revised on 4/30/20 under Considerations for the Public Health Response to COVID-19 in Nursing Homes revealed, .Resident Cohorting .Assign dedicated resident care equipment (e.g. vitals machine) to the cohort unit. Cleaning and disinfection of shared equipment should be performed between residents and the equipment should not leave the cohort unit. Further review of the same document under Considerations for new admissions and readmissions revealed, .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of a N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown . 1. On 6/25/20 at approximately 12:15pm, during the 3rd floor unit tour with the Director of Nursing, E1 was observed cleaning inside R2's room. R2 was on his bed resting. E1 did not have an isolation gown on. When asked about the observation, E1 responded. I'm sorry; I forgot to put one on. The DON was also asked about the observation. The DON confirmed staff should use complete PPE when entering a PUI's room. The DON verbalized that all the housekeepers were trained on proper donning and doffing of PPE just like the nursing staff. Review of R2's clinical notes under Nurses' notes dated 6/21/20 at 07:07am revealed, Resident (R2 [AGE] years old) is on 14 days (sic) droplet and contact isolation until 7/3 per facility's protocol post hospital visit . Review of the third floor unit's daily census for 6/25/20 revealed there were 45 residents residing on the unit during the survey. Review of the 45 residents' demographics revealed their age ranged from 62 to [AGE] years old. Further review of the residents' face sheets indicated presence of various underlying chronic medical conditions such as diabetes mellitus, [MEDICAL CONDITION], asthma, different type [MEDICAL CONDITION] and [MEDICAL CONDITION] to name a few. 2. On 6/25/20 at approximately 3:15pm, NA1 entered R1's room without an isolation gown and an eye shield. NA1 brought a MVSM inside R1's room and closed the door. The unit's Social Service Director who was nearby was asked to confirm the observation. The SSD knocked on R1's door that was opened by NA1. NA1 was observed in the middle of taking R1's blood pressure using the MVSM. The SSD confirmed the observation and stated, You are right she's not wearing a gown. When asked about the observation, the SSD stated that as far as she knew all staff members were expected to wear all PPE as shown on the visual sign posted outside a PUI resident's room. A few minutes later NA1 emerged from R1's room with the MVSM in tow. NA1 was observed with gloves on. NA1 left the MVSM outside R3's room, proceeded to remove her gloves, and discarded the used gloves in the hallway's trash bin. NA1 proceeded to go to where R3 was and was about to take R3's vital signs when she was stopped by the UM. The UM was notified by the surveyor of the observations prior. In a concurrent interview with the seventh floor unit manager (UM) and NA1 on 6/25/20 at approximately 3:30pm, NA1 was asked about the observation. NA1 responded, I did not know that she's on isolation. The UM added, Look at the signs (pointing to the isolation precaution signs and visual signs on how to don and doff PPE posted on the door). The UM proceeded, Did you not see those, how about this one (pointing to the isolation cart set-up located outside the door)? NA1 did not provide an answer. The UM instructed NA1 to clean and disinfect the MVSM. The UM explained that NA1 should not have used the MVSM since each PUI resident had his or her own dedicated vital signs equipment. The UM was also asked about NA1's lack of hand hygiene. The UM explained that NA1 should have removed her gloves and performed hand hygiene before she exited R1's room. During an interview with the Director of Nursing (DON) on 6/25/20 at approximately 3:45pm, the DON was asked about the observations. The DON stated, I am disappointed with (name of NA1). She had training a couple of days ago. The DON further stated, I understand the gravity of this concern, I really do. The DON confirmed that staff should wear all PPE when inside a PUI room and that there was no excuse not to follow because the isolation cart set up outside the room was full of PPE. Review of R1's clinical notes under Face Sheet revealed R1 ([AGE] years old) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical notes under Nurses' notes dated 6/23/20 at 11:00AM (CDT) revealed, Placed on droplet contact isolation due to persistent coughing, resident/family aware . Review of R1's MD/NP progress notes signed by the Advance Practice Registered Nurse (APRN) dated 6/24/20 revealed, Reason for appointment: 1. Cough History of Present Illness: Isolation Precautions .further review of the same document under Assessment indicated, 1. Infiltrate of lung present on imaging of chest - R91.8 (Primary) 2. [MEDICAL CONDITIONS]-I50.9 3.Cough -ROS . Record review of R1's care plan dated 6/23/20 under Problems revealed .Infection: 06/23/20- STRICT DROPLET/CONTACT ISOLATION FOR SUSPECTED COVID-19. 06/23/20-PNEUMONIA . under Interventions indicated, 06/23/20-STRICT DROPLET/CONTACT ISOLATION PRECAUTIONS, 06/23/20- CHEST X-RAY TO REVIEW, 06/23/20-LABS TO REVIEW, 06/23/20-MONITOR COUGH.LUNG SOUNDS, SOB , 06/23/20-MONITOR VITAL SIGNS, TEMPERATURE EVERY 4HRS ,06/23/20-RESIEDNT /FAMILY EDUCATE REGARDING ISOLATION PRECAUTIONS STATUS: Active (Current) . Review of R3's Face Sheet revealed R3 ([AGE] years old) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the seventh floor unit daily census for 6/25/20 revealed there were 42 residents residing in the unit during the survey. Review of the 42 residents' demographics revealed their age ranged from 62 to [AGE] years old. Further review of the residents' face sheets indicated presence of various underlying chronic medical conditions such as hypertension, [MEDICAL CONDITION], asthma, different type [MEDICAL CONDITION] and heart failure to name a few. During a follow up interview with the seventh floor UM on 7/1/20 at approximately 12:30pm, the UM was asked about NA1's primary resident assignment on 6/25/20. The UM confirmed that NA1 was assigned in the D wing and had eight other residents in addition to R1 and R3. The UM further explained that although each NA had primary assignments they were expected to care for other residents as needed and cover other NA's during break time. Review of the facility's COVID19 Guidelines and Emergency Preparedness Plan revised on 5/28/20 under Clinical Guidance indicated .C. Isolation. Suspect PUIs: Patients should be asked to wear a surgical mask as soon as they are identified .Healthcare personnel entering the room should use standard precautions, contact precautions, droplet precautions, and use of eye protection (e.g. googles or a face shield) . Review of the CDC's Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings revised on 4/13/20 under 2. Adhere to Standard and Transmission-Based Precautions revealed, .HCP (see Section 5 for measures for non-HCP visitors) who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Review of the facility's Hand Hygiene policy revised on August 2015 under Policy Interpretation and Implementation indicated, 1. All personnel shall be trained and regularly in serviced on the importance of hand hygiene .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .8. Hand hygiene is the final step after removing and disposing of personal protective equipment . The Administrator and the DON were notified that the immediacy was removed on 7/1/20 at 3pm after the surveyor verified (through observation and interview) implementation of an acceptable removal plan that included the following: 1. Formally in-serviced NA1 and E1 on proper donning and doffing of PPE when entering the rooms of PUI residents who were on contact and droplet precautions. 2. In-serviced all staff on the importance of removing gloves and good hand hygiene prior to leaving the room of a PUI resident. 3. In serviced all staff on all shifts regarding strict infection control protocol when entering a PUI room including donning and doffing of PPE. 4. Educated nursing staff on how to properly clean and disinfect shared medical equipment using an approved EPA disinfectant after each resident use. 5. Trained nursing staff to use the dedicated vital signs monitoring equipment for residents on contact and droplet precautions (PUIs).

Based on observation, interview and record review, the facility failed to follow their fall care plan interventions of bed in low position, floor mats and adequate supervision to avoid falls; failed to address root cause of injury to prevent further falls; and failed to follow facility policy and procedures to manage high risk frequent fallers. These failures affected 2 of 3 residents (R1, R2) reviewed for falls. These failures resulted in R1 sustaining a subdural hematoma, brain hemorrhage, and left wrist fracture and subsequently sustained a right [MEDICAL CONDITION] requiring surgical intervention. R2 sustained a right [MEDICAL CONDITION] requiring surgical intervention. Findings include: R1 is an [AGE] year-old with [DIAGNOSES REDACTED]. On [DATE]20 at 11:03 AM R1 was observed sitting in her wheelchair in the hallway in front of two elevator doors. 3 other residents where congregated along with R1 with no staff present. Surveyor walked down a hall and went to the nursing office where R13 (RN and R14 (LPN) were both sitting. Surveyor asked R13 if anyone was in the hallway supervising the 4 residents sitting in front of the elevators, R13 stated, I don't know, I'm only registry here. Asked who was in charge, R13 pointed to R14 who stated, I am the regular nurse here. We have 4 CNA's (certified nurse's aides) but one called in sick, so we have only 3 so they are splitting the floors. Asked which CNA's were splitting the floors, R14 stated, I don't know. Asked who creates the CNA's schedules, R14 stated, they have their own assignments made. On [DATE]20 at 1:20 PM R1 was observed lying in her bed with her bed raised up to waist level. A blue-colored vinyl cushion was folded up and standing in the corner against the window. Surveyor asked V4 (sitter) how R1 was doing, V4 stated, She's resting and had her lunch, but she likes to stay in bed because she fell several weeks ago and likes to stay in bed now. Surveyor asked about the blue vinyl cushions that were folded up against the window, V4 stated, the CNA's are supposed to put that down on the floor when they put her back to bed so she don't fall. I cannot do anything for her because I'm not supposed to touch her or anything but I'm here, so I guess it's fine. Surveyor asked how often the staff was supposed to check on R1, V4 stated, I don't know. When I'm here they don't come in at all because I guess they depend on me to watch her. Facility fall risk assessments dated 11/9/2019, R1 scored a 13 meaning a moderate risk for falls (score of 16 and above is considered high risk for falls). R1's Care plans dated 11/9/2019 states in part but not limited to, (R1) is at risk for falls related to impaired balance, impaired judgement, behavior of swinging legs over her bed, attempt to transfer/mobilize without staff assistance. Interventions: re-educate resident on calling for assistance, keep bed at lowest position with wheels locked, floor mattress, keep personal items within reach, keep nurse call light within easy reach and instruct (R1) to use call bell or call out for assistance. R1's MDS (Minimum Data Set) dated 11/9/2019 however shows R1 with no behavioral problems that impacted her care; R1 requires extensive assistance from staff for bed mobility and locomotion and is totally dependent on staff to transfer from bed to chair. On 11/9/2019 at 4:25 AM, R1 was found flat on her back on the floor at the foot of her bed with her feet extended towards the door. R1 was sent via 911 ambulance to the hospital emergency room , diagnosed and treated for [REDACTED]. A consecutive facility falls risk assessment dated [DATE] score R1 as a 22 for very high risk for falls with a score of 16 and above considered high risk for falls. On 1/7/2020 at 10:00 PM R1 was sent out 911 to the hospital emergency room as she was complaining of right hip pain earlier in the day during lunchtime. Hospital records dated 1/7/2020 show there is a comminuted (broken into pieces) intertrochanteric right [MEDICAL CONDITION] with fragmentation of the lesser trochanter. Hospital physician on 1/12/2020 wrote, (R1) is an [AGE] year-old female with primary medical history of [REDACTED]. On presentation to the emergency department, patient was found to have comminuted intertrochanteric right [MEDICAL CONDITION]. Of note patient was recently hospitalized after a fall sustaining a left wrist fracture which was managed non operatively. That hospital course was complicated by [MEDICAL CONDITION] (brain bleed), after which time her Eliquis (blood thinner) was stopped. status [REDACTED]. Post-operative course complicated by hypoxemia and [MEDICAL CONDITION] requiring ICU (Intensive Care Unit) admission. Interviews with V2 (Director of nursing) and V3 (Assistant Director of Nursing) on [DATE]20 at 1:00 PM V2 stated, We did a root cause investigation and determined (R1) had injury of unknown origin but didn't fall and that she could have bumped her hip based from our interview with her. Surveyor asked V2 if R1 was interviewable, V2 stated, She speaks only [REDACTED] but we had an interpreter ask her what happened but she could not tell us whether she fell or not, but she mentioned that she may have bumped her leg and she also has behavior of dangling her legs. Surveyor asked whether it was a possibility R1 fell again, V2 stated, Well, yes it's possible but she can't get up by herself. V2 and V3 both stated, R1 has [MEDICAL CONDITION] she is prone to fractures. Surveyor asked what would determine [MEDICAL CONDITION] in residents, V2 stated, Bone density scans would determine this. Bone density results obtained from R1's radiological report dated 1/7/2020 states: Normal bone mineral density for the patient's age. A second radiological report dated 1/7/2020 states, Normal bone density seen. On [DATE]20 at 2:00 PM interview with V10 (Certified Nurses Aide) stated, I generally work with (R1) and I went in 8:30 AM Tuesday (1/7/2020) to get her ready while in bed because she has a broken arm and placed her in the wheelchair and pushed her into the dining room for breakfast. After breakfast, I pushed her to common area, but she didn't want to stay there so I put her back to bed. She doesn't like to stay in the common area, so we always put her back in bed. When I went for lunchtime to get her up, she didn't want to get up and so I let the nurse know she didn't want to get up. The nurse came in and talked to her. I found out later she must have fallen so they sent her out and I found out she had a fracture. Surveyor asked V10 what care plan interventions there were to prevent R1 from falling a third time, V10 stated, We just check on her a lot I don't know about care plans I don't do those. Asked if she has access to R1's care plans, V10 stated, No, they don't show that to the CNA's (certified nurses aides). On [DATE]20 at 2:30 PM interview with V4 (Sitter) stated, I'm here six days week, every day except Tuesday. She (R1) was not complaining of pain on the day I was taking care of her. Her daughter called me on Wednesday that she was in the hospital. R1 likes to stay in bed but before she fell the first time, if she wants to she will just get up and go. She used to be independent. They hired me to watch her. I will call somebody and two people come (CNA's) and change her. She needs two people to transfer her and the facility told me they cannot allow me to transfer her so maybe she fell when that happened when I was off. I am here except Tuesdays and that's when she was sent to hospital. Most of the time when I'm here I just sit with her when she's in bed. Surveyor asked V4 how often staff come in to check on R1, V4 stated, I don't see them come in when I am here, they just come when she gets up for lunch and they put her back to bed. They expect me to watch her all the time, so I guess when they see me, they don't think they have to watch her anymore. Maybe that's why on the day I'm not here she goes to hospital. They are supposed to watch her too. On [DATE]20 at 2:45 PM interview with V5 (Nurse Manager) states, (R1) was complaining of pain after lunchtime and I found out she had a fracture. I'm the manager for the 6th floor and I educate the staff to check (R1) frequently for fall monitoring and for fall prevention. Surveyor asked V5 to clarify what she meant by fall monitoring and fall prevention, V5 stated, Staff should frequently check on R1. Frequent meaning every hour check on her (R1). We also have her on a bowel and bladder program. I usually call the nurses and check, but I do not see this for myself. R1 is in the falling leaf program, in the room there is a sign like falling leaf to show staff she is on the program. Surveyor's observations of R1's room conducted on two consecutive days show no signs of a falling leaf anywhere in the room or outside the room designating the fall program. At 1/28/2020 at 12:16 PM interview with V9 (translator and activity coordinator) stated, I manage the 6th floor activities and I provide activities on that floor and translate for our [REDACTED] residents. I provided translation to the nurse (V6) on Tuesday (1/7/2020) around lunch time. V6 needed to find out what was wrong with her leg. He asked me for help to translate. I went with the nurse to the resident's room. R1 was in her bed and she was complaining of pain, She was gesturing towards the left leg she has pain that's hurting. Her cognition is confused, and we'd ask her several times and she wouldn't be able to tell me what was going on and we couldn't get much information. Surveyor asked V9 if R1 verbalized anything about bumping her leg, V9 stated, No she's confused, she was just pointing to her leg. Asked if R1 was one of the residents that attended activities on the floor, V9 stated, (R1) doesn't attend activities much. Very few times she's come. She likes music but mostly she's in her room. On 1/28/2020 at 1:00 PM interview with V6 (Registered Nurse) stated, On Monday (1/6/2020) I remember getting (R1) up around 7:30 for breakfast. She was in the wheelchair and she was trying to stand from the wheelchair, and she's been doing that for a couple of weeks when she came back from the hospital 2 months ago when she fell and had a left wrist fracture, was casted for it, but I don't know if (R1) had surgery. After she eats lunch, the caregiver comes around 11-11:30 am usually she will go to her room after lunch. Around 12:30-1:00 (R1) is placed in bed until around 4:30 for dinner. Surveyor asked V6 what they do to prevent R1 standing from her wheelchair, V6 stated, We supervise her more closely and put (R1) right outside the nursing office. Surveyor asked V6 what happened the day R1 was sent to the emergency room , V6 stated, On Tuesday (1/7/2020), I saw her in the wheelchair in the dining room. She ate her breakfast and I gave her morning medications. Around 9:30-9:45 the CNA (V10) said R1 wanted to go to bed so I said sure lets put her back. I asked her about pain, and she said no but I noted she wasn't her regular self, so we put her to bed. Around lunch time R1 was positioned on the bed and V10 called me and said R1didn't want to get up. She was sitting on edge of the bed and refusing to get up and she was holding her right upper thigh and rubbing it. I was asking if she was in pain and got the [REDACTED] translator (V9). According to V9, R1 kept pointing to the right thigh. We laid her back down and the translator tried to pinpoint where the pain was on her right leg. anything, but she didn't. I then called the NP (V7) and she ordered X-rays for entire leg and hip. Surveyor asked V6 how the facility planned to keep R1 from falling a third time, V6 stated, we usually put her with CNA's to watch her. She's usually in activities all the time when caregiver is not here. She cannot be unsupervised, so I keep her in my supervision. The nursing office is in the D-wing. R1's room is in the A-wing so usually from 9:30-10:30 I place her right outside of nursing office. Surveyor asked V6 whether the nursing office was in a central location, V6 stated, No, it's in an office located on the opposite side of the building but there's constant supervision and she has medication to calm her down given at 8:30-9 am. Surveyor asked V6 if putting her to sleep to calm her down was part of her plan of care, V6 stated, I don't know but it calms her down and she sleeps. When she's in bed we make sure bed is in lowest position, there's a fall mattress and her head of bed is up a little. She doesn't like to get up, but she likes to dangle her feet to face the window. Asked how she can dangle her feet if her bed is in the lowest position and there's a fall mat on the floor, V6 stated, No I misspoke, her feet will actually touch the floor then. Asked if there's a possibility she may have fallen, V6 stated, Yes she must have fallen because bumping her leg wouldn't do that. 1/28/2020 interview at 1:47 PM with V7 (Nurse Practitioner), states, The first incident I am aware of for (R1) happened over the weekend and I was notified she was sent to the hospital with a subdural hematoma and fracture. According to the hospital reports she hit her head and had a hematoma and wrist fracture. She was casted for her wrist but no surgery. She has progressive dementia and its worsening, and she doesn't call for help. Her balance isn't good either. She has chronic [MEDICAL CONDITIONS] and it is hard to manage her condition. Combination of everything she is 02 (oxygen) dependent and doing treatment management. The most recent event in the afternoon, the nurse called me V6 (RN) and said the patient is having pain and told me she was okay in the morning but in the afternoon, she was having pain while they were transferring her. I never expected a [MEDICAL CONDITION] because I was never notified of a fall. I don't know whether she fell or not. Since it was unwitnessed there is certainly a possibility that it occurred due to a fall. According to the hospital, they said it was an unwitnessed fall. Surveyor asked if R1 used to walk, V7 stated, (R1) used to walk independently with a walker but lately she doesn't walk much, and I see her in bed a lot. Asked about fall prevention measures for R1, V7 stated, She has behavioral management. Staff should be monitoring her more frequently. I don't really know the facility protocol, but someone can offer the family an overnight care giver. She's in a single room far away from nursing station. She should be in activities. Asked if a dangling feet or bump to her leg could cause this fracture, V7 stated, If the patient has [MEDICAL CONDITION] perhaps but certainly not due to dangling of legs or a mere bump. If that is what they (the facility) are saying, I don't believe so. (R1)'s not reliable and confused so I don't know how they can even interview her because she's not reliable and can't tell you whether she fell or not. 1/28/2020 at 3:19 PM with V8 (Physician) states, I was informed about both falls and the latest by my partner (Doctor). I know (R1) had a fall twice and it was unwitnessed. (R1) has some dementia but she doesn't have any behavioral problem and is a very cooperative person. If she fell , she might not even tell anybody not even tell the nurse. She's definitely high risk for falls. She needs to be observed more after her recent falls and needs to be by the nursing station. At night she's more difficult because she should be checked more often. She should have a bed alarm. If you know the floors there, it is 4 wings, it's impossible to be stationed in a wing and monitor the patients so they know somebody is moving, that is why they need bed alarms, so they know when she moves from her bed. Sometimes they have floor mats but if she moves around in the room she can fall still so I don't know how helpful that is after all she was found beside her bed last time and I don't think there was a fall mat because she still got a fracture. Asked about dangling feet behavior or whether a bump could cause this fracture, V8 stated, I do not think that can cause fracture not unless she was hanging from the bed from her leg. It should be a forceful movement to cause trauma and fracture, that I can understand but not just because it was dangling or a mere bump. Is that what they (facility) is saying because that is very unlikely. Someone did not watch her and I'm certain she fell . This is not good. On 1/28/2020 at 4:08 PM interview with V11 (Certified Nurses aide) stated, The 6th floor is my regular floor most of the time. I know (R1), she used to walk but she doesn't walk anymore after she fell . Since I started, I must check on her every two hours. Surveyor asked V11 about the plan of care for R1, V11 stated, The nurse doesn't show me care plans, but I know how to care for her. I know, we check on her a lot. I don't see any care plan. Asked about the falling leaf program, V11 stated, I don't know about any leaf program nobody told me about that. Nobody told me she fell twice, just this last time. R2 is an [AGE] year-old resident with [DIAGNOSES REDACTED]. R2's Risk assessment dated [DATE] scored a 12 for moderate risk for falls with 16 and above considered high risk. R2 has a history of 6 falls from 3/17/2019 to 1/12/2020. On 3/17/19 R2 was found on the floor due to a wet floor; on 10/15/19 R2 was found sitting on the floor; on 10/20/19 R2 was found on bathroom floor; on 12/5/19 R2 was found lying flat on the floor and sent to the emergency room ; on 12/22/19 R2 was found on the floor and sent out again to the emergency room ; on 1/12/2020 R2 was found sitting on her floor mat in her room. R2's care plan dated 3/7/19 to 1/12/20 states in part but not limited to, R2 is at risk for falls related to poor safety awareness, poor balance/decreased muscle strength. Resident also receiving anti-depressants and antipsychotic medication which can affect gait and motor function. Interventions: Resident was educated to ask for assistance by using the call light; offered to use a bed side commode; evaluate for proper attention to safety; implement safety measures, bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bell quickly; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions to reduce the risk of falls or injury. On 12/4/2019 at 7:00 AM, R2 was found on the floor lying on her left side by her dresser. R2 was sent 911 to the hospital emergency room and admitted for fluid overload, [MEDICAL CONDITION] exacerbation, and closed [MEDICAL CONDITION] hip. R2 required ORIF (Open Reduction Internal Fixation) Surgery and after a 9-day hospitalization returned to the nursing facility. Facility policy dated 2015 titled Fall Management states in part but not limited to, A fall is defined as a sudden, unexpected descent form a standing, sitting, or horizontal position. Evidence of a fall is based on the recollection of the patient and/or a description of the fall from a witness. This definition includes patients slipping from a chair to the floor, patients found lying on the floor, and assisted falls. a. An episode where a resident lost his/her balance and would have fallen were it not for staff intervention is a fall. In other words, an intercepted fall is still a fall. b. A fall without injury is still a fall. c. When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred. d. If a resident rolled off a bed or mattress that was close to the floor, this is a fall. Policy and Purpose: This facility has a fall management policy designed to minimize the risk of falling and to minimize the ill effects of the fall that occurs. All residents will be screened for risk of falls at admission and at least quarterly. All disciplines participate in the identification of such residents, evaluation of causative factors, implementation strategies, and evaluation of efficacy of these strategies and their implementation. Residents who fall are assessed and have interventions implemented.

Based on observation, interview and record review, the facility failed to ensure that a pressure sore did not increase in size/decline; failed to follow interventions in preventing deterioration of pressure sore related to repositioning and failed to ensure proper functioning of low air loss mattress for one (R4) of four residents reviewed for pressure ulcers. These failures resulted in worsening of R4's Stage 4 pressure ulcer on the sacrum and Unstageable pressure ulcer on the left buttock. Findings include: R4 is a [AGE] year - old, female, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per facility's census report, R4 was transferred to the local hospital on the following dates: 03/31/18 - transferred to hospital 04/03/18 - return date to facility 07/10/18 - transferred to hospital 07/22/18 - return date to facility R4's MDS (Minimum Data Set) dated 07/31/2018 documented: Sec. C - has memory problem for short and long-tern memory; severely impaired cognition for daily decision making Sec. G - needs extensive assistance from two persons physical assist during transfer; extensive assistance from one person physical assist during dressing, toileting, hygiene and totally dependent from one person physical assist during eating and bathing Sec. H -has nephrostomy tube and incontinence of bowel Sec. M - M0300: Current Number of Unhealed Pressure Ulcers at each stage - Stage 4 is one; Unstageable slough and/or eschar is one Sec. M1200: Skin and Ulcer Treatments - pressure reducing device, turning/repositioning program, pressure ulcer care R4's Wound notes documented: MD (Medical Doctor) notes 05/11/18: Stage 4 pressure wound Sacrum - measuring 4.5cm (centimeters) x 4.2 cm x 0.4cm treatment plan: [REDACTED] Recommendations: off-load, reposition per facility protocol MD notes 05/25/18: Stage 4 pressure wound sacrum - measuring 4.0cm x 4.2cm x 0.4cm 06/04/18 - progress notes documented that R4 went to hospital for tube feeding replacement and came back to the facility the same day MD notes 06/15/18: Stage 4 pressure wound sacrum - measuring 3.5cm x 4.2cm x 0.4cm MD notes 06/29/18: Stage 4 pressure wound sacrum - measuring 6.5cm x 4.5cm x 0.4cm; Wound progress: Deteriorated Shear wound of the Left buttock - measuring 2.0cm x 2.0cm x 0.1cm Primary dressing: dry protective dressing, apply once daily for 30 days, santyl apply once daily for 30 days Recommendations: off-load wound, reposition per facility protocol 07/05/18: hospitalized due to tube feeding malfunction and returned to the facility the same day 07/10/18: sent to hospital due to lethargy, increased congestion, [MEDICAL CONDITION] 07/22/18: Readmission into the facility 07/23/18: Per R4's progress notes on skin assessment - readmission head to toe skin assessment done, R4 non-verbal, bedbound, there is a nephrostomy tube at the right flank area, in place and draining well, there is a 7.5 x 5.5 x 2.5cm Stage 4 pressure injury at the coccyx area, with moderate serosanguinous discharge, wound bed clean with 50% granulation tissue, noted to have a 1.0 x 2.0 x 0.1cm Stage 2 pressure injury at the left buttock, with minimal serous discharge, wound bed with 50% slough, there is a 1.0 x 1.5cm DTI (deep tissue injury) at the left heel. MD notes 07/27/18: Stage 4 pressure wound sacrum - measuring 8.5cm x 5.5 x 1.0cm;Wound progress: Deteriorated Unstageable (due to necrosis) of the Left buttock - measuring 1.5cm x 1.5cm x Not measurable 08/03/18: Nursing notes - R4 seen today by V10 (Wound Care Nurse) and V11 (Wound Physician). V12 (Licensed Practical Nurse, LPN) was unable to change the left wound on buttocks, R4 was uncooperative. MD notes 08/10/18: Stage 4 sacrum - measuring 7.5cm x 5.5cm x 1cm Unstageable(due to necrosis) of the Left buttock - measuring 2.0cm x 2.0cm x not measurable cm.; Wound progress: Deteriorated R4's POS (Physician order [REDACTED].>07/27/18 Coccyx/Sacral wound: apply santyl to wound bed, pack with sterile foam, cover with transparent tape, attach to [DEVICE] at 125 mm Hg every Mon-Wed-Fri. 07/27/18 Left buttock: clean with NSS (normal saline solution), apply santyl, cover with calcium alginate and dry dressing daily. R4's current care Plan dated documented: Skin: Potential for breakdown due to (e.g. history breakdown/incontinence/decreased mobility/poor nutrition/poor circulation/terminal illness. Status: Active Interventions: use moisture barrier cream; use specialty pressure relieving equipment (mattress); use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/reposition every two hours. On 08/13/18 at 11:54 AM, R4 was observed in bed, asleep, with oxygen inhalation treatment at 2 liters per minute (lpm) via nasal cannula; on low air loss (LAL) mattress. The mattress was covered with a fitted sheet. On top of the fitted sheet, an underpad was placed. R4 was wearing an incontinent brief. The pressure pump for the LAL mattress was observed off. At 2:00 PM, V10 is about to do wound care on R4. It was observed that the pump for the LAL mattress which R4 was using was still off. V10 was asked if the pump was supposed to be off. V10 stated, The pump should be turned on at all times. V10 turned on the pressure pump on R4's LAL mattress. Wound care was provided by V10 assisted by V13 (Resident Care Assistant, RCA). V10 with gloved hands removed the old dressing on R4's left buttock wound and started cleaning it. Afterwards, V10 removed the dressing on R4's sacral wound. The sacral wound is connected to a [DEVICE]. V10 disconnected the [DEVICE] to the wound and started cleaning R4's sacral wound. R4's sacral wound appeared to be like pear-shaped which extends to the coccygeal area. The wound bed appeared to be dry and pinkish in appearance. On 8/14/18 at 9:40AM, R4 was again observed in bed, awake but unable to verbalize needs, with oxygen inhalation at 2lpm via nasal cannula. R4 was lying on her back with a pillow placed under right shoulder. The following were observed on R4's position while in bed: 9:45 AM - lying on back, awake, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 10:00 AM - lying on back, awake, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 10:15 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 10:30 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 10:45 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 11:00 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder. V7 (RCA) was observed in R4's room putting some towels in R4's cabinet. 11:15 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 11:30 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder 11:45 AM - lying on back, asleep, with oxygen inhalation at 2lpm via nasal cannula, with pillow placed under right shoulder At 12:45 PM, V7 (RCA) and V8 (RCA) was observed providing incontinence care on R4. It was observed that R4's low air loss mattress is covered with a fitted sheet. A white blanket folded into 4s was placed under R4's lower back. R4 was wearing incontinent brief. V7 and V8 were asked on the number of sheets used for low air loss mattresses. V7 stated, we need to cover the mattress with two sheets which is a flat sheet and an underpad. V8 stated, only one flat sheet should be covering the low air loss mattress. V7 and V8 were also asked regarding R4's pressure sores. V7 stated, I'm first time with her (R4). She (R4) needs to be changed very often like three times per shift or when needed. She (R4) also need to be reposition to sides every two hours because she (R4) has wound on the back. V8 stated, I have worked with her (R4) before but now I have a different wing. She (R4) needs to be changed every two hours and be turned from left to right every two hours. After the provision of incontinence care on R4 by V7 and V8, R4 was turned to the left side. A pillow was placed under R4's right shoulder covering the upper and lower back. The sacral area was also observed resting on the pillow. At 1:05 PM, V10 was interviewed regarding ways to prevent further decline of pressure sores. V10 stated, We do repositioning every two hours, keep the sacral area dry and dressing intact, provide pillows or cushion in between legs to protect bony prominences and the use of low air loss mattress. For the low air loss mattresses, there should be one sheet covering the mattress, that one sheet is the top sheet which ideally is the fitted sheet to keep it in place. At this time also, surveyor showed V10 the position of R4 in bed. V10 stated, Oh, she (R4) should be turned a little bit more to the left side. The pillow should be placed before the sacral area making sure the sacral area is not resting on the pillow. On 08/16/18 at 12:17 PM, V10 was asked to clarify exactly on R4's pressure ulcer. Wound MD notes documented Stage 4 pressure wound sacrum and V10 documented in her (V10) notes coccyx wound. V10` stated, Her (R4) wound is on the sacrum but because it extends to the coccyx, I wrote coccyx, but it is on the sacrum area. On 08/16/18 at 1:42PM, V9 (Medical Director) was interviewed regarding pressure ulcer.V9 stated, I've been working in the facility as the Medical Director for 4 - 6 months now. Yes, one of the issues in the facility that we talked about during quality assurance meetings are pressure ulcers. I expect that staff do a team approach in preventing and treating pressure ulcers. There is a wound care nurse and a Wound doctor seeing residents with pressure ulcers. And nurses and aides should also help in implementing ways to manage pressure ulcers. I expect staff to ambulate residents and if residents are unable to get up and stay in bed, there should be off-loading, repositioning on a consistent basis based from the protocol. Facility's policy titled Skin Management Program, revised date 05-2016, stated in part but are not limited to: Policy: (Facility name) will have in place a skin management program that promotes identification of residents at risk for skin breakdown and utilizes interventions that minimize that risk. If breakdown occurs or is present at the time of admission, a systematic approach and monitoring process will be in place for managing pressure ulcers to promote healing and maximize function and quality of life and minimize risks, complications, and functional decline. Facility's policy titled, Prevention of Pressure Ulcers undated documented: Interventions and Preventive Measures: General 2. For a person in bed: a. Change position at least every two hours or more frequently if needed. Interventions and Preventive Measures: Residents with Risk Factors 3. Risk Factor - bed fast a. Change position at least two hours and more frequently as needed. The Operation Manual on the low air loss mattress currently used by R4 stated in part: 2.0 Safety Precautions Bed Linens: This device incorporates a waterproof cover that is moisture vapor permeable; therefore it is recommended to limit bed linens to one sheet in order to maximize the system's performance.

Based on observation, record review, and interview, the facility failed to implement timely and appropriate fall prevention measures and to provide adequate supervision for 1 of 16 residents (R23) reviewed for falls in a sample of 30. These failures resulted in R23 falling and sustaining a laceration to the back of his head, and being transferred to the local hospital where R23 received staples. Findings include: R23 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R23 ' s admission MDS (Minimum Data Sheet) dated 6/27/13 documents: C0100 Should Brief Mental Interview for Mental status -0- (not entered) C0600 Should the Staff Assessment for Mental Status be conducted- Yes Short term memory- Memory problem Long term memory- Memory Problem Cognitive skills for daily decision making- moderately impaired D0500 Trouble concentrating on things, such as reading the newspaper or watching television E0100 Potential indicators of psychosis- delusions G0110 Transfers- Extensive assistance, 1 person physical assist Walk in room- Limited assistance, 1 person physical assist Walk in corridor-Extensive assistance, 1 person physical assist Locomotion on and off unit- Extensive assistance, 1 person physical assist Toilet use- Extensive assistance, 1 person physical assist G0300 Balance during transitions and walking- Not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface-to-surface transfer G0400 Mobility devices- walker, wheelchair J1700 Falls- no falls any time in the last 6 months prior to admission R23's physician's orders [REDACTED]. Enoxaparin 40mg/0.4ml subcutaneous once daily (anti-coagulant). Aspirin 81 mg Enteric coated, by mouth daily. The facility's Fall Incident Reports for R23 documents the following falls: 6/21/13 7/11/13, 7/26/13, 8/3/13, 8/7/13, and 8/11/13. The documented fall reports are listed below. Fall: 6/21/13 at 2:30am-Location by the bathroom door. Description- noted lying on the floor on his back by the bathroom door. Fall: 7/11/13 at 9:15pm-Location-resident room On 8/14/13 at 12:03pm, E13 (Registered Nurse/RN/Resident Care Manager) stated that she was responsible for adding fall interventions for the falls R23 sustained on 7/11/13 and 7/26/13. E13 stated that on 7/11/13, R23 wanted to go to the bathroom and was agitated because staff assisting him was female. E13 stated to the survey team, "his daughter told us, when he came here, that he didn't like females." E13 stated that R23 was resistant when the female staff was trying to toilet him. This according to E13 led to staff sliding him to the floor. When asked what interventions were added, E13 stated, "It was just the fact that we tried to keep him safe." The question was rephrased, and E13 was asked what interventions were placed to prevent this situation from reoccurring. E13 then stated, "he already had alarms and a low bed, but this was for night." E13 was then asked if there were male staff in the facility. E13 stated there's a male Certified Nursing Assistant and there are male staff in therapy. E13 stated that no male was notified to assist R23 with toileting. R23's investigation report for the fall dated 7/11/13 documents: Interventions to be implemented to minimize possibility of recurrence of fall-R23 is impulsive, has cognitive deficits, does not use call light, daughter and staff present. Staff eased him to the floor. There were no actual interventions documented. Fall: 7/26/13 at 9:30am- Location- hallway, Description-nurse noticed resident on the floor. Resident stated, " I just wanted to walk and I stood up." The fall investigation tool documents: Interventions to be implemented to minimize possibility of recurrence- Appears weaker and had a cough. Started on Z-pack, Mucinex, and tessalon pearls. Order for Megace to help stimulate appetite. Fall: 8/3/11 at 8:42am, Location resident room doorway. Intervention- Place reminder on bathroom door. Fall: 8/7/13 at 8:45pm, on the floor in his room. Noted 2cm skin tear on his elbow with small bleeding. His wheel chair found on his side. Fall: 8/11/13 at 7:30pm, in front of room 512. Intervention- this section was left blank as the investigation was not complete as of 8/13/13, there were no documented interventions on R23 ' s care plan. On 8/13/13 at approximately 1:00pm, E16 (RN, Resident Care Manager) stated that for the fall R23 sustained on 8/3/13 the intervention was to place a sign on his bathroom door. E16 then went to R23 ' s room. Located on R23 ' s bathroom door was a sign which read: " (R23), Please ask for help before you get up from your chair " . However, the bathroom door which was a sliding accordion type door was pushed open. The sign was folded up inside the door and not visible. R23 was alone in his room, asleep in bed. R23 ' s bed was on the other side of the bathroom wall and not in view of the door or sign. R23 ' s wheel chair was next to his bed. E16 stated that when R23 fell he was sitting in his wheel chair in front of the bathroom door. The object is for him to read the sign if he is sitting in front of the bathroom door. For the fall R23 sustained on 8/7/13, E16 stated that R23 fell in the doorway of his room. E16 stated " he has a history of getting up and falling." E16 pointed to a sign posted both on the outside and inside bathroom wall. The sign read " please call, don't fall". When asked how this helps R23 when he's on the other side of the wall. E16 stated, "it's a reminder." E16 also stated that R23 has cognitive impairment and memory problems. As of 8/13/13, the investigation for the fall R23 sustained on 8/11/13 was not complete. E16 stated she is in the process of completing the investigation. E16 stated that R23 fell outside of his room. E16 stated that R23 wanted to go to his room. E16 stated that staff allowed E16 to go to his room and he was not escorted. E16 added that she had not updated R23's care plan. E16 stated the policy is to update the care plan and add interventions after the investigation is complete. E16 stated that the facility has folded R23's walker up and placed it out of his reach. At this time, R23 remained asleep in his bed with the wheel chair next to the bed. When R23 fell on [DATE] he sustained a laceration to the back of his head, and was transferred to the local hospital where he received staples. The facility's policy for fall management documents: Care and Interventions: The care plan will be reviewed and updated to reflect the fall, its causes, interventions, and goals. The policy does not document timeliness of interventions. R23's discharge instructions from the local hospital documents: Head injury, scalp laceration. Make appointment to have staples removed.