Every finding on record at Warren Barr North Shore

Based on observation, interviews and record review, the facility failed to ensure dialysis treatments were provided for a resident dependent on dialysis. This failure resulted in R107 having a change of condition and was hospitalized for bradycardia and hyperkalemia due to missed dialysis treatments requiring emergent hemodialysis. This applies to 1 of 10 residents (R107) reviewed for dialysis in the sample of 33. The findings include: R107's face sheet shows diagnoses including chronic kidney disease, end stage renal disease, dependence on renal dialysis, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarct affecting right dominant side and hypertension. R107's Physician Order Sheets dated June 2026 shows orders including hemodialysis three times a week every Tuesday, Thursday and Saturday.On 6/2/26 at 1:56 PM, R107 was in his room lying in bed. He said he gets dialysis three times a week. R107 said he went out for a MRI in February and missed his dialysis treatment afterwards because he was tired. R107 said he was having trouble breathing a couple of days later and was sent out to the hospital. R107 said the physician told him not to miss any more dialysis treatments. On 6/2/26 at 2:07 PM, V12 (Registered Nurse-RN) said We usually inform the dialysis nurse if a resident misses their dialysis treatment and it gets scheduled the next day. If a resident misses a 2nd dialysis treatment we notify (V2 Director of Nursing-DON) and the physician and request for them to be sent out to the hospital. (R107) receives dialysis three times a week, he has not had any refusals. Nursing should notify the physician for any missed treatments. Residents could show signs and symptoms of lethargy, short of breath and a change from their baseline. On 6/3/26 at 10:02 AM, V2 (DON) said We notify the dialysis nurse, NP (nurse practitioner) or physician if a resident missed their dialysis treatment. They typically will be scheduled the following day. If a resident misses a 2nd treatment, nursing should notify the physician and follow the physician orders.R107's nurses note dated 2/26/26 documents (R107) refused the hemodialysis treatment today. (R107) stated, After the MRI appointment I feel very tired. Dialysis nurse was notified and rescheduled for 2/27/26. (There was no documentation the physician was notified). R107's nurses note dated 2/27/26 documents (R107) refused to go to dialysis today, which was the make up from 2/26/26. (R107) stated, I feel very tired. Dialysis nurse was notified. (There was no documentation the physician was notified) R107's HD (Hemodialysis) Treatment Flow Sheet dated 2/28/26 shows treatment was initiated at 10:04 AM at 11:04 AM treatment was terminated. R107 signed off early, had a bowel movement and stated he can't stay. R107 was rescheduled for Monday 3/2/26. V21 (Nephrologist) was notified of this treatment, however there was no mention of the previous missed treatments. R107's nurses note dated 3/1/26 shows he had a change of condition and was sent out to the local hospital. R107's Transfer to Hospital Form dated 3/1/26 shows reason for transfer: left arm weakness. Respiratory: new O2 at 3LNC 98%. R107's nurse practitioner note dated 3/16/26 documents he was admitted to the hospital on [DATE] with chest pain and was found to have junctional bradycardia and hyperkalemia (K (potassium) 8.3) due to missed dialysis sessions. He required ICU admission initially and emergent hemodialysis with improvement in potassium levels and resolution of bradycardia. he was discharged on 3/4/26 to the facility. R107's current care plan shows he requires hemodialysis three times a week. Assess for fluid excess (weight gain, increased BP (blood pressure), shortness of breath, wheezing, edema.), monitor/document/report signs of renal insufficiency: changes in level of consciousness, changes in heart and lung sounds and notify MD. On 6/3/26 at 12:18 PM, V2 (DON) confirmed there was no documentation form nursing notifying the physician of R107's missed dialysis treatments on 2/26/26 and 2/27/27 and the physician should have been notified. The facility's Hemodialysis Policy dated 6/30/26 states, It is the policy to ensure that appropriate care for resident on hemodialysis is provided.

Based on interview and record review the facility failed to give bed hold notices to residents that were hospitalized for 2 of 2 residents (R13, R4) reviewed for bed hold notices in the sample of 33.The findings include: 1. R13's progress notes dated 5/22/26-5/24/26 were reviewed. R13's progress notes dated 5/22/26 showed R13 was sent to a local hospital for a scheduled procedure. A note dated 5/23/26 showed R13 never returned to the facility post-procedure and was subsequently admitted to the hospital for surgery. The notes showed no documentation of the facility attempting to issue a bed hold notice to R13 or R13's power of attorney once learning R13 was being hospitalized for surgery. On 6/3/26 at 12:02 PM, V1 Administrator stated, upon finding out R13 was hospitalized , the facility did not attempt to give R13 a bed hold notice. On 6/3/26 at 12:46 PM, V16 Executive Director stated the facility never issued a bed-hold notice to R13. On 6/3/26 at 1:22 PM, V19 Admissions Director stated a copy of the facility's bed hold policy is given to a resident every time a resident is sent to the hospital and/or hospitalized . 2. R4's EMR (Electronic Medical Record) shows that R4 was sent to the hospital on 2/6/26 for oxygen desaturation. R4's Change in Condition Form dated 2/6/26 states on Page 5, Prior to hospital transfer, the facility's Bedhold policy WAS NOT GIVEN to the resident and/or representative. On 6/3/26 at 12:23 PM V1 (Administrator) stated, I don't know why that is even an option the policy is right there (on the same form). I don't know what we send with the resident when they go to the hospital.On 6/3/26 at 12:24 PM V2 (Director of Nursing) stated, We send the Change in Condition Form to the hospital with the resident. On admission they get the bed hold policy, then we send this change of condition form with the resident to the hospital. We do not give them another paper copy. Then we send an email to the liaison at the hospital and they check on them. I see what you are saying but that is not what is done. The facility's Bed Hold and readmission policy dated 6/26/25 showed, It is the facility's policy to adhere to the federal regulation on bed hold and on readmission of resident transferred out of the facility. The facility must inform the resident or family members being transferred of the duration of bed hold in writing.

Based on observation, interview and record review the facility failed to offer a bedbound resident meaningful activity to support her mental health.This applies to 1 of 33 residents (R4) reviewed for activities in the sample of 33. The findings include: On 6/1/26 at 10:30AM, R4 was in bed with her television on. R4 was able to answer questions but was not willing to engage with Surveyor. On 6/2/26 at 12:24 PM, R4 was lying in bed. Per staff R4 does not get up. R4's television was on but R4 did not appear to be watching it. R4 did not have any other activities available to her while she was in her room. On 6/3/26 at 9:28 AM, R4 was lying in bed but in a much more talkative mood. R4 welcomed the Surveyor into her room and stated that she was having a good day and that some days are better than others. Surveyor asked R4 was she does in her room all day and R4 stated, I don't do nothing. They bring in coloring, but I don't really like to color. I like to feel productive- I like to feel like I'm doing something. I used to work on an assembly line putting things together, I really liked that. I would love some pet therapy, puppies and kittens. I like latch hook and making those flowers out of colored tissue paper.On 6/3/26 at 10:00 AM, V9 (Activity Assistant) stated, We do pop ins- most of them refuse our visits. We chit chat, organize their room, give water, things like that. For R4 we chit chat with her, reorganize her snacks or her refrigerator, talk about the TV show she is watching, the weather, or how the staff are caring for her. She has never asked for activities in her room. We did play a couple of games before. We shift around with everyone. I have seen her about 3 times, but sometimes I forget to document. There is another activity assistant that has that unit I will see if she has documented her visits with (R4) in the binder.No documentation was ever provided regarding R4's pop-in visits and there was no documentation in R4's electronic medical record under the activities section.R4's Face Sheet shows she is a [AGE] year-old resident with diagnoses including Schizophrenia, Dementia, Bipolar and Metabolic Encephalopathy. R4's Care Plan dated 5/6/26 states, Independent Leisure Pursuit: (R4) is functioning at a reasonably independent level concerning leisure pursuits. (R4) is alert, sufficiently oriented and coherent, able to express her needs. Limited mobility, mainly in bed. She currently engages in the following leisure/recreation pursuits: Music., Reading/writing, Television, movies, writing her shopping list, talking to staff and residents.R4's Activity assessment dated [DATE] states, Resident has limited opportunity to participate in group programs due to her current condition, mainly in bed. Has access to a wheelchair in-room. Resident would benefit from staff-initiated in-room activities until further notice. Resident currently pursues watching television, reading, and conversing with staff members.

Based on observation, interview, and record review the facility failed to provide appropriate nail care and services and failed to ensure daily weights were performed for a resident with CHF (Congested Heart Failure). This applies to 2 of 33 residents (R107, R5) reviewed for quality of care in the sample of 33. The findings include: 1. R107's face sheet shows diagnoses including chronic kidney disease, end stage renal disease, dependence on renal dialysis, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarct affecting right dominant side and hypertension. On 6/2/26 at 1:56 PM, R107 was observed in his room lying in bed. His left fingernails were overgrown, curved, hardened and significantly thickened with a white chalky buildup underneath the nailbed and a yellowish/brownish discoloration. R107 said he has asked the staff to cut his nails, but they said they can't. When the podiatrist came, he asked him to cut his finger nails and he said he can only cut his toe nails. R107 said he thinks he has fungus on his nails because he's had in the past. The staff suggested I go to a nail salon to get my nails trimmed. On 6/2/26 at 2:07 PM, V12 (Registered Nurse-RN) said he is not sure what is going on with R107's nails, they have been like that since he started at the facility about two months ago. On 6/3/26 at 12:18 PM, V2 (Director of Nursing-DON) said R107 was getting fungal medication in 2023 for his nails. She was not aware of R107's nail condition and staff should have notified the physician to obtain treatment orders. R107's Physician Order Sheets dated June 2026 shows there are no treatment orders or appointments for nail care. R107's current care plan shows he requires extensive assistance with activities of living including personal hygiene care. 2. R5's Face Sheet printed on 6/1/26 showed R5 had the diagnosis of heart failure. R5's Order Summary Printed on 6/1/26 showed and order for daily weights as appropriate for 2 weeks, then weekly unless specifically indicated by the cardiologist. The order had a start date of 5/15/26. The same document showed an order to monitor weight daily and to notify the doctor of a 2 pound weight gain in one day or 5 pounds gain in one week. The order had a start date of 5/27/26 On 6/1/26 at 12:26 PM, R5 said she was not being weighed daily and is only weighed when she goes to dialysis on Monday, Wednesday, and Friday. R5's Weight and Vital Summary for May 2026 only contained weights on 5/14/26 and 5/20/26. R5's Medication Administration Record starting on 5/16/26 indicated daily weights were to be done. A check mark was recorded for the daily weights. There was no numerical value recorded for R5's weights. On 6/2/26 at 10:48 AM, V2 (DON) confirmed daily weights were not recorded for R5. V2 said R5's daily weight order was entered incorrectly. The order was entered for a check mark to be recorded and not a numerical value. On 6/2/26 at 10:28 AM, V7 (Registered Nurse) said for a resident with heart failure, weights are done to monitor the fluid status. R5's Care Plan with an initiated date of 5/15/26 showed R5 was at risk for fluctuating weights and to monitor weights as ordered.

Based on observation, interview, and record review, the facility failed to ensure weekly wound assessments were performed and failed to ensure the prescribed treatment orders were in place for a resident with deep tissue injury and failed to ensure a low air loss mattress was in place for a resident at risk for pressure injury. This applies to 2 of 33 residents (R22, R153) reviewed for pressure injuries in the sample of 33. The findings include: 1. R22's face sheet shows she has diagnoses including end stage renal disease, type 2 diabetes with diabetic neuropathy, major depressive disorder, and cerebral infarction. On 6/1/26 at 11:15 AM, R22 was observed in her room sitting in her wheelchair. R22 was complaining of left heel pain. R22 was wearing a medical shoe with velcro straps in place to her left foot. R22 said anytime there is pressure on the heel it hurts. She said they have been putting a dressing on to her heel. On 6/1/26 at 11:48 AM, V15 (Certified Nursing Assistant-CNA) said R22 has a lot of pain to her left heel. V15 removed the velcro shoe, gripper socks was covering half of her foot with the heel resting on the sole of the shoe. V15 lifting R22's foot a small black/necrotic area was observed to the left lateral side of her heel. A large round black/necrotic area covering the medial heel approximately the size of a tennis ball was observed without a protective dressing in place. On 6/2/26 at 10:59 AM, R22 was in her room sitting in her wheelchair. V13 (Wound Nurse) lifted R22's left foot. A small black/necrotic area was observed to the left lateral side of her heel. A large round black/necrotic area covering the medial heel approximately the size of a tennis ball was observed without a protective dressing in place. V13 said there are two separate wounds to her left heel. On 6/2/26 at 11:54 AM, V13 said the left heel wound was identified on admission 4/29/26. The last measurement was on 5/14/26 measuring 3.5 cm (centimeters) x 3.5 cm. Weekly wound assessments should be performed and there should be a protective dressing in place to the heel. V13 said R22 has a deep tissue injury with eschar. She said last week the wound was not assessed due to the holiday. On 6/2/26 at 1:40 PM, V14 (Wound Nurse Practitioner) said R22 has been difficult to assess due to her left heel pain. I think there was a lack of communication regarding R22's left heel. She would expect staff to notify her of any changes. V13 said there have been times when R22 was not present in her room when she rounded. I was not aware of the separate area, and I thought it had approved. Now I know there was a change she will assess the resident on 6/4/26. She confirmed R22 has two separate pressure areas. R22's Skin wound note dated 4/30/26 documents a left heel pressure measuring 3.0 cm (centimeters) x 2 cm, suspected deep tissue injury. R22's Wound assessment dated [DATE] documents a left heel stage 2 pressure measuring 5 cm x 4.5 cm x 0.1 cm. R22's Wound assessment dated [DATE] documents left heel is now a deep tissue injury due to purple discoloration measuring 3.5 cm x 3.5 cm x 0.1 cm. Treatment order include apply skin prep to base of wound, secure with bordered foam. Change 3 times per week and as needed. There were no further assessments of the left heel deep tissue injury. R22's Wound assessment dated [DATE] shows one left heel pressure injury measuring 0.5 cm x 0.5 cm, but there was no additional wound assessment to the left medial heel and no further lateral left lateral heel pressure injury. R22's Physician Order Sheets dated June 2026 shows orders including treatment left heel cleans with normal saline, pat dry, apply skin prep then cover with bordered foam dated 4/30/26. The facilities Wound Care Guidelines Policy dated 1/2026 states, This facility adheres to the Federal and State regulatory requirements for wound care management. 2. R153's current care plan showed R153 had a history of MASD (moisture associated skin damage) to her buttocks. The plan showed R153 was at high risk for skin breakdown and pressure injuries due to her diagnoses of incontinence and obesity. R153 required extensive staff assistance to reposition in bed and for all ADL (activities of daily living) cares. The plan showed R153 required a low air loss mattress on her bed. A physician order dated 4/7/26 showed an order for R153 to have a low air loss mattress. On 6/1/26 at 10:05 AM, R153 was in pain, complaining of pain to her buttocks. R153 was on a standard facility mattress, not a low air loss mattress. R153 said, They just cleaned me up and checked my butt. I used to have a wound there, so my skin is just fragile. On 6/2/26 at 9:28 AM, R153 was asleep in bed lying on a regular mattress. On 6/2/26 at 9:07 AM, V3 (Licensed Practical Nurse) stated, Our low air loss mattresses are attached to monitors that are programmed to automatically off-load areas of pressure throughout the day. The monitor usually hangs off the footboard on the resident's bed. Nursing is responsible for making sure the resident has the right mattress. On 6/2/26 at 10:48 AM, V6 (Wound Nurse) stated, Residents with pressure injuries or that are at risk for skin breakdown have low air loss mattresses. V6 stated R153 currently had no wounds but has a history of MASD to her buttocks that comes and goes. V6 stated R153 should have a low air loss mattress on her bed. The facility's Wound Care Guidelines policy dated 1/24/26 showed, The purpose of the prevention guidelines is to guide evidence-based care to prevent development of pressure injuries. The policy showed the facility utilizes pressure redistribution surfaces such as low air loss mattresses as interventions to prevent skin breakdown.

Based on observation, interview and record review the facility failed to ensure a resident with limited range of motion wore a hand splint or padding for the treatment of his hand contracture for 1 of 11 residents (133) reviewed for restorative services in the sample of 33.The findings include:R133's current care plan showed R133 required restorative services due to the contractures to his right arm and leg caused by a cerebrovascular accident (stroke). The plan showed R133's right hand and wrist were contracted. The plan showed, Please ensure that my affected extremity is well padded. R133 was severely cognitively impaired and dependent on staff for all cares.On 6/1/26 at 9:47 AM, R133 was in bed. His right hand was contracted into a tight fist. R133's fingernails appeared to be pressing into the palm of R133's right hand. No splint or padding was noted to R133's right hand contracture. R133 was able to slightly lift his right arm but could not open or relax his right hand. On 6/2/26 at 9:30 AM, R133 was in bed. His right hand was contracted into a tight fist. No splint or padding was noted to R133's right hand contracture. On 6/2/26 at 10:12 AM, R133's current restorative care plan was reviewed with V5 (Restorative Aide). V5 stated R133's should have padding or towel roll in place to his contracted right hand to prevent skin breakdown and to make sure his contracture isn't getting worse. On 6/2/26 at 10:25 AM, V5 (Restorative Aide) stated, I just assessed (R133). I put a towel roll in (R133's) right hand. His right hand is contracted into a fist. He doesn't seem to be able to relax that hand.On 6/3/26 at 9:58 AM, R133 was assessed by V20 (Restorative Nurse). R133's right hand was contracted into a tight fist. V20 asked R133 to relax and open his right hand. R133 was unable to do so. V20 then manually straightened the fingers on R133's right hand. R133's right hand immediately contracted back into a tight fist when V20 let go of R133's hand. V20 stated, Yes, he does need a splint or towel roll to that hand.The facility's Restorative Nursing Program policy dated 7/3/25 showed, Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. Nursing and Restorative Services may include the following: a. Ambulation b. Transfer c. Contracture Prevention and Management include PROM (passive range of motion), AROM (active range of motion), splint/orthotic management. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment.

Based on observation, interview, and record review the facility failed to ensure a resident received their dietary supplement for 1 of 33 residents (R3) reviewed for nutrition in the sample of 33.The findings include:R3's Care Plan with an initiated date of 7/16/24 indicated R3 was at risk for alteration in nutritional status. Listed under interventions was to provide diet and supplements as ordered.R3's Order Summary Report printed on 6/1/26 showed an order for house supplement of magic cup with dinner and fortified pudding with lunch and may substitute with house supplement. R3's Meal Ticket for 6/1/26 showed R3 was to get fortified pudding with lunch. On 6/1/26 at 12:33 PM, R3 was eating lunch in his room. R3 did not have pudding or magic cup on his tray. R3 confirmed he did not receive fortified pudding.R3's Medication Administration Record for 6/1/26 had a check mark that indicated R3 received a supplement with lunch. V8 (Registered Nurse) was the staff that documented R3 received the supplement. On 6/1/26 at 1:41 PM, V8 said fortified pudding was provided by the kitchen and should be on the resident's meal tray when it comes from the kitchen. V8 confirmed she documented R3 received the fortified pudding supplement. V8 was unaware the fortified pudding was not on R3's meal tray. On 6/1/26 at 1:50 PM, R3 confirmed he did not receive a dietary supplement with lunch.R3's Dietary Note dated 5/16/26 showed R3 was to receive fortified pudding with lunch.

Based on observation, interview and record review the facility failed to ensure medications were administered as prescribed. This applies to 2 of 33 residents (R48, R69) reviewed for pharmacy services in the sample of 33. The findings include: 1. On 6/1/26 at 9:49 AM, R48 was in her room lying in bed. A medication cup with five pills was located on her bedside table. R48 said nursing just leaves them there. R48's Medication Administration Record dated June 2026 shows orders at 9:00 AM including Amiodarone 200 mg (milligrams) give 0.5 mg daily for abnormal heart rate, Clopidogrel 75 mg daily for blood clots, Metformin 500 mg one tablet daily for diabetes, Cyanocobalamin 500 mcg (micrograms) daily, Losartan Potassium 100 mg daily for hypertension. On 6/3/26 at 10:30 AM, V2 (Director of Nursing-DON) said staff should not leave medications at the bedside table. We have talked to nursing about this and it's very disappointing. The facility's Medication Pass Policy dated 7/25 states, It is the policy of the facility to adhere to all Federal and State Regulations with medication pass procedures.PO meds after medication is administered to each resident, sign the MAR it was given. 2. R69's Physician's Order Sheet dated June 2026 shows that R69 has an order for Potassium Chloride ER 20 MEQ (milliequivalents), take 1 tablet by mouth one time a day for supplement. On 6/2/26 at 8:58 AM, V10 (LPN- Licensed Practical Nurse) dispensed the Potassium Chloride pill, crushed it, mixed it with applesauce and administered it to R69. R69's Potassium Chloride medication card displays a sticker that says, Do not crush. Surveyor pointed this out to V10 and V10 stated, Oh, I'm sorry. My bad. She is so anxious and wants her meds when she wants them so I always crush the potassium so she can swallow it.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) for a resident on enhanced barrier precautions and failed to implement enhanced barrier precautions. This applies to 2 of 33 residents (R154 and R80) reviewed for infection control in the sample of 33. The findings include: 1. R154's Care Plan with an initiated date of 10/21/25 showed R154 was on enhanced barrier precautions and to ensure gloves and gowns are used during high contact care. The same care plan showed R154 had a tracheostomy. On 06/01/2026 at 10:05 AM, there was an enhanced barrier precaution sign near the door of R154's room. The sign indicated staff were to wear gloves and gowns for high contact care such as device care. On 06/01/2026 at 10:05 AM, R154 was in bed. R154 was receiving oxygen via a tracheostomy collar. The oxygen tubing had disconnected from the tracheostomy collar. R154 appeared to be resting comfortably and did not appear in any respiratory distress. V7 (Registered Nurse) entered the room. V7 put on gloves and reconnected the oxygen tubing to the tracheostomy collar and adjusted the tracheostomy collar around R154's neck. V7 did not have a gown on. On 06/02/2026 at 10:28 AM, V7 said for a resident that is on enhanced barrier precautions, such as R154, staff should wear gloves and gown when providing direct care or device care. 2. R80's admission/current care plan showed R80 required EBP (Enhanced Barrier Precautions) due to his nephrostomy tube (urinary catheter that drains urine directly from R80's kidney). The plan showed staff were to wear a personal protective gown and gloves when handling and/or providing cares to R80's nephrostomy tube. On 6/1/26 at 10:00 AM, R80 was in bed with V4 (Family of R80) seated in the room. R80's nephrostomy drainage bag lay in bed next to R80. A scant amount of urine was noted in the bag. No EBP and/or isolation signage was noted on or around the door to R80's room. No PPE cart (personal protective equipment) was noted in the hallway by R80's room. V4 stated she visits R80 daily in the facility. V4 stated she had never seen staff wear a gown when handling and/or providing cares to R80's nephrostomy tube. On 6/2/26 at 9:25 AM, R80 was seated in a chair in his room with V4 seated next to him. No EBP and/or isolation signage was noted on or around the door to R80's room. No PPE cart (personal protective equipment) was noted in the hallway by R80's room. On 6/2/26 at 11:10 AM, V3 Licensed Practical Nurse stated R80 was not currently on EBP. V3 stated, He should be on it because of his nephrostomy tube. He should have an EBP sign on his door too. The facility's EBP policy dated 9/16/25 showed EBP will be implemented on any resident with open wounds, indwelling medical devices including urinary catheters, and resident's colonized or infected with multi-drug resistant organisms.

Based on interview and record review the facility failed to offer the Pneumococcal vaccine upon admission. This applies to 1 of 7 residents (R18) reviewed for immunizations in the sample of 33. The findings include:R18's Facesheet shows R18 admitted to the facility on [DATE]. R18's Immunization Report dated 6/1/26 shows no information regarding having offered R18 the Pneumococcal vaccine. There are no records indicating R18 had historical pneumonia vaccines in the past on R18's electronic medical records. R18's Pneumonia vaccine consent form shows R18 was provided education and verbally refused the Pneumonia vaccine on 11/10/2025. On 6/1/26, V17 (Infection Prevention Nurse) said upon admission, V17 will ask the resident or the resident's representative if they would like any immunizations they offer including the pneumococcal vaccine. V17 said she's the only that offers vaccinations at this time and gets signed consents or declinations. V17 said the time she gets to offer new admissions vaccinations depends how backed up V17 is. V17 said sometimes short-term stay residents admit and discharge from the facility too quickly to offer vaccinations. On 6/3/26 at 12:36 PM, V2 (Director of Nursing) said new admissions should be offered immunizations when they come. If they admitted to the facility in July, V2 would expect them to have been offered vaccinations prior to November. Facility Pneumococcal Vaccination dated 7/15/25 states, . 4. Pneumococcal vaccination will be offered upon admission if recommended by ACIP (CDC's Advisory Committee on Immunization Practices). All current residents recommended by ACIP to receive pneumococcal vaccine shall receive vaccination unless otherwise medically contraindicated or refused.

Based on interview and record review the facility failed to offer the COVID-19 vaccine upon admission. This applies to 1 of 7 residents (R18) reviewed for immunizations in the sample of 33. The findings include:R18's Facesheet shows R18 admitted to the facility on [DATE]. R18's Immunization Report dated 6/1/26 shows R18 refused the COVID-19 vaccine. R18's COVID-19 Vaccine consent form shows R18 was provided education and verbally refused the COVID-19 vaccine on 11/10/2025. On 6/1/26, V17 (Infection Prevention Nurse) said upon admission, V17 will ask the resident or the resident's representative if they would like any immunizations they offer including the COVID-19 vaccine. V17 said she's the only that offers vaccinations at this time and gets signed consents or declinations. V17 said the time she gets to offer new admissions vaccinations depends how backed up V17 is. V17 said sometimes short-term stay residents admit and discharge from the facility too quickly to offer vaccinations. On 6/3/26 at 12:36 PM, V2 (Director of Nursing) said new admissions should be offered immunizations when they come. If they admitted to the facility in July, V2 would expect them to have been offered vaccinations prior to November. Facility Preventing and Controlling Acute Respiratory Illness Outbreaks in Skilled Nursing Facilities and Other Facilities Providing Skilled Care policy dated 2/27/26 states, .Provide all recommended vaccines in a timely manner (i.e., before the peak of the fall respiratory season) to residents and health care personnel (HCP).

Based on observation, interview, and record review the facility failed to ensure the state agency survey binder with past results was accessible without having to ask. This has the potential to affect all residents residing in the facility. The findings include:Centers for Medicare and Medicaid Services form 671, dated 6/1/26, shows there are 159 residents residing in the facility. On 6/2/26 at 10:15 AM, no residents were aware of where the state agency survey binder was that showed results of past survey results. On 6/2/26 at 11:08 AM, this surveyor found the state agency survey binder that shows results of past surveys on a table in the corner of the sitting area of the lobby. The table was located against the wall on two sides of the table. In front of the table were a sofa, a chair, and a coffee table. The table was only accessible on one end of the table and in order to access the table, there was approximately only two and a half feet between the back of the chair and the wall, preventing residents in a wheelchair to access the binder without having to ask for assistance. On 6/3/26 at 10:15 AM, V1 (Administrator) said if residents weren't able to reach where the binder was currently, they could ask staff for assistance in grabbing it. At 12:43 PM, V1 said the binder should ideally be on a table in the lobby with nothing impeding its ability to be grabbed by residents to view.

Based on observation, interview and record review the facility failed to ensure a qualified staff member operated a resident's enteral feeding pump for 1 of 30 residents (R4) reviewed for qualified persons/staff in the sample of 30.The findings include:R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a gastrostomy tube (G-tube) in place for enteral feedings. R4's current care plan showed R4 required enteral feedings as the primary source of nutrition.On 8/18/25 at 10:25 AM, V8 Certified Nursing Assistant (CNA) entered R4's room to provide cares. R4 was in bed with his enteral feeding infusing via an enteral feeding pump at R4's bedside. V8 CNA reached over and paused R4's feeding pump as she began repositioning R4. At 10:29 AM, V8 CNA left R4's room to get additional staff to help provide cares to R4. At 10:38 AM, V8 CNA returned to R4's room and paused R4's enteral feeding pump again to allow V8 CNA and V7 Wound Nurse to provide cares to R4. On 8/19/25 at 11:03 AM, V3 Director of Nursing stated CNAs are not allowed to operate a resident's enteral feeding pump because CNAs are not licensed to do so and have not been trained to operate a feeding pump.

Based on observation, interview and record review the facility failed to provide feeding assistance and incontinence care to residents that require staff assistance to complete these activities of daily living for 3 of 30 residents (R4, R6, R61) reviewed for activities of daily living (ADLs) in the sample of 30. The findings include: 1.R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a tracheostomy and gastrostomy in place. R4's current care plan showed R4 was cognitively impaired and completely dependent on staff for all cares, including toileting/incontinence care. On 8/18/25 at 10:01 AM, R4 was in bed. An odor of stool was noted in R4's room. On 8/18/25 at 10:24 AM, R4 remained in bed. An odor of stool remained in R4's room. At 10:25 AM, V8 Certified Nursing Assistant (CNA) was asked when she last did incontinence care on V4. V8 stated she had yet to provide incontinence care to V4 that morning. V8 stated, He was last changed on nights (before 7 AM). I haven't changed him yet today. I am waiting on wound care to come see him and I will change him then. At 10:36 AM, V8 CNA and V7 Wound Nurse entered R4's room to provide cares. V8 pulled down R4's brief. R4's brief was saturated with urine and a contained a large amount of mushy stool that had leaked out of the side's of R4's brief, onto the bed. R4's groin and buttocks were red. The bottom half of a large, rectangular adhesive dressing was no longer secured in place over R4's sacral wound. Stool was noted under the dressing, in R4's sacral wound. 2. R6's current care plan showed R6 was dependent on staff for toileting/incontinence care. R6 was incontinent of bowel and bladder. On 8/18/25 at 9:25 AM, V6 CNA entered R6's room to provide cares. V6 CNA stated he had yet to provide incontinence care to R6 that morning. R6 stated his incontinence brief was last changed around 6 AM this morning. As V6 CNA pulled back R6's brief, liquid stool leaked out of R6's brief. R6's brief contained a large amount of urine and liquid stool. Dried stool was also noted on R6's buttocks. R6's buttocks and groin appeared bright red. On 8/19/25 at 11:03 AM, V3 Director of Nursing stated incontinence care and/or toileting should be offered and/or provided to residents every two hours by staff. The facility's Incontinence and Perineal Care policy dated 6/30/25 showed, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Do rounds at least every 2 hours to check for incontinence during shift. 3. R61's Face Sheet dated 8/16/25 shows that R61 is a [AGE] year old Spanish speaking resident with diagnoses including Metabolic Encephalopathy and End Stage Renal Disease. On 8/18/25 at 12:20PM R61 was lying in bed with her head elevated to about 20 degrees, turned partially on her left side. R61 summoned (waved for) Surveyor to come into her room. R61's empty meal tray was propped on the tray table and resting on her bed and her plate of food was sitting on the side of the bed. R61 was eating her mechanical soft diet with her hands. R61 had food all over the bed, her silverware, tray lid and cookie were on the floor under the bed. R61 was coughing. Surveyor left the room to find staff. V16 Licensed Practical Nurse (LPN) was at the nurse's station at the other end of the hall. Surveyor reported R61's condition to V16 and V16 came to assist R61 after she found V15 (CNA) in the room next to R61. V16 picked up the items off of the floor and assisted V15 to reposition R61 to an upright position with her tray table and plate in front of her. V16 left the room and returned with a new set of silverware but did not bring in a new cookie. V15 then stated that R61 usually eats with her hands because she is unable to hold a spoon. V16 handed R61 a spoon and R61 finished every bite of food on her plate with the spoon. Per V15, R61 stated the food is good in Spanish. R61's care plan dated 1/30/25 states, Instruct resident to eat in a n upright position, to eat slowly and to chew each bite thoroughly, Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards, Observe the resident during mealtimes for any signs and symptoms of aspiration, coughing, throat clearing, drooling, holding food in mouth (pocketing), prolonged swallowing time, repeated swallows per bite or difficulty swallowing. R61's Dietary Note dated 7/7/25 states, CCHO/renal diet (Constant Carbohydrate), mech(anical) soft texture, thin liquids. NKFA (No known food allergies). 1:1 feeding assistance or set-up and orient Pt to plate r/t blindness. Intake good most meals. Baseline intake fair-good, consistent with current intake per staff on unit. Does not eat fish. ABT may affect appetite, monitor. Intervention: therapeutic, mechanically altered diet as tolerated, Nepro QD, Prostat SF AWC 30 ml QD, fortified pudding QD with dinner for additional calories/protein for weight maintenance with HD (Hemodialysis). Use same method of weighing/time of day for consistency. Provide feeding assistance PRN. Encourage continued good intake, adequate hydration. Goal: stable dry weight, PO intake >65%. Monitor intake, appetite, weights, skin integrity, labs as available.

Based on observation, interview and record review the facility failed to provide wound treatments to a resident with a pressure injury. The facility failed to provide pressure relieving interventions to residents with pressure injuries and to residents at risk for pressure injuries for 3 of 8 residents (R4, R2, R6) reviewed for pressure injuries in the sample of 30.The findings include:1.R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a tracheostomy and gastrostomy in place. R4's Skin and Wound Note dated 8/4/25 showed R4 was admitted to the facility with a Stage 4 pressure injury to his sacrum. The note showed R4's wound currently measured 12.5 cm (centimeters) x 13.9 cm x 3.8 cm. The note showed R4 was incontinent of bowel and bladder. Staff were to provide thorough skin care to R4 after each incontinence episode.A physician order for R4, dated 8/1/25, showed R4 was to have a urinary condom catheter in place.R4's current care plan identified R4's Stage 4 sacral pressure injury. The plan showed, Apply wound treatment as ordered by the physician. keep wounds clean and dry. The plan showed R4 wore a urinary condom catheter related to his urinary incontinence. The plan showed R4 was cognitively impaired and completely dependent on staff for all cares.On 8/18/25 at 10:01 AM, R4 was in bed. An odor of stool was noted in R4's room. On 8/18/25 at 10:24 AM, R4 remained in bed. An odor of stool remained in R4's room. At 10:25 AM, V8 Certified Nursing Assistant (CNA) was asked when she last did incontinence care on V4. V8 stated she had yet to provide incontinence care to V4 that morning. V8 stated, He was last changed on nights (before 7 AM). I haven't changed him yet today. I am waiting on wound care to come see him and I will change him then. At 10:36 AM, V8 CNA and V7 Wound Nurse entered R4's room to provide cares. V8 pulled down R4's brief. R4's brief was saturated with urine and a contained a large amount of mushy stool that had leaked out of the side's of R4's brief, onto the bed. R4's groin and buttocks were red. The bottom half of a large, rectangular adhesive dressing was no longer secured in place over R4's sacral wound. Stool was noted under R4's dressing. Stool was noted in R4's sacral wound. The skin noted around V4's sacral wound was red and excoriated with a moderate amount of bleeding noted from the skin around the wound. No condom catheter was noted on R4's penis or in R4's brief. V7 Wound Nurse stated R4 is really someone who needs to be monitored every two hours for incontinence because of his wound. We need to keep it clean and dry to prevent infection. V7 stated R4's sacral pressure dressing should be changed as soon as possible if found soiled. V7 stated any nurse can provide wound care treatments and dressings. On 8/19/25 at 10:24 AM, V7 Wound Nurse stated V4, has an order to wear a condom catheter to keep him dry and help his wound heal. He does try to pull it (catheter) off, but we need to try to keep applying it. He needs it. 2. R2's Skin and Wound Note dated 8/14/25 showed R4 had a Stage 2 pressure injury to his left heel, measuring 3.5 cm x 3 cm x 0 cm. The note showed a bordered foam adhesive dressing was to be in place, covering R2's left heel pressure injury, at all times.A physician order dated 6/24/25 showed R2 was to have a low air loss mattress in place as a pressure treatment intervention for R2.R2's weight record dated 8/11/25 showed R2 weighed 168.2 pounds (lbs).On 8/18/25 at 11:42 AM, R2 was in bed, lying on a low air loss mattress. R2's low air loss mattress was inflated however the mattress settings showed the mattress was programmed for a resident weighing 200 lbs, not 168 lbs. R2 wore no socks on either foot. No pressure injury dressing was noted to R2's left heel. On 8/18/25 at 1:25 PM, R2 was asleep in bed with no dressing noted to his left heel.On 8/19/25 at 8:31 AM, R2 was in bed. R2's low air loss mattress was still programmed for a resident weighing 200 lbs. A small band-aid was noted to R2's posterior left heel. When R2 was asked about the band-aid to his heel, R2 stated, They just put that on there this morning. I didn't have anything (dressing) on my (left) heel yesterday. On 8/19/25 at 10:24 AM, V7 Wound Nurse stated a low air loss mattress should be programmed to support an accurate weight of the resident because if the weight is off, the mattress could be to hard or soft. That won't help wounds heal or help prevent them. V7 stated R2 should have an adhesive dressing covering his left heel pressure wound at all times, not a band-aid. 3.R6's pressure injury risk assessment dated [DATE] showed R6 was at a high risk for developing pressure injuries. R6's current care plan showed pressure injury prevention interventions for R6 included for him to have a low air loss mattress and to offload his heels in bed with either a pillow or heel boots. R6's weight record dated 8/11/25 showed R6 weighed 196 lbs. On 8/18/25 at 9:25 AM, R6 was in bed on a low air loss mattress. R6's low air loss mattress was inflated however the mattress settings showed the mattress was programmed for a resident weighing 250 lbs, not 196 lbs. R6's heels rested directly on the mattress. No pillow was noted under his heels. Heel boots were noted on the window ledge in R6's room. On 8/19/25 at 8:24 AM, R6 was in bed. R6's low air loss mattress was still programmed for a resident weighing 250 lbs. R6's heels rested directly on the mattress. Heel boots were noted on a chair in R6's room. The facility's Skin Care Regimen and Treatment Formulary policy dated 7/3/25 showed, It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily. Residents with Stage III and IV pressure injuries will be placed on specialized air mattresses like Low Air Loss Mattress.

Based on observation, interview, and record review the facility failed to ensure a urinary catheter bag was maintained below the level of the bladder and failed to apply a condom catheter as ordered to 2 of 11 residents (R42, R4) reviewed for catheters in the sample of 30.The findings include:1. On 8/18/25 at 11:10 AM, R42 was in bed. V12 (Wound NP) and V7 (Wound Nurse) were in the room to perform R42's wound care. R42 was incontinent of stool. V17 and V19 both Certified Nursing Assistants (CNAs) were in the room to provide incontinence care. V19 (CNA) unhooked the catheter and handed the catheter over to V17 who was at the opposite side of the bed. V17 (CNA) then placed the catheter in bed beside R42 at hip level higher than the bladder. Both V17 and V19 then provided incontinence care while the catheter bag kept in bed at hip level. The catheter was half full of urine with urine backflow was noted. After incontinence care, V12 (Wound NP) performed wound assessments showing this surveyor R42's different wounds while catheter was still in bed hip level. On 8/19/25 9:30 AM, V7 Wound Nurse said the catheter bag should be placed below the level of the bladder for gravity and to prevent UTI. R42's care plan dated 7/22/25 under catheter shows, (R42) has indwelling catheter. Please Position catheter bag and tubing below the level of the bladder. The facility policy on Indwelling Catheter dated 6/30/25 documents, 7. Indwelling catheter bag will be positioned below the bladder region to prevent backflow. 2. R4's admission Record dated 7/24/25 showed R4 was admitted to the facility with diagnoses of respiratory failure and dementia. R4 was admitted with a tracheostomy and gastrostomy in place. A physician order for R4, dated 8/1/25, showed R4 was to have a urinary condom catheter in place. R4's current care plan identified R4's Stage 4 sacral pressure injury. The plan showed, Apply wound treatment as ordered by the physician. keep wounds clean and dry. The plan showed R4 wore a urinary condom catheter related to his urinary incontinence. The plan showed R4 was cognitively impaired and completely dependent on staff for all cares. On 8/18/25 at 10:36 AM, V8 CNA and V7 Wound Nurse entered R4's room to provide cares. V8 pulled down R4's brief. R4's brief was saturated with urine and a contained a large amount of mushy stool that had leaked out of the sides of R4's brief, onto the bed. R4's groin and buttocks were red. The bottom half of a large, rectangular adhesive dressing was no longer secured in place over R4's sacral wound. Stool was noted under the wound dressing. Stool was noted in R4's sacral wound. The skin noted around V4's sacral wound was red and excoriated with a moderate amount of bleeding noted from the skin around the wound. No condom catheter was noted on R4 or in R4's brief. On 8/19/25 at 9:26 AM V9 Certified Nursing Assistant (CNA) stated R4 did not have a condom catheter on. On 8/19/25 at 10:24 AM, V7 Wound Nurse stated V4, has an order to wear a condom catheter to keep him dry and help his wound heal. He does try to pull it (catheter) off, but we need to try to keep applying it. He needs it. The facility's External Condom Urinary Catheterization policy dated 1/14/25 showed, The facility will observe and implement the following procedures in the nursing management of a resident on condom catheterization in order to prevent urinary tract infection and skin breakdown for an incontinent episode. Nurse shall review that there is a physician's order in the resident's clinical record indicating placement of external urinary catheter.

Based on observation, interview and record review the facility failed to provide colostomy care to a resident as ordered and as per the resident's preference for 1 of 1 residents (R54) reviewed for colostomy care in the sample of 30. The findings include:R54's admission Record dated 7/9/25 showed R54 was admitted to the facility with a colostomy in place. R54's current care plan showed R54 had a colostomy in place due to an alteration in bowel. The plan showed, Perform ostomy care daily and as needed per physician's order. The plan showed R54 was cognitively intact. A physician order dated 8/9/25 showed R54's colostomy bag was to be changed by staff every 3 days. R54's August 2025 Treatment Administration Record (TAR) showed R54's colostomy bag was changed on 8/9/25. The TAR showed documentation that R54's colostomy bag was changed by V5 Licensed Practical Nurse (LPN) on 8/12/25. The TAR showed documentation that on 8/15/25, R54 refused to have her colostomy bag changed. On 8/18/25 at 9:49 AM, R54 was seated in a chair in her room with colostomy bag intact to her abdomen. R54 stated, My only issue is that I need to have my (colostomy) bag changed. It hasn't been done since I got back from the hospital (8/9/25). The skin around it is starting to itch and get irritated. It's gets emptied every day, but the bag and appliance should be changed every 3 or 4 days. I don't want it to leak. R54 stated she had never refused to allow staff to change her colostomy bag. On 8/19/25 at 1:03 PM, V5 LPN stated he never changed R54's colostomy bag on 8/12/25. When V5 LPN was asked why R54's 8/12/25 TAR showed documentation that he changed R54's colostomy bag, V5 LPN stated, I don't know. The facility's Colostomy Care policy dated 6/30/25 showed, It is the policy of this facility to perform proper ostomy care in order to prevent exposure of the resident's skin/stoma sites from fecal manner.The facility's Physician Orders policy dated 7/3/25 showed, 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.

Based on observation, interview and record review the facility failed to ensure the required volume of enteral feeding was administered for a resident with insidious weight loss for 1 of 8 residents (R10) reviewed for nutrition in the sample of 30. The findings include: R10's face sheet shows she has diagnoses including Alzheimer's Disease, moderate protein-calorie malnutrition, and gastrostomy placement.R10's Enteral Feeding care plan initiated on 7/20/23 shows she requires enteral feedings via a Gastrostomy tube as her sole source of nutrition.R10's Weight Summary shows the following: On 4/3/25 she weighed 121 lbs. Additional monthly weights show she began to have trending weight loss as follows: On 5/4/25 she weighed 119.8, on 6/5/25 she weighed 117.6, on 7/7/25 she weighed 115.8.A Dietary note completed by V11 (Registered Dietician) on 4/3/25 shows that R10 has had weight loss after a desired weight gain. V11's note also shows R10's Jevity 1.5 (enteral feeding) should be increased from a total volume of 560 ml. to a total volume of 630 ml. (milliliters) at a rate of 35 ml. per hour until the total volume has infused.R10's Physicians Order Summary (POS) and Medication Administration Summary (MAR) both show active orders for Jevity 1.5 at a rate of 35 ml/hr. start at 7:30 PM and infuse until 560 ml total volume is reached per day turn off during ADLs PRN (as needed). The most recent order dated 4/3/25 shows Jevity 1.5 rate 35 ml/hr. infuse until 630 ml. total volume has infused turn off for feedings and during ADL's and PRN. R10's MARs from April through August 2025 show both of the Jevity orders were still being signed off as being given. On 8/19/2025 at 9:50 AM, V11 said she did increase R10's enteral feedings in April 2025 to a total volume of 630 ml.On 8/19/25 at 11:10 AM, V10 (Nurse Practitioner) said a resident on tube feeding should not lose weight if the required tube feeding amounts are administered.On 8/20/25 at 8:27 AM, R10's tube feeding was hanging at her bedside infusing at 35 ml/hr. The mechanical pump showed that 430 ml. had infused and 130 remained to be infused. The tube feeding bag showed the Jevity was hung at 7:30 PM on 8/19/25. On 8/20/2025 at 8:29 AM V3 (Director of Nursing) went into R10's room with this surveyor and verified that the amount administered was 430 ml and the remaining amount to be administered was 130 making the total 560 ml. On 8/20/25 at 10:50 AM, V3 said when the new order for R10's Jevity was received the old order should have been discontinued and they should only follow the current Jevity order (630 ml.).

Based on observation, interview, and record review the facility failed to ensure medications were supervised a resident during medication administration. This applies to 1 of 30 (R26) in the sample of 30 reviewed for medications at the bedside.The findings include:On 8/18/2025 at 9:37AM, R26 had a medication cup on her bedside table in front of her with multiple unknown medications in the cup.On 8/18/2025 at 9:37AM, R26 stated staff leave medications on my table when I'm sleeping.On 8/18/2025 at 9:39AM, V20 Licensed Practical Nurse (LPN) said nurses stay with the residents every time to make sure the resident takes the medication and for safety reasons like choking. V20 said none of her residents can self-administer medications. V20 said she is [R26's] nurse. V20 said she doesn't know where the medications came from, and she didn't pass medications to [R26] yet. V20 said they could be medications from night shift.R26's current Care Plan dated 7/29/2025 doesn't list R26 as being able to self-administer medications.R26's Order Summary Report active orders as of 8/18/2025 does not list R26 as being able to self-administer medications.

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's Face Sheet printed on 6/11/25 showed R1 was [AGE] years old and had the diagnosis of lack of coordination and had an abnormal gait. The May 2025 Incident report had R1's name listed with a date of 5/29/25. R1's Progress Note dated 5/29/25 showed R1 had an unwitnessed fall and found next to her bed. R1's Care Plan with a last reviewed date of 5/19/25 showed R1 was at high risk for falls. Listed under interventions was to provide floor mats at bedside. On 6/11/25 at 9:10 AM and 1:26 PM, R1 was in bed. There were no floor mats in place. No floor mats were visible in R1's room. On 6/11/25 at 1:19 PM, V12 (Restorative Nurse) said after a fall occurs, they do an investigation and come up with fall interventions. V12 said the interventions are listed in the care plan. V12 added the care plan interventions should be in place.

Based on interview and record review the facility failed to ensure a resident was repositioned safely. This failure resulted in R1 sustaining a intertrochanteric (thigh/femur/hip bone) fracture that required an open reduction surgery. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 12. The findings include: On November 23, 2024 at 1:08 PM, R1 stated, V11 Certified Nursing Assistant (CNA) came to her room to change her multiple times. She refused to have V11 change her because she felt like she was rough with her. She refused to be changed two times. The third time, V11 CNA told her she was going to get changed and threw her legs over the rail and she heard a pop. After that she had pain in her left leg. She stated, she (V11) would not listen to nothing. Told her don't touch me and no, thank you. Now, I have to suffer for my hip fracture and have surgery. I might not be able to walk again. R1 started crying and gave the phone to her daughter (V3). R1's local hospital records dated November 21, 2024 shows, General: Admission H&P (history and physical): History of present illness: R1 is a 60F ([AGE] year old female) w PMH (with a past medial history of) GERD (gastroesophageal reflux disease), OSA (obstructive sleep apnea), bipolar 1, HTN/HLD (hypertension/hyperlipidemia), asthma, hip replacement 8/17 with V14 c/b (complicated by) recurrent prosthestic left hip joint infection w recent discharge on 11/13, discharged on vancomycin and cefepime (both antibiotics), pw (patient with) left hip pain. She was at the facility receiving antibiotics and stated that one of the staff was too rough with me when changing my diaper and felt a pop in the area, reporting pain in the left hip . Assessment & Plan: .Stated she was handled roughly by staff and heard a pop in her joint. XR (x-ray): Left revision total hip arthoplasty with acute comminuted periprosthetic fracture of the left intertrochanteric region as described . On November 23, 2024 at 3:38 PM, R12 (R1's room mate) stated, she woke up to R1 having a problem with someone. R1 was upset because they hurt her while turning her. It had to do with her being moved in bed. Apparently whatever the CNA did added to her pain. R1 complained of pain the next day. Then she left to the hospital. I was under the impression she was in more pain than normally. On November 24, 2024 at 9:05 PM, V11 CNA stated, she worked November 19th on the night shift (into November 20th morning). That night she went to R1's room to change her and R1 stated no. She went back again and told her no again. The third time she tried to change her, R1 told her no, don't touch me. She denied ever changing her or touching her that night. R1's task list for November 19, 2024 shows, she was incontinent during the night shift. R1's change in condition form dated November 20, 2024 shows, Situation: patient is complaining of pain anytime you move the left leg. On November 26, 2024 at 11:04 AM, V13 Physician Assistant (PA) stated, he is part of R1's surgery team. R1 originally broke her left hip and had surgery back in August. She had an infection in the hip so they placed a cement spacer. She was sent to the facility following that cement spacer placement. They had followed up with her after and re-did x-rays, there was no fracture. When she came into the hospital this time she claimed staff was aggressive with her, twisted her leg and she heard a pop. The x-rays showed a fracture. She had surgery for an open reduction the day before (November 25th) with him. The fracture is caused by a twisting torsion type of injury. The only way to get the fracture is by twisting the leg. On November 24, 2024 at 9:50 PM, V15 Assistant Administrator stated, R1 told her V11 CNA tried to change her 3 times where she told her no and on the third time, she changed her. She moved her and heard a pop in her leg. V11 CNA, swears R1 refused to be changed three times. The facility's SNF/NF (skilled nursing facility/nursing facility) to hospital transfer form dated November 20, 2024 shows, R1 is dependent on staff for all ADL's (activities of daily living) and is incontinent of bowel and bladder. R1's minimum data set (MDS) shows, she is cognitively intact. R12's (R1's room mate) minimum data set (MDS) shows, she is cognitively intact. R1's care plan initiated on November 14, 2024 shows, Focus: R1 has an ADL Self Care Performance Deficit and Impaired Mobility r/t (related too) weakness, impaired balance, impaired balance and pain, therefore requires weight bearing assist with bed mobility, transfer, toileting, dressing, locomotion and walking. Comorbidities include: Infected left total hip Arthroplasty, AKI (acute kidney infection), Hypercalcemia, Anemia, Bipolar, HTN, Asthma, Obesity and OSA. Interventions: I would like staff to provide gentle range of motion as tolerated with daily care. BED MOBILITY: R1 use(s) assistive device (bed rails) to reposition and turn in bed. TOILET USE: [NAME] require(s) Max. staff participation to use toilet. The facility's resident council minutes for the month of September 2024 shows, Nursing/CNAs: Residents had some concerns about CNAs professionalism. Resident expressed 3rd shift is rough at times. CNAs tends to just get in and get out of rooms.

Based on interview and record review the facility failed to provide ongoing assessments for a resident who had an injury of unknown origin on 7/3/24. R1 remained at the facility until he was sent to the emergency roiagnom on [DATE] for abnormal behavior. This failure resulted in R1 having a mildly impacted and angulated left femoral neck fracture and deep venous thrombosis for 1 of 3 residents reviewed for a change in condition in the sample of 6. The findings include: The Nursing Daily Evaluation dated 7/3/24 for R1 showed R1 was wincing when being changed. The nurse practitioner was notified. An order for an x-ray to both hips was received and completed. The Nurse Practitioner Note dated 7/3/24 at 11:12 AM for R1 showed, R1 seen and examined in his room, per nurses, he has not been at his baseline lately as he is usually seen walking in halls. Per staff, resident noted to be wincing when leg is touched. On exam, resident noted to be rubbing along his left lateral and anterior thigh. He does show some discomfort with palpation to left upper leg. Plan to order x-rays and follow up. The eMAR (electronic medication administration record) note dated 7/3/24 at 5:14 PM showed R1 was given 1000 mg of Tylenol Extra Strength. The X-ray (radiography) dated 7/3/24 for R1 showed, faintly visualized linear sclerotic opacity of the neck of the left femur - suspicious for a stress fracture in the appropriate clinical setting. Mild degenerative arthritic changes are seen in both hip joints, left greater than right. The bony mineralization and the visualized portion of the pelvis are unremarkable. The Progress Note dated 7/3/24 at 6:59 PM for R1 showed, medical doctor/nurse practitioner is aware of x-ray results to both hips. Left his is suspicious of a stress fracture. Order for orthopedic consult. Need consult as soon as possible, Tylenol PM given at 5:00 PM. R1's Progress Notes/Nurse's Notes from 7/4/24 - 7/7/24 did not show any assessments of R1's left leg. The facility did not have any Nursing Daily Evaluations for R1 from 7/4/24 - 7/7/24. The SBAR (situation background assessment and response) Note dated 7/8/24 at 11:50 AM for R1 showed, patient behavior noted not at baseline. V6 NP (Nurse Practitioner) notified of change and ordered patient to be sent out to ER (emergency room ) for further evaluation. The Progress Note dated 7/8/24 at 7:50 PM for R1 showed he was admitted to the hospital for a closed left hip fracture. The Emergency Department Doctor's Note dated 7/8/24 showed, R1 presented to the emergency department with the complaint of not being able to walk where he is usually very ambulatory. Per emergency medical services report he has been in bed for the last 4-5 days. About a week ago he had difficulty with transitions per wife, and now he has not been able to get up at all and likes to lay on his right side. The patients baseline mental status limits his ability to communicate and give an appropriate history. He does call out in pain when his left hip and knee is palpated or moved in any way. The hospital X-ray dated 7/8/24 for R1 showed, mildly impacted, and angulated left femoral neck fracture. The Orthopedic History and Physical Note dated 7/8/24 for R1 showed, found to have a left femoral neck fracture; has been bed bound for about a week. Patient lying in bed, left hip rotated, and pain to left hip. Decision made to proceed with surgery. Assessment/Plan: admit to orthopedics, bedrest until surgery, non-weight bearing to left lower extremity, pain management, venous doppler of lower extremities (prolonged bedbound, not on deep venous thrombosis prophylaxis), medical per-operation evaluation and risk stratification, and preoperative for surgery (done). The Orthopedic Surgery Note dated 7/8/24 for showed, patient (R1) seen in hospital room with wife at bedside. R1 with severe dementia, does not recognize wife or where he is. Appears anxious, scared. Unable to provide history but grimacing on attempt to passively move left leg. Assessment and Recommendations: admitted to hospital for hip pinning The Operative Report dated 7/10/24 for R1 showed he had an open reduction and internal fixation of the left femoral neck fracture. R1's Vascular Imaging Studies dated 7/9/24 showed, acute occlusive vein thrombosis of the popliteal vein, gastrocnemius vein and peroneal vein. Acute partially occlusive vein thrombosis of the mid to distal femoral vein. The Vascular Medicine Consult dated 7/11/24 for R1 showed, on 7/8/24 presented from Memory Care after staff reported that, patient usually ambulatory; but has been bed bound and moans in pain x 10 days when his leg is moved/touched. Last time the patient was seen walking was 6/28/24 of note, the patient has been living at the nursing home since 9/2023 due to his Alzheimer's, had a fall episode 2 months ago but was able to ambulate until 6/28 per wife (V4). Hip x-ray on 7/3 at the memory care reportedly showed a fracture leading to his emergency department visit on 7/8. In the emergency department, CT (computerized tomography) of the hip (7/8) showed angulated left femoral neck fracture. Subsequently, he was admitted for hip ORIF (open reduction and internal fixation) procedure, which he underwent on 7/10. On 7/9, bilateral lower extremity dopplers obtained and showed acute left lower extremity deep venous thrombosis. Vascular medicine service consulted to assist with anticoagulation management. On 7/9/24 an IVC (inferior vena cava) filter placed per vascular medicine recommendation. On 7/30/24 at 11:20 AM, V5 (Licensed Practical Nurse/LPN) stated on 7/3/24 the CNAs (certified nursing assistants) were changing R1 and when they were moving him, he was wincing. V5 stated she was there to see R1, and he was uncomfortable. When they would go to turn R1 he was uncomfortable. V5 stated she talked to V6 (NP) and the doctor. V5 stated she did not document an assessment. V5 stated she should do an assessment when they see something new or different; she should at least do that. V5 stated assessments can be documented in the general progress notes. V5 stated R1 normally walked around; that day he wasn't getting up for us. That wasn't normal. V5 stated the NP wanted an orthopedic consult. V16 (Unit Secretary) schedules the appointments. V5 stated she would continue to assess r1 for pain after that and he was fine if he was still but if he was moved, he had pain. V5 stated they should do physical assessments and see if R1 was in pain. On 7/30/24 at 11:50 AM, V4 (R1's wife) stated she was with R1 on 6/25/24 and he was fine. When she saw R1 on 6/28/24 he wasn't fine. R1 was sitting in his roommate's bed, and she could not get him to his bed. V4 stated the CNA (Certified Nursing Assistant) helped her and they pushed the beds together as close as they could to get R1 into his bed. On 6/28/24 at around 6:00 PM, the CNA said R1 wouldn't walk that day. V4 stated she wasn't at the facility on 6/29/24. On 6/30/24 when she came in to see R1 he was laying on his right side and he would yell out when they would change him. R1 maintained that pattern of laying on his right side and was not eating as well. On 7/3/24 R1's x-rays came back, and the nurse said it was a hairline fracture. V4 stated she kept coming in and R1 was the same, so she doesn't know what prompted the facility to take R1 to the hospital on 7/8/24. R1 yelled in pain when rolling him and he did not get out of bed during that time from 7/3/24 - 7/8/24. At the ER (emergency room ) the nurse wanted an x-ray of R1's left knee; it was swollen when he went there. They said he must have a blood clot. R1 was admitted to the hospital and was sent to another hospital where they could do orthopedic surgery. On 7/30/24 at 2:39 PM, V12 (CNA) stated she was told R1 had a stress fracture then he had another test and that said he had a hip fracture. V12 stated R1 would normally get up with one assist for activities of daily living. R1 would walk around. One day she came in for her shift and R1 was lying in bed and did not want to get up. V12 stated after 7/4/24 she noticed when they would touch his leg he would scream. On 7/8/24 R1 had pain just on touching him so her and her partner told the nurse. V12 stated R1's son and wife even said R1 did not want to be touched. That had been going on since 7/4/24, but 7/8/24 was the day they sent him out. On 7/31/24 at 9:21 AM, V6 NP (Nurse Practitioner) stated, on 7/3/24 R1 had an x-ray done because before that date he was walking and then stopped walking. V6 stated the nurse told him that the night before on 7/2/24 R1 was rubbing his leg. V6 stated he discussed it with the nurse and ordered an x-ray to be done on 7/3/24. V6 stated either on 7/3/24 or 7/5/24 the results of the x-ray came back and showed a suspected left proximal femur fracture. V6 stated he put in for an urgent orthopedic evaluation, Tylenol, and ice packs. V6 stated there weren't any fall reports. V6 stated he saw R1, and he was laying on his right side. R1 could extend his left leg partially but not fully. The orthopedic consult was put in as urgent. Usually, we put in for the consult and the facility sets up the appointment. V6 stated he did not hear any follow up with that. V6 stated he wanted it done as soon as possible. V6 stated the nurses should be checking R1's vital signs, assess his leg, and assess for pain. Vital signs should be done every shift. An assessment of the leg every shift and during the shift. V6 stated it was important to assess because of a suspected fracture, to see if there are any changes and/or increased pain. V6 stated he went to assess R1 closer on 7/8/24 and he did not look comfortable. V6 stated he felt R1 needed to be assessed further for a fracture. V6 stated he saw swelling to R1's leg and he had not received any reports from staff that R1 had swelling. V6 stated what could have been done differently would have been closer assessments and checking on R1 more often, then notify of any little changes in his assessment that the staff find. On 7/31/24 at 11:23 AM, V3 (Director of Nursing/DON) stated R1 was a resident that would normally be up walking around. On 7/1/24 R1 had a temperature, they called his wife, had lab work and urine collected. R1's lab work and urine came back normal. On 7/3/24 R1 was wincing when being changed so the NP ordered an x-ray. The results came back at 6:00 PM with a stress fracture. The nurse tried to reach the doctor who did not respond. The nurse called the NP who gave an order for an orthopedic consult. We called and the appointment was made for 7/10/24 at 9:15 AM. In the meantime, we tell the staff to monitor him. The NP said to notify him of any change in condition. V3 stated the only way to know if there is a change in condition is to assess. The nurses can document in the progress notes or an SBAR (situation background assessment and response). Take vitals at least once a day. V3 stated there wasn't any nurse's notes/assessments for R1 from 7/3/24 - 7/8/24. V3 stated she is counting on them to do assessments and document. V3 stated they must assess thoroughly. V3 stated she saw R1 had a blood clot when he went to the hospital; if staff had been assessing R1 they would have caught it. V3 stated staff must assess, document the assessment and let the doctor or NP know. The Face Sheet dated 7/31/24 for R1 showed diagnoses including fracture, osteoarthritis, acute embolism and thrombosis, depression, insomnia, dementia, dysphagia, unsteadiness on feet, metabolic encephalopathy, anxiety disorder, and Alzheimer's disease. The MDS (Minimum Data Set) dated 5/20/24 for R1 showed severe cognitive impairment; supervision or touching assistance for rolling left and right, sit to lying, lying to sitting, transfers, and walking 150 feet. The facility's Notification Procedures for Change in Resident Condition policy (1/14/24) showed, the charge nurse or nurse supervisor will notify the resident's attending physician or covering physician when there has been; a significant change in the resident's physical, emotional/mental condition. Significant change in medical treatment or plan of care. SBAR (situation background assessment and response) communication form and progress note - documentation tool that guides the licensed nurse through structured evaluation of change in condition by facilitating structured and systemic communication with the resident's attending physician. The policy did not show any procedure for ongoing assessments after a change in condition. The Facility's Incident/Accident Procedures policy (8/20/23) showed, an accident or incident report must be completed by the nurse for all incidents/accident including injuries of unknown source. Assess all accident/incident patients for signs and symptoms of injuries. Assess for pain and manage accordingly. Notify the patient's attending physician and family/next of kin or guardian of the accident or incident. Transfer patient to the hospital as medically necessary when ordered by the physician.

Based on observation, interview, and record the facility failed to supervise a resident who was at risk for falls due to history of falls and failed to put specific fall intervention in place to prevent further falls, this failure resulted in R3 sustaining a nasal fracture and left forehead lacerations requiring stitches for 1 of 3 residents reviewed for falls in the sample of 6. The findings include: R3's face sheet show R3 is 76 y/o with diagnoses that include chronic venous hypertension, kidney failure and heart disease. R3's fall risk assessment dated [DATE] shows R3 is HIGH risk for falls. A Facility Reported Incident dated 3/22/24 (initial) show, At 1 pm, NOD (Nurse on duty) responded to a call for help from the room. Resident noted lying face down on then floor with wheelchair behind her. No loss of consciousness. Resident alert and oriented and verbally responsive. Residents states that she dropped something on the floor and wanted to pick it up, but resident unable to recall what item. Rapid response and 911 called. Resident noted with lacerations on left eyebrow, bridge of nose, left elbow, and left foot. Pressure applied to all areas, ice pack in place. R3's Hospital Records dated 3/22/24 show, pt arrives (from nursing home) c/o (complaint of) fall out of wheelchair, states she was reaching for something on the floor , reached too far, lost her balance and fell out of w/c striking face onto floor, laceration to forehead, skin tear to left elbow . CT scan of face results dated 3/22/24: bilateral acute nasal bone fracture. There is a laceration and small to moderate-sized soft tissue swelling involving the left forehead . diagnoses,complex laceration of left eyebrow, contusion of face, skin tear left elbow. R3's Hospital discharge instructions show, you have a bilateral fractured nasal bones and laceration above left elbow. Sutures will need to be removed in 7 days. R3's progress notes dated 3/22/34 show, x-rays- nasal bone fracture, R3's laceration above the left eye has 6 sutures in place, sutures have to be removed in 7 days. On 3/25/24 at 9:30 AM, R3 was in bed alert. R3 has deep dark purple bruising from the top of her forehead to underneath both of her eyes to her nasal area. There was stitches noted above her left eyebrow. When asked what happened, R3 said she was in her wheelchair, she thought something was on the floor so she leaned forward and fell . R3 said that was all she can remember. On 3/25/24 at 12:30 PM, V9 (License Practical Nurse-LPN) said she was the Nurse working last 3/22/24. V9 (LPN) said it happened around lunch time. V9 said R3 was found facedown on the floor, her wheelchair behind her. There was poll of blood around R3's head. R3 had fallen forward from her wheelchair. V9 said 911 was called and R3 was sent to a local hospital. V9 said R3 had a fall last month, (R3 fell out of her wheelchair inside her room reaching for something.) V9 said R3's room is in the middle of the hallway, far from the Nurses Station where staff usually are. R3's room cannot be seen when in the Nurses Station so R3 cannot be supervised. V9 said there was also no device to alert staff when R3 was trying to reach too far when in her wheelchair to prevent her from falling forward. R3's fall careplan dated 2/2/24 show R3 is high risk for falls due to recent fall, poor safety awareness, impaired balance due to disease process. She has a habit of reaching/bending down to obtain items from the floor despite education and redirection. She requires max weight bearing assistance with bed mobility, transfers locomotion and toileting. She is noted to experience dizziness when changing position. She utilizes wheelchair as a primary mode of locomotion at this time. R3's fall interventions did not address R3's behavior of reaching/bending until today, 3/25/24 when surveyor was at the facility investigating R3's fall. The facility policy dated 7/1/7/23 entitled Fall Occurrence show It is the policy to ensure that residents are assessed for risk for falls, that intervention are reevaluated and revised as necessary. On 3/25/24 at 1PM, V2 (Director of Nursing) said they will be looking for R3's room placement and ways for R3 being monitored closer.

Based on observation, interview and record review the facility failed to ensure a mechanical lift (Hoyer) was used to safely transfer a resident to bed for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being sent to the hospital with a laceration to her right posterior thigh that required 9 stitches after being transferred with a sit to stand lift. The findings include: R1's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of end stage renal disease, lack of coordination, hypotension, dependence on renal dialysis, anemia, abnormalities of gait, abnormal posture and bradycardia. R1's Minimum Data Set assessment dated [DATE] shows that R1 requires substantial/maximal assistance to roll from left to right and is dependent on staff to move from sitting to lying, lying to sitting on side of bed, sit to stand and chair/bed to chair transfers. On 1/24/24 at 10:17 AM, R1 was laying in bed. R1 had a bandage to her right mid-posterior thigh. R1's Facility Incident Report dated 1/20/24 shows, On 1/16/24 around 5:00 PM patient was being transferred from the wheelchair to the bed with the sit to stand machine, her right knee buckle and she slid down during transfer. The patient did not make contact with the floor. Patient slid down by the bed where she was laid back down. When asked what happened, the patient stated that her legs became weak suddenly. Bleeding was noted on her pants, on the posterior right thigh skin tear was noted on the posterior right thigh ordered to send patient to ER (emergency room ) for further evaluation and treatment. Patient returned to the facility within couple of hours with stitches present on right posterior thigh. R1's After Visit Summary from the local hospital dated 1/16/24 shows a diagnosis of: laceration of right lower extremity. R1's Wound Assessment Details Report dated 1/17/24 shows R1 has a wound on the right posterior thigh measuring 9 centimeters (cm) x 7 cm x 0.2 cm with 9 stitches present. R1's Change in Condition Form dated 1/16/24 shows, the patient had a skin tear during the sit to stand transfer machine, the patient was sent out due to skin tear needing stitches, before ambulance transferred patient to ER, PRN (as needed) pain medication was administered . R1's Medical Professional Progress Note dated 1/17/24 shows, She was sent from the facility due to buckling of the knees and obtained a deep laceration to her left thigh. Per hospital records, stitches were placed . On 1/24/24 at 1:34 PM, V10 (Nurse Practitioner) stated she heard about the incident with R1. V10 stated that she heard R1's knees buckled during a transfer and obtained a laceration on her right thigh that required sutures. V10 stated she is not aware of what R1's transfer status was at the time of the incident but the staff should be following whatever therapy recommends for a safe transfer. On 1/24/24 at 11:57 AM, V5 (Certified Nursing Assistant) stated that she was transferring R1 from her wheelchair to the bed using a sit to stand lift when her legs started giving out. V5 stated when they got her into bed, they noticed blood coming from the back of her pants. V5 stated she and V8 (Licensed Practical Nurse) took down her pants and noticed a skin tear. At 2:30 PM, V5 stated she checked with the patient and the nurse on how R1 transfers, and they both said a sit to stand so that is what she used. On 1/24/24 at 12:08 PM, V8 stated that he was assisting V5 with a sit to stand transfer of R1. V8 stated during the transfer, R1's right leg buckled a little bit. V8 stated R1's feet did stay on the base of the machine, but he is not sure that her knees stayed up against the machine. V8 state, She just slid a bit. On 1/24/24 at 12:58 PM, V9 (Therapy Director) stated if a resident is in physical therapy, the therapy department communicates with the nursing staff to let them know how a resident is able to safely transfer. V9 stated R1 has been a mechanical lift (Hoyer) transfer since her admission and therapy had just started working with her on safely using the sit to stand lift. V9 stated R1 just started using the sit to stand lift with the therapist on 1/12/24. V9 stated the sit to stand was used on 1/12/24 but was not attempted during her therapy sessions on 1/14/24 and 1/15/24. V9 stated the nursing staff should have been using the mechanical lift (Hoyer) to safely transfer R1 since they had not given the recommendation to the nursing staff to upgrade her transfer status to a sit to stand. V9 stated R1 still has days that she is weaker, especially on her dialysis days. On 1:48 PM, V2 (Director of Nursing) stated physical therapy or restorative therapy if they are in therapy can upgrade a resident's transfer status. V2 stated the departments communicate with the nursing staff on what way the resident is able to transfer safely. R1's Fall Care Plan initiated on 12/18/23 shows R1 transfers between surfaces using a mechanical lift (Hoyer) due to fear of falling. Interventions include PT/OT (physical therapy/occupational therapy) to treat as ordered to increase strength and mobility and prevent further falls.

Based on interview and record review the facility failed to provide ongoing assessments for a resident after an incident for 1 of 3 residents (R1) reviewed for change in condition. This failure resulted in R1 experiencing a delay in acute care treatment and treatment for pain after sustaining a left hip fracture. The findings include: R1's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, dementia, psychotic disorder, dysphagia, neuromuscular dysfunction of bladder, atherosclerotic heart disease, contracture, major depressive disorder, hemiplegia, and osteoarthritis of knee. R1's facility assessment dated [DATE] showed he had moderate cognitive impairment and required extensive assistance from staff for all cares. R1's February 2023 Physician Order Sheet showed a current order for Pain Assessment: Numeric Scale (0 = No Pain; 1 to 3 = Mild Pain; 4 to 7 = Moderate Pain; 8 to 10 = Severe Pain) every shift. R1's Nursing Note dated 2/25/23 at 6:00 PM showed, Received a call from [acute care hospital] at 5:51 PM, resident will be admitted . Diagnosis: left hip fracture . There were no progress notes between 2/6/23 and 2/25/23 note showing R1's admission. There were no progress notes entered in R1's record indicating the reason R1 was sent to the hospital. R1's complete medical record was reviewed and showed no evidence of any nursing assessments being completed for R1 during the month of February. R1's 2/25/23 Change in Condition form completed by V8 (Licensed Practical Nurse/LPN) showed, At around 10:00 AM, during patient care, nurse on duty went to resident room to give medications. Resident complained of pain to left groin. When tried to assess his left leg and groin, resident refused. Resident verbalized pain 8/10. Tylenol 1000 mg given. [Primary Physician] was informed at 10:21 AM and ordered to send the resident to the hospital for evaluation . R1's February 2023 eMAR (electronic Medication Administration Record) showed an order for Tylenol 500 mg, Give 2 tablets by mouth every six hours as needed for pain or fever. The only dose of Tylenol given during the month of February was documented at 10:05 AM on 2/25/23. On 3/1/23 at 1:09 PM, V8 (LPN) said, Last Thursday (2/23/23) around 9 PM I was doing medication pass when V9 (Certified Nursing Assistant/CNA) came up to me and said they were changing [R1] when they heard something 'pop'. I went in and asked him about pain, and he told me he did not have pain. I went back at the end of my shift because I was worried about him. At the end of my shift I told the oncoming nurse what happened and asked the CNA to explain to the oncoming nurse what happened also. I did not work on Friday (2/24/23). On Saturday morning the same CNA [V9] who was working with me on Thursday came up to me and told me R1 was still in pain. I went into R1's room and he said 'don't touch me'. I asked if he was still having pain and he pointed to his leg/groin area and said his pain was an 8 (Pain scale 1-10). I contacted the doctor, and R1 was sent to the emergency room . He would not allow me to assess his leg, which is why I messaged the doctor right away. On 3/1/23 at 2:20 PM, V9 (CNA) said she was assisting to change R1's incontinence brief when R1 became very combative. V9 said R1 flails his arms, curses, and calls staff names. V9 said they heard a noise, so they stopped changing his brief and went to get V8 (LPN) to check on him. V9 said she was concerned about him, so she checked on him again before she left after her shift. V9 said she explained to the nurse coming onto the shift what happened before she left. V9 said on Saturday morning (2/25/23) she went into R1's room to try and change his incontinence brief and she could not change it because he was 'getting too crazy' with her. V9 said she went and told V8 (LPN) that R1 would not allow her to change his brief. V9 said R1 is always combative verbally but they are usually able to distract him and get it done. On 3/1/23 at 1:27 PM, V10 (CNA) said he was working Thursday (2/23/23) and was changing R1's incontinence brief with V9 (CNA). V10 said while they were changing R1's incontinence brief, R1 got combative, and they heard something crack or pop. V10 stated, We stopped and got the nurse. It was the first time we heard something like that while changing him. V10 said he worked Friday, and he was able to change R1 but they were careful to make sure they turned him on the other side. V10 said R1 did not complain of pain to him on Friday (2/24/23) but said to leave him alone which is a normal behavior for him. On 3/1/23 at 3:00 PM, V14 (LPN) said she worked Friday 2/24/23 starting at 7:00 AM. V14 said R1 did not express that he was having pain. V14 said she does not know much about the resident because she does not usually work on his hall. V14 said she gave him his medications and he took them. V14 said she did not assess R1 on Friday and she did not ask him if he was having pain. On 3/1/23 at 2:52 PM, V11 (CNA) said she worked Friday 2/24/23, and she was assigned to R1. V11 said, He was in a lot of pain. He said he could not turn on his side because he was hurting. We could not turn him at all because he would yell out in pain. We talked to V12 (LPN) because she came in the room because he was yelling. V12 acted like it was not unusual for R1 to do this, but I have taken care of him frequently before this and this was different. On 3/2/23 at 9:00 AM, V12 (LPN) confirmed she worked on 3rd shift on Thursday night. V12 said the nurse before her told her to keep an eye on R1, but there was nothing new. V12 said it is normal to be told in report to monitor everyone because of the kind of hall it is. V12 said the only thing she knows is that R1 did not complain of pain to her and his yelling out is not new to her. When V12 was asked about entering R1's room because she heard him yelling, she stated that this maybe happened. V12 said, I went in to calm him down. It seemed like regular behavior. I told him if the pain is really not going away, I will send him to the hospital. He said 'no stop, don't touch me'. I'm not ignoring what he is saying but if he is saying he really has pain and wants to go to the hospital I would send him. The pain assessments I do is I go in their room and ask 'How are you doing? How's your day? Is there anything you want to say?' I have a regular conversation with them. They say nothing. On 3/2/23 at 9:34 AM, V17 (CNA) said, I had R1 last Friday on 3rd shift. He is normally combative, but if you give him a different approach it takes his mind off of being changed. That day I did go to change him, but he was screaming that his leg hurt. I asked another CNA to come help so we could roll him the other way. I think it was his left leg, because he always has that one bent. I looked at it and tried to touch it with my finger, but he kept screaming. I told him it might feel better if we straighten that leg out, but it didn't work. He was hitting us saying 'please don't'. I told the nurse [V12] that he was screaming. I let her know so she could see him. I told her he was refusing care. He does always get upset during care, but this time the screaming was different. I was just taking off the covers and he was screaming. I knew it was probably something else (not behaviors). He was screaming so loudly you could hear him outside the door, at the top of his lungs. I told V12 that R1's leg was hurting, he was refusing care, and screaming, she said 'ok, thanks for letting me know'. On 3/1/23 at 3:41 PM, V2 (Director of Nursing/DON) said the nurse called her on Saturday morning to let her know R1 was in pain. V2 said she asked the nurse what happened, and she told her while the CNAs were doing cares on Thursday R1 started getting combative and they heard 'something.' V2 said R1 is different for the nurses than the CNAs because R1 does not like to be touched and the nurses don't have to touch him very much since they are passing his medications. V2 said the timeframe for pain assessments is not specific, but vitals are done every shift. V2 said pain is documented on the eMAR when a PRN pain medication is given. V2 said R1 is able to give a pain level if he is asked. V2 said if the nurse is notified of a resident having pain, she would expect an assessment be documented. V2 said since V12 works that hall all the time he may have assumed this was just his normal behavior. On 3/2/23 at 3:14 PM, V18 (Nurse Practitioner) said, I was not notified of R1 having anything happen with him during care. I was told he sustained a fracture and went to the hospital. They should have notified myself or the primary care physician when the resident was complaining of pain. There should have been an assessment done when the injury first occurred, and once he started complaining of pain it should have been charted and assessments completed. If I had been notified that he had an incident during care which the aides heard a pop and he was complaining of pain, I would have ordered diagnostic tests to be done. The facility's policy and procedure revised 7/28/22 showed, Policy Name: Pain . Policy Statement: It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain, For pain complaints and for situations/incidents that might result to pain (ex: fall incident, altercation, cute, bruises, wound care, etc.) the nursing staff may document it in any part of the resident's medical record that includes nurses notes, incident report, and medication administration record . Procedures: 1. After the administration of PRN (as needed) pain medications, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer the lack of relief . The facility's policy and procedure revised 7/28/22 showed, Policy Name: Notification for Change of Condition . Policy Statement: The facility will provide care to residents and provide notification of resident change in status. Procedures: The facility must immediately 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. An accident involving the resident which results in injury and has the potential for requiring physician intervention; b. A significant change in the resident's physical, mental, or psychosocial status .

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse for 1 of 6 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 sustaining a large hematoma and being hospitalized . The findings include: The facility's Incident Investigation Report dated 3/11/22 shows R2 was found on the ground in the dementia unit and that she may have been pushed by R1. A head-to-toe was completed on R2 with some swelling noted on back of head and resident complains of headache and pain in left hip R2 will be sent out for evaluation and x-rays of head and hip. R2's Progress Notes dated 3/11/22 shows R2 was pushed by another resident and hit her head on the wall. Resident also fell on the floor and complained of left hip pain. 911 was called and patient was sent to the hospital ER. On 3/16/22 at 12:43 PM, R2 stated I was attacked by someone. She wanted to get to the toilet. I said please wait till I get away from the door, but she punched me. I was unaware it was coming, I fell down here (R2 points to her left hip). The second day was rough I thought I was going to die, my legs were shaking, and I couldn't stand. I have had difficultly with that person before, she is mean to me and called me an animal. On 3/16/22 at 12:50 PM with V5 Licensed Practical Nurse present, R2 lowered her pants and showed her left buttock/hip area. R2's buttock was a dark purple with slight yellowing at the edges. The bruising covered almost R2's entire left buttock and around to the left hip area. R2 pointed to the center area of the bruise and stated, right here is so hard, its hurts when I move a certain way. On 3/16/22 at 11:45 AM, V2 Director of Nursing stated I saw R1 punch R2 closed fisted, twice in the arm and then, R1 with a flat hand, pushed R2 in the shoulder area knocking R2 down to the ground. R2 landed on her back, hitting the back of her head on the trim along the wall. R2's head was red and swollen but not bleeding. R2 complained of severe pain to her left hip so we sent her out to the hospital. R2 was admitted to the hospital for observation of a closed head injury and a large hematoma to her buttocks. R1 was sent out for a behavioral evaluation due to the unprovoked altercation. On 3/16/22 at 11:45 AM, V4 Social Services said R1 has had past behaviors of verbal aggression where she becomes slightly agitated and then 5 minutes later is pleasant and polite V4 said in December of 2021, there was an unwitnessed allegation that R1 swatted another resident with her shoe but there have been no incidents with R1 to this severity. R2's Hospital Records shows patient presented to theER on [DATE] after an altercation at the nursing home. Cat scan (Computerized tomography scan) showing a 9.5cm (centimeters) x 6.8cm x 4.0 cm subcutaneous hematoma in the left buttock which demonstrates active hemorrhage with hematoma in the left gluteus muscle as well .recommended monitoring and a pelvic binder. Kept nothing by mouth and on bedrest with serial Complete Blood Count bloodwork. Trauma Surgeon Consult plan: admit to trauma surgery .serial hemoglobin and hematocrit, monitor vital closely. The same records show R2's hemoglobin (red blood cells) went from 12.2g/dL (grams per deciliter) on admission to 9.7 g/dL. R2 was in the hospital for 2 days and was discharged back to the facility on [DATE]. The facility's Abuse and Neglect Policy dated 1/17/22 shows it is the policy and facility to provide professional care and services in an environment that is free from any type of abuse The facility follows the federal guidelines dedicated to prevention of abuse.

Based on interview and record review that facility failed to provide care and services to a resident with an indwelling catheter by not assessing a resident with catheter pain, monitoring urine output, and not providing catheter care for 1 of 3 residents (R1) reviewed for urinary catheters in the sample of 3. This failure resulted in R1 being admitted to the hospital with a genital abscess requiring a critical care stay. The findings include: R1's Face Sheet shows that he is a [AGE] year-old male admitted to the facility on [DATE]. R1's Minimum Data Set assessment dated [DATE] shows that his cognition is intact. R1's Admission assessment dated [DATE] shows that he arrived at the facility without a urinary catheter. R1's Progress Notes dated 11/12/21 from V8 (Primary Nurse Practitioner) show, Dysuria. Urinary retention. Has a foley cath in place now. Hospital has recommended ordering wick system for incontinence. On foley now .Alert but anxious about the foley foley cath, pink tinged output, no clots .Dysuria-counseled to continue foley. No other progress notes were in R1's electronic medical record with visits from V8. On 1/5/22 at 1:27 PM, V8 said that she received a call from V5 (Licensed Practical Nurse) that R1 had not urinated since admission. V8 said that she gave an order to insert an indwelling urinary catheter at that time. V8 said that she saw R1 on 11/12/21 and he had a catheter in place and had pink tinged urine in tubing and iced tea colored urine in the catheter bag. V8 said that R1 was complaining of catheter discomfort and did not want the catheter. V8 said that she started R1 on [MEDICATION(S)] (for urinary pain) and did not hear of any issue from the nursing staff after that about him having catheter discomfort, but he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress notes dated 11/17/21 from V9 (Infectious Disease Nurse Practitioner) shows, On examination, writer noted that patient's foley had bloody drainage. Spoke to NOD (Nurse on duty) and patient was supposed to have (pure) wick system set up (still waiting arrival of product) but until product arrives, they placed foley catheter in. Patient was noted to have bloody output yesterday and no output overnight. NOD (nurse on duty) flushes foley this AM and there was bloody output again. Patient is complaining of dysuria .On examination, there was frank red blood coming from catheter site. Patient complaining of dysuria. STAT (immediate) CBC, CMP, and UA C&S (urinalysis with culture) ordered-nursing to call with results. R1's Progress Notes dated 11/20/21 show that V8 was notified of Urine culture results and changed the antibiotic to [MEDICATION(S)] twice a day for 5 days. R1's Progress notes dated 11/24/21 from V9 shows, Patient states he is still having discomfort with the catheter and is still waiting for the wick system to be delivered. On 1/5/22 at 1:45 PM, V9 (Infectious Disease Nurse Practitioner) said that she saw R1 on 11/17/21 and noticed blood in his catheter tubing. V9 said that there was a mix between blood and urine in his catheter bag. V9 said that she thought maybe R1 had a [CONDITION(S)] so she did a urinalysis that came back positive, so she started R1 on antibiotics. V9 said that she saw R1 again on 11/24/21 for a follow up and was still complaining of catheter discomfort. V9 said that if he was having issues with his catheter and discomfort, it should be managed by his primary physician since she only oversees R1's infections. V9 said that she saw R1 again on 12/22/21 and his urine was amber in color and he really wanted his catheter out. V9 said that the only time that she assessed R1's genital area was on 11/17/21. R1's Progress Notes (PN) dated 12/2/21 from V12 (Physical Therapy Physician's Assistant) shows, Admits to discomfort at catheter site. Discussed with nursing, will monitor R1's PN (progress note) dated 12/6/21 from V12 show, Pt (patient) is having discomfort at foley cath site, especially with movements. Catheter has been recently changed. Notable for pain, weakness, fatigue. R1's PN dated 12/9/21 from V12 show, Admits to discomfort at catheter site, wants catheter removed. R1's PN dated 12/13/21 from V12 shows, Admits to continued irritation at catheter site with activity. Per nursing type of catheter was going to be changed, on hold due to supply issue. R1's PN dated 12/16 from V12 shows, Pt admits to discomfort to catheter site. On 1/6/22 at 10:18 AM, V12 (Physical Therapy Physician's Assistant) said that when she saw R1 on 12/6/21 R1 was complaining of catheter pain with any type of movement. V12 said that she notified nursing and they said that he recently had his catheter changed so that was why R1 was having the pain. V12 said that she saw R1 again on 12/9/21 and he was still complaining of the pain and wanted his catheter out. V12 said that she notified nursing. V12 said that the last time she saw him was on 12/16/21 and he was still complaining of the pain and she spoke with nursing and they said that they have a new type of catheter ordered for him. V12 said that the catheter pain was interfering with R1's progress in therapy. V12 said that she notified the primary team several times. V12 said that any interventions for R1's catheter would be done by the primary nursing team as she just saw him for therapy. R1's PN dated 12/16/21 shows that V8 was notified of R1's urinalysis results and started R1 on [MEDICATION(S)]/Sulfamethxozole (antibiotic) twice a day for 5 days. There was no documentation that an assessment was done or notification of the Nurse Practitioner the resident was still complaining of catheter discomfort. R1's PN from V9 (Infectious Disease Nurse Practitioner) dated 12/22/21 shows, Patient has been complaining of dysuria from foley catheter. Patient states he really needs his foley catheter removed as it has been bothering him for some time now .CBC and CMP ordered for 12/23/21. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation in the EMR (Electronic Medical Record) that shows that this order was completed. R1's PN dated 12/23/21 at 7:27 PM show, Around 1800 (6PM) writer notified NP (Nurse Practitioner) of WBC (white blood cell) 27.2 (normal 4.8-10.8) and BUN (Blood Urea [MEDICATION(S)]) 105 (normal 5-28), NP ordered to send out to [local hospital] for evaluation and tx (treatment). No documentation was found in R1's electronic medical record (EMR) that R1's primary physician or nurse practitioner was made aware of this continued catheter discomfort. R1's EMR does not document any assessments of his urinary catheter or genital area by the nursing staff after complaints of pain. R1's EMR does not have documentation of catheter care being done or urinary outputs being monitored. On 1/6/22 at 7:30 AM, V6 (Registered Nurse) said that she was R1's primary day shift nurse. V6 said that R1 did complain of catheter pain and she had let the Director of Nursing know along with the Nurse Practitioner (NP). V6 said that R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 said that R1 was ordered [MEDICATION(S)] (pain medication) for his catheter pain. V6 said that the last time she did an assessment of R1's genital area was on 12/16/21 and R1 had some red discoloration on his penis. V6 said that she notified the NP and R1 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . V6 said that she did not assess R1's genital area after that, but the CNAs would have notified her if there was something abnormal. V6 said that catheter output is typically monitored to make sure that it is ok. On 1/5/22 at 11:49 AM, V2 (Director of Nursing) said that catheter care should be done daily and if there are any issues, the nurse should be notified so they can do an assessment and notify the physician. V2 said that if a resident was having pain with a catheter, the nurse should assess the resident, document the findings, and notify the physician. V2 said that if a resident is requesting that the catheter be taken out, they would notify the physician and get an order to take it out and monitor his output. On 1/6/22 at 9:09 AM, V2 said that output is monitored/documented daily for residents but R1 does not any output amounts documented. V2 said that R1 had continued pain after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/6/22 at 7:19 AM, V7 (emergency room Physician) said that R1 arrived in the emergency room due to an elevated white blood cell count and elevated BUN. V7 said that R1's catheter tubing was full of pus drainage and his catheter bag was empty. V7 said that it looked like it had been like that for quite some time. V7's catheter was taken out and replaced and drained a small amount of pus drainage. R1's genital area was reddened including his urethral meatus. V7 said that R1 had imaging done and it showed that he had a large abscess of his penis/urethra/scrotal area. R1 was admitted to the Intensive Care Unit. R1's Indwelling Catheter Care Plan initiated on 11/11/21 shows, Catheter care every shift and as needed .Monitor urine/catheter output every shift .Monitor for pain/discomfort due to catheter use .Report any signs and symptoms of discomfort on urination and frequency . The facility's Urinary Catheter Care Policy revised on 7/28/21 shows, Input/Output: Observe the residents urine level for noticeable increases or decreases. If the level stays the same, or increase rapidly, report it to the physician or supervisor. Maintain an accurate record of the resident's daily output, per facility policy and procedure .Observe the resident for complications associated with urinary catheters .Check urine for unusual appearance (i.e., color, blood, etc.) .Report any complaints the resident may have of burning, tenderness, or pain in the urethral areas .Documentation: The date and time that catheter care was given .all assessment data obtained when giving catheter care Character of urine such as color and odor .Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting or pain Any problems or complaints made by the resident related to the procedure.

Based on observation, interview, and record review the facility failed to provide care in a safe manner for a resident at risk for falls to avoid injury. This applies to one (R3) of three residents reviewed for falls with injury. This failure contributed to R3 falling out of bed and fracturing her right ankle on March 23, 2020. The findings include: R3's Admission Record printed on July 27, 2020 showed R3 to be a [AGE] year old female with [DIAGNOSES REDACTED]. R3's Facility assessment dated [DATE] showed R3 to be cognitively intact, needing extensive/dependent 2 person assistance with bed mobility, transferring, dressing, and toileting. R3's Care Plan dated July 22, 2020 showed R3 is a high risk for falls due to limited range of motion [MEDICAL CONDITION] activity, stroke, impaired balance, inability to bear weight on bilateral lower extremities, and needs 2 people assistance with changing and repositioning. On July 27, 2020 at 10:30 AM, V17 Wound Nurse and V20 Wound Tech had to position R3's legs to complete a dressing change. R3 was asked to move her legs. R3 could not lift her legs, and only slightly shake her feet back and forth. R3's Nurses Notes (Incident Summary) dated March 25, 2020, showed R3 was guided to the floor with no open wounds noted. An X-ray was of right foot was ordered per resident request. On July 27, 2020 at 12:15 PM, V14 Licensed Practical Nurse (LPN) reviewed the fall incident report of March 25, 2020. V14 stated V19 Certified Nursing Assistant (CNA) told her R3 was on the floor. V14 said she was getting R3 cleaned up when she started sliding off the bed. V19 said she guided R3 to the floor. V14 stated V19 was the only CNA in the room, and they had to get another CNA to help with the mechanical lift to get her back into bed. V14 stated R3 needs 2 person assist with turning and toileting. On July 27, 2020 at 12:25 AM, V24 CNA was starting R3's incontinence care. V24 was alone and attempted to turn R3 on her right side. R3 yelled where is my rail. I don't want to fall again! at that time V24 walked around the bed, locked the quarter bedrail in place, and attempted to turn R3 on her right side again. At this time this surveyor stopped V24 to get assistance. On July 27, 2020 at 2:00 PM, V24 stated she had not worked with R3 before. She could have asked another CNA or checked the mobility sheet at the nurse's station. V24 stated she did not check the sheets at the desk before going to provide care for R3. The undated Weekly Bed Mobility Report, at the 1st floor nurses station, showed R3 on the list of residents needing 2 person assist. On July 27, 2020 at 12:40 PM, V2 Director of Nursing stated, during the investigation of R3's March 25, 2020 fall, the only CNA getting R3 cleaned up was V19 at the time of the fall. V2 stated R3, is currently and at the time of her fall, an extensive assist of 2 people at the time of the fall. The Hospital Discharge summary dated March 31, 2020 showed R3 to weigh 300 pounds while in the hospital and included R3's Cat scan impressions. The Cat scan Impression lists 4 fractures within the right ankle and localized area. On July 29, 2020 at 11:20 AM, V26 Orthopedic Surgeon stated confirmed he reviewed R3's Cat scan and medical records. V26 stated The fractures for (R3) were acute in nature. She had soft tissue swelling to her right ankle when I examined her which is consistent with a traumatic (impact) injury. Due to (R3's) Osteopenia, the impact which caused the injuries could even have been low energy/impact in nature.

Based on observation, interview, record review, the facility failed to provide infection control prevention to include separation of residents who were infected with COVID-19 from residents who were not infected with COVID-19 for one of five sampled residents (Resident (R) 5). The facility failed to provide adequate supervision to R5 who was not infected with COVID-19 but wandered into other resident's rooms who were infected on the dementia care unit. The facility failed to provide Personal Protection Equipment (PPE) such as a face mask to R5. The facility failed to keep isolation room doors closed and failed to dedicate specific staff to provide services to residents infected with COVID-19 on the dementia care unit. On 05/26/20 at 3:42 PM, the Administrator and the Director of Nursing (DON) were notified that immediate jeopardy was identified in the area of infection control prevention on the dementia care unit for the potential transmission of COVID-19 infection where R5 resided. The facility failed to provide adequate supervision to prevent R5 from wandering in residents' rooms who were in isolation for COVID-19 infection. The deficient practice placed R5 and 20 other residents who resided on the dementia care unit, at risk of becoming infected with COVID-19 when R5 wandered in and out of rooms. The facility presented an acceptable removal plan for the immediate jeopardy at F880 on 05/27/20 at 1:45 PM. The plan included moving the seven residents who were COVID-19 positive to the 2nd floor which was designated as the COVID-19 wing. R5 was placed on one on one supervision during the transfer process. The plan included in-service to all staff regarding supervision of wandering residents, application of facial protection and the requirement for doors to COVID-19 isolation to be closed at all times. The plan included random observations of all residents who are COVID-19 positive to ensure staff compliance with closing doors of the isolation rooms, and ensuring staff assigned to COVID-19 residents are not caring for residents who are negative for COVID-19. The plan included random observation results to be provided to the Quality Assurance and Performance Improvement Committee for review and recommendation for a period of six months. The removal plan was validated through observation of the COVID-19 designated unit, interviews with staff, policy and record review. Observations validated that the facility moved the seven COVID-19 positive residents from the dementia care unit to the designated COVID-19 unit on the north side of the 2nd floor. Entry to the dedicated unit was secured by way of a zippered partition that was zippered on approach. The doors were closed on the rooms with COVID-19 isolation. Interviews with staff validated their in-service training, understanding of the policy for COVID-19 precautions, and the use of personal protective equipment. On 05/27/20 at 2:12 PM, the Administrator was notified that the immediate jeopardy at F880 was removed. Findings include: R5's Face Sheet, located in the Electronic Medical Record (EMR), under the admissions tab, indicated the facility admitted the resident on 01/18/19 with [DIAGNOSES REDACTED]. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/20, indicated R5 had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated moderate cognitive impairment. The MDS indicated R5 required supervision from staff when walking between locations on the unit and indicated that R5 had a behavior of wandering. On 05/25/20 at 10:00 AM, R5 was observed walking on the hallway of the dementia care unit near the end of the hall. R5 was not wearing a protective facial covering and was near the entrance to room [ROOM NUMBER] where isolation equipment was set up. The door to room [ROOM NUMBER] was open and had signage on the door indicating the resident was under droplet isolation precautions. The DON who accompanied the surveyor, stated, His (referring to R5) room is at the front of the hall but he wanders. This end of the hallway is where we place residents who are in isolation for COVID-19. We have to redirect him, so he doesn't go in these rooms. On 05/25/20 at 10:00 AM the DON identified seven resident rooms near the end of the hallway on the dementia care unit where isolation was set up for droplet precautions. The DON identified rooms 107, 108, 109, 110, 111, which were all private rooms and room [ROOM NUMBER] which was shared by two residents, all as residents who were tested for COVID-19 and were confirmed to be infected with [MEDICAL CONDITION]. During this observation, the doors to the rooms where the infected residents resided were observed to be open. The DON stated 20 residents on the dementia care unit had rooms near the front of the hallway and had been tested and were not infected with COVID-19. The DON also stated the doors to the isolation rooms should be closed. During an interview on 05/25/20 at 3:27 PM, Licensed Practical Nurse (LPN) 1 stated, He (referring to R5) wanders all over the hall and into the resident rooms. He goes into the isolation rooms and has to be redirected. Sometimes the staff forget to close the doors, but he can open the doors too. During an interview on 05/25/20 at 3:57 PM, Certified Nursing Assistant (CNA) 1 stated, He (referring to R5) goes into the isolation rooms. We try to re-direct and he doesn't resist. We can't close the doors because we have to watch the residents. During an interview on 05/26/20 at 10:10 AM, CNA2 stated, He (referring to R5) wanders and goes everywhere and in every room. He opens the door if the door is closed. He goes into the isolation rooms because he gets confused. We try to redirect him and take him out of the room. He is easily re-directed. Review of R5's Nursing Progress Notes, located in the EMR under the progress notes tab, dated 02/01/20 through 05/24/20 revealed no documentation of staffs attempts to redirect the resident when he wandered into the rooms or to assist the resident with protective facial covering. During an interview on 05/25/20 at 1:30 PM, the Clinical Care Coordinator (CCC) verified the facility could not provide documentation in R5's nursing progress notes where staff had attempted to redirect R5 from wandering into COVID-19 positive rooms or attempts to assist the resident with facial protection. The interview also revealed R5's CNA Plan of Care (POC) did not include being care planned for wandering behaviors. During an interview on 05/26/20 at 11:30 AM, the DON stated, We had an understanding that we could put the residents with COVID-19 on the same wing with the residents who were not infected. We have placed them near the end of the hall. We cannot provide one on one supervision for him (referring to R5) because we don't have enough staff. We have not assigned dedicated staff to provide care to the infected residents. They are assigned to the unit and not specifically to just the residents with COVID-19 infections. During an interview on 05/26/20 at 2:15 PM, the Administrator confirmed the facility had not dedicated staff to care for residents who were infected with COVID-19. The Administrator stated, They are assigned to the unit and are not specifically assigned to just residents with COVID-19. The facility policy titled COVID-19-Dedicated Unit/space: Its Operational Considerations, dated 05/02/20 indicated, Recent CMS (Centers for Medicare & Medicaid Services) and federal directives encourage operators to develop dedicated segregated units with dedicated teams of health care personnel . as focal care space and recovery center for COVID-19 patients . create a special unit as a focal point for COVID-19 early recognition and care management . separate residents with positive and negative results. The facility policy titled COVID-19 Guidelines and Emergency Preparedness Plan, revised 05/08/20, indicated, Isolation-patients should be asked to wear a surgical mask as soon as they are identified and be evaluated in a private room with the door closed.

Based on observation, interview, and record review the facility failed to monitor for safe coffee temperatures prior to serving to residents which resulted in a resident (R1) sustaining a second degree burn after attempting to consume coffee that was too hot. This applies to one of three residents (R1) reviewed for safety and supervision in the sample of 11. The findings include: 1. R1's facility assessment dated (MONTH) 2, 2019 showed R1 was cognitively intact. R1's Skin/Wound Note dated (MONTH) 17, 2019 showed the nurse was called to R1's room after R1 sustained a burn after drinking hot coffee. The note showed noted areas of redness and superficial partial thickness serum-filled blisters to chest, wound size 10 x 11 x 0.01 cm (centimeters), estimated BSA (burn surface area) of less than 9% . R1's Progress Note dated (MONTH) 18, 2019 showed, Yesterday she (R1) was drinking coffee and did not notice how hot it was and spit it out of her mouth and dropped the cup on her chest. The coffee spilled on her chest causing blisters to form . The note showed R1 complained of severe pain at the time of the incident. On (MONTH) 24, 2019 at 8:55 AM, R1 was alone in her room, eating breakfast. R1 had 2 oval shaped wounds to her chest with some peeling skin noted from the wound to her left chest area. R1 pointed to her chest and stated, I did have blisters. I burnt myself on coffee last Tuesday evening. I was eating dinner and asked the CNA to get me a cup of coffee. She brought me a cup and left. I eat in my room. I took a sip and spit it out right away because it was burning. The coffee landed on my chest. I may have spilled some too. I knew it was burning my chest. It was so painful. I hit the call light right away . On (MONTH) 24, 2019 at 10:30 AM, V14 CNA stated she was caring for R1 on the evening of (MONTH) 17, 2019. V14 stated, Around 6:30 PM, she (R1) was eating dinner in room and hit the call light and asked for a cup of coffee. I went out the hallway and got a cup of coffee out of the carafe on the food cart on the second floor. I took it immediately to (R1), gave it to her, and walked out and left. I wasn't there when she started drinking it. Around 6:36 PM, I answered her call light and she was upset. She said she had burnt herself on the coffee . On (MONTH) 24, 2019 at 1:37 PM, V15 Wound Physician stated he began treating R1 on (MONTH) 17, 2019 after she sustained a second degree burn with blistering caused by her either spitting or spilling hot coffee on her chest. 2. On (MONTH) 24, 2019 at 11:40 AM, 2 carafes of coffee were delivered to the second floor on food carts. At 11:47 AM, after calibrating the thermometer, the surveyors and V13 Wound Nurse confirmed carafe #1's temperature was 170.6 degrees Fahrenheit (F) and carafe #2's temperature was 157.4 degrees (F). At 12:01 PM, V9 Licensed Practical Nurse (LPN) poured a cup of coffee out of carafe #1 and delivered a cup of steaming coffee to R5 in his room. R5 began drinking the coffee. At 12:22 PM, twenty minutes after the initial temperature check, the surveyors confirmed the temperature of carafe #1 was 167.7 degrees (F). On (MONTH) 24, 2019 at 2:30 PM, V8 Food Service Director stated coffee is available to any resident that wants coffee and all of the coffee in the facility is made in the kitchen in a coffee machine. The coffee is made and then poured directly into carafes that are delivered to each floor, including the first floor dementia unit, for meals and as needed. V8 stated that coffee should not be given to or available to residents until the temperature is at 147 degrees (F) or below. V8 stated, Not that I am aware of, we have never checked coffee temperatures at all, not before it leaves the kitchen or before it is available to the residents. V8 stated the facility had no process in place to ensure the coffee was given to residents at or below 147 degrees (F). On (MONTH) 25, 2019 at 9:40 AM, V16 Dietary Regional Consultant stated coffee should be at or over 135 degrees (F) for resident consumption. V16 stated, Our coffee is made in the kitchen. It is poured directly into the carafes, not allowed to cool at any time that I am aware, and sent to the floor. V16 stated coffee temperatures have never been checked at the facility. On (MONTH) 25, 2019 at 11:48 AM, V17 Registered Dietician stated, All hot things need to be temped. Hot coffee needs to be monitored. Coffee temps should be checked before it leaves the kitchen. On (MONTH) 25, 2019 at 9:03 AM, V18 CNA stated, I have worked on the dementia unit for 5 years. We serve the coffee to residents when it's delivered to the unit. I assumed the kitchen checked the coffee temps before they sent it up to us in the carafes . The facility's Food Temperature Maintenance Policy dated (MONTH) 30, 2019 showed, Purposes 1. To reduce the risk of injury, such as burned mouth or lips . The policy does not address hot beverage temperatures.

Based on interview and record review, the facility failed to follow physician's orders for post-operative amputation care for 1 of 3 residents (R10) reviewed for wound care in the sample of 17. This failure resulted in further wound complications and possible additional amputations. The findings include: R10's electronic face sheet provided by the facility on 9/19/19 showed R10 has [DIAGNOSES REDACTED]. On 9/17/19 at 10:53 AM, R10 stated My surgical flap had to be under pressure and (V4) sent instructions to leave the flap under pressure and not remove the dressing. The nurse here changed it 3 times after my surgery. The flap filled up with fluid and I had to have the fluid removed. I might have to have another surgery if the flap doesn't take to my foot now. On 9/18/19 at 11:10 AM, V13 (wound care nurse) stated, (R10) had a non-removable dressing to his left foot when he came back from surgery. We were not allowed to take it off and had orders to reinforce the dressing only if drainage was noted. On 9/19/19 at 4:18 PM, V4 (R10's podiatrist and surgeon) stated, (R10) underwent a mid-foot amputation on 8/28/19 resulting from an extensive foot ulcer. I applied a skin flap over the area to attempt to fill the defective area. The dressing that I applied after surgery was a dressing soaked in [MEDICATION NAME] as the primary dressing, gauze fluff over the primary dressing, and then a pressure dressing to keep the flap in place and attempt to get it to start adhering to the foot. When (R10) arrived back in my office on 9/6/19, the dressings I applied were completely gone. His foot was wrapped with some type of gauze and kerlix and was nowhere near what I had applied. The dressing was placed on loosely which caused seromas (fluid filled sacs) to build up that erupted and were draining on his stiches and the skin flap. The amount of pressure you apply to an amputation and skin flap plays a large part in how well the healing process will go. The skin flap was very delicate and had been risky to begin with so the facility removing the dressing I applied caused these seromas and poor viability of the skin flap. I'm not saying that the facility will directly cause this man to receive a leg amputation but they largely tipped the scales in that direction. I am also concerned that (R10) is developing a pressure ulcer to his foot now as well and I'm not sure what to do about that. He should have a [DEVICE] (device to contain wound drainage) on but I don't trust that the facility will carry it out and maintain it properly. This is a sad situation for this man and the facility's failure to follow post-operative instructions only worsened the situation. R10's (MONTH) 2019 order review report showed an order dated for 8/31/19 stating Leave dressing clean, dry, and intact until follow up with (V4) within 1 week of discharge. Ok for nursing to reinforce surgical dressings with ABD and kerlix if strike through (drainage) noted. R10's (MONTH) 2019 and (MONTH) 2019 treatment administration records (TAR) showed no orders to reinforce surgical dressings with ABD (thick gauze) and kerlix if strike through noted or to leave dressing clean, dry, and intact. R10's podiatry office visit notes with V4 (R10's podiatrist and foot surgeon) on 9/5/19 showed R10 is a [AGE] year old male status [REDACTED]. DO NOT REMOVE DRESSING! Unsure if flap will survive. Keep pressure off the flap. New sterile dressing applied with mild compression. R10's facility assessment dated [DATE] showed R10 is cognitively intact, has a surgical wound, requires surgical wound care, has application of nonsurgical dressing, and has no dressings to feet. R10's care plan dated 9/10/19 showed R10 has skin impairments and was assessed to be at risk for skin breakdown and pressure injury development related to status [REDACTED]. Intervention dated 8/31/19 showed left foot- (per surgeon's order) leave dressing clean, dry and intact until follow up with (V4) within 1 week of discharge. Ok for nursing to reinforce surgical dressings with ABD and kerlix if strike through noted. R10's wound assessment details reports showed the following: 8/31/19 showed head to toe assessment performed post left foot surgery. Per surgeon's order, dressing to the left surgical wound to be kept clean/dry/intact until seen at the next follow up appointment within 1 week. Ok for nursing to reinforce surgical dressings with ABD and kerlix if strike through noted. Nurse Practitioner aware of the current order. Dressing to the surgical site to be monitored every shift and reinforce if needed. Patient aware. Wound notes of 9/5/19 non-removable dressing-no signs of infection. Will be seen by (V4), podiatrist.

Based on observation interview and record review, the facility failed to provide adequate supervision and assistance to a resident who is at risk for falls this resulted in R5 falling twice and sustaning a laceration requiring 15 stitches. This applies to 1 of 3 residents (R5) reviewed for safety and supervision in the sample of 9. The findings include: R5's Electronic Medical Record shows R5 is [AGE] years old with [DIAGNOSES REDACTED]. R5's Minimum Data Set assessment dated [DATE] shows R5's cognition is intact. R5 requires limited assistance of one person with transfers and ambulation. R5's Fall Risk assessment dated [DATE] shows R5 is high risk for falls. On 7/1/19 at 2:06 PM, R5 was in her room sitting in her chair. R5 was pleasant and smiling and said she was ok. R5 had steristrips at the back of her head. V4 (R5's daughter) was in the room with R5. V4 said she had a concern regarding R5's falls. V4 said R5 fell twice last month. V4 said with both falls, R5 hit her head and was sent to the hospital. V4 said with the first fall, R5 received three staples and with the 2nd fall R5 received 15 stitches. V4 said both falls, R5 was walking in her room by herself. V4 said both falls happened after eight at night. V4 said she doesn't think staff are supervising or helping R5 enough at that time. V4 stated staff need to check (R5) more often. V4 said she does not think R5 knows how to use the call light if she needed help so staff need to check her more often. R5 is not safe for her to be walking by herself in her room. An Incident Report dated 6/17/19 at 8:11 PM, shows resident screaming for help, writer responded to the room, found patient laying on the floor. Observed resident bleeding from the back of her head, immobilized head and applied pressure. Could not stop bleeding .called 911 .paramedics arrived, transferred to the hospital. R5's Hospital Record dated 6/17/19, shows R5 had a laceration of scalp and closed head injury. A Wound Note dated 6/18/19, shows laceration to the back of the head with 3 staples done at the Emergency last night per report. An Incident Report dated 6/20/19 at 8:08 PM, shows, heard resident screaming for help, writer responded immediately. Patient laying on the floor .observed resident bleeding from the back of her head. Applied pressure dressing and ice pack at the bleeding site, could not stop the bleeding .called 911 for emergency transfer. R5's Hospital Record dated 6/20/19, shows R5 had a laceration of scalp and closed head injury. A Wound Note dated 6/21/19 shows laceration to the back of the head with 15 stitches. Wound size 1.5 x 8.0 x 0.1 centimeters with scant serosanguinous drainage {and) swelling. On 7/2/19 at 10:27 AM, V7 (Registered Nurse-RN) said he was R5's nurse when the 2 falls happened. R5 said the first fall was a little after eight at night. V7 (RN) said he was at the end of the hallway passing medications when he heard R5 screaming for help. V7 said he ran to R5's room and saw R5 on the floor bleeding. V7 said R5 said she was trying to put her [NAME]et on unassisted. V7 said there was no staff with R5 when the incident happened. V7 said there were no Certified Nursing Assistants (CNAs) around, they were busy putting other residents to bed. V7 said he had to call 911 since he could not control the bleeding. V7 said R5 was sent to a local hospital for staples. V7 said R5's 2nd fall, on 6/20/19 (3 days after) the same thing happened, V7 said it was again past eight at night. V7 said he was at the end of the hallway passing medication when he heard R5 screaming for help. V7 said CNAs were busy putting other residents to bed. R5 was found on the floor bleeding. R5 was sent to the hospital again, because the bleeding could not be controlled. V7 said R5 received stitches at the back of her head. V7 said R5 does not use the call light, R5 screams when she needs help. V7 said R5 has to be checked more often. On 7/2/19 at 10; 07 PM, V8 (CNA) said she had worked evening shift and had been assigned to R5. V8 said R5 has a routine that she wants to go to the bathroom around 8 PM and wants to be in bed at 9 PM. V8 said R5 needs assistance due to unstable gait. Staff has to anticipate her needs. If there's no staff available around that time, she will ambulate herself to the bathroom. On 7/2/19 at 10:14 PM, V9 (CNA) said R5 uses the bathroom by 8PM and wants to be in bed at 9PM. R5 is unsteady. R5 needs staff to supervise her when she is ambulating around her room or the bathroom at night. On 7/2/19 at 11:51 AM, V10 (Nurse Practitioner) said for residents that have history of falls with injury, frequent rounding is needed for resident's safety. R5's current care plan shows R5 is at risk for falls due to unsteady gait, weakness, impaired balance. R5's careplan interventions include staff are to offer toileting assistance between 8:00 and 9:00 PM, Anticipate and meet resident's needs. The facility policy entitled Fall Occurrence dated 2/20/17 shows it is the policy to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling.

Based on observation, interview and record review the facility failed to ensure a resident was free from abuse by staff. This failure resulted in R1 being physically restricted from going outside, slipping on the floor during the struggle with staff and sustaining a [MEDICATION NAME] head trauma with mild concussion and a facial laceration requiring 4 stitches on (MONTH) 23, 2019. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3. The findings include: On 5/28/19 at 11:30AM, R1 stated, Thursday (5/23/19) night I got up about 10:45PM. I went downstairs and asked the nurse on the first floor to buzz me out. She told me I have to get a nurse from the second floor to come down and let me out. {V2- Director of Nursing} told me on the 22nd that I can get a first floor nurse to let me out. There is a sign posted in the lobby that says to ask the first floor nurse to buzz you out. I went to the front and two of them (staff) then blocked the door- they stood there in front of the door like security guards. Then they put their hands on me. She was holding me by the collar of my shirt. I slipped and smacked my head on the floor. I was dazed for a minute. There was blood all over the floor. I called the police. They came out and talked to me. They also talked to the hospital because I reported it to them too. The detective came out the next day and asked if I wanted to press charges and I told him yes. (R1 showed Surveyor pictures of blood on the floor near the front entrance, a bloody towel used against his head, and blood stains on the couch in the front lobby. R1 also showed pictures of the gash in his forehead prior to being sutured at the hospital and a picture of the sign at the front entrance telling guests to see the first floor nurse if they need to be buzzed out.) Sometimes I go out to smoke, sometimes I just go out to clear my head. I go out all the time. I've never been stopped before from going out. They (the Facility) said from the video it shows that I'm being aggressive. I wasn't aggressive at all. They put their hands on me! On 5/28/19 at 2:30PM, V3 (CNA) stated, He (R1) came downstairs. I never worked with him, I don't know him. He said he wanted to go outside. The nurse wanted him to clarify with his nurse that it was ok. (R1) started cursing and talking loud and then left and went to the lobby. Then the nurse asked me to open the door because a family member wanted to leave. Everything happened so fast. I didn't know how safe he was outside and I didn't want anyone to say that I let him outside. The nurses said not to let him go out. I went to open the door for the family member and one of my co-workers (V5-CNA) went with me. I told (R1) not to come close to the door. He started yelling, Don't F*** with me! and Don't F***ing tell me what to do! I said he wants to try to escape. Me and my co-worker held our hands together and he was pushing towards us. He had slippers on and he was fighting. He lost his slippers and he had socks on. I turned around and to tell me partner to move so the door would close and he fell on the floor. I saw the blood on the floor and I told my partner to go get help. I was worried that he might get hurt if he went outside. I was touching him. I grabbed him from his shirt at his shoulder. He was so agitated. They tell us not to touch or restrain a resident. He was so close to us. He never tried to hit us he was just pushing us and trying to get out the door. He lost his balance and fell . Then he got up and he was so unsteady. The nurse from the second floor came down and then I went home. On 5/29/19 at 11:15 AM, V5(CNA) stated, I was at the nurse's station (on the first floor) and (R1) asked us to open the door for him. The nurse said he had to go to the second floor and ask his nurse to come and let him out. He got so mad. Then a family member wanted to go out so the the nurse asked (V3) and me to go open the door for the family member. I didn't want to let (R1) out but he wanted to go out so bad. I don't know if I touched him or not. I turned around and saw him on the floor and I went to get help. I didn't want to let him go out. The nurse told me not to let him go out. I see him everyday and he goes outside to smoke all the time. Then they told us that we can't just let them (residents) go out anytime they want and they changed the code (on the front door). Maybe a few days before this happened. On 5/28/19 at 2:00PM, V4 (Licensed Practical Nurse) stated, I was the nurse on that day. One of the staff on the first floor told me that (R1) was on the floor in the lobby. He was very upset. He was on the phone and he just kept pacing. I told him to sit down but he was so upset. I finally told him I was going to have to call 911 and then he sat down. I got him upstairs and I called the doctor and the ambulance. The ETA (Estimated time of arrival) for the ambulance was one hour. Before I could get back to him, he wanted to go outside. I had one of the staff go with him. (R1) goes in and out all the time. He is independent. Then they started changing the code. I have no idea how the residents are supposed to get out. The CNAs told me they were stopping him from going out and he fell on the floor. I didn't have time to talk to the CNAs because I was too focused on his wound. No one should ever try to physically restrain a resident. Sometimes (R1) walks like he is unsteady but that is how he is. He moves his hands a lot but he is not trying to hit. He can be verbally aggressive but not physically. He is allowed to go outside anytime to smoke or get some fresh air. He is up and down all night. ON 5/28/19 at 1:00PM, V2 (Director of Nursing) stated, The staff told me that he fell but the report from the nurse said that he called 911. She said he was trying to leave the building when he fell . The first floor nurse told him to wait while they were trying to get the second floor nurse. (R1) was trying to go out and he was pacing in the front lobby. A CNA accompanied a family to the front door and (R1) was following the family member out the door to leave the building. They tried to prevent the resident from leaving. He was pushing himself towards the staff Staff tried to redirect him from the door. His slipper came off and CNA was trying to hold his shirt because he was pushing against the staff. Then he fell . He said the CNA yanked him by his shirt. The day before I told him to inform the staff that he is leaving so the staff can call the front desk or the first floor staff and know where he is. I told them (the CNAs) if a resident wants to go outside then to go with the resident and supervise. Call the nurse or the police to assist if necessary. Not to lay hands on any resident, allow some space. On 5/28/19 at 1:30PM This surveyor viewed video showing incident from 5/23/19 beginning at 10:37PM. The video show R1 enter the front lobby while talking on his phone. R1 begins pacing through the front lobby then sits down in a chair in a sitting area on the left side of the lobby while still talking on the phone. Then a family member (visitor) enters the lobby and (V3) goes behind the front desk (opposite end of lobby from where R1 is sitting) and opens the door for the visitor to leave. As the electronic sliding door opens, V3 and V5 immediately walk towards the R1 and hold their hands together to block R1 from getting to the door. R1 tries to push past V3 and V5 on the right, then on the left several times as the CNAs dodge back and forth in efforts to not let him through. V3 then takes a hold of the left shoulder/neck area of R1's T-shirt. R1 begins to struggle with V3, his shirt comes up exposing his back and stomach, his slipper comes off, he dropped his phone and tries to pick it up. R1 then falls to the floor onto his stomach and hits his head on the tile floor. V3 let go of R1's shirt and V5 left the lobby area. R1 then gets up and appears very unsteady. V3 took a hold of R1's T-shirt again and they both make their way to sit on the couch. On 5/28/19 at 1:35PM V1 (Administrator) stated, The CNAs were worried about his safety. They didn't want him to go out in the parking lot at 10:30 at night. They didn't know him and he wouldn't listen to them. They were just worried about him. A sign posted at the front door of the facility states, Between 9:45PM and 8:00AM please see the 1st floor staff to let you out. The Preliminary Incident Investigation Report dated 5/24/19 shows that (R1) reported that (V3) yanked my shirt and made me fall. Full body assessment was completed and resident sustained [REDACTED]. R1's Minimum Data Set (MDS) of 5/13/19 shows that R1 has no documented behaviors. R1's MDS of 3/30/19 shows that R1 scored a 15 on his BIMS (Basic Interview for Mental Status) showing no cognitive deficit. R1's (MONTH) 2019 physician's orders [REDACTED]. On 5/28/19 R1's Electronic Medical Record showed a physician's orders [REDACTED]. (This order did not print on the hard copy of R1's physician's orders [REDACTED].) R1's Care Plan dated 4/6/19 states, (R1) would like to have OOP privileges. Has been deemed able with doctor's recommendations, orders and correct mobility DME if needed. R1's Hospital Discharge Instructions dated 5/24/19 at 4:08AM state: Diagnosis: [REDACTED].< =30 min, Facial Laceration. The facility policy entitled Abuse and Neglect dated (MONTH) 28, (YEAR) states, 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.

Based on observation, interview and record review the facility failed to provide sufficient staffing to meet resident needs. This failure resulted in R1 falling and sustaining a right wrist fracture. The facility failed to provide showers due to lack of staffing. This applies to 27 of 33 residents (R1, R3, R5-R14, R16-R30) reviewed for staffing in the sample of 33. The findings include: 1.R1's Physician order [REDACTED]. R1's Minimum Data Set assessment dated (MONTH) 6, 2019 shows R1 has no cognitive impairment. R1's careplan dated (MONTH) 28, 2019 shows R1 is at high risk for falls The Facility's Incident Report dated (MONTH) 11, 2019 shows R1 was observed in a crawling position on the hallway. R1 had an abrasion on the forehead with slight bleeding. R1 was sent to a local hospital and was found to have a fracture of his right wrist. R1's Radiology report dated (MONTH) 12, 2019 shows R1 has a non displaced fracture of R1's right wrist On (MONTH) 22 2019 at 9:30 AM, R1 was in bed. R1's right hand was elevated with a pillow. R1 said he fell more than a week ago. R1 said it was around past ten at night. R1 said the facility was short of help. R1 said he had his call light on and was needing assistance from staff to get up. R1 said his back was bothering him so he was also needing the nurse. R1 said he waited for staff to come to his room. R1 said no one answered his call light for almost an hour. R1 said he got up and decided to walk towards the nurse's station to look for a staff. R1 said before he made it to the nurse's station, his legs buckled. R1 said he tried to use his right hand to balance himself but he ended on the floor. R1 said he was so weak to get up, he ended up crawling until someone helped him from the floor. R1 said if the staff would have only answered his call light promptly he would have not fallen. On (MONTH) 22, 2019 at 10:30 AM, V7 (CNA) said she was the only CNA working today on North wing. V7 said there were supposed to be 4 CNAs. V7 said she was doing the best she could. V7 said it was not safe for the residents to only have 1 CNA for the whole wing. V7 said she needs help to take care of all these residents. V7 unable to answer call light on time and unable to give scheduled showers. V7 said it was impossible to do her job. On (MONTH) 22, 2019 at 10:40 AM, V5 (License Practical Nurse-LPN) said she has 1 CNA for the whole wing. V5 said the quality of care suffers if there is not enough staff to take care of all the residents. On (MONTH) 22, 2019 at 12:00 PM, V4 (Registered Nurse-RN) said they were short of staff that night. (April 11, 2019) V4 said there were supposed to be 4 CNAS (Certified Nursing Assistants) on 1st floor (Long Term and Dementia Unit) but there were only 2 CNAs working that night. V4 said she was so busy that night that she cannot remember if R1 had his call light on. V4 said she saw R1 crawling towards the nurses station. V4 said she saw R1's forehead was bleeding. R1 was sent to the local hospital for evaluation. The facility nursing schedule dated (MONTH) 11, 2019 shows there were 2 CNAs working instead of 4 CNAs on the first floor. On (MONTH) 23, 2019 at 10:30 AM, V11 (concierge) said she was only on the floor to pass ice water and collect room trays. She has no direct care staff responsibilities. On (MONTH) 23, 2019 at 11:30 AM, (confidential interviews from staff) we work with 1 CNA on each wing most of the time. It is impossible to perform our job by being alone, unable to answer call lights on time, unable to turn and reposition residents, unable to give bath, feed, etc . we feel sorry for the residents, if they need help and we are not there, then they get up on their own just like what happened which resulted with the resident falling and hurting himself. On (MONTH) 23, 2019, at 11:45 AM, V10 (License Practical Nurse) said we work with 2 CNAs instead of 4. When we are short of staff, it limits the time we care for the residents. Most of the residents need extensive assist to go to the bathroom, get up from bed to their wheelchair or assist during feeding. We were unable to answer call lights timely. On (MONTH) 23 2019 at 2:00 PM, V2 (Director of Nursing) stated we never denied we are short of staff. There were supposed to be 2 Nurses and 4 CNAs working on each floor and we are not meeting that. The facility Nursing Schedule shows there was 1 CNA on each wing in each floor scheduled on (MONTH) 22, 2019. A concierge staff was helping on each floor. The Facility Resident Council Minutes for January- (MONTH) 2019 shows residents requesting more CNAs. The facility policy entitled Staffing dated (MONTH) 17, (YEAR) shows It is the policy to provide adequate staff to meet the needs of the residents which is the requirement under the federal regulations. 2. On (MONTH) 23, 2019 at 10:45AM, R5 was in a wheel chair sitting in the hallway by her room. On (MONTH) 23, 2019 at 11:00AM, R3 was in a wheel chair sitting in the hallway by the nurse's station. On (MONTH) 23, 2019 at 10:45AM, R5 said, I was told I got taken off the shower schedule. I went five weeks without a shower. On (MONTH) 23, 2019 at 11:00AM, R3 said, I did not get my bath on Saturday. I usually get my bath Saturday morning. I asked the CNA-Certified Nursing Assistant the reason why I did not get my bath and I was told they were too busy. Everyone thinks I do not have a good memory but I know when I do not get a bath. It has been over ten days from the time I received a bath. On (MONTH) 23, 2019 at 11:21AM, V7 CNA-Certified Nursing Assistant said, Yesterday I was the only CNA on the third floor. I was only able to bath one resident. This job is very hard, too impossible to do with only one CNA on the floor. On (MONTH) 23, 2019 at 2:15PM, V3 provided Shower Record/Skin Audit forms dated (MONTH) 19, 2019 for R15 and (MONTH) 22, 2019 for R31, R32, and R33. V3 said, this is all I have. We are calling staff to check if the other residents received their showers. On (MONTH) 23, 2019 at 2:30PM, V2 DON-Director of Nursing said, residents are scheduled to have showers twice a week. The nurses monitor when the resident gets a shower. The Shower Record/Skin Audit form is filled out by the CNA during every shower. The nurse signs off that it has been reviewed. The shower record is a part of our wound care program. On (MONTH) 23, 2019 V3 ADON-Assistant Director of Nursing was asked for Shower Record/Skin Audit forms for R3, R5, and R6-R33, based on the shower schedules for (MONTH) 19, 2019, (MONTH) 20, 2019, and (MONTH) 22, 2019. The facility Shower Schedule dated (MONTH) 21, (YEAR) shows R3 is scheduled for showers twice a week on Wednesday and Saturday morning. The facility's CNA Daily Assignment book shows, R3's last bath was received Saturday (MONTH) 13, 2019 (10 days ago) by V8 CNA.

Based on observation, interview, and record review the facility failed to ensure a resident was free from abuse. This failure resulted in R8 receiving a scratch to her stomach and bruising to her left forearm during care on (MONTH) 31, 2019. This applies to 1 of 7 residents (R8) reviewed for abuse in the sample of 11. The findings include: 1. On (MONTH) 15, 2019 at 1:05 PM, R8 was sitting in her wheel chair in her room. She stated, I'm aggravated today about waiting for 40 minutes to get help to go to the toilet since I filed a police complaint. R8 was asked why she filed the police complaint and she stated, She was on lunch (V10 Certified Nursing Assistant (CNA)). She's always been, hate to use this word prejudice against white people. I heard her on the phone and I knew that she was the one that had me that night. I went past her and said excuse me, because she was on the phone. I'll be ready in an hour. She replied, 'God Damn residents even disturb me during my lunch, I never get a break.' I was just saying an hour would be ok. I rolled away thinking, 'great'. I was going to try to put myself in bed so she wouldn't have to handle me much. I had the light on. Another girl (V6 CNA) came in and seen I was about to fall, she went to get V10. V10 came in like a mad woman from hell and said, 'God damn it!' I'm ready to fall and I said 'just need you to push me back.' She said, 'I know how you people are, you'll do something like this to get what you want.' And then she just picked me up and threw me in bed. Her nails crossed my stomach and put bruises on my arm. When she threw me, I felt I got hurt. Then I reported it. I honestly think I reported it to the nurses station and first thing in the morning. I have pictures that I took. This surveyor looked at the pictures on R8's personal cell phone. The pictures were taken on (MONTH) 1, 2019 at 2:24PM. The first picture was a horizontal red line approximately 9 inches long from the edge of her abdomen towards her outer hip that looked like a scratch with some scabbing at the start. The second picture was a golf ball and a ping pong size purple bruise approximately 7 inches long on R8's left outer forearm. R8 continued saying, 'They called the police. The police came and I gave them the information. Obviously they investigated and she's here (R8 was tearful saying) It's not right, it pisses me off. I know so many more it's happening too. On (MONTH) 16, 2019 at 12:11 PM, R8 stated that the scratch/mark on her stomach was from V10's big 'ol nails. The facility's preliminary incident investigation report dated (MONTH) 1, 2019 for R8 shows, .On (MONTH) 1, 2019 at 5:10 PM, R8 reported to V5 (Guest Relations) that CAN V10 was rough with her and left bruises on her the night prior. Resident did not say why she waited to report this incident. A full body assessment was completed she was noted with bruising on left thigh, bruising on forearm and discoloration on her stomach. Highland Park Police contacted . The progress notes by V8 Nurse Practitioner (GNP) for R8 dated (MONTH) 4, 2019 shows, CC (chief complaint): complaints of bruising on abdomen and left arm. HOPI (history of present illness): This is a 64 y/o (year old) female with PMH (past medical history) as stated below, seen today for stated above. Patient states the CNA was really rough and grabbed me and threw me on the bed, I called the police and a report was made She states that she hit her left arm on the side of the bed . Physical Exam: Skin: warm, well perfuse, bruising noted on left forearm and linear bruise noted on mid lower abdomen. A/P (Assessment/Plan): Bruising from unknown source. The Minimum Data Set, dated dated dated (MONTH) 25, 2019 for R8 shows she is cognitively intact. The same assessment shows she requires extensive assist of two people for bed mobility, transfers, and toilet use. The facility's order summary report for R8 shows her [DIAGNOSES REDACTED]. The facility's screen to determine abuse/neglect for R8 dated (MONTH) 5, 2019 shows, R8 is determined to be at risk for abuse as she has a [DIAGNOSES REDACTED]. Resident will be reassessed and monitored. On (MONTH) 16, 2019 at 9:56 AM, R7 stated about V10 CNA, She's not good. She procrastinates and blows everyone off. 'too busy, too busy.' She'll stick her finger up, 'I'm busy' and never come back. She's abusive and ignores them (other residents). On (MONTH) 16, 2019 at 10:39 AM, R12 stated, She's always rude (V10 CNA). I think she is passive aggressive. She doesn't ask, she just tells you. She's the type you won't win with her. V21 (R12's sister in law) was in the room and also stated, V10 is someone I wouldn't want mad at me, she's unpredictable. The facility's abuse and neglect policy dated (MONTH) 28, (YEAR) shows, 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 guideline 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.

Based on interview and record review the facility failed to monitor a cognitively impaired resident with a known behavior of manipulating her [MEDICAL TREATMENT]. On (MONTH) 3, (YEAR) R2 was discovered deceased due to hemorrhage and fatal blood loss. This failure resulted in an Immediate Jeopardy. (IJ). The Immediate Jeopardy began on (MONTH) 3, (YEAR). V1 (Administrator) was notified of the Immediate Jeopardy on (MONTH) 19, (YEAR) at 1:25 PM. This applies to 1 of 3 residents (R2) reviewed for death in the sample of 3. This past noncompliance occurred on (MONTH) 3, (YEAR). The findings include: R2's computerized face sheet showed R2 had [DIAGNOSES REDACTED]. R2's Physician order [REDACTED]. The POS showed an order to monitor the site for circulation, motion, and sensation of extremity distal to AV fistula every shift. R2's POS also showed orders for aspirin 81 milligrams daily for [MEDICAL CONDITION]- hold if rectal bleeding occurs, and Eliquis (Apixiban) 2.5 milligrams two times daily for blood thinner. Both medications had start dates in (MONTH) (YEAR). R2's MDS (Minimum Data Set) dated (MONTH) 11, (YEAR) showed R2 was severely cognitively impaired with long and short term memory problems. The MDS showed R2 required total staff assistance for transfers, locomotion, and toilet use. The MDS showed R2 required extensive staff assistance with bed mobility, dressing, eating and personal hygiene. The MDS also showed R2 had no upper extremity impairment. R2's progress note dated (MONTH) 4, (YEAR) at 21:54 (9:54 PM) stated CNA called this writer to come see pt (patient) quickly. Upon entering room found pt lying in ________. This writer removed fistula dressing and saw fistula oozing very little. Sheets full of coagulated blood, also sheets were hardened and brownish in color (indicative of dried blood) .A second note on the same evening stated called to see pt this writer went to room and pt bood (blood) moderate amounts all over sheets looked at fistula sit (site) and was bleeding from there pressure dressing applied . R2's progress note dated (MONTH) 21, (YEAR) at 21:35 (9:35 PM) LATE ENTRY stated .called by caregiver on [DATE] with concern of a new wound proximal to her LUE (left upper extremity) graft. Caregiver states that AM, she found (R2) ace wrap to the LUE loosened. (R2) is known to scratch at her chest and other areas . R2's progress note dated (MONTH) 3, (YEAR) at 6:06 am LATE ENTRY stated .around 11 pm went to resident room. Hand was relocated away from left anticubital due to scratching the site. AV fistula to left arm intact with bruit and thrill appreciated. Covered resident with warm blanket. Around midnight resident seen sleeping comfortably and covered with warm blanket. No sign of distress noted. Around 3 am, resident seen sleeping comfortably and covered with warm blanket with no signs of distress. At 4:12 am while doing round, resident was noted unresponsive with no vital signs and with blood on the floor, the source of blood was later noted to derive from AV fistula on left arm and scattered blood on the bed and walls behind her. At 4:17 am (V9-RN) confirmed vital signs not appreciated, pupils dilated, upper body cold to touch, not responsive to stimulus. RN continue to search for source of bleeding and vital signs until 4:20 am and then paramedics arrived and took over. Page (V10-physican) and made aware of resident's death . On (MONTH) 12, (YEAR) at 10:45 AM, V6 ([MEDICAL TREATMENT] registered nurse) stated R2 received [MEDICAL TREATMENT] at the in-house [MEDICAL TREATMENT] center three times per week since the time of admission to the facility (2017). V6 said R2 was alert, but confused. V6 said R2 could easily move her arms and legs. V6 said R2 would scratch and itch at her left arm and it possibly was due to the itching of the [MEDICAL TREATMENT] tape. At 1:30 PM, V6 said R2 was routinely scheduled for [MEDICAL TREATMENT] sessions before 6 AM and facility staff typically got her out of bed around 4 or 5 AM. On (MONTH) 12, (YEAR) at 11:30 AM, V3 (Assistant Director of Nurses) stated R2 had an incident on the night shift and her fistula bled out. V3 said she routinely cared for R2, generally five times per week, and R2 would scratch at the fistula site. On (MONTH) 12, (YEAR) at 12:35 PM, V7 (Certified Nurse Aide-night) stated he remembered R2 very well and cared for her often. V7 said R2 was confused most of the time and many times she would scratch and pull at her [MEDICAL TREATMENT] thing (fistula). V7 said he was working the night shift on (MONTH) 3, (YEAR) when an incident occurred. V7 said he checked in on R2 every two hours and found her sleeping soundly. V7 said R2's arms were covered under her blanket and he did not remove or check her body underneath the bedding during rounds. V7 said sometime in the early morning, before 5:00 AM, he heard the floor nurse calling out for help. V7 said he entered R2's room and saw blood on the bedding and the dressing that covered her left arm was off. V7 said he had no idea what caused the bleeding. V7 said R2 was found covered with blood after the floor nurse entered her room to prepare her for her scheduled 5AM [MEDICAL TREATMENT] session. On (MONTH) 12, (YEAR) at 2:20 PM, V9 (Registered Nurse-night) stated he was working the third floor night shift on (MONTH) 3, (YEAR) when he was called to the second floor for a resident issue. V9 stated he entered R2's room and saw blood all over her body. V9 said R2 was covered from head to toe in blood. V9 said R2's blanket was wet from blood and her bed sheet was completely saturated. V9 said there was blood on the floor under her bed. V9 said R2 had passed away by the time he arrived to her room. During the course of this survey, the second floor night nurse on duty (MONTH) 3, (YEAR) was attempted to be interviewed, but no longer works at the facility. On (MONTH) 13, (YEAR) at 11:15 AM, V10 (R2's physician) stated R2 was known to scratch at her fistula site and died due to prolonged bleeding at that site. V10 said something should have been done to reduce the scratching, such as increased monitoring. V10 said the fistula was a direct connection to an open artery which can bleed out within five to ten minutes, regardless of blood thinner use or not. V10 said R2's daily blood thinner use would cause longer bleeding. R2's State of Illinois Certificate of Death Worksheet was reviewed and showed a date of death of (MONTH) 3, (YEAR) and occurring at the subject facility. The death certificate showed the cause of death due to: Exsanguination (loss of blood to a degree sufficient to cause death). R2's [MEDICAL TREATMENT] care plan and end stage [MEDICAL CONDITION] care plans (both initiated dated (MONTH) 1, (YEAR)) were reviewed. Both care plans showed interventions put in place on (MONTH) 1, (YEAR) but no new interventions addressing R2's (MONTH) or (MONTH) (YEAR) AV fistula scratching. The facility's [MEDICAL TREATMENT] Policy reviewed dated (MONTH) 1, (YEAR) states: It is the policy of the facility to ensure that appropriate care for resident on [MEDICAL TREATMENT] is provided by facility staff. On (MONTH) 20, (YEAR), the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediacy of the situation: 1. Audits were performed twice weekly to identify [MEDICAL TREATMENT] residents with behaviors. 2. The Behavior Management Policy was updated on (MONTH) 3, (YEAR) to instruction staff to respond to cognitively impaired [MEDICAL TREATMENT] residents displaying a behavior of scratching, picking, touching or manipulating the [MEDICAL TREATMENT] immediately. The resident will immediately be redirected and monitored. Staff will immediately report the behavior, reassessments will occur, and care plans will be updated. 3. An IDT will be involved in reporting and intervening when the behavior is identified. 4. [MEDICAL TREATMENT] patients will be assessed for cognitive impairment at admission and on an ongoing basis. 5. All licensed nursing staff have been individually in-serviced on the care of [MEDICAL TREATMENT] patients, behavior specific to [MEDICAL TREATMENT] residents manipulating access sites, and emergency response to access site bleeding. Completed (MONTH) 3, (YEAR).

Based on observation, interview, and record review the facility failed to initiate Cardio [MEDICAL CONDITION] Resuscitation (CPR) when a resident had no pulse or respirations. The resident had made the decision to be a Full Code in case of [MEDICAL CONDITION] on [DATE]. The resident was found without a pulse at 4:16 AM on [DATE]. No resuscitative efforts were initiated by facility staff. The Immediate Jeopardy began on [DATE], when the facility did not initiate cardiopulmonary resuscitation on a resident who was a Full Code. On [DATE] at 9:27 AM, E16 (Director of Nursing) was informed of the Immediate Jeopardy related to not performing CPR on a resident that was a Full Code. While the immediacy was removed on [DATE] at 1:50 PM, the facility remains out of compliance at Severity Level 2 due to the need to evaluate the effectiveness of the new/revised policies and training provided to the staff. This applies to 1 of 72 residents (R1) who was designated as a Full Code if [MEDICAL CONDITION] occurs in the sample of 74. The findings include: R1's Order Summary Report dated [DATE] showed R1 had [DIAGNOSES REDACTED]. General Progress Note dated [DATE] showed that R1 was checked at 4:16 AM by E3 Licensed Practical Nurse (LPN). R1 was found to be without a pulse and had no respirations. E3 LPN checked R1 ' s chart for advanced directives and R1 was noted to be a DNR. E3 LPN rechecked R1's chart again at 4:30 AM and noted that R1 was not a DNR but was a full code. R1 expired on [DATE]. On [DATE] at 6:20 AM, E3 LPN stated, I checked her (R1) around 2:00 AM that morning. She was breathing and her skin was not clammy. I checked on her every two hours. At 4:16 AM, E4 Certified Nursing Assistant (CNA) notified me that R1 was not breathing. I went in to check the resident for a pulse, she didn't have one. I went out to check R1's written chart for her code status. I looked at the top of advanced directives form and I swear it said that R1 was a do not resuscitate. As I was talking with the police department, I looked at R1's chart again and I saw that the box was checked stating that R1 was a Full Code. I think this was around 4:30 AM. On [DATE] at 10:30 AM, E3 LPN stated, I did not do CPR and the 2 other staff members did not do CPR on R1 at any time once I realized she was a Full Code. I called a Code Blue and called 911 right away. The police and fire showed up right away. I don ' t think they did CPR on her either. The local police report dated [DATE] showed that the local fire department/EMS arrived at the facility at 5:03 AM on [DATE]. On [DATE] at 7:24 AM, E1 Administrator stated, The nurse did not immediately do CPR on R1. Yes, CPR should be initiated immediately if a resident is a Full Code. On [DATE] at 9:50 AM, E16 DON stated, When a code blue is called, it is announced overhead. We do not keep a code sheet or any log or documentation of the code or of who responds to the code blue. Notes related to code blues are written in the clinical notes in the chart. I don ' t think the staff ever did CPR on R1. R1 was presumed dead based on their (staff) assessment. R1 did not have a pink bracelet on when she died . The use of pink bracelets to identify residents that are DNR did not start until around the third week of [DATE]. There was a black/white copy of R1's code form in the written chart to verify her Full Code status on [DATE]. The current DNR policy is a new corporate policy that was just updated. We do not have a new policy addressing the use of pink bracelets to identify DNR residents. Prior to the incident with R1, the facility kept a black and white copy of all resident ' s code forms in their charts to verify a resident ' s code status. On [DATE] at 10:00 AM, E1 Administrator stated that staff can now determine if a resident is a DNR by looking for a pink bracelet on the resident ' s wrist. E1 stated, The use of the pink bracelet to identify a resident's DNR status, without looking in the chart, was started a few months ago, after the incident with R1. I am not sure if the staff was in-serviced on the use of the pink bracelet or not. We worked with nursing and the detectives to investigate this. We did full audits and now continually audit the code status of each resident . We also offered CPR classes to the staff. I also spoke to our medical director about this. On [DATE] at 4:25 AM, E5 LPN (Night Shift/1st Floor) stated, I check a resident's code status by checking in the written chart. If there is no DNR form in the written chart, I know the resident is a Full Code. On [DATE] at 4:35 AM, E6 LPN (Night Shift/First Floor), stated, I look at the 24 hour report sheet to check if a resident is a DNR. If a resident is a DNR, they have an orange sticker on the outside of the written chart. On [DATE] at 4:45 AM, E7 RN (Night Shift/Second Floor) stated, I look at the 24 hour report sheet to check a resident's code status. We don ' t have orange stickers on our DNR charts. On [DATE] at 4:30 AM, E8 RN (Night Shift/Third Floor) stated, I check the written chart or the computer to verify a resident's code status. E5 LPN, E6 LPN, E7 RN, and E8 RN did not mention the use of pink bracelets to identify DNR residents during their interviews. On [DATE] at 9:30 AM, E12 CNA stated that a pink bracelet on a resident's wrist means that the resident is a fall risk. On [DATE] at 9:43 AM, E14 CNA stated that the pink armbands on residents identify limb restrictions. On [DATE] at 10:27 AM, Z3 Physician stated, I was notified by the nursing home that there was a delay in CPR on R1. R1 was basically found dead. Not doing CPR immediately harmed her dignity because her wishes were not followed. On [DATE] at 11:20 AM, E1 Administrator stated, I can't find a policy in writing addressing the use of pink bracelets to identify residents that are a DNR. E1 stated the staff was in-serviced on DNR/Advanced Directives on [DATE], [DATE], [DATE], [DATE], and [DATE]. In-services for staff on Code Blue were done [DATE] and [DATE]. A mock code blue drill was held on [DATE]. E1 also states that CPR classes were held for staff on [DATE] and [DATE]. R1's Code Status form (Illinois Short Form) dated [DATE] showed that R1 was a Full Code with Full Treatment in the event of [MEDICAL CONDITION]. The Code Status form was signed by R1, Z1, and Z2 Advanced Practice Nurse. R1's General Progress Note dated [DATE] showed that R1, was checked again at 4:16 AM to have her get ready for early am [MEDICAL TREATMENT]. Resident noted pale, no pulse, no breathing appreciated. Checked chart for advanced directives and noted to be a DNR/Do Not Resuscitate. Rechecked chart again and noted that resident is not a DNR but a full code around 4:30 AM. Immediately Code Blue was called and paramedics were called. 911 came and checked resident, CPR was not initiated, resident with no respiration, pulse not appreciated, pupils were dilated and reflexes gone. The Follow Up for R1 Form (undated) showed, Facility conducted directed in-services on Medical Emergency Policy and Procedures, Physician order [REDACTED]. The facility's Advance Directives Policy and Procedure dated [DATE] does not identify how staff can quickly identify if a resident is a Full Code. Through observation, interview, and record review the surveyor confirmed the facility took the following steps to remove the immediacy: 1. The Facility revised its Advance Directive Policy to reflect the most current process as of [DATE], including the new practice regarding the pink wristbands and re-education was initiated to all actively direct care staff presently at work. 2. The Facility immediately re-educated (even those who previously participated in the in-services after the event) all active direct care staff (RNs, LPNs, Certified Nursing Assistants, Restorative Aides, Licensed Therapists and Certified Therapy Aides) presently at work regarding the revised Advance Directive Policy. The Facility will also ensure the incoming scheduled direct care staff will receive re-education on the facility ' s newly revised policy prior to returning to work. These in-services will be conducted by the Nursing Administration. The facility's newly revised Advanced Directive Policy will be included in all new employee's orientation training beginning today ([DATE]). 3. The Nursing Administration initiated a QA (Quality Assurance) process on [DATE] with all active direct care staff presently at work. This QA process will be ongoing on a daily basis for 30 days and random check will be done. 4. Social Services will check daily new admissions and residents with change of condition to ensure that newly revised Advance Directive policy is being followed. Ongoing audits will be completed on a weekly basis.

Based on observation, interview, and record review the facility failed to identify pressure ulcers before they advanced to full-thickness pressure wounds. The facility failed to provide ongoing assessment and provide interventions to reduce pressure after pressure wounds were identified. The facility failed to ensure a physician ordered treatment was in place for a resident with a sacral pressure wound. This applies to 1 of 3 residents (R3) reviewed for pressure ulcers in the sample of 3. The findings include: R3's Physician order [REDACTED]. R3's Care Plan dated February 2016 shows she requires extensive assist of 2 persons with bed mobility and transfers. R3's Braden Scale dated February 2016 has a score of 12 (high risk) for developing pressure sores. The facility's Wound Report dated April 5, 2016, shows R3 developed 3 facility acquired pressure ulcers. R3's first pressure ulcer was identified on March 8, 2016, on her right heel. On March 8, 2016 R3's wound assessment report completed by E3 (Wound Nurse) showed a 5.0 centimeter (cm) x 5.50 cm 100% deep maroon suspected deep tissue injury to her right heel. On March 16, 2016 Z1's (Wound Physician) wound assessment shows the right heel measured 4 cm x 5.5 cm and was unstageable with eschar. On April 5, 2016 at 11:45 AM, R3 was sitting at edge of bed and stated, My feet hurt. On April 5, 2016 at 12:30 PM, E3 (Wound Nurse) provided wound care to R3's wounds. R3's right heel had a large (golf ball size) necrotic area. R3 stated during the dressing change that's tender (my heel). The facility's Wound Report dated April 5, 2016 shows R3 developed a two additional pressure ulcers on March 15, 2016 to her left heel and sacrum. On March 11, 2016 the nurse's note for R3 shows the nurse practioner was notified of wounds to her heels (four days later a wound assessment was done). On April 6, 2016 E3 said he was not aware of an additional wound. He discovered the wound on March 15, 2016. On March 15, 2016 R3's wound assessment report completed by E3 showed a 2.5 cm x 2.50 cm 100% deep maroon suspected deep tissue injury to the left heel. On March 16, 2016 Z1's wound assessment showed a 2.5 cm x 2.50 cm a suspected deep tissue injury to the left heel. On April 5, 2016 at 12:30 PM, E3 provided wound care to R3. R3's left heel was black (eschar). On April 5 2016 at 1:30 PM, R3 stated, I don't like those things (heel protectors) can you just use the pillow. On March 15, 2016 R3's wound assessment report completed by (E5) showed a 2.00 cm x 1.00 cm suspected deep tissue injury to the sacrum. On March 16, 2016 Z1's wound assessment report showed a 1.5 cm x 1.3 cm unstageable eschar wound to the sacrum. On April 5, 2016 at 12:30 PM, E3 provided wound care to R3. R3 did not have a dressing to her sacrum. R3 had a small black (eschar) area to her sacrum. On April 5, 2016 at 1:40 PM, E3 said, I'm not sure how (R3) developed three acquired pressure ulcers. I don't know why R3 did not have a dressing to her sacrum. It may have come off. No one told me. Staff should let nursing know if the dressing came off. On April 5, 2016 at 1:45 PM E4 (Certified Nursing Assistant) said if a dressing comes off notify the nurse right away. Residents who are high risk for pressure should be repositioned every 2 hours, elevate heels, and keep clean. On April 5, 2016 at 1:52 PM, E5 and E6 (Both Certified Nursing Assistants) said they provided incontinence care to R3 prior to her dressing change. They both said there was no dressing to her sacrum. E5 & E6 said R3 prefers pillows to elevate her legs. On April 5, 2016 at 2:00 PM E3 said, R3 should have had interventions in place prior to her wounds developing. It's hard to tell if her wounds were avoidable. On April 6, 2016 at 11:50 AM, E3 said skin checks are done weekly for residents who are high risk. I think they should be done more frequently. R3's Treatment Administration record dated March 2016 shows skin checks are done weekly. Skin checks should be checked daily as of March 18 (10 days after first pressure ulcer identified 7 days later two additional pressure ulcers were identified to her left heel and sacrum). R3's Skin checks were not performed 13 out of 14 days in March 2016. R3's Care Plan date initiated March 18, 2016 (10 days after the first pressure ulcer was identified) shows interventions were implemented. R3's care plan documents she is at high risk for pressure and should be repositioned every two hours, skin check every shift, pressure relieving mattress and cushion to her wheelchair. Administer treatment as ordered, monitor dressing daily to ensure it is intact and adhering. On April 5, 2016 at 11:00 PM, E5 said, residents who are at risk for pressure should be repositioned every 2 hours, off load heels, relieve any pressure points. On April 6, 2016 at 12:50 PM, Z1 (Wound Physician) said if R3 was not willing to wear to heel protectors staff could use a pillow to elevate her heels and monitor that her legs are elevated. Wounds should not be found with eschar on discovery if skin checks are being performed. My job is not identifying the cause of the wound. It is to treat the wound. The facility's Wound Care Program dated August 2013 states, residents whose clinical conditions and medical [DIAGNOSES REDACTED].assessed and managed inspection of the skin every shift .establish an individualized turning and repositioning schedule .every 2 hours or as indicated, off load heels, . the care plan shall be evaluated and revised based on residents response to treatment, .develop a care plan with appropriate interventions, .

Based on interviews and record reviews, the facility failed to provide consistent and individualized supervision to R5 to prevent her from falling. This failure resulted in R5 sustaining a Hip Fracture on 10-29-13, after experiencing multiple falls in the facility. This applies to one of five residents (R5), who were reviewed because of their history of falls, in the sample of twenty four residents. The findings include: R5's Admission Face Sheet showed R5 was admitted to the facility on [DATE] and has the following Diagnoses: [REDACTED]. R5's State Report Of Patient Incident showed: On 10/29/13 at approximately 6:40 PM, staff heard patient yell out and found patient lying on her back on the floor near the bathroom door... (R5 had a laceration with bleeding) R5 transferred to ...hospital via 911 for evaluation and admitted with [DIAGNOSES REDACTED]. R5 did not pull the call light for staff assistance. R5 struggles to maintain her independence and does not understand her physical limitation of unsteady gait." The review of other Incident Reports for R5 showed she had multiple falls, which occurred on the following dates: 4/16/13 at 12:50 PM showed: "Noted resident (R5) sitting on the floor (left side of the bed) with no proper footwear but the floor is dry." R5's Incident Report dated, 7/21/13 at 10:55 PM showed: Resident (R5) was noted on the floor next to her bed in a sitting position with rolling walker next to her." Review of R5's Incident Report, dated 10/28/13 at 12:15 AM, showed the following: "Type: Fall... Resident (R5) was noted on the floor in her room next to bed in a sitting position. Stated she was coming back from toilet and slid... landed on buttock first. R5's care plan, dated 12/22/13, showed she was assessed at risk for falls because of impaired balance/poor coordination, unsteady gait, history of falls and impaired cognition. R5's plan of care consist mainly of interventions for staff encourage to R5 to remember to follow safety measures such as: use her walker and call for help. These measures were not effective in keeping this cognitively impaired residents from falling. Only one measure initiated on 7/20/12 was for staff to "Check and monitor every 30 minutes between 2 AM to 4 AM". This intervention was initiated on 7/20/12, but R5 continued to fall. R5's care plan had no other documentation of staff to monitor or supervise R5. The facility Falls Policy showed the following: Comprehensive Care Plan... "The approaches for fall interventions are clear, specific and individualized for the patient's needs. Managing falls can be complex as many falls do not have a single cause but include a combination of risk factors and causes." The facility staff failed to follow this policy by not meeting the need to implement specific and consistent interventions to address R5's mental and physical problems that put her at risk for falling. The certified nurses aide taking care of R5 was interviewed on 12/12/13 at 12:45 PM. E15 described R5 as confused and often trying to ambulate by herself. E15 stated R5 needs to be check every one to two hours because she is resistant to staff providing care and thinks she can walk by herself. R5's nurse (E13) was interviewed on 12/12/13 at 12:35 PM. E13 stated, "R5's alert but forgetful..." E13 said R5 got up by herself , fell on [DATE], fractured her right femur and required surgery. On 12/12/13 at 2:15 PM, the acting restorative nurse (E4) was interviewed. E4 stated that R5 was assessed to be at risk for falls since April of 2013. E4 said, R5 tries to get up by herself and will not asking for help. E4 stated, R5 can ambulate, but she needs supervision. E4 said interventions were put in place to encourage R5 to use her call light, use proper footwear and and move slowly. E4 said it's been difficult to get R5 to follow staff's instructions and be less resistant to encouragement to cooperate with staff. E4 was asked to review R5's care plan and identified what interventions were put in place to address R5's resistance and staff interventions to monitor/supervise R5. After reviewing R5's comprehensive care plan, E4 said we monitor R5 between 2 AM to 4 AM for help to the bathroom. E4 did not identify any other interventions that staff were doing to consistently monitor/supervise R5. E4 stated no interventions were identified to address R5's resistance to follow staff instructions to try to prevent R5 from falling.

Based on observation, interview and record review, the facility failed to implement appropriate interventions to prevent development of pressure ulcer caused by constant friction and pressure from splints. The facility also failed to ensure specific intervention was in placed to relieve pressure on both contracted knees. This applies to 1 of 6 (R11) residents reviewed for pressure ulcer in a sample of 24. As a result of this failure, R11 developed an unstageable pressure ulcer on the lateral aspect of bilateral feet. Findings include: R11 is an [AGE] year-old resident with multiple [DIAGNOSES REDACTED]. R11 requires extensive assistance of staff for transfers, mobility, hygiene, and toileting needs according to the Minimum Data Sets ((MDS) dated [DATE] and 7/23/2012. Review of the "Braden Scale " assessment dated [DATE] and 10/17/2012 showed that R11 is at high risk for developing pressure ulcer. Review of physician telephone order sheet showed that splints for R11's contracted lower extremities were ordered on [DATE]. Review of "Skin Progress Notes" dated 9/7/2012 reflect the following: - " Noted a dark purplish blood blister to (R11's) left lateral outer aspect of foot, measured 2 cm (centimeters). in length and 1.6 cm in width. Skin intact with redness and swelling to surrounding skin and area tender to touch. " Review of "Skin Progress Notes" dated 9/10/2012 indicated that the splints had caused friction and pressure on both lateral aspect of R11's feet. Review of "Wound Care Specialist Report" dated 9/11/2012 reflected the following initial wound consultation skin assessment: - Unstageable DTI (Deep Tissue Injury) of the Left and Right lateral foot, - Etiology: Pressure - "(R11) recently placed on splints for the contracted lower extremities. (R11's) wound sites appear to be on locations where the splints are causing pressure on the lateral aspects of her feet bilaterally." - Wound Size of left lateral foot: 1.5-cm length, 1.6-cm width, and surface area - Wound size of right lateral foot: 0.3 cm. in length, 0.2 cm, and surface area 0.06 cm Review further of "Wound Care Specialist Report dated 9/18/2012, 9/25/2012, 10/2/12 and 10/9/2012 showed that R11 developed unstageable pressure ulcer on the lateral aspect of both feet due to tissue injury caused by pressure from the splints. The 10/2/2012 report reflects that the unstageable deep tissue injury was noted with blister that was filled with fluid. R11 was sitting in her motorized wheelchair on 10/16/2012 at 11:50 A.M., 1:10 P.M. and 2:20 P.M. R11's lower extremities were contracted with knees rubbing together. There was no device in place to prevent both knees from rubbing together and prevent friction and pressure. As documented on the nurse's notes dated 7/30/2012 and 8/1/2012 indicated that R11 was noted with redness on the right knee. On 10/17/2012 at 10:00 A.M., R11's skin condition was checked in the presence of E3 (Registered Nurse, Wound Nurse), E8(Licensed Practical Nurse, Wound Nurse) and E4 (CNA-Certified Nurse Assistant). E3 applied [MEDICATION NAME] dressing on both lateral aspects of the feet. E3 stated that "these are unstageable pressure ulcers due to deep tissue injury caused from friction and pressure from the splints." E3 also added that she was not aware that R11 was placed on a splint for the contracted lower extremities. As E3 added, if she would have known, more padding could have been applied to the splints to avoid pressure. E4 stated during the dressing change that the splints had caused R11's tissue injury on the lateral aspect of both feet. Review of R11's care plan for the skin alteration shows that there were no interventions on how the splint was monitored to prevent skin breakdown. Further review of the current care plan showed that there was also no intervention to prevent pressure from the contracted knees . E10 (Director Rehabilitation Services, Occupational Therapist) stated on 10/16/2012 at 2:00 P.M. that she would consider a "knee separator". E10 also added that R11's lower extremities appeared to be rotated to right side and thus rubbing the knees.

Based on observations, record reviews and interviews the facility failed to ensure that appropriate assistance was given to prevent accident and ensure safe transfer and bed mobility for 2 of 3 (R1 and R3) residents in the sample, identified by the facility as requiring extensive assistance with two or more person physical assistance. This failure resulted in R1 rolling out of bed on 5/4/11, while a staff was assisting in turning the resident to fix the bed sheets. R1 sustained a fractured left femur that required medical attention. Findings include: 1. R1 is a an [AGE] year old female with multiple [DIAGNOSES REDACTED]. Review of R1's current quarterly MDS (minimum data set) dated 4/12/2011 shows that the resident requires extensive assistance x 2 or more person physical assist with bed mobility. Bed mobility per MDS is defined as, "how resident moves to and from lying position, turns side to side, and position body while in bed or alternate sleep furniture." Review of R1's weight for April 7, 2011 shows a weight of 228.8 pounds. Review of R1's incident report dated 5/4/11 (10:30 AM) shows, "Resident rolled out of bed while being given a bed bath causing her to fall on the landing mat and hit her left forehead on the nightstand." The same incident report shows documentation that, "body assessment done, noted bump to left forehead, ice compress applied: patient c/o (complained of) pain to LLE (left lower extremity) and left hip, noted with shortening of LLE, immobilized LLE." The incident report indicated that R1 was sent to the hospital for evaluation and treatment on 5/4/11 at 12:10 PM. Review of the facility report dated 5/5/11 indicated that R1 sustained a fracture to the left femur. Review of E3's (CNA/Certified nursing assistance) signed statement of witness report dated 5/4/11, documents, "I was on the left side of the resident's bed trying to fix the bed after giving her a bed bath. R1 was helping me turn to her right side and she was holding on the bed frame. She then rolled off the bed hitting her head on the bedside table. I noticed that she has a bump on the left side of her head and I noticed some blood coming from her feet. I then called the nurse to see R1." E3's signed statement documents that she (E3) did not read/check R1's task information/POC (point of care) prior to taking care of R1 to inform her of how to take care of the resident. E3's signed statement also documents that she did not seek another staff assistance when turning R1. Review of the facility's investigation report shows, "Investigation reveals that resident rolled off the bed while being turned by the staff CNA." During an interview held on 5/16/11 at 11:50 AM, E3 confirmed her signed statement dated 5/4/11. E3 stated during this interview that she has been working as a CNA in the facility for 3 months. Per E3, she have taken care of R1 before, prior to the fall incident on 5/4/11. E3 indicated that she have always given R1 a bed bath, turned and repositioned the resident all by herself, even prior to 5/4/11 fall incident. E3 stated that she did not read/check R1's task information prior to taking care of the resident on 5/4/11. E3 stated that after the fall incident on 5/4/11, she read R1's task information which indicated that the resident requires 2 staff assist for turning and cleaning, including bed bath. During an interview held on 5/16/11 at 3:33 PM, E2 (Director of Nursing) stated that the CNA's should read/check each of their residents Task information/POC before taking care of the resident to ensure proper care and to note for any changes in the care. On another interview held on 5/16/11 at 11:20 AM, E2 stated that R1 requires 2 person assist for ADL's (Activities of daily living) for years now, especially since R1 is morbidly obese. Review of R1's computerized task list report initiated since 7/22/09, which was in effect on the day of the fall incident (5/4/11), indicated that the resident requires "ADL assist - usually 2 person with extensive level of assist." The facility failed to provide two or more person physical assistance during R1's bed mobility on 5/4/11, which resulted in the resident rolling out of bed and sustaining fracture of the left femur. 2. R3 is a [AGE] year old male with multiple [DIAGNOSES REDACTED]. During an observation made on 5/16/11 at 1:28 PM, R3 was up on his wheelchair, awake and verbally responsive. R3 was noted to be overweight. R3 stated during the interview that he fell sometime March 2011. According to R3 he was being assisted by a staff from his wheelchair to bed, when he fell on the floor, buttocks first. Review of R3's current annual MDS dated [DATE] shows that the resident requires extensive assistance x 2 or more person physical assist with transfer. Transfer per MDS is defined as, "how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet)." Review of R3's weight for May 3, 2011 shows a weight of 310 pounds. Review of R3's incident report dated 3/16/11 (7:00 PM) shows, "alerted to resident's room by CNA. CNA was helping resident transfer from w/c (wheelchair) to bed. He sat to close to edge and slid to the floor on his butt." The same incident report shows documentation that, body assessment done and no bruises or wounds were noted. Review of E4's (CNA/Certified nursing assistance) signed statement of witness report dated 3/18/11, documents, "I was putting R3 to bed and he was on the walker and I noticed that he was standing not standing right and I instructed him that I will be putting the wheelchair behind him so that he can sit down and he just slid down on the floor. He had grazed on the wheelchair and fell . I was trying to catch him but it was too late and he's too heavy." The same signed statement had a question, "What was on the POC task regarding the resident's level of assistance?" R3 responded on the signed statement, "I don't know, but I know he is extensive. He can stand up and turn but you just have to be there." Review of the facility's investigation report shows, "Investigation reveals that while staff CNA was assisting the resident to go back to bed, the patient experienced leg (both) weakness resulting for the resident to fall on the floor on his buttocks." During an interview held on 5/16/11 at 11:50 AM, E4confirmed her signed statement dated 5/4/11. E4 stated during this interview that she does not remember if she read/check R3's task information/POC prior to taking care of the resident on 3/16/11. According to E4, she and another staff (does not remember who) assisted R3 to get up from his wheelchair. E4 stated that once R3 was standing up, she handed him his walker and the other staff who assisted with getting R3 up, left the room. E4 stated that R3 started walking towards the bed with the use of the walker. According to E4, while R3 was turning to transfer to bed, she noticed that R3's legs were becoming unstable, so she attempted to place the wheelchair behind the resident, but it was too late and R3 fell on his buttocks, on the floor. Review of R3's computerized task list report indicated that the resident requires "ADL assist - usually 2 person with extensive level of assist." The facility failed to provide two or more person physical assistance to complete R3's transfer from wheelchair to bed on 3/16/11, which resulted in the resident falling on the floor.