Every finding on record at Warren Barr Orland Park

Based on interview and record review, the facility failed to maintain confidentiality of resident's record by failing to ensure that resident's medications were secured at the facility and not sent home with another resident. This failure affected one (R172) of two residents reviewed for confidentiality of records.Findings include:R172 is [AGE] years old and resided at the facility from 4/21/2026 to 6/5/2026. R172's face sheet listed the following medical history: Cerebral ischemia, anemia in chronic kidney disease, hyperlipidemia, essential primary hypertension, atherosclerosis of coronary artery bypass graft (s) without angina pectoris, andchronic diastolic (congestive) heart failure.MDS (Minimum Data Set) assessment, dated 4/22/2026, scored R172 with a BIMS (Brief Interview for Mental Status) score of 13. Section gg (functional status) documented R172 is dependent on staff for transfers, toileting hygiene and lower body dressing, requires maximal/substantial assistance to partial/moderate assistance for other ADL (activities of daily living) care needs.On 5/10/2026, R236 was discharged from the facility. Staff inadvertently supplied the incorrect medications to a resident who was discharging. The following medications belonging to R172 were sent home with R236 Amlodipine 10mg, Carvedilol 6.25mg, Clonidine 0.1mg, Furosemide 20mg, Hydralazine 100mg, Trazadone 50mg and Zofran 4mg. As stated in the variance form, dated 5/12/2026, the nurse did not complete proper medication reconciliation with R236 prior to discharging resident. On 6/9/2026 at 3:29PM, V23 (Registered Nurse/RN) said the following day, she realized R172 did not have her medications. V23 volunteered to go the discharged resident's house to switch the medications, notified the Director of Nursing (DON), who authorized her to go to the discharged resident's house and retrieve R172's medications. V23 brought medication back and medications were put back in the medication cart and were administered to R172. Review of R172's medical record did not show any documentation R172 or her daughter were notified of the medication variance; her physician or pharmacy were not notified either.On 6/10/2026 at 9:30AM, V45 (RN) said she recalls R172. V23 brought the medications from the discharged resident's house (R236) and gave them to her around 10:00AM. V45 added she put the medications back in the medication cart, R172 had her morning medications at that time, resident had extra medications in the cart. V45 was not told why V23 brought the medications or where they came from, she just continued to use the medications that were brought back.On 6/9/2026 at 3:29PM, V2 (DON) said R236 discharged from the facility on 5/10/2026; they realized the mistake and went and swapped the medications. V2 added the physicians for both residents and the pharmacy were not notified, R172 or her daughter were not notified. The swapped medications were placed back in the medication cart and continued to be administered to R172.On 6/10/2026 at 1:40PM, V43 (Consultant Pharmacist) said once medication is sent out, facility should notify pharmacy and order new medications. V43 added the facility should make sure the medication is complete, set them aside and order new medications. V43 was asked if the medications that left facility ground exposed resident's protected health information and she said, Yes, residents' information is on the bingo card, exposing that information to another resident is definitely a health insurance portability and accountability act (HIPAA) violation.On 6/11/2026 at 10:46AM, V39 (Social worker) said she recalls R236; R236 lives at home by herself and gets home care from the Department of Aging. V39 said she set R236 up with a home health care agency. R236 is alert but gets home health nurses 2 or 3 times a week.On 6/11/2026 at 12:08PM, V1 (Administrator) said R172's daughter was involved in her care, neither the resident nor her daughter was informed that her medication was sent home with another resident. V1 said the resident and her daughter could have been informed after the investigation. V1 is not sure if the physicians were notified either, stating that he is not clinical; the Director of Nursing will be in a better position to answer that question. V1 was asked what the impact would be for a resident whose information was exposed to the community, and he said, The bingo card does not contain sensitive information, just the resident's name and the name of the medication. A bingo card was reviewed with V1 and V47 (LPN/Licensed Practical Nurse/unit manager) and noted it contains the following:Resident's name, medication name, prescription number, pharmacy name and an inscription that says: prohibits transfer of medications to other persons. A bingo card from the narcotic locked box was reviewed and noted it contains resident's date of birth .Surveyor attempted to contact R172 on 6/11/2026 at 2:17PM but resident did not answer, and her mailbox was full.Privacy and dignity policy, revised 7/3/2025, stated:Policy statement: It is the facility's policy to ensure that residents' privacy and dignity is respected by the staff at all times.Procedures #6. Resident's health information will not be shared by anyone who is not involved in resident's care and to anyone whom the alert and oriented resident does not wish to share his/her information with.

Based on interview and record review, the facility failed to ensure staff conducted appropriate discharge instruction prior to discharging a resident and failed to ensure a resident was discharged home with the right medications. This failure affected one (R236) of one resident reviewed for discharge.Findings include:R236 is [AGE] years old admitted to the facility on [DATE]. R236's face sheet listed the following past medical history: Diverticulosis of large intestine, without perforation, specified disorders of the muscle, other symptoms and signs involving the musculoskeletal system, personal history of malignant neoplasm of breast, chronic kidney disease stage 3, secondary attack (TIA), and cerebral infarction without residual deficits, hyperlipidemia, essential primary hypertension etc.Minimum Data Set (MDS) assessment, dated 5/9/2026, section C0100 (cognitive pattern) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident is somewhat cognitively intact. Functional abilities section GG0100 documented the resident needed partial assistance from another person to complete activities; functional cognition documented R236 needed assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury. Section GG0130 (self-care assessment) indicated R236 is dependent on staff for toileting hygiene, chair to bed transfer and toilet transfer, substantial/moderate assistance for walking 50 feet, sit to stand, lying to sitting, putting or removing footwear and lower/upper body dressing.Medication variance form, dated 5/12/2026, completed by V2 (Director of Nursing/DON) documented: Type wrong drug. Summary: R236 was discharged from the facility, additional information regarding variance states: On 5/10/2026 staff inadvertently supplied the incorrect medications to a resident who was discharging. Staff stated that as she was preparing the medications, she set the stacks down and then when she picked it back, she accidentally grabbed another resident R172's medication.Follow up/facility notified date/time: Staff realized the error on 5/11/2026 and reported to the Director of Nursing. The resident was called and notified and the resident stated she had not taken any of the medications because she still had some of her own at home. On 5/12/2026, the correct medications were delivered to R236 and swapped out with the incorrect medications.Additional monitoring/labs/procedures needed related to the error: N/A, resident discharged , she was encouraged to follow up with her primary care physician for further review. There was no mention of the resident whose medication was wrongly sent home with another resident in the variance form.Part C factors contributing to variance: Other: Lack of medication review.How could this error have been prevented: Closer review of medications upon discharge and medication reconciliation with residents prior to discharge.The following wrong medications were sent home with R236:Amilodipine 10mg, Carvedilol 6.25mg, Clonidine 0.1mg, Furosemide 20mg, Hydralazine 100mg, Trazadone 50mg and Zofran 4mg. Review of physician order for R236 shows the only medication like the ones sent home with R236 is Amlodipine 5mg tablet, take one tablet by mouth one time a day.Surveyor attempted to reach R236 at the number listed in her face sheet several times on 6/9/2026 at 12:24PM, 6/10/2026 at 10:18AM, and 6/11/2026 at 2:15PM, but resident did not answer or return calls. R172's MDS assessment, dated 4/22/2026, scored R172 with a BIMs score of 13. Section GG (functional status) of the same assessment documented R172 is dependent on staff for transfers, toileting hygiene and lower body dressing, requires maximal/substantial assistance to partial/moderate assistance for other ADL care needs.Physician order summary for R172 shows the above medications were ordered for the resident; there was no documentation in resident's medical record that she or her representative were notified of the medication variance, no documentation her physician or pharmacy were notified,Surveyor attempted to contact R172 on 6/11/2026 at 2:17PM but resident did not answer, and her mailbox was full.On 6/9/2026 at 3:29PM, V23 (Registered Nurse/RN) said she pulled resident's medication from the medication cart and set it aside, then pulled resident's Tramadol from the narcotics box and mistakenly put it in front of another resident's medication. When the resident was leaving, V23 pulled the tramadol with other bingo cards that belonged to another resident. V23 realized the mistake the following day; she realized the other resident that is still at the facility did not have her medications. V23 volunteered to go the discharged resident's house to switch the medications. V23 said R236 was discharged on Sunday around 12:00PM; she called the resident the following day around 8 or 9:00AM and she said that she has not used any of the medications from the facility, she still has her own home medication. V23 said V2 (DON) was notified, and he authorized her to go and switch the medications. V23 dropped the correct medications at the resident's house and brought back the medications for R172.On 6/10/ 2026 at 9:27am, V23 (RN) was interviewed again and said the day she brought medications back from R236, she gave them to the assigned nurse for R172 because V23 was off work that day. V23 said she volunteered to go and get the medications though it was her off day.On 6/10/2026 at 9:30AM, V45 (RN) said she recalls R172. V23 brought the medication from the discharged resident's house (R236) and gave them to her around 10:00AM. V45 added she put the medications back in the medication cart. R127 had her morning medications at that time; resident had extra medications in the cart. V45 was not told why V23 brought the medications or where they came from, she just continued to use the medications that were brought back.On 6/10/2026 at 1:40PM, V43 (Consultant Pharmacist) said for someone already on a blood pressure medication, taking additional hypertensive medications can drop the blood pressure too low. V43 was asked what the potential harm could be if someone takes a lot cardiac and hypertensive medications that are not prescribed for them and she said, drop in blood pressure and heart rate, syncope and fainting can occur depending on how many doses the person have taken.V43 was asked if the facility should take medications back after leaving the facility grounds for more than 24 hours and she said, No, once medication is sent out, facility should notify pharmacy and order new medications. The facility should make sure the medications returned from the community is complete, set them aside, and order new medications. On 6/9/2026 at 3:29PM, V2 (DON) said R236 discharged from the facility on 5/10/2026. They realized the mistake and went and swapped the medications. V2 was asked why the nurse did not do a medication reconciliation before discharging resident and he said that the nurse did; she went over the medication list. V2 was asked if that was the expectation for appropriate medication reconciliation during discharge and he said, I guess she should have gone over the medications physically. V2 added the physicians for both residents and the pharmacy were not notified, R172 or her daughter were not notified, the swapped medications were placed back in the medication cart and continued to be administered to R172. On 6/10/2026 at 12:14PM, V44 (Quality Assurance Manager/Pharmacist) said accepting medication back after it has left the facility grounds for more than 24 hours depends on the facility; it is not a pharmacy policy once the medication leaves the pharmacy and changes hands with the facility. V44 said that the integrity of the medication could have been affected after it left the facility; they could have contacted their pharmacy and reordered those medications.On 6/10/2026 at 12:36PM, V14 (Medical Director) said accepting medications after it has left the facility grounds is not typical; the facility could have gotten new medications for the resident, that would have been the best practice. V14 added the prescribing physicians should have been notified. V14 was not sure if he was notified; could have been but he does not recall and cannot say it did not happen. V14 was asked if he would consider the discharge process as inappropriate and he said, maybe an erroneous discharge.On 6/11/2026 at 10:46AM, V39 (Social worker) said she recalls R236; she was previously at another facility and came to the facility from the hospital. R236 lives at home by herself and gets home care from the Aging Department. V39 said she set R236 up with a home health care agency. R236 is alert but gets home health nurse 2 or 3 times a week. R236 was picked up by her friend when she was discharged .On 6/11/2026 at 12:08PM, V1 (Administrator) said a resident's medication were given to another resident who was discharged , the nurse notified the Director of Nursing and reached out to the resident, the nurse then went to the discharged resident's home to get the wrong medications that belong to a resident still at the facility. V1 was asked what could have been the impact of sending the resident home with the wrong medications and he said, The resident could have taken the wrong medication, the resident that was still at the facility did not miss any medication, nurses administered her medications to her. V1 was asked if it is a normal practice for the facility to allow a nurse who was off duty to go and collect medications from a discharged resident's house and bring it back to the facility and he said, I am not sure it is allowed or not, I have to look at the schedule to determine if the nurse was off duty that day. V1 added that R172's daughter was involved in her care, neither the resident nor her daughter was informed that her medication was sent home with another resident. V1 said the resident and her daughter could have been informed after the investigation. V1 is not sure if the physicians were notified either, stating he is not clinical; the Director of Nursing will be in a better position to answer that question. Pharm script discharge with medication policy #5.2 stated:Medications may be sent with the resident upon discharge from the facility only under conditions that protect the residents and ensure compliance with applicable state laws.Procedures:1. Medications may be sent with the resident on discharge if ordered by the prescriber. The prescribershould list the medications to be released upon discharge.2. The labels on discharged medications are verified for completeness and accuracy by reconciling them against the most recent physician orders.3. Directions for use are reviewed with the residents and/or the party responsible. If current directions for use are not the same as those on a prescription label, the medication name, strength, and the correct directions for use are written on a separate piece of paper. The correct directions are given to the resident and/or responsible party, not affixed to the container .Facility discharge planning and instructions policy, revised 6/30/2025, documented:Policy statement: It is the policy of this facility to conduct proper discharge planning for all residents and provide appropriate discharge instructions in preparation for discharge on ce a discharge order is obtained from the resident's attending physician.Procedure: 9. Medications will be sent with resident being discharged to the community. For Medicaid residents, residents on commercial insurance that does not do consolidated billing, and Part D prescription plan residents, all medications had been previously paid for, so the medications belong to the resident, therefore should be sent with the resident upon discharge except for narcotic pain medications.

Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 2 medication errors out of 30 medication opportunities resulting in a 6.67% medication error rate. This failure affected one (R195) of three residents reviewed for medication administration. R195's face sheet documents R195 is an [AGE] year-old resident admitted on [DATE] with diagnoses including but not limited to Type 2 diabetes mellitus without complications, supraventricular tachycardia, and acute gastroenteropathy due to Norwalk agent, and Alzheimer's disease with late onset.R195's Minimum Data Set documents a Brief Interview of Mental Status (BIMS) summary score of 5, indicating R195 has severe cognitive impairment.On 06/09/2026 at 9:05 AM, the surveyor observed V21 (Licensed Practical Nurse/LPN) administer R195 scheduled 8:30 AM morning medications. Two medications (Metformin HCL Oral Tablet500 mg 1 tablet by mouth two times a day for diabetes and Eliquis Oral Tablet 5 mg. 1 tablet by mouth two times a day for A-Fib) were not available for administration because the medication cart ran out of stock and medications were not reordered. V21 stated, This is my first time on this cart. I will reorder. The medications should be re-ordered when there are three doses of medications left. V21 obtained the Metformin and Eliquis from the automated medication dispensing machine after she completed all her scheduled 8:30 AM medication passes. R195 was administered Metformin and Eliquis and administration of these medications were documented on 06/09/2026 at 10:20 AM. V21 stated medications administration timeframes are one hour before or one hour after the scheduled administration time. Review of Ordering and Receiving Non-Controlled Medications Policy#3.3, with no date, documents, Reorder medication based on the reorder date on the Pharmacy Rx label, to assure an adequate supply is on hand. The facility did not comply with its reordering policy.

Based on observation, interview, and record review, the facility failed to ensure staff were aware of required LALM (Low Air Loss Mattress) settings and failed to ensure the LALM settings were set to the correct settings (while in use) for two of three residents (R3, R6) reviewed for pressure ulcers. Findings include: 1.R3 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, paraplegia, and pressure ulcer of sacral region (stage 3).R3's (2/1/26) functional assessment affirms resident is dependent on staff for toileting hygiene and requires supervision or touching assist with rolling left/right.R3's (4/10/26) evaluation for potential skin integrity impairment affirms resident is high risk. R3's care plan states (12/20/24) Resident has potential for impairment to skin integrity related to paraplegia, protein-calorie malnutrition, spinal stenosis, impaired mobility, incontinence and history of refusal of care, interventions: low air loss mattress for pressure reduction. (1/5/26) Resident has an actual impairment to skin integrity sacrum (stage 3) resolved. R3's (1/5/26) POS (Physician Order Sheets) include air mattress - check working condition.R3's (4/8/26) wound assessment states the patient continues on an alternating air/low air loss mattress for pressure redistribution. Ensure settings are maintained at an appropriate level based on the patient's needs and body habitus. On 4/13/26 at 3:51pm, R3 was lying atop of a LALM. R3's LALM settings were on 260 pounds and static mode, however, R3 did not appear to weigh 260lbs, and static mode provides a firm surface. R3's (2/1/26) BIMS (Brief Interview Mental Status) determined a score of 14 (cognition intact). On 4/13/26 at 4:07pm, R3's sacrum was observed and noted to be healed at this time. Surveyor inquired about R3's LALM settings. V13 (Registered Nurse) stated, It's on 260. Surveyor inquired how much R3 weighs; R3 responded, About 150. V13 was asked if R3's LALM was on static mode. V13 replied, Static? it's on. V13 was asked if R3's LALM was supposed to be in static mode while just lying in bed. V13 stated Yeah; however static mode provides a firm surface. R3's (4/14/26) weight was 146 pounds.On 4/15/26 at 12:39pm, V16 (Wound Care Coordinator) was asked who's responsible for resident LALM settings. V16 (Wound Care Coordinator) stated, Either me or the wound nurse; we check it every day first thing in the morning. The CNAs (Certified Nursing Assistants) check it as well. I also have wound care techs too and they check it daily. Nobody is to touch the air mattress settings, except myself or the wound care nurses. V16was aed what R3's LALM settings should be on. V16 responded, Her air mattress setting should be somewhere around 140 or 150 because the boxes might not be exact, but also its adjusted to the patients' comfort. So, if the patient is 150 (pounds) were not gonna (sic) have it at 300. V16 was asked what happens when the LALM weight setting is too high? V16 replied, It could increase the pressure under the patient. SV16 was asked about R3's LALM (mode) setting. V16 stated, It would be on intermittent; it wouldn't be on static. Static makes it equally firm across the mattress. 2.R6's diagnoses include type II diabetes mellitus, cellulitis of right lower limb, and absence of left leg below knee.R6's (4/10/26) evaluation for potential skin integrity impairment affirms resident is high risk. R6's (3/19/26) care plan states the resident has an actual skin integrity impairment to right lower leg.R6's (3/12/26) BIMS determined a score of 15 (cognition intact). On 4/13/26 at 3:29pm, R6 was lying atop of a LALM with the setting on 350 pounds; however, R6 did not appear grossly obese. V11 (Registered Nurse) stated, The weight setting is 350. Surveyor inquired how much R6 weighs. R6 responded, 242. R6 was asked about the dressing observed on R6's right medial calf. R6 stated, There's a wound there but it's just about healed. R6's (4/13/26) weight was 238.2 pounds.On 4/15/26 at 1:04pm, V16 was asked what R6's LALM settings should be on. V16 (Wound Care Coordinator) responded, His settings should be somewhere between 230 or 250; it depends on the box we are using. The skin care regimen policy (revised 7/3/25) states residents with stage III or IV pressure injuries will be placed in specialized air mattresses like low air loss mattresses.The (undated) LALM manufacturer guidelines state; press the static mode button from the touch panel - to provide a firm surface.

Based on observation, interview, and record review, the facility failed to provide a dignified dining environment for one resident (R10) and failed to accommodate one (R3) request during dining in a sample of 10 residents reviewed for resident rights.Findings include: R3 is an [AGE] year-old male, admitted to facility 03/09/2026, and has diagnoses that include: Weakness, Parkinson's Disease Without Dyskinesia, Without Mention of Fluctuations, Paroxysmal Atrial Fibrillation, Long Term (Current) Use of Anticoagulants, Overactive Bladder, Gastro-Esophageal Reflux Disease Without Esophagitis, Orthostatic Hypotension, Repeated Falls, Displaced Intertrochanteric Fracture of Right Femur, Spinal Stenosis, Cervical Region, Anemia, Unspecified, Other Specified Disorders of Bone Density And Structure, Unspecified Site, Cerebral Ischemia, Acute On Chronic Diastolic (Congestive) Heart Failure, Moderate Protein-Calorie Malnutrition, Other Specified Disorders of Muscle, Dysphagia, Oral Phase, Other Symptoms and Signs Involving Cognitive Functions And Awareness R3's BIMS (Brief Interview for Mental Status), dated 3/16/2026, is 12, indicating moderate cognitive impairment R3's active orders, dated 03/19/2026, documents: Dietary - Diet Order summary Regular diet Puree texture, Thin liquids consistency Order status Active Order Date/Start Date 03/19/2026. R10 is a [AGE] year-old male, admitted to facility 03/16/2026, and has diagnoses that include: Cerebral Ischemia, Vitamin D Deficiency, Unspecified, Hyperlipidemia, Unspecified, Cardiomegaly, Acute Pulmonary Edema, Chronic Kidney Disease, Stage 3 Unspecified, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Chronic Diastolic (Congestive) Heart Failure, and Presence of Prosthetic Heart Valve On 3/20/2026 at 1:00pm, R3 was sitting in wheelchair, dressed, groomed, and wearing non-skid socks. R3 stated he was not happy because he is supposed to be getting a puree tray, and he did not get puree for breakfast or lunch. R3 stated he has only received one puree meal since it was changed. R3's meal ticket had regular diet scratched out and puree written in meal type. R3 was served regular breaded fish fillet with a slice of cheese on top, whole hamburger bun, and green beans. R3 stated, It is hard for me to chew food that is not pureed. Sometimes I eat with my fingers. I told them I needed a puree meal; they know that I told someone yesterday. Sometimes it is hard for me to chew. They are supposed to cut my food up for me. Fish is not cut up. It is in my chart that I need my food pureed. On 3/21/2026 at 12:01pm, R3 was sitting in bed with V15, Certified Nursing Assistant (CNA) helping R3 to sit up in bed to eat R3's meal. V15 exited room. R3 stated, I am upset and stated I wanted to sit in a chair instead of eating in my bed and (V15) did not listen to me. Sitting in bed during mealtime restricts my ability to feed myself and I spill my food because my movement is restricted. I asked her (V15) to put me in chair, and she stated, 'I put you up in a sitting position'. This is not a chair, I need a chair, and staff are not listening to me. R3 was attempting to eat his pureed meal and unable to manipulate his hands while sitting in bed. On 3/21/2026 at 12:12pm, R10 was sitting in bed being fed lunch by V15, while V15 was standing up over R10. On 3/21/2026 at 12:18pm, V15, stated, (R10) is not a feeder, but he was having trouble, so I was helping fed him. I always stand. Regarding (R3), I was just sitting him up. I did not give him a tray, and he did not ask me nothing. (sic) They asked me to just pull him (R3) up. On 3/21/2026 at 12:25pm V20, Certified Nursing Assistant (CNA) stated, (R3) is alert and will let you know what he needs. He can feed himself; he is just a set up. When feeding a resident, I stand up. On 3/21/2026 at 12:31pm, during observation of V19 feeding R3, R3 stated, If I can sit in a chair, I can feed myself, but I cannot feed myself in bed. They just sit my tray down, I cannot move my arm, and I drop my food. (V19) is helping me. When they brought in meal, I asked to be put in a chair so I could eat, and they said it's not their job. I ask every day to be put in the chair so I can feed myself. Care Card posted in R3's closet documents: independent feeder. On 3/21/2026 at 12:44pm, V2, Director of Nursing (DON), stated, When feeding a resident, prepare the tray and cut up food for that particular resident and whatever assistance the resident needs is provided. If feeding a resident, hand hygiene prior to feeding, and they are supposed to sit so they are at the same level as the resident and not hovering over them. CNAs receive training in orientation when they first start and periodically training. If a resident asks to sit in a chair, they should be gotten up to the chair unless there is a reason why they cannot. Care card in closet that specified level of mobility and in CNA binder. Transfer status, bed mobility as well as feeding assistance. Care cards are updated by restorative. On 3/21/2026 at 1:25pm, V2 stated, I will follow up with (R3) regarding up in chair. If he requests to get up, he should be gotten up. Facility Policy:Privacy and Dignity (rev. 7/3/25) documents: Policy Statement It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times. Certified Nursing Assistant job description, dated 12/01/2019, documents: Summary/Objective In keeping with our organization's goal of improving the lives of the Guests we serve the Certified Nursing Assistant (C.N.A.} plays a critical role in providing superior customer service and nursing care to all Guests. The C.N.A. safeguards the health, safety and welfare of all Guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: Provides quality nursing care to Guests in an environment that promotes their dignity and freedom of choice. 2. Provides individualized attention, which encourages each Guest's ability to maintain or attain the highest practical physical, mental and psychosocial well-being. 3. Carry out assignments required for the Guest's activities of daily living (AOL's) Which include but not limited to bathing, dressing, grooming, toileting, and feeding. 14. Maintains the comfort, privacy and dignity of Guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment. Resident's Rights documents: You Have Rights! To be treated with care, dignity and respect for Residents rights. The resident has a right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility, including those specified in this section. (I) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. Respect and dignity. The resident has a right to be treated with respect and dignity, including: The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences

Based on interview and record review, the facility failed to administer medications as ordered by the physician for one resident (R1) in a sample of 10 residents reviewed for quality of care. Findings include: R1 is [AGE] years old, with the diagnosis but not limited to: Hemiplegia and Hemiparesis, COPD, Atrial Fibrillation, Type 2 Diabetes Mellitus, Hyperlipidemia, Hypertension, Mild Persistent Asthma, Major Depressive Disorder, Acute Embolism and Thrombosis of Right Femoral Vein, Dependence on Wheelchair, Glaucoma, GERD, and Obstructive Sleep Apnea. R1's BIMS (Brief Interview for Mental Status) score is 11, meaning R1 has moderate cognitive impairment. On 3/20/2026 at 2:57pm, R1 was lying in bed, groomed, dressed, alert and oriented. R1's right side was paralyzed. R1 stated she has missed getting her eye drops on multiple times and she needs new eyeglasses, but it is not time. R1 stated she is supposed to get her eye drops three times a day and she is not getting her eye drops at night, at times it is missed completely. R1 further stated her doctor said she could give herself the eye drops and she use to give them to herself, but they took her eye drops away and she does not know why. R1 stated she is capable of giving herself the drops and now that she has been missing getting her drops three times a day, and not getting her medication is what is the most important right now. R1 stated, When I had my eye drops at the bed side, I never missed my drops. I have my drops at 5:00am, 1:00pm, and 9:00pm. I did not miss my medicine when I was able to have my eyedrops with me and now I am missing getting my eye drops when I am supposed to get them. On 3/20/2026 at 3:14pm, V6, Registered Nurse (RN) stated, (R1) is alert and will call if she needs something. She will get up but she cannot walk. She gets up with the sit to stand. (R1) gets eye drops and the nurse gives. She wants to give to herself, and she has requested to give eye drops to herself, but we do it for her. On 3/21/26 at 9:31am, R1 said she gets up every day and just used the bathroom. R1 said she goes to the dining room to eat most of the times. R1 said her only concern is her eye drops. R1 said she is able to administer them herself and she should be able to. R1 said usually nurses do not wake her up in the morning to administer her the eye drops. R1 said she usually takes the eye drops at 5:00am, 2:00pm, and at 8:00pm. R1 said she wants to administer her medications on her own. R1's 3/2026 (3/1/26-3/21/26) medication administration record documents: Dorzolamide HCl Solution 2 % Instill 1 drop in both eyes three times a day for glaucoma May keep eye drop at bedside for patient to administer Per NP. (Start Date 08/28/2025). The record documents the early morning administration as S (sleeping) for 11 out of 21 days. R1's (3/26) physician order documents: Dorzolamide HCl Solution 2 % Instill 1 drop in both eyes three times a day for glaucoma May keep eye drop at bedside for patient to administer Per NP (start 8/28/25). On 3/23/26 at 10:37 am, V22 (R1's Doctor) said the facility should have let him know that R1 was not receiving the medication as ordered., V22 said, eye drops reduce the pressure in the eye and R1 should be getting it 3 times per day. V22 said, If the resident is sleeping, the medication should be given as soon as she wakes up, no need to wake her up. (R1) should be receiving the medication 3 times per day as ordered. On 3/23/26 at 11:01 am V2 (Director of Nursing) said, Some medications are ordered as patient centered. Those medications do not require specific times are ordered this way (morning and evening) and some are ordered with scheduled time. The medications ordered as early morning are 5:00am to 7:00am and can be given during those times and early pm is 1:00pm to 3:00pm and HS (night) is 8:30pm to 10:00pm. If a resident has an order for medication to be kept at bedside, then the medication should be at bedside. If the resident does not want the medication at bedside, then it should not be at bedside. Marking s on the March MAR (Medication Administration Record) for (R1) that means sleeping. The medication should be administered when (R1) wakes up. (R1) is allowed to have the eye drops at bedside. If she prefers, she could administer the medication herself. (R1) was seen on 3/9/26 by the eye doctor. Facility's Medication Pass (rev 7/2/25) documents: e. After medication is administered to each resident, sign MAR that it was given. Facility's Self–Administration of Medication (rev. 7/3/25) documents: 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. Facility's RN Floor Nurse job description documents: 5. Administer medications within the scope of practice of the RN Licensure.

Based on observation, interview, and record review, the facility failed to safely turn a resident in bed for cares. This failure resulted in R1 rolling off the bed and sustaining a right femur fracture. This applies to 1 of 3 residents (R1) reviewed for falls. The findings include: R1's Face Sheet showed she was originally admitted to the facility on [DATE]. R1's Face Sheet included diagnoses of functional quadriplegia, reduced mobility, muscle wasting and atrophy, morbid (severe) obesity, body mass index (BMI) 50-59.9, anxiety disorder, and need for personal care. R1's Activities of Daily Living (ADL) care plan focus statement (last revised 3/2023) showed R1 has an ADL Self Care Performance Deficit and Impaired Mobility [related to] impaired balance, weakness, decreased strength and endurance [due to] recent hospital stays. Needs assistance with self care and mobility; extensive assistance of 2 staff with mobility and transfers .May use full body lift machine with total assist of 2 staff .non ambulatory at this time. An intervention (last revised 10/1/2022, over two years ago) showed May require 2 staff assist with mobility and transfers depending on her level of participation and endurance. Another intervention (also not revised since 10/1/2022) showed BED MOBILITY: [R1] requires extensive assist of 1 staff participation to reposition and turn in bed, and scooting towards head of bed [due to bilateral lower extremity] weakness. A 3/20/2023 intervention showed TOILET USE: [R1] requires extensive assist of 2 staff participation with toileting needs. R1's 5/4/2025 nursing note from 9:16 AM (late entry) showed, At approximately 5:28 AM, writer responded to staff calling for nurse and resident was observed with right hand and knee on the floor, left leg was on the bed, and left arm was holding on to bed. [R1] let go of bed rail and placed left hand/leg onto floor. She then rolled onto right side, then onto her back to floor .the resident stated 'My leg slid over the bed while the CNA [Certified Nursing Assistant] was turning me and I rolled off the bed.' .resident remained on the floor .[R1] assisted to stretcher by 6 paramedics and was sent to [local] hospital. Under History of Present Illness in R1's 5/5/2025 Hospital admission note, it showed, Patient is a [AGE] year-old bedbound, non-ambulatory female with a BMI of 55 who presented after a fall from bed .she has a complex medical history, notably a severe COVID-19 infection three years ago that led to prolonged hospitalization, deconditioning, and eventual complete loss of ambulatory status. She has not stood or walked in over a year and has since experienced significant weight gain and progressive immobility. On presentation, radiographs and a CT (computed tomography) scan of the right lower extremity revealed a comminuted, supracondylar distal femur fracture with intra-articular extension into the lateral condyle . The Objective section in R1's 5/5/2025 hospital note showed R1 is 5' 9 tall and weighs 380 pounds. R1's 2/28/2025 Minimum Data Set (MDS) showed her cognition was moderately impaired. R1's April/May 2025 POC Response History 30-day lookback (from 4/29/2025 forward) asks for the amount of assistance needed to Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. Seven documented staff entries were available up to R1's fall, one showing R1 needed Substantial/maximal assistance- helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. The other six entries showed R1 was Dependent- Helper does ALL the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. R1's 2/18/2025 MDS showed R1 was also dependent for toileting hygiene. On 5/28/2025 at 8:31 AM, R1 was in her bed wearing a hospital gown. R1 was alert and in a bariatric bed with a gel overlay. R1 stated staff took her stiches out the day before, and she was told there were three screws in her right knee. On 5/28/2025 at 9:36 AM, R1 stated V4 (CNA) was changing her by herself, when R1 fell. R1 stated when V4 was going to change R1's incontinent brief, V4 was standing on the right side of R1's bed, and V4 turned R1 away from her. R1 stated she told V4 her leg is going to fall. R1 stated V4 stood there and removed the soiled brief, and her leg slid off the bed. R1 stated she fell on her knees with her butt sticking up in the air. R1 stated 6-7 people came to her room after she fell. R1 stated her left leg has arthritis, and now her right knee was broken. On 5/28/25 at 2:51 PM, V4 (CNA) stated she worked on 5/4/2025 night shift, and she was taking care of R1 when she fell. V4 stated R1 turned herself towards the door. V4 stated as R1 was turning herself, one of her legs pulled out of the bed and R1 was on the floor. V4 stated she did not touch R1. V4 stated she yelled for the nurse. V4 stated R1 became a two person assist after she fell. V4 stated R1 never told her her leg is going to fall. On 5/29/2025 at 1:45 PM, V10 (Restorative LPN- Licensed Practical Nurse) stated R1 has never been on a bed mobility program, and she believed R1 has used a full-body mechanical lift for transfers for around two years. On 5/29/2025 at 2:25 PM, V3 (Therapy Director) stated R1 had a fall from bed resulting in a fracture. V3 stated, Staff should not roll residents away from them. V3 stated, If (R1's) leg started going off the side of her bed, she couldn't have stopped it .at 380 pounds the momentum would carry her leg over. On 5/29/2025 at 3:10 PM, V8, ADON (Assistant Director of Nursing), stated she completed the investigation into R1's fall. V8 stated R1 has full ROM (Range of Motion) to her arms, but not a whole lot of ROM to her legs as R1's baseline. V8 stated, You should not push a resident away from you in bed. You have more control of the patient if you roll them toward you. V8 stated the root cause of R1's fall was Resident stated, my leg slid over the bed and I rolled off the bed. V8 stated nobody was on that opposite side of the bed. The facility's General Care policy (revised 7/30/2024) showed, Policy Statement- It is the facility's policy to provide care for every resident to meet their needs 1 Physical needs would include, but are not limited to ADL .2. The facility will assist the resident to meet those needs .

Based on interview and record review, the facility failed to protect a resident's right to be free from theft. This applies to 1 of 3 residents (R3) reviewed for abuse/theft in the sample. The findings include: R3's Face Sheet showed he was admitted to the facility on [DATE]. The Face Sheet showed his diagnoses include cerebral infarction, abnormalities of gait and mobility, need for assistance with personal care, and sepsis. On April 29, 2025, R3's 4/29/25 Minimum Data Set showed his cognition was severely impaired. The facility's 5/26/25 Abuse Report Final Form showed, On May 20, 2025 .[R3's Son] reported .that his father's debit card is missing and that he received a notification that someone tried to use the card. [R3's Son] mentioned that he brought his father's wallet on Sunday and today 5/20/2025 he received the notification that someone tried to use the card. The charge to the card was declined. The Abuse Report Final Form continued to show Interview with [V7] Orientee CNA [Certified Nursing Assistant- former]: .[V7] admitted taking the debit card, but stated none of the transactions she attempted went through. [V7] mentioned that when she went to the gas station with the debit card that attempt was declined. [V7] refused to answer any other questions from the Administrator. The Form ended with Through the investigation and collaboration with the (city) Police Department it was determined that [V7] is the perpetrator. The allegation of theft was confirmed by the (city) Police Department . On 5/29/25 at 12:55 PM, V9 (Human Resources Director) stated V7 had finished her training modules and was assigned to work on the floor on the 2 PM- 10 PM shift. V9 stated, It was [V7's] very first day on the floor when this happened she didn't even finish her first day. On 5/29/25 at 1:05 PM, V1 (Administrator) stated she interviewed V7 after the theft, and initially V7 denied the incident. V1 stated she told V7 she could see her on video, and V7 answered none of the transactions went through. V1 stated she asked V7 how she accessed R3's debit card, and V7 hung up on her. The Abuse Final Report Form showed (city) Police identified [V7] as the perpetrator through video footage from the gas station where the debit card was attempted to be used. The Abuse Final Report Form showed, (city) Police identified [V7] as the perpetrator through video footage from the gas station where the debit card was attempted to be used. The facility's Abuse and Neglect policy (revised 7/12/2024) showed, Financial/Misappropriation of Property: Financial abuse includes, but is not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently

Based on observation, interview, and record review, the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 162 residents in the facility receiving dietary services. Findings include: On 04/09/25 at 01:11 PM, V2, DON (Director of Nursing), confirmed 162 residents were being served from dietary services on 04/08/25. 1. On 04/08/25 at 10:24 AM, the coffee station drainpipe in the kitchen was wrapped in black tape that looked like electrical tape. The pipe was dripping over a silver container that had brown liquid with a gray furry film floating on top and white unidentifiable chunks. The stand mixer was covered with plastic. The mixer had white and yellow crusted drips. The vents over the stove cook top had a layer of dust. On 04/10/25 at 01:47 PM, V6, Dietary Director, stated the vents over the stove are cleaned by an outside company that comes out quarterly. They came out February 2025, and will return in May this year. V6 stated administration is responsible for setting up those visits, but he can put in a request for them to come out if needed. V6 stated the person who last used the stand mixer should have cleaned it thoroughly before covering it up. V6 stated he would inform maintenance about repairs needed in the kitchen. V6 stated he did not know the coffee station drainpipe was leaking prior to the survey. 2. On 04/08/25 at 10:24 AM, the ice machine did not have a log. V6 (Dietary Director) stated he was not responsible for the ice machine, and he was unaware of a log for its cleaning schedule. On 04/09/25 at 1:38 PM, V1, Administrator, stated the facility did not have a policy for the ice machine or cleaning logs for the ice machine. On 04/09/25 at 02:30 PM, V27, Executive Director, stated an outside company comes to the facility to clean the ice machines. V27 did not have documentation of services from the outside company. 3. On 04/08/25 at 10:03 AM, the walk-in cooler contained: *A 48 fl. (fluid) oz bottle of prune juice with a use by date of 4/7/25. *A 5lb container of cottage cheese with a use by date of 4/7/25. *A 5lb container of sour cream partially used without an open on or use by date. *A silver metal pan with viscous dark orange liquid and a thick dark orange frothy foam labeled JL identified by V6 as orange juice. *A 5lb container of cottage cheese with a manufacture best by date of 3/30/25. The plastic seal and lid were bubbled out. V6 stated it should not be used because it is past the date printed on the container. On 04/10/25 at 1:47 PM, V6, Dietary Director, stated, Food should be labeled with a received date, opened on date, and use by date to assure no one becomes ill form eating outdated food. Food items are good for seven days in the cooler. Dry storage goods are good for six months and freezer items are good for up to a year. We wouldn't use food items past the best by date because that is the date set by the manufacturer. 4. On 04/10/25 at 11:13 AM, the first-floor unit refrigerator was reviewed with V33, Social Services. A bag of someone's personal food did not have any dates. No temperature log was on the refrigerator. On 04/10/25 at 11:19 AM, the second-floor unit refrigerator was reviewed with V34, Social Services, and it did not have a temperature log. On 04/10/25 at 11:25 AM, the third-floor unit refrigerator was reviewed with V38, LPN (Licensed Practical Nurse), and it did not have a temperature log. On 04/10/25 at 03:27 PM, V27, Executive Director, stated Housekeeping does the refrigerator logs for the unit refrigerator and some logs were missing. Three months of unit temperature logs were requested for each unit. V27 provided one temp log for each unit. The first-floor refrigerator on January 26, 2025, PM a reading of 42 degrees was logged with no documented corrective action provided. The third floor February 2025 had fifteen shifts with temperature log of 42 degree with no documented corrective action. 5. On 04/08/25 at 09:57 AM, the kitchen tour began in the dry storage withV6, Dietary Director. *A 5lb (Pound) bag of baking cocoa was open to air *A 6lb 10 oz (ounce) can of cream corn was dented *A 6lb 9oz can of pizza sauce was dented *A 25lb box of food thickener in clear plastic bag was open to air. On 04/10/25 at 01:47 PM, V6, Dietary Director, stated, Dented cans should be discarded to prevent food borne illness related to botulism. Food items should be wrapped up and sealed tight to prevent moisture, mold development, foreign object or pest contamination. The facility policy Maintenance, dated 8/16/24, states it is the facility policy to maintain equipment and the building environment. Any equipment that cannot be fixed will be replaced accordingly. The facility policy Food Handling, dated 7/26/24, states all food service equipment and utensils will be sanitized according to current guidelines and manufactures recommendations. The facility policy Kitchen, dated 8/16/24, states food should be free of slime mold. Refrigerated food should be covered, dated labeled and shelved to allow air circulation. Open containers or potentially hazardous food or leftovers should be dated and used within 3-5 days in the refrigerator. Dented cans will be returned to the food company and will not be utilized and served to residents The facility policy Food Handling, dated 7/26/24, stated functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirement. Federal standards require that refrigerated food be stored below 41 degrees Fahrenheit. The facility policy Food from the Outside, dated 7/26/24, states all food brought in by visitors and family members from outside of the facility will be labelled with the date it was brought to the facility. All undated food items will be discarded to ensure safety of the residents.

Based on interview and record review, the facility failed to have documentation that staff were educated and offerred the Covid-19 immunization. This applies to all 168 residents in the facility reviewed for immunizations in the sample of 33. The findings include: The CMS (The Centers for Medicare and Medicaid Services) form 671 titled Long-Term Care Facility Application for Medicare and Medicaid, dated 4/8/25, shows the facility has a census of 168 residents. On 4/9/25 at 3:01 PM, V15 (RN-Registered Nurse /Infection Control Nurse) stated, I don't have the documentation that shows where I offered the vaccine to staff. I think they offer the covid vaccines to staff through an outside company. They are not required to have covid boosters. I personally have not offered to them. I have to check with Human Resources if they have a log of it. On 4/10/25, V15 was unable to provide surveyor any logbook showing that the facility offered staff Covid-19 vaccines. V15's infection control binders did not have any documentation staff were educated regarding the benefits and potential side effects of the Covid-19 vaccine. The binders also did not contain any documentation staff accepted and/or received the vaccine, and there was no documentation to show the vaccination status of staff. On 4/11/25 at 12:49 PM, V1 (Administrator) emailed surveyor saying (V2-Director of Nursing) enters Covid data on employees into a tracker. She stated V2 would provide his staff covid vaccine tracker. As of 3:11 PM on 4/11/25, no tracker had been provided by the facility. Facility's policy titled Covid 19 Vaccination Policy (7/16/24) shows: The facility will comply with the applicable CMS, CDC (Centers for Disease Control and Prevention), and/or IDPH (Illinois Department of Public Health guidance on Covid-19 vaccination. As CMS had rescinded the mandatory Covid 19 vaccine requirement for staff and resident, the facility will continue to promote and provide Covid-19 vaccination whenever the vaccine is available, and individuals consent to Covid vaccination

5. A review of R80's electronic health record showed a 4/3/25 at 07:53 AM progress note that R80 was sent to the local community hospital for a dislodged G-tube (gastric tube). On 04/09/25 at 4:33 PM, V2, DON (Director of Nursing), said the family representative and R80 did not get the notice of transfer in writing, because R80 was not admitted to the hospital he was only sent to the ER (emergency room). V2 said both the resident and family are to get written notification of the transfer and the reason for transfer and the bed hold policy, along with notifying the Ombudsman. The facility's Transfer and Discharges policy, dated 8/19/24, showed notify the resident, family, or legal representative of the transfer or discharge and the reason for the move in writing. Based on interview and record review, the facility failed to provide residents and/or their representatives written notification of the reason for transfer to the hospital, and failed to notify the Ombudsman of the transfers. This applies to 5 of 5 residents (R29, R33, R37, R54, and R80) reviewed for discharge in a sample of 33. The findings include: 1. R29's Face Sheet showed R29 was admitted to the facility on [DATE]. R29 had multiple diagnoses which included cerebral ischemia, chronic obstructive pulmonary disease, psychotic disorder, mood disorder, and dementia. R29's MDS (Minimum Data Set), dated 03/03/25, showed R29 was cognitively impaired. R29's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form, dated 02/13/25, showed R29 had a fall. The same form showed R29 was transferred to the hospital via emergency medical transport on 02/13/25. The form showed written notice for reason of transfer was not given to the resident and or/representative. R29's Change in Condition with SBAR Form, dated 02/25/25, showed R29 had a fall. The same form showed R29 was transferred to the hospital via emergency medical transport on 02/25/25. The EMR (Electronic Medical Record) contained no documentation of written notice for reason of transfer or discharge to the hospital provided to R29 and/or the representative for the hospital transfer dated 02/13/25. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital for either transfer. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and ombudsman notification. 2. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's Change in Condition with SBAR Form, dated 12/20/24, showed R33 was observed sitting on the floor, next to her bed. The same form showed R33 was transferred to the hospital via emergency medical transport on 12/20/24. The form showed written notice for reason of transfer was not given to the resident and or/representative. The EMR contained no documentation of written notice for reason of transfer or discharge to the hospital. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and ombudsman notification. 3. R37's Face Sheet showed R37 was admitted to the facility on [DATE]. R37 had multiple diagnoses which included disorders of the brain, dementia, Alzheimer's Disease, chronic kidney disease, diabetes, hemiplegia, and hemiparesis. R37's MDS, dated [DATE], showed R37 had moderate cognitive impairment. R37's Change in Condition with SBAR Form, dated 01/24/25, showed R37's change in condition was an abnormal lab, potassium 6.7. The same form showed R37 was transferred to the hospital via emergency medical transport on 01/24/25. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for ombudsman notification. 4. R54's Face Sheet showed R54 was admitted to the facility on [DATE]. R54 had multiple diagnoses which included Parkinson's Disease with dyskinesia, weakness, muscle disorders, dementia, orthostatic hypotension, seizures, and congestive heart failure. R54's MDS, dated [DATE], showed R54 had severe cognitive impairment. R54's Change in Condition with SBAR Form, dated 09/15/24, showed R54's change in condition was more lethargic and less responsive. The same form showed R54 was transferred to the hospital via emergency medical transport on 09/15/24. R54's Change in Condition with SBAR Form, dated 12/27/24, showed R54's change in condition was altered mental status. The same form showed R54 was transferred to the hospital via emergency medical transport on 12/27/24. The form showed written notice for reason of transfer was not given to R54 and/or the representative. R54's Change in Condition with SBAR Form, dated 12/31/24, showed R54's change in condition was resident fell forward on dining room table, hitting head. The same form showed R54 was transferred to the hospital via emergency medical transport on 12/31/24. The EMR contained no documentation of written notice for reason of transfer or discharge to the hospital given to the resident and/or the representative for the transfer dated 12/27/24. The EMR contained no notice sent to the Ombudsman for transfer or discharge to hospital. The facility was unable to provide documentation for written notification of the reason for transfer to the hospital and ombudsman notification. On 04/09/25 at 4:10 PM, V1 (Administrator) stated, The Ombudsman wasn't notified of the hospital transfers of the residents who returned to the facility starting September 2024 through March 2025. The Ombudsman should have been notified. It a regulation that they are notified.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs. This applies to 7 of 7 residents (R23, R29, R33, R68, R75, R96, R116) reviewed for personal hygiene in a sample of 33. The findings include: 1. On 4/8/25 at 10:59 AM, R96 was lying in bed. His hair was disheveled and greasy. V33 (R96's wife) was beside him and she stated, They never wash or comb his hair. R96 confirmed what V33 had said. R96's care plan, dated 3/4/25, shows she has a ADL self care performance deficit and impaired mobility related to disease process. Intervention: Dressing and grooming (R96) .groom self and wash body and comb hair daily. R96's face sheet shows diagnoses of major depressive disorder, single episode, unspecified and suicidal ideations. 2. On 4/8/25 at 11:37 AM, R116 was lying in bed. He had a full beard and very long nails with a dark substance underneath on both hands. R116 stated, I've been asking to be shaved but the CNAs (Certified Nursing Assistants) say they don't have time. I don't know what my face looks like. I wanted to be shaved and I want my nails cut. R116's face sheet shows diagnoses of generalized anxiety disorder, spinal stenosis, cervicothoracic region, other cervical disc degeneration at C6-C7 level, encounter for orthopedic aftercare following surgical amputation, other reduced mobility, need for assistance with personal care. R116's care plan, dated 1/31/25, requires assistance with ADL's. Goal-(R116) will be assisted with ADL's as needed. Encourage participation in ADL's and help with grooming. 3. On 4/8/25 at 12:12 PM, R23 was lying in bed. R23's hair was not combed, and it was greasy. R23 stated, They are not washing my hair. Can't you see? It's greasy. I had a bed bath only a week ago. And I smell. R23's face sheet shows diagnoses of lymphedema, sepsis, lack of coordination, depression, morbid (severe) obesity due to excess calories, anxiety disorder. R23's care plan, dated 7/7/22, shows she has ADL self care performance and impaired mobility. Personal Hygiene-she requires extensive assist of 1 staff participation with personal hygiene. On 4/09/25 at 12:09 PM, V2 (DON-Director of Nursing) stated, CNA's under the supervision of the nurse are responsible for shaving, cutting nails, and washing the residents' hair. 48526 4. On 04/09/25 at 10:00 AM, R29 was sitting in the dining room in a wheelchair. R29 was seated on a mechanical lift sling. R29 had a foul odor. V25 (CNA) and V26 (CNA) transferred R29 via mechanical lift from the wheelchair to the bed. V25 and V26 provided incontinence care to R29, assisted by V13, RN (Registered Nurse/Nurse Manager). R29's mechanical lift sling and wheelchair cushion had a strong foul odor. R29's incontinence brief was minimally wet. R29's Face Sheet showed R29 was admitted to the facility on [DATE]. R29 had multiple diagnoses which included cerebral ischemia, chronic obstructive pulmonary disease, psychotic disorder, mood disorder, and dementia. R29's MDS (Minimum Data Set), dated 03/03/25, showed R29 was cognitively impaired. The same MDS showed R29 required partial/moderate assistance with toileting hygiene and was dependent with transfers. R29's ADL care plan initiated 09/24/23 showed R29 requires assistance with ADL's (transfers and toileting). The ADL care plan goal showed resident will be assisted with ADL's as needed. On 04/09/25 at 10:00 AM, V13 (RN) stated, The resident should have not been placed on a soiled mechanical transfer sling. The slings should be changed when they are soiled, dirty, or smell like urine. The wheelchair cushions should be cleaned and wiped down twice per week. V13 stated R29's mechanical lift sling and the wheelchair cushion smelled like urine. 5. On 04/09/25 at 9:40 AM, R33 was sitting at the dining room table. R33's fingernails on both hands were long, jagged, and had a dirty substance underneath. R33 stated she would like her nails clipped and cleaned. On 04/10/25 at 2:26 PM, R33's fingernails remained long, jagged, with a dirty substance underneath. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's ADL care plan, initiated 11/04/24, showed R33 requires assistance with ADL's (personal hygiene). The ADL care plan goal showed resident will be assisted with ADL's as needed. On 04/10/25 at 2:26 PM, V13 stated, Tesidents nails should not be long and jagged. Nails should not have a dirty substance underneath. Nails should be clipped on shower days and as needed. 41384 6. On 4/8/25 at 2:26 PM, R68's fingernails were long, jagged, and with a brown substance under them. V11 & V12 (R68's daughters) were present at the time, and they both said that R68's nails always look like that, and they ask staff to provide nail care for R68, and it is still not provided. V11 and V12 said because staff does not provide nail care for R68, they do it for her, because they are afraid she will get and infection because she will scratch her skin to the point of bleeding. Then V11 and V12 provided nail care for R68. R68's 3/18/25 MDS showed her cognition is severely impaired, and she needs partial/moderate assistance with personal hygiene. On 04/10/25 at 12:10 PM, V2, DON (Director of Nursing), said he expects nail care to be provided regularly to prevent infection and overall cleanliness to the resident. V2 said the facility policy says ADL (Activities in Daily Living) care should be given daily as needed. The facility's Nail Care policy, dated 8/16/24, showed the purposes of the procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 46409 7. On 4/8/25 at 12:21 PM, R75 had fingernails which were 1.5 inches long on all her fingers, and had a brown substance underneath them. R75 said the facility staff do not ask her if she needs them cut, and she would want the staff to cut them for her. On 4/10/25 at 10:02 AM, R75's fingernails remeined the same length, and still had a brown substance underneath them. On 4/10/25 at 10:40 AM, V23 (LPN/Licensed Practical Nurse) said the residents' nails should not be long and the residents should be offered clipping weekly. V23 said the residents' nails should be cleaned daily. V23 said the residents should have short nails to prevent scratching, which could cause infections. On 4/10/25 at 12:46 PM, V19 (CNA/Certified Nurse Assistant) said she had cared for R75 on 4/7/25 and had provided her a bed bath, but had not provided nail care. V19 said the residents' nails should be short and clean so they do not scratch themselves. V19 said long nails can cause skin breakdown, which can create a wound. On 4/10/25 at 12:54 PM, V18 (CNA) said every time the staff provide a bath, they should cut their nails if they are long. V18 said the nails should also be cleaned if they are dirty. V18 said long nails can cause the resident to scratch and cause infections. R75's face sheet showed diagnoses including osteoarthritis, anxiety disorder, and hypertension. R75's MDS, dated [DATE], showed she had moderate cognitive impairment. R75's care plan showed R75 has potential for impairment to skin integrity. R75's care plan showed she requires assistance with ADL's (Activities of Daily Living) (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Facility's policy titled General Care (7/30/24) shows: It is facility's policy to provide care for every resident to meet their needs. 1. Upon admission or readmission, the facility will evaluate the resident for physical needs. Physical needs would include, but are not limited to ADL .2. The facility will assist the resident to meet these needs.

Based on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers, and ensure it was readily available in the resident's medical record. This applies to out 5 of 5 residents (R20, R81, R96, R136, R529) reviewed for pacemakers in a sample of 33. The findings include: 1. R81's face sheet documents an admitted [DATE]. R81's POS (Physician Order Sheet) shows an order (6/16/23) for Pacemaker-Check for functionality and effectiveness. Check pulse rate and blood pressure daily and as needed. R81's face sheet documents the following diagnoses: presence of cardiac pacemaker, chronic combined systolic (congestive) and diastolic (congestive) heart failure, pure hypercholesterolemia, hyperlipidemia, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension, and hypertensive heart disease with heart failure. R81's medical record was reviewed. R81's progress notes, admission assessment, and care plan do not document the pacemaker serial and model number. It was also unknown as to when the pacemaker was last assessed. R81's care plan on pacemakers shows: Check upon admission/readmission and every 3 to 6 months in accordance to my physician's order. Check and document in chart: Heart rate, Rhythm, and Battery check. On 4/10/25 at 10:01 AM, V2 (DON-Director of Nursing) stated, The model and serial number should be in the care plan. It's notoriously difficult to get that information. I've tried myself. The families and residents don't know. The admission nurse is the first person who should try to get it. I'm the second person who follows up and tries to get that information. I've tried calling cardiology offices. There should be an order in the POS and how often it should be checked. The model and serial number of the pacemaker should be in the care plan. 2. R96's face sheet documents an admitted [DATE]. R96's face sheet documents the following diagnoses: presence of cardiac pacemaker, paroxysmal atrial fibrillation, acute on chronic systolic (congestive) heart failure, and hypotension. R96's POS did not have any orders for the pacemaker, or how often it should be checked. R96's medical record was reviewed. R96's progress notes, admission assessment, and care plan do not document the pacemaker serial and model number. It was also unknown as to when the pacemaker was last assessed. R96's care plan on pacemakers shows: Check for functionality and effectiveness. Check pulse rate and blood pressure daily and as needed. Check upon admission/readmission and every 3 to 6 months in accordance with physician's order. Checks per facility protocol and document in chart: Heart rate, Rhythm, Battery check. 46409 3. R529's face sheet documents an admitted [DATE]. R529's face sheet showed diagnoses of presence of cardiac pacemaker, hypertensive heart disease with heart failure, hypertensive urgency, cardiomyopathy, chronic diastolic heart failure, acute on chronic diastolic heart failure, and syncope and collapse. R529's EMR (Electronic Medical Record) was reviewed. R529's POS (Physician Order Sheet) did not include any orders for a pacemaker. R529's care plan, dated 10/22/24, showed to Check upon admission/readmission and every 3 to 6 months in accordance to physician's order. 4. R20's face sheet documents an admitted [DATE]. R20's face sheet shows diagnoses of presence of cardiac pacemaker, hypertension, and heart failure. R20's EMR was reviewed, and R20's POS did not show the serial or model number of the pacemaker. R20's care plan also did not show a serial or model number. 5. R136's face sheet documents an admitted [DATE]. R136's face sheet showed diagnoses of presence of cardiac pacemaker, acute on chronic diastolic heart failure, hypertensive heart disease with heart failure, atherosclerotic heart disease, paroxysmal atrial fibrillation, personal history of transient ischemic attack, and cerebral infarction without residual deficits. R136's EMR was reviewed, and R136's POS did not show the serial or model number of the pacemaker. R136's care plan also did not show a serial or model number. Facility's policy titled Pacemakers (8/16/24) shows: Procedures-1. Residents who have pacemakers must have the following documented in their medical record: a. The date of insertion, physician who inserted it, and the place where it was inserted. b. Make, model and serial number of the pacemaker. c. Orders in the POS for how often the pacemaker is to be checked and by whom (physician office, cardiology clinic, by telephone, etc.). 2. The pacemaker remote follow-up/check should be done every 3-12 months for depending on the physician's orders .

Based on observation, interview, and record review, the facility failed to remove expired items from resident refrigerators. This applies to 4 of 4 residents (R36, R38, R47, R84) reviewed for refrigerators in a sample of 33. The findings include: 1. On [DATE] at 12:07 PM, inside R38's fridge, she had two cartons of yogurt (113 grams). One carton was raspberry flavored which expired on [DATE], and the other one was strawberry flavored that expired on [DATE]. There was a carton of (gelatin) with a best by date of [DATE]. R38 stated, I didn't know those were expired. You can throw those out. I won't eat those. I don't wanna get sick. R38's face sheet shows diagnoses of dysphagia, prediabetes, impaired glucose tolerance, cachexia and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R38's MDS (Minimum Data Set), dated [DATE], showed R38 is cognitively intact. 2. On [DATE] at 12:30 PM, inside R36's fridge, there were 2 cartons of yogurt (113 gram) mixed berry flavor that expired on [DATE], a bottle of freshly squeezed orange juice with a sell by date of [DATE], and a bottle of freshly squeezed mint, lemon, sugar alkaline water with a sell by date of [DATE]. R36 stated, I didn't know they were not good. You can toss them out. It's not worth it to get food poisoning. R36's face sheet shows diagnoses of dysphagia, unspecified, mild protein-calorie malnutrition, and extended spectrum beta lactamase (ESBL) resistance. R36's MDS, dated [DATE], shows R36 is cognitively intact. On [DATE] at 12:09 PM, V2 (DON-Director of Nursing) stated, Housekeeping, nurses or CNA's (Certified Nursing Assistants) are responsible for removing expired food items from the residents' personal refrigerators. 46409 3. On [DATE] at 1:09 PM, R84's personal room fridge had a packet of pepperoni that expired on [DATE], and a packet of cracker barrel sharp white cheese which expired on [DATE]. R84's face sheet showed she was admitted to the facility with diagnoses including nutritional deficiency, type 2 diabetes mellitus, osteoarthritis, muscle wasting and atrophy, and need for assistance with personal care. R84's MDS/ dated [DATE], showed she was cognitively intact. 4. On [DATE] at 11:41 AM, R47's personal room fridge had a blueberry yogurt/ which had a best by date of [DATE]. R47's face sheet showed she was admitted to the facility with diagnoses including hemiplegia and hemiparesis, muscle wasting, neuralgia and neuritis, hallucinogen use, and psychoactive substance abuse. R84's MDS, dated [DATE], showed she was cognitively intact. On [DATE] at 10:49 AM, V22 (CNA/Certified Nurse Assistant) said the housekeeping staff are supposed to throw away expired food and clean out the fridge. On [DATE] at 12:39 PM, V21 (Assistant Director of Housekeeping) said the housekeeping staff were the ones who should check the fridges. V21 said the staff are supposed to make sure everything was dated and if there was anything outdated, they should throw the food out. V21 said the housekeeping staff are supposed to clean the fridge out every week to make sure nothing was spoiled or rotten. On [DATE] at 12:40 PM, V20 (Director of Housekeeping) said the housekeeping staff are supposed to throw away expired food. V20 said there were no logs which showed the housekeeping staff had cleaned out the fridge. Facility's policy titled Food from the Outside Policy dated [DATE] shows: The facility will comply with sanitary food practices in storing, handling, and consumption of food brought by family and visitors from the outside of the facility 3. After ,d+[DATE] days, these food items will be discarded. 4. All undated food items will be discarded to ensure safety of the residents .

Based on observation, interview, and record review, the facility failed to follow infection control measures. These failures apply to 5 of 5 residents (R27, R5, R529, R383, & R63) reviewed for infection control practices in a sample of 33 residents. The findings include: 1. On 04/08/25 at 12:35 PM, V3 (Restorative) was sitting at a table; R529 was to V3's left, and R63 was to her right. V3 was feeding R529 with her right hand, and then put down R529's fork, and V3 got up to move R63's wheelchair, touching the wheelchair. V3 then touched R63's lunch tray that R63 was eating his lunch from. After touching R63's wheelchair with both hands and touching R63's tray with her right hand, V3 then opened R529's mustard and ketchup packets with R529's fork, and then put a forkful of hamburger into R529's mouth. V3 never cleaned her hands between handling R63's wheelchair and tray and then feeding R529. At 12:54 PM, V3 was still feeding R529 with her right hand, and she reached over with her right hand and handed R63 his drink, and then turned back to R529 and put a forkful of hamburger in R529's mouth. V3 then picked up R63's coffee cup to give him a refill. V3 refills R63's cup, then cleans her hands with sanitizer and brings the cup of coffee back to the table and adds cream to the cup, and then hands the cup to R63 with her right hand. Then after handing the cup to R63, V3 touches the arm of R63's wheelchair with her right hand, and then picks up R529's fork and puts a forkful of hamburger into R529's mouth. On 04/10/25 at 12:15 PM, V2, DON (Director of Nursing), said his expectations are if staff is interacting with 2 residents, they should perform hand hygiene in-between the residents to prevent cross-contamination. 2. On 04/08/25 at 01:51 PM, V8, CNA (Certified Nurse's Assistant), was assisting R5 with toileting. V8, with gloved hands, pulled R5's pants down and removed her soiled brief, and then assisted R5 with sitting on the toilet. V8 then, with her dirty gloved hands, went to R5's closet, open the closet, got a new brief out of the closet, and brought the new brief back to the bathroom. V8, then with the same dirty gloved hands, cleaned R5's buttocks, had R5 stand, and V8 attached the new brief on R5. Then V8 pulled up R5's pants and R5 began to yell that her pants were wet. V8 then removed the soil pants from R5, removed the glove from her right hand, opened R5's closet with her bare right hand, then removes her left glove, picked up a clean pair of pants, came back to R5 in the bathroom, and put the clean pair of pants on R5 with her ungloved and unwashed hands. V8 then assisted R5 into her wheelchair and moved R5 out of the bathroom, and then V8 with her dirty ungloved hands, received R5's water pitcher from V9 (Restorative Aide), and hands it to R5, still with her bare and unwashed hands. On 04/10/25 at 12:07 PM, V2, DON (Director of Nursing), said his expectations of staff are once they have done a dirty task, they are to remove their gloves and perform hand hygiene and put on new gloves before doing the new task. V2 said this should be done to prevent infections. 3. On 04/08/25 at 1:51 PM, after V8 assisted R5 with toileting, V8 (CNA) and V9 (Restorative Aid) provided incontinence care for R27. V8 removed R27's saturated brief, wiped R27's buttocks, placed a clean brief under R27, then applied barrier cream to R27's buttocks wearing the soiled gloves, then opened R27's closet with her dirty gloved hands and put the barrier cream in the closet. V8 never removed her gloves, cleaned her hands, or put on new gloves after leaving a dirty area and before going to a clean area. On 04/10/25 at 12:03 PM, V2 (DON) said his expectations of staff are once they touch a soiled brief, they are to remove their gloves, clean their hands, and put on new gloves before going to a clean area. V2 said staff are to also clean their hands after removing their gloves and before putting on clean gloves and they are to perform hand hygiene. V2 said staff must do this to prevent potential infections. The facility's Hand Hygiene policy, dated 7/30/24, showed hand hygiene is important in controlling infections. The policy shows hand hygiene should be done before and after direct resident contact, before and after assisting a resident with meals, before and after assisting a resident with toileting, and before moving from work on a soiled body site to a clean body site on the same resident. 46003 4. On 04/09/25 at 3:48 PM, R383's bedroom door was wide open. V31, Guest Services, entered R383 Covid isolation room with a surgical mask and gown. V31 exited R383 isolation room, removed gown, and did not change her mask and did not perform hand hygiene. V31 did not close R383's bedroom door. On 04/09/25 at 4:16 PM, V31 stated R383 was in isolation for Covid. V31 stated she had been educated on PPE (Personal Protective Equipment). V31 stated when she enters a covid isolation room, she should wear protective eye covering or face shield, mask, gown, and gloves. V31 stated she guesses she should have worn an N95 mask, but didn't remember. V31 states she changes her surgical mask every three hours. V31 stated she did not change the mask she had worn into R383's room until she went up to the second floor. V31 stated after she left R383's room, she went to the admissions office to retrieve a folder, then went to the second floor to see other residents. V31 stated she did hand hygiene when she went to the second floor, but did not do hand hygiene when she left R383's room. V31 stated she did not follow the proper procedure because she was in the middle of doing something and got distracted. On 04/08/25 at 3:01 PM, V30, CNA (Certified Nursing Assistant), stated, If a resident is in isolation for Covid, their bedroom door should be closed. On 04/10/25 at 1:14 PM, R383's bedroom door was left wide open. V36, Repair Vendor, was observed entering R383's room wearing a surgical mask and gown. V36 stated he was there to work on the call light. No one educated him on PPE use. On 04/10/25 at 2:30 PM, V15 (IP/Infection Preventionist) stated, Covid isolation room door should be closed to stop the spread of disease. Staff entering a Covid isolation room should ware an N95 mask. Vendors going into a Covid isolation room should be stopped and directed by staff to put on an N95 mask. Staff should be doing hand hygiene before the leave the isolation room to stop the spread of the disease. They should wear a shield or protective eye wear to keep the disease from getting inside the eye socket or conjunctiva and masks should be changed when they leave the room. It's an unsafe practice if they are not wearing the proper PPE and not doing hand hygiene. It puts other residents and staff at risk. The facility policy Covid 19 Guidelines and Emergency Preparedness Plan states the facility can place the positive resident in a single room with isolation signage. With staff wearing full Covid PPE (N95, face shield, gown and gloves) upon entering the room. 46409 5. On 4/8/25 at 11:48 AM, V18 (CNA/Certified Nurse Assistant) was in R63's room providing care to R63 with just gloves on for PPE (Personal Protective Equipment). R63's room door had signage which showed he was on EBP (Enhanced Barrier Precautions). V18 provided incontinence care, then changed his clothing and linen. At 11:58 AM, V24 (CNA) also entered R63's room with just gloves on for PPE to assist V18 with transferring R63 from the bed into his wheelchair using the mechanical lift. On 4/10/25 at 12:54 PM, V18 (CNA) said for EBP, gloves, gown, and a mask are worn for direct care for the residents. V18 said the PPE was worn to protect the staff and the residents. On 4/10/25 at 10:30 AM, V23 (LPN/Licensed Practical Nurse) said for residents on EBP, the staff need to wear PPE during patient care including toileting, dressing, and transferring. V23 said gloves and a gown need to be worn. On 4/10/25 at 10:49 AM, V22 (CNA) said for residents on EBP, a gown, gloves and a mask are worn. On 4/10/25 at 2:03 PM, V15 (IP/Infection Preventionist) said the staff would need to wear a gown and gloves when having direct contact with the patient. R63's face sheet showed he was admitted to the facility with diagnoses including hemiplegia and hemiparesis, cellulitis of the right lower limb, acute bronchitis, need for assistance with personal care, and chronic kidney disease. R63's POS (Physician Order Sheet) showed R63 had an order for Insertion of PICC (Peripherally Inserted Central Catheter) ordered 4/3/25. R63's MDS (Minimum Data Set), dated 3/21/25, showed R63 had moderate cognitive impairment and required supervision for personal hygiene, partial assistance for upper body dressing, substantial assistance for shower/bathing, and was dependent on staff for toileting hygiene, lower body dressing, and putting on/taking off footwear. The facility's Enhanced Barrier Precautions policy, dated 7/26/24 showed EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high-contact resident care activities for residents known to be colonized or infected with MDROs (Multi-Drug Resistant Organisms) as well as residents with wounds and/or indwelling medical devices. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .Examples of high-contact resident care activities requiring gown and glove use among residents that trigger EBP use include: a) Dressing .c) Transferring d) Providing hygiene e) Changing linens f) Changing briefs or assisting with toileting.

3. A review of R80's electronic health record showed a 4/3/25 at 07:53 AM progress note that R80 was sent to the local community hospital for a dislodged G-tube (gastric tube). On 04/09/25 at 4:33 PM, V2, DON (Director of Nursing), said the family representative and R80 were not given the facility's Bed Hold policy because R80 was not admitted to the hospital, he was only sent to the ER (emergency room). V2 said both the resident and family are to get written notification of the transfer and the reason for transfer and the bed hold policy, along with notifying the Ombudsman. V2 said the facility's Bed Hold policy that is given to the resident and representatives does not notify about the facility's reserve bed payment. The facility's Bed Hold policy, dated 7/26/24, showed it is the facility's policy to adhere to the federal regulation on bed hold and on re-admission of resident transferred out of the facility. The Bed Hold policy did not show the facility's reserve bed payment. Based on interview and record review, the facility failed to provide the resident and/or their representative of the facility's policy for bed hold in writing. This applies to 3 of 3 residents (R33, R54, and R80) reviewed for discharge in a sample of 33. The findings include: 1. R33's Face Sheet showed R33 was admitted to the facility on [DATE]. R33 had multiple diagnoses which included monoplegia of upper limb, Alzheimer's Disease, cerebral ischemia, diabetes, vascular dementia, and hypertension. R33's Change in Condition with SBAR (Situation, Background, Assessment, Recommendation) Form, dated 12/20/24, showed R33 was observed sitting on the floor, next to her bed. The same form showed R33 was transferred to the hospital via emergency medical transport on 12/20/24. The form showed the facility's bed hold policy was not given to the resident and or/representative. The EMR (Electronic Medical Record) contained no documentation showing the bed hold policy was given to R33 and/or the representative. The facility was unable to provide documentation that the bed hold policy was given prior to the hospital transfer or after. 2. R54's Face Sheet showed R54 was admitted to the facility on [DATE]. R54 had multiple diagnoses which included Parkinson's Disease with dyskinesia, weakness, muscle disorders, dementia, orthostatic hypotension, seizures, and congestive heart failure. R54's MDS (Minimum Data Set), dated 04/09/25, showed R54 had severe cognitive impairment. R54's Change in Condition with SBAR Form, dated 12/27/24, showed R54's change in condition was altered mental status. The same form showed R54 was transferred to the hospital via emergency medical transport on 12/27/24. The EMR contained no documentation showing the bed hold policy was given to R54 and/or the representative. The facility was unable to provide documentation of the bed hold policy being given prior to the hospital transfer or after.

Based on observation, interview, and record review, the facility failed to ensure resident beds were kept at a safe height. This applies to 2 of 4 residents (R167 and R173) reviewed for accidents in a sample of 33. Findings include: 1. On 04/10/25 11:59 AM, R167's bed and over bed table were in a very high elevated position. On 04/10/25 at 12:00 PM, R167 stated his bed was dangerous. V35, PTA (Physical Therapy Assistant/Therapy Director), entered R167's room and stated, The bed should not have been left that high. If (R167) had fallen from bed the impact of an injury would be worse. R167's diagnoses includes sequelae of cerebral infarction, hypertension, muscle wasting and atrophy. R167's care plan showed R167 was at risk for falls, with interventions include to provide a safe environment. 2. On 04/08/25 at 12:55 PM, R173's bed and over bed table were in a high position. On 04/08/25 at 12:57 PM, V29, Certified Nursing Assistant/CNA, stated R173 was a high fall risk. V29 stated she left R173's bed in the high position. R173's diagnoses includes displaced intertrochanteric fracture of left femur, type 2 diabetes, wedge compression fracture of fifth lumbar vertebra and dementia. R173's current care plan showed R173 is risk for falls related to recent falls. Interventions include to provide a safe environment. Resident is at risk for altered thought process related to her diagnosis of Lewy body dementia. The facility policy Fall Occurrence, dated 7/26/24, states those identified as high risk for falls will be provided fall intervention.

Based on observation, interview, and record review, the facility failed to store medications securely. This applies to 3 of 3 residents (R125, R119, R379) reviewed for medication storage in a sample of 33. The findings include: 1. R125's face sheet showed R125 was admitted to the facility with diagnoses muscle wasting and atrophy, abnormalities of gait and mobility, aftercare following joint replacement surgery, intervertebral disc disorders with radiculopathy lumbar region, rheumatoid arthritis, unilateral primary osteoarthritis right knee, and osteoarthritis. R125's POS (Physician Order Sheet) did not have an order for Biofreeze Roll On Pain Relieving Gel. On 4/8/25 at 11:43 AM, R125's had a Biofreeze Roll On Pain Relieving Gel sitting on her bedside table. On 4/10/25 at 10:19 AM, R125's bedside table had the Biofreeze Roll On Pain Relieving Gel on it. R125 said she used the Biofreeze on her knees when she had pain. R125 said she puts the Biofreeze on, and she had put it on a few days ago. On 4/10/25 at 1:03 PM, V16 (Agency RN/Registered Nurse) said she did not have any residents who were allowed to keep medications at bedside, and if she saw a resident with medication at the bedside, she would remove them and report it to administration. 31327 2. R119's face sheet shows diagnoses of multiple sclerosis, muscle wasting and atrophy, not elsewhere classified, unspecified lower leg, unspecified severe protein calorie malnutrition. On 4/8/25, review of R119's POS (Physician Order Sheet) shows no order for the Biofreeze and the Vitamin C. On 4/8/25 at 12:12 PM, R119 was in bed. On her dresser, there was a Biofreeze (Menthol-Pain Relieving Gel) roll on and Vitamin C 750 MG (Milligrams) Gummies. R119 stated, It's always kept here. I brought them from home. R119's MDS (Minimum Data Set), dated 3/18/25, shows she is cognitively intact. On 4/9/25 at 12:09 PM, V2 (DON-Director of Nursing) stated, All medications that are stored in resident rooms need an order by the doctor. If the resident and/or family wants them to take it or be at the bedside, it's the same thing. You need an order from the physician. 46003 3. On 04/08/25 at 11:33 AM, a tube of diclofenac sodium gel 1% 3.35 oz (Ounces) with R379's name was on her overbed table. On 04/09/25 at 3:39 PM, R379 stated she still had the diclofenac. R379 showed the tube of diclofenac gel 1% 3.35 oz in her wash basin. R379 stated a nurse gave it to her, and she applies it for a sciatic nerve problem. R379 stated she may use it twice a day as she needs it. On 04/10/25 at 11:04 AM, V32, LPN (Licensed Practical Nurse), assigned to R379, stated he did not have any residents assessed to keep medications at the bed side. V32 confirmed R379 was prescribed diclofenac topical, but it was not scheduled for administration during his shift. On 04/10/25 at 12:38 PM, V32 confirmed R379 had kept the tube of diclofenac at her bedside. Facility's policy titled Medication Storage, Labeling and Disposal (8/16/24) shows: It is the facility's policy to comply with federal regulations in storage, labeling, and disposal of medications. 4. Medications will be secured in a locked storage area.

Based on interview and record review, the facility failed to follow the physician's orders for obtaining a urinalysis in a timely manner. This applies to 1 of 3 residents (R1) reviewed for care delay. The findings include: R1's diagnoses included metabolic encephalopathy, unspecified fracture of the right pubis, muscle weakness, dementia, depression, scoliosis, and altered mental status. R1 was cognitively impaired per the MDS (MDS/Minimum Data Set), dated 04/04/24. The same MDS showed R1 was dependent upon staff for toileting. Per the EMR's (EMR/Electronic Medical Record) progress notes, dated 06/18/24, R1 had urine collected for urinalysis, and culture & sensitivity. R1's preliminary results were received on 06/19/24 and an oral antibiotic (Cefdinir) was started pending the final urine culture & sensitivity. Per the physician's order sheet, Cefdinir was discontinued on 06/21/24 and another oral antibiotic (Macrobid) was started. R1's final urine culture dated 06/21/24 showed Klebsiella pneumoniae ESBL. On 06/16/24, per the EMR (EMR/Electronic Medical Record) physician's orders, an order was written to collect urine for a UA (Urinalysis) and C&S (Culture and Sensitivity). There was no documentation in the progress notes that explained the reason or symptoms for the UA/C&S. The progress notes, dated 06/18/24, showed R1's urine was collected and called in to the lab, to be picked up the next day 06/19/24. There was no documentation in the progress notes that explained why the urine sample had not been collected prior to 06/18/24. On 6/27/24 at 11:25 AM, V3, LPN (Licensed Practical Nurse), stated he straight-catheterized R1 on 6/18/24, the lab collected the urine specimen on 6/19, and an antibiotic was started on 6/20/24. On 06/28/24 at 11:03 AM, V2 (Director of Nursing) said R1's daughter reached out to her on 6/16/24. She said (R1) was tired and had a headache and asked if we could check her out. We got an order for STAT (immediately) labs and a regular urinalysis on 06/16/24. V2 stated she did not put in a note in the medical record about the conversation that she had with the residents daughter, and she should have. V2 verified there was no documentation in the medical record for the reason why the urinalysis was not collected until 06/18/24, but it should have been, adding, if we get an order for a UA, it should have been collected as the order states. On 06/28/24 at 9:47 AM, V7 (Medical Doctor) said, (R1's) family requested a UA, and the NP (Nurse Practitioner) gave the order for the UA on 06/16/24. If an order was put in on 6/16/24 for a UA, it is expected that the nurses follow the orders and collect the urine as ordered. The urine should not have been collected two to three days later. The facility's Infection Prevention and Control Policy, reviewed 06/06/24, showed 4. If a resident develops signs or symptoms of infection, the nurse will notify the Director of Nursing or designee, so that the occurrence of infection can be recorded and monitored. The resident's attending physician will be notified to obtain treatment for the infection.

Based on observation, interview, and record review, the facility failed to provide ADLs (Activity of Daily Living) care to residents. This applies to 4 of 16 residents (R8, R9, R14 and R19) reviewed for ADL care. The findings include: 1. On 4/4/24 at 12:12 PM, R8 was in bed in his room watching TV. R8 had short beard on his face. R8 said he does not like his beard; he would like it shaved and staff has not assisted him with shaving. R8's Minimum Data Set (MDS) of 2/29/24 shows his cognition is intact and R8 needs partial to moderate assistance with hygiene. R8's care plan (initiated 2/26/24) shows R8 requires assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene and toileting). 2. On 4/4/24 at 12:32 PM, R9 was sitting in her wheelchair in the dining room during lunch. R9 had several white hairs on her chin. R9 said she wants the facial hair off. She said staff used to take care of it, but they have not done it recently. The next day on 4/5/24 at 1:03 PM, R9 was in bed watching TV; the facial hair still noted on her chin. R9's MDS of 3/27/24 shows R9's cognition is moderately impaired, and R9 needs partial to moderate assistance with personal hygiene. R9's care plan (initiated 7/16/21) shows R9 requires assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene and toileting). 3. On 4/4/24 at 1:05 PM, R14 was sitting in reclining chair in dining room eating lunch. R14 had dirty nails, had brownish/black substance on her nail bed. The next day on 4/5/24 at 12:38 PM, R14 was still noted with dirty fingernails. R14's MDS of 3/25/24 shows R14's cognition is severely impaired and R14 needs substantial to maximal assistance with personal hygiene. R14's care plan (initiated 12/20/22) shows R14 requires assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene and toileting). 4. On 4/5/24 at 1:06 PM, R19 was sitting in her wheelchair in the dining room eating lunch. R19 had several white hairs on her upper lip and chin. R19 said she did not like the facial hair and staff has not assisted with taking it off. R19's MDS of 2/12/24 shows R19's cognition is intact, and R19 needs partial to moderate assistance with personal hygiene. R19's care plan (initiated 8/7/23) shows R19 requires assistance with ADLs (bed mobility, transfers, dressing, walking, personal hygiene and toileting). On 4/5/24 at 11:28 PM, V16 (Certified Nurse Aide) said CNAs were responsible for shaving and nail care, and it is done during the resident's shower days. On 4/9/24, V1 (Administrator) and V2 (DON/Director of Nursing) said CNAs are responsible for ADL care, which includes, showers/bathing, grooming, shaving and nail care. They said shaving and nail care are done on residents' shower days. The facility's Nail Care policy (revised 7/28/23) shows nursing staff to check residents' nails care which includes cleaning and regular trimming. The facility's Shower and Hygiene policy (Revised 7/28/23) states that any resident who needs hygienic care will be provided care to promote hygiene (facial, body and perineal care).

Based on observation, interview, and record review, the facility failed to maintain resident nutritional status and monitor weights as ordered. These failures resulted in R33 experiencing a significant weight loss. This applies to 1 resident (R33) reviewed for weight loss in a sample of 34. The findings include: R33 was admitted originally admitted to the facility on [DATE]. R33 was readmitted on [DATE] per the Face Sheet. R33's MDS (Minimum Data Set), dated 03/13/24, showed no BIMS score for R33, but showed R33's cognitive skills for daily decision making were severely impaired. The same MDS showed R33 was dependent upon staff for most ADL's (Activities of Daily Living). The same MDS showed R33 received nutrition through a feeding tube. The facility's Weights and Vitals Summary showed R33 had a -10% change [comparison weight 10/15/23, 94.6 pounds, -10.1%, -9.6 pounds]. R33's recorded weight on 10/15/23 was 94.6 pounds. R33's recorded weight on 03/19/24 was 85 pounds. R33's enteral feed orders were flush Gtube with 120 ml of water every six hours, every day shift total volume infused in 24 hours (feeding: 1260 ml, flush 480 ml), every shift tube feeding Jevity 1.2 via Gtube continuous @70 ml/hr to total volume of 1260 ml, one time a day turn on tube feeding at 5 PM daily. R33 had orders for daily weights written 11/24/23. The Weights and Vitals Summary showed multiple dates where no weights were obtained. R33's Enteral Feeding care plans, dated 10/16/23, showed R33 receives enteral feedings as the primary source of nutrition due to malnutrition and weight loss. Interventions included enteral nutrition prescription as ordered and monitor weights. R33's tube feeding care plan, dated 10/30/23, showed weight loss. Interventions included R33 is dependent with tube feeding and water flushes, see MD (Medical Doctor) orders for current feeding orders. Weight will be obtained as ordered by MD. R33's progress notes from 10/15/23 through 03/22/24 were reviewed. R33 had one episode of vomiting on 11/17/24, and was admitted to the hospital. No other episodes of vomiting were documented. Registered Dietitian's notes, dated 12/24/23, was reviewed. Dietitian stated, nursing reports resident tolerating tube feeding well, no vomiting reported. The same note showed an increase in the tube feeding to 65 ml/hr and the total volume to be infused was 1040 ml in a 24-hour period. The Dietitian's note, dated 01/18/24, showed a trigger for significant weight loss of 8.2% in one month. The tube feeding was increased to 70 ml/hr, with a total volume to be infused was 1260 ml in a 24-hour period. On 03/19/24 at 11:53 AM, R33 was not in R33's room. R33's tube feeding pump was in the room, next to the bed. R33's tube feeding pump did not have any formula hanging. On 03/20/24 at 10:09 AM, R33 was sitting in her wheelchair, awake and alert, but confused. R33's tube feeding pump was in her room, with no feeding hanging. On 03/20/24 at 5:07 PM, R33 was in bed. V33 (Licensed Practical Nurse) was in R33's room preparing for her Gtube (Gastrostomy tube) feeding and water flushes. R33's pump was set for Jevity 1.2 @70 ml/hr. with 120 ml of water for flush. R33's Gtube placement was verified, and the tube feeding was started. R33 tolerated the Gtube feeding without difficulty. On 03/21/24 at 8:43 AM, R33 was in the bed. R33's Gtube feeding of Jevity 1.2 @70 ml/hr continued to infuse. The tube feeding pump showed 1208 ml total volume had already infused. 1000 ml of Jevity was left in the bag. The tube feeding pump showed the water flush of 120 ml every six hours. 800 ml of water was left in the bag. On 03/21/24 at 8:56 AM, V34 (RN, Unit Supervisor) said there is no set time for R33's feeding to be turned off. V34 said the feeding is completed once the total volume is infused. V34 said R33 received the Gtube in October 2023, and became NPO (nothing by mouth) in October 2023. On 03/21/24 at 12:33 PM, V35 (Dietitian) said if residents tube feeding orders are for 70 ml/hr to infuse 1260 ml, the resident should be receiving the feedings for 18 hours. V35 said if residents are not receiving the feedings as ordered, it can lead to weight loss or a decrease in nutritional status. V35 said the weight loss R33 has had could be from her not getting the full amount of the tube feeding. V35 said she was not aware of R33 having an order for daily weights. V35 said she did not know there were any missing weights for R33. On 03/21/24 at 12:38 PM, V2 (Director of Nursing) said, (R33) should be receiving the tube feeding starting at 5 PM and ending at 11 AM, or 18 hours. (R33) is at risk for weight loss if she is not receiving the tube feeding for the correct amount of time. V2 said he does not know why R33's feeding was turned off before 11 AM. V2 said nurses should follow the orders as written. V2 said he was not aware of R33 having orders for daily weights, and the weights were not being done daily. On 03/22/24 at 3:21 PM, V44 (Palliative Nurse Practitioner) said he visits R33 every week or every other week. V44 said R33 has esophageal stricture. V44 said R33 used to have vomiting when she was eating by mouth. V44 said since R33 receives tube feedings and is NPO, she has not had any vomiting. V44 said he was not aware of R33 not getting the correct amount of feeding. V44 said he had documented in his notes the weight loss R33 had. V44 said his expectation is that the resident receives the correct amount of feeding that is ordered. V44 said if R33 is not getting the feeding as ordered, and she is not receiving oral foods, she can lose weight.

Based on observation, interview, and record review, the facility failed to provide R1 adequate hydration resulting in R1 being admitted to the hospital for hypernatremia (high sodium). This applies to 1 of 6 residents (R1) reviewed for hydration. Findings Include: R1's September Physician's Order Sheet list the following diagnoses including: cerebral infarction, dementia, diabetes, hyperlipidemia, sleep apnea, atrial fibrillation, hyperlipidemia, dysphagia, and aphasia. Physician, order dated 9/26/23, documents enteral feeding Glucerna 1.2 at 65 ML/HR (Milliliters per hour) continuous to 1040 ML water flush 350 ML six times per day total volume 2100 ML in 24hour period. R1's MDS (Minimum Data Set), dated 9/17/23, show resident is completely dependent upon staff for (Activities of Daily Living). R1 was hospitalized for hypernatremia due to dehydration from 9/17/23 to 9/26/23 per progress notes. R1's shows critical lab results indicating severe dehydration was reported to the facility on [DATE] at 3:55 PM. Blood Urea Nitrogen elevated at 102 MG/DL (Milligram per Deciliter) (Normal 7-28). Creatine elevated at 1.96 MG/DL (Normal 0.44-1.32), Sodium elevated at 177 mEq/L (Normal 138-147). Hospital progress note, dated 9/20/23 at 3:11 PM, physician assessment and plan identified sodium lab value related water deficit nearly 10L probably due to limited intake of water through the feeding tube. Dehydration and high sodium probably associated with worsening mental status and brain damage (encephalopathy). On 9/28/23 at 9:20 AM, R1 was gowned and in bed with feeding tube running. R1's feeding tube solution, Glucerna 1.2, was being delivered by pump at 65 ML/HR (milliliter per hour) with water flushes preset at 350 ML every four hours. The feeding pump showed 926 ML of feeding delivered and 350 ML of water flushes delivered. The volume of feeding that remained in the bag was approximately 300 ML. The amount of water flush that remained in the bag was approximately 800 ML. R1 lips appeared dry. The urine in R1's collection chamber was amber and cloudy. On 9/28/23 at 9:58 AM, V17 (Licensed Practical Nurse) observed R1 tube feeding, flush, and pump. Tube feeding total volume delivered at that time was 961 ML. Total water volume delivered 350 ML. V17, LPN, stated 350 ML of water should have automatically been delivered by the feeding pump since she last saw R1. V17, LPN, manually pushed a button to deliver 350 ML of water to R1. On 9/28/23 at 10:27 AM, V16, DON (Director of Nursing), stated by looking at the reading on R1's feeding pump and the amount of feeding and flush remaining in the bag, R1's water flush had not been delivered. On 9/27/23 at 2:08 PM, V15, MD (Medical Doctor), stated R1 does not have any medical condition that would cause her to become dehydrated. V15 stated was R1 was rehydrated in the hospital within 48 hours, and her IV (Intravenous) fluids had been stopped 2 to 3 days before she was discharged , and her labs stayed stable. On 9/27/23 at 2:30 PM, V14, Dietician, stated, The total amount of fluid (R1) receives in a 24-hour period is 3,072 ML. R1 should not have become dehydrated if she was receiving that amount of fluid. V14 did not know of any medical condition that would cause R1 to become so severely dehydrated.

Based on interview and record review, the facility failed to ensure that a resident did not fall out of bed during staff provision of care. This applies to 1 of 3 residents (R2) reviewed for fall incidents in the sample of 12. This failure resulted in R2 sustaining lacerations on the head, requiring emergency care treatment and staples at the hospital. The findings include: R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses which includes encephalopathy, type 2 diabetes mellitus, fibromyalgia, muscle wasting and atrophy, lack of coordination, abnormal gait and mobility, abnormal posture, and history of falling, based on the face sheet. R2's fall risk evaluation, dated April 28, 2023, showed the resident was high risk for fall. R2's side rail evaluation, dated April 30, 2023, showed, Bilateral 1/2 side rails are being utilized for bed mobility and repositioning, to assist resident's independence and to serve as enabler from lying to seated at bedside during transfer. Provides a hand hold for getting into or out of bed. R2's admission MDS (Minimum data set), dated May 1, 2023, shows the resident is cognitively intact. R2's MDS shows the resident requires extensive assistance with one staff physical assist during bed mobility, dressing, toilet use and personal hygiene, and total dependence with two or more staff physical assist during transfer. The same MDS shows R2 is always incontinent of both bowel and bladder functions. R2's documented weight as of June 7, 2023 was 218.8 pounds, based on the resident's weights and vitals summary. R2's fall incident report, dated June 11, 2023, showed the resident had a fall during staff provision of incontinence care. The fall incident report documented, At approximately 9pm writer was called to room by CNA (Certified Nursing Assistant) supervisor. When entering writer observed patient laying on the floor on her back on the right side of the bed near the dresser. Writer asked staff what happened, and staff stated that she was providing toileting needs on the resident, she asked the resident to turn towards her to pull the bed pan from up under her, then she asked her to turn to her left side, when she turned, she crossed her right leg to far and slid off the bed, staff attempted to catch her but was unable to. Patient stated, I messed up this time. The same fall incident report documented R2 sustained a laceration to the back of the head. R2's facility incident report initially reported to the State Agency on June 12, 2023 via email, showed on June 11, 2023 at approximately 9:00 PM, while the resident was receiving incontinence care from staff, R2 turned to her side, and she (R2) slid off the bed to the floor. The initial report documented two half rails were in place for positioning and bed mobility at the time of the fall incident. The same initial report showed the CNA (Certified Nursing Assistant) notified the nurse of the fall incident, and the resident was assessed and assisted by the staff. R2 did not verbalize pain, ROM (range of motion) of all extremities were within baseline, no loss of consciousness was observed, and neuro checks were initiated with normal findings. R2 sustained laceration with bleeding on the left posterior area of her head. A pressure dressing was applied to the site with ice pack to control the bleeding. R2's responsible party and physician were notified of the fall incident. R2's physician ordered for the resident to be sent out to the hospital for further evaluation and treatment. R2 was sent to the hospital via 911. R2's final incident report was sent to the State Agency on June 16, 2023 via email. The final incident report showed, Upon resident's return to the facility, resident noted to have two staples to the rear left side of her head. R2's active care plan, initiated on April 28, 2023, shows the resident is at risk for falls related to current medication use, poor safety awareness, unsteady gait, pain, seizure disorder, use of narcotics and history of fall. This care plan showed multiple interventions initiated on April 28, 2023 which includes, side rails to prevent rolling out of bed. The same at risk for fall care plan had an added intervention dated June 12, 2023 (post fall) for, When giving patient care, please provide me 2 CNAs (Certified Nursing Assistants). On June 22, 2023 at 11:16 AM, R2 was in bed, alert, oriented, and verbally responsive. R2 stated she came to the facility from the hospital after a fall at home. R2 stated she was admitted to the facility to receive rehab to gain her strength, and then eventually go back home. According to R2, her stay at the facility was going well, until she had a fall that caused her to be sent to the hospital due to bleeding from her head. R2 does not remember the exact date and time of her fall at the facility, but believes that it was approximately between the first and second week of June 2023. According to R2, when she had the fall incident, a female staff was attending to her. R2 could not remember what care was being provided to her, but remembered while in bed with both upper side rails raised, she (R2) was asked by the female staff to turn on her side (could not be certain which side), and when she placed one of her leg on top of the other leg to turn (could not be certain which leg), she felt a push from behind her where the female staff was, and she rolled out of the bed and fell on the floor. According to R2, I remember seeing blood everywhere and they took me to the hospital. During the same interview, R2 was asked where she was positioned in bed before turning on her side. R2 responded she does not believe she was in the center of the bed, and commented, I think I was closer to the side where I turned and fell , definitely not in the center. R2 added, I know I went over the rail, I felt a push, I can't move too much in bed, and I will not throw myself off the bed. According to R2, prior to her fall (on June 11, 2023), she remembers at least two staff assisting her while in bed during incontinence care. On June 22, 2023 at 12:36 PM, V21 (agency CNA, Certified Nursing Assistant) stated she was the assigned staff for R2 on June 11, 2023, when the resident had a fall incident. V21 stated on June 11, 2023 between 8:50 PM and 9:00 PM, R2 activated her call light and asked to use the bed pan. V21 stated she placed the bed pan under the resident, left the room for several minutes, and when R2 was ready she went back to the room to remove the bed pan. According to V21, after she had removed the bed pan, she noticed R2's brief was wet, so she decided to change the resident. V21 stated while R2 was on her back in the center of the bed, she provided incontinence care to the resident, while she (V21) was at the left side (towards the door) of the resident. She then instructed R2 to turn on her right side (towards the window), and while she (V21) was walking towards the right side of the resident, she saw R2's left leg overthrown, it passed the right leg that caused the resident to roll out of bed and landing on the floor between the bed and the closet/dresser by the window side. According to V21, during the entire care, including the turning/repositioning, R2's bilateral upper side rails were in place (raised). V21 stated when R2 overthrew her left leg over her right leg, it caused the resident's left leg to pass the edge of the bed, causing R2's lower body to fall out of the bed first, then her upper body followed. V21 stated, It was very quick. By the time V21 reached the right side of the bed, R2 was already on the floor. V21 stated she had positioned R2's bed during the above mentioned care, about her waist level for easy accessibility, which according to V21 was not too high. V21 stated when R2 fell on the floor, the resident did not lose consciousness, but there was blood all over the floor especially on the head area of the resident. V21 stated she immediately called the nurse to inform of the fall, and the nurse had assessed R2. On June 22, 2023 at 2:08 PM with V2 (Director of Nursing), R2's bed was moved to simulate the same bed and room orientation when the resident had a fall on June 11, 2023, since R2 was occupying a different room at the time of this interview. R2 verbalized, It is not easy to remember everything because it was a traumatic experience. R2 stated she remembered being attended by one female staff when she fell out of bed, however, she cannot remember what care was being provided to her at the time of the fall incident. R2 stated -her bilateral upper side rails were raised, and the female staff asked her to turn on her side (was not certain which side it was). R2 remembered lifting her leg to go over her other leg (was not certain which leg) to turn on her side and felt a push from her back side where the female staff was standing. R2 stated, I did not jump out of bed, but I felt that I was pushed out of bed. I remember, I went flying out of bed to the floor and she (referring to the female staff) was behind me. According to R2, she was not in the center of the bed when she was asked to turn on her side. R2 stated, I know I was not in the middle of the bed. She (referring to the female staff) was on my back side, and I was further away from her, closer to the side of the bed where I turned towards. R2 also stated, When I turned away from her (referring to the female staff) to turn on my side, I fell out of the bed. On June 27, 2023 at 9:53 AM, V20 (Nurse) stated she was the nurse assigned to R2 on June 11, 2023, and she was the staff who sent R2 to the emergency room via 911 after the fall. V20 stated she was told by V21 (agency CNA) that she (V21) was changing R2's brief, and while turning R2 to her side, R2 placed one of her leg on top of the other leg (does not know which leg), overthrew her leg to the side (does not know which specific side), and fell out of bed with both upper bilateral 1/3 side rails up. According to V20, V21 has a short stature and V21 told her she (V21) was not able to catch/reach R2 before the resident fell out of bed to the floor. V20 stated when she entered R2's room, the resident was on her back on the floor on the right side of the bed (window side), between the bed and the closet/dresser. There was a pool of blood on the floor, especially on the head part of R2. According to V20, she could not determine where exactly the blood was coming from, so she applied pressure dressing on the entire head of R2 to stop the bleeding until 911 came and transported the resident to the hospital emergency room . V20 stated the staff did not move R2 after the fall, and the resident did not lose consciousness. V20 stated it was the hospital who saw exactly on which side of the head R2 had sustained the laceration. On June 26, 2023 at 3:20 PM, V19 (Physician) stated he does not know how R2 moves in bed and how many staff assistance she may need during turning and repositioning and during incontinence care while in bed. V19 stated R2 may require one or more staff assistanc,e depending on the day and the status of R2 at the time the care was being provided, as well as the staff comfort. According to V19, it is concerning R2 fell out of bed during staff provision of care, and sustaining laceration on the head because of the fall.

Based on interview and record review, the facility failed to provide narcotic pain medication to a resident as ordered by the physician. This failure resulted in R1 not receiving physician-ordered pain medication for more than 20 hours and causing R1 to experience severe pain. This failure also resulted in psychosocial harm as evidenced by R1 stating she felt great sadness, helplessness, and anxiousness due to her pain level and the lack of available pain medication. This applies to 1 of 3 residents (R1) reviewed for pain medication in the sample of 4. Findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged to home on June 15, 2021. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated June 6, 2021 shows R1 was cognitively intact, required extensive assistance with bed mobility, limited assistance with toilet use, and supervision with personal hygiene. All other ADLs (Activities of Daily Living) either occurred only once or twice or did not occur at all during the MDS observation period. R1's MDS continues to show, during the previous 5 days, R1 had received scheduled and PRN (as needed) pain medication, frequently experienced pain that limited her day-to-day activities, and had experienced pain of 6 out of 10 (zero being no pain and ten as the worst pain imaginable). Facility documentation shows a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR (Medication Administration Record) dated June 1 to June 30, 2021 shows R1 received 10/325 mg of [MEDICATION(S)] on June 8, 2021 at 0841 (8:41 AM) for 9 out of 10 pain. The next documented dose of [MEDICATION(S)] was thirty-three hours later. R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Controlled Substances Proof of Use sheet dated May 30, 2021 shows a dose of R1's [MEDICATION(S)] medication was used by nursing staff on June 8, 2021 at 9:00 PM. This dose of [MEDICATION(S)] was never documented on R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Controlled Substances Proof of Use sheet shows, Important: The nurse who signs this record must also sign the separate Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Pharmacy delivery logs shows R1's [MEDICATION(S)] order was delivered to the facility on [DATE] at 1:01 AM. On June 29, 2021 at 1:28 PM, R1 said, While I was living at the nursing home, I went over 21 hours without receiving [MEDICATION(S)] (narcotic pain medication), even though I asked for it over and over. They ran out of my pain medicine! How does a nursing home run out of pain medication? The night nurse (V4-RN Registered Nurse) gave me a [MEDICATION(S)] around 8:00 or 9:00 PM on June 8, and said it was my last pain pill until they could order more. She showed me a cardboard card with little blister packs that hold the pain pills. All the blister packs were empty. I think she was trying to prove to me that they were out of my pain medication. I was very upset. She said they could give me Tylenol until the pain medication was delivered. Tylenol does not work for me. I have a broken bone in my foot! The next morning, it was early, around 7:00 AM, and I needed some pain medication. I was told by the nurse they did not have any pain medication for me. By the time I finally received pain medication, about 21 hours had gone by since my last pill. As the hours went by and I wasn't receiving any pain medication, I told [V2] (DON-Director of Nursing) I felt like I was having a [CONDITION(S)]. I have very bad anxiety, and I think I was so anxious about the pain medication it gave me the feeling of having a [CONDITION(S)]. During the interview with R1, the resident became tearful and verbally upset. R1 expressed feelings of helplessness, great sadness, and anxiety when she found out she did not have pain medication available to her and waited over 20 hours between pain medication doses. On June 29, 2021 at 10:52 AM, V2 (DON) said, The nurses should be vigilant about reordering medications before the medication runs out. When the resident has less than three to five doses of medication, the nursing staff needs to get the medications refilled because there may be a wait for the medications. I was caring for [R1] the entire day of June 9, 2021. Around 4:00 PM, [R1] stated she was having a [CONDITION(S)] and she couldn't take it. I had not given her any pain medication that day. We were waiting for her [MEDICATION(S)] to be delivered from the pharmacy. On June 9, 2021 at 8:44 AM, V4 (RN) documented, [R1] asked writer for her [MEDICATION(S)] during the night shift, writer observed that there was only 1 pill left and explained to resident about the last dose and let resident know that a new script will be needed in the AM by the MD. Resident went off writer very rudely. Verbally redirect behavior in order to calm [R1] down. [R1] not receptive to intervention. Ordered dose of [MEDICATION(S)] was given. On June 9, 2921 at 8:49 AM, V4 (RN) documented, Alternate comfort measures offered throughout the shift [R1] refused. Endorsed to oncoming day shift nurse to F/U (Follow Up) with provider for new script for pain medication. On June 9, 2021 at 8:52 PM, V2 (DON) documented, [R1] verbalized I feel like I am having a [CONDITION(S)]. When writer asked her to describe what she was feeling patient then stated to writer Maybe it's just anxiety. I get anxiety medication and I have not had it for a while, I just feel like I am about to lose it. On June 30, 2021 at 1:30 PM, V5 (Physician) said, I would expect the facility to have R1's [MEDICATION(S)] medication in stock and available to administer to R1 as I ordered it. When I met the resident, she did fixate on her pain and pain medication. She was very anxious about experiencing pain. The facility should have had pain medication available so the resident did not get to the point where she experienced pain at a level of 10 out of 10 pain. For her to be told the facility was out of her pain medication and then not receiving the pain medication for 15 or 20 hours could definitely cause this resident to have signs of anxiety, including stating she felt like she was having a [CONDITION(S)]. I was never notified by the facility the resident was out of pain medication, experiencing 10 out of 10 pain levels or complaining of feeling as if she was having a [CONDITION(S)].

Based on interview and record review the facility failed to identify a Pressure Injury for an incontinent resident at increased risk for pressure injury. The facility also failed to monitor and provide weekly wound documentation for 2 of 4 residents (R1 and R2) reviewed for pressure injury. As a result of this failure, R2 was initially discovered with a stage 4 Sacral pressure injury exposing the bone, with slough and undermining. The Findings Include: 1). The Face Sheet documents that R2 a Caucasian female was admitted on [DATE] without any pressure wounds. Care Plan dated [DATE] said R2 was at risk for altered skin integrity due to impaired mobility and incontinence and listed as an intervention to monitor skin daily during care. R2 also had care plans dated [DATE] for incontinence of bowel and bladder and required extensive assistance with activity of daily living skills due to immobility. physician progress notes [REDACTED]. The Facility Wound Care assessment dated [DATE] says a stage 4 sacral wound was discovered on this day. The measurements were as follow; 3.0 cm in length by 3.60 cm in width by .8 cm in depth with sloughing and bone exposure. The Wound Care Doctors Notes (Initial Wound Evaluation and Management Summary) dated [DATE] says R2 was seen for a stage 4 sacral wound of one day duration measuring 4 cm in length by 4 cm in width by .9 cm in depth with undermining of 1.5cm by 12 o' clock and 30 percent slough with bone exposure. On this day the large wound was debrided. On [DATE] at 9:02AM, V7(Wound Care Nurse) said it is a problem to initially discover a stage 4 sacral wound with bone exposure on a resident who is incontinent of bowel and bladder. On [DATE] at 10:06AM, V20(Wound Care Physician) said he saw R2 for the first time on [DATE] and she had a stage 4 sacral wound exposing the bone with slough and undermining. V20 said the facility did not provide a good explanation for discovering a wound of this size and depth on an incontinent resident. There is no good explanation. 2). The Face Sheet documents that R1 was admitted on [DATE] with the following pertinent Diagnosis: [REDACTED]. Progress Note dated [DATE] says R1, [AGE] year old black female was readmitted from the hospital on [DATE] and has the following Diagnosis: [REDACTED]. Head to toe skin assessment was done. Left knee scab/lower leg scab, Discoloration to the bilateral bottom foot. Right heel Deep tissue injury and stage 2 pressure ulcer to the coccyx area. Resident is susceptible to skin breakdown related to co-morbidities and decreased mobility. Family called . Staff will continue to monitor. Weekly Wound Assessments were reviewed and documentation showed the right heel was assessed on [DATE] and then on [DATE]. This was more than 3 weeks and the wound deteriorated. The Pelvic region wounds were assessed on ,[DATE], ,[DATE] and [DATE], again more than 3 weeks and the pelvic wound deteriorated. On [DATE] the Wound Care Doctors Notes (Initial Wound Evaluation and Management Summary) were reviewed. The notes document multiple wounds: site 1 unstageable sacral necrosis, site 2 left ischium unstageable necrosis and site 3 unstageable deep tissue injury to the left heel. There was no documentation about a right heel wound. Progress Notes dated [DATE] states R1 was hospitalized and returned on [DATE] with wound decline. Progress Notes review from [DATE] to [DATE] states, R1 returned on hospice, the wounds continued to decline and R1 expired on [DATE]. Care Plan dated [DATE] for skin alteration stage 2 pressure ulcer and deep tissue injury was reviewed. Interventions included: treatment as ordered, weekly documentation and monitor skin daily and report changes. On [DATE] at 9:02AM, Z7(Wound Care Nurse) said weekly documentation is done on all residents wounds. On [DATE] at 12Noon , V7 said this is all the documentation they have for R1.

Based on observation, interview and record review the facility failed to ensure safety measures were in place and working correctly to prevent falls for a resident identified as high risk for falls. This failure resulted in (R1) being hospitalized after a fall and sustaining multiple facial fractures and abrasions. This applies to 2 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: 1. Review of R1's EHR (Electronic Health Record) showed R1 was originally admitted to the facility 6/6/15 with [DIAGNOSES REDACTED]. R1's annual MDS (Minimum Data Set) dated 10/14/19 showed R1 required extensive assistance of one-person physical assist with transfer and toilet use. The MDS shows R1 with impairment on both sides of the lower extremities. Review of R1's fall risk evaluation dated 6/12/19 showed R1 with a score of 16=High Risk for fall. Review of R1's fall risk evaluation dated 8/14/19 showed R1 with a score of 16=High Risk for fall. There was no fall risk evaluation done for R1 in (next quarter) (MONTH) 2019. On 1/21/2020 at 9:10am, V10 (Hospital Social Worker) stated R1 was received at the hospital's emergency roiagnom on [DATE] with multiple facial fractures. V10 stated R1 is presently admitted to the hospital and undergoing treatments for the injuries sustained from the fall. Review of R1's clinical notes dated 1/16/2020 and authored by V3 (Nurse) showed on 1/16/2020, V3 was walking down the hallway when she heard R1 crying out in pain. The note showed V3 opened R1's door to observe R1 on the floor lying on left side at the foot of the bed. The clinical note also shows (R1) noted with laceration to right forehead and bridge of nose, both sides actively bleeding, The note also shows R1 with left arm skin tear on elbow. Review of R1's physician order [REDACTED]. Review of R1's care plan created 10/3/19 shows R1 at risk for falls as related to dementia, limited transitioning and balance performance, history of limited range of motion to bilateral lower extremities, nutritional health, [MEDICAL CONDITION], diuretic prescribed, incontinence, hypertension, [MEDICAL CONDITIONS], difficulty hearing at times, other abnormalities of gait and mobility, repeated falls, muscle wasting, atrophy and abnormal posture. The care plan shows: Bed alarm ordered and check for proper functioning when in use. Review of restorative nursing program progress note dated 12/13/19 shows R1 requires extensive assistance to complete most activities of daily living (ADL). The note also shows R1 needs one person assistance to complete her transfers. Review of R1's incident report dated 1/16/2020 showed at around 2am, R1 was observed on the floor next to the bed. R1 stated that she fell getting back in bed. The report further showed, R1 was sent to the hospital. The report also showed R1 was admitted to the hospital with [REDACTED]. Review of hospital records show computed tomography (CT) of head for R1 with Right periorbital soft tissue swelling with [MEDICAL CONDITION] also noted overlying the nasal ridge and nasal bones. Moderate partial opacification of the paranasal sinuses with several collections of air identified in the soft tissues of the face consistent with underlying facial bone fractures. CT of R1's facial bones without contrast shows R1 with multiple bilateral facial bone fractures with moderate to severe opacification of the paranasal sinuses. R1 also noted with small frontal scalp hematoma with laceration and mild to moderate right periorbital soft tissue swelling consistent with posttraumatic [MEDICAL CONDITION], bilateral nasal bone fractures. Acute fracture noted along the anterior and posterior lateral walls. The hospital record dated 1/16/2020 showed R1 with clinical impression of: Fall, closed head injury, laceration of nose, right eyelid laceration, laceration of forehead, multiple closed fractures of facial bone. On 1/21/2020 at 11am, V6 (Restorative Nurse) stated fall risk assessments are done by nursing staff on resident's admission, quarterly, annually and with each fall or significant change. On 1/21/2020 at 12:11pm, V2 Acting DON (Director of Nursing) stated residents with risk assessment fall score of 10 and above are considered high risk for fall. V2 stated nursing staff are expected to pay extra attention to such residents, apply a red dot by the name by resident's door, perform appropriate interventions like assist in toileting. V2 stated nursing staff are trained to properly fill out resident's risk assessment form and are responsible for completing the forms as expected after each fall, on admission, and quarterly. On 1/21/2020 at 2:29pm, V5 CNA (Certified Nursing Assistant) stated she is the regular staff that cares for R1 on night shift. V5 stated R1 is high risk for fall. V5 stated R1 always requires extensive assist of one staff to go to the bathroom or move in and out of the bed. V5 stated on 1/15/2020 at 10pm, she observed R1 trying to move her legs out of bed when she went in R1's room to provide R1 with assistance to the bathroom. V5 stated she could not recall if R1 was placed on bed alarm at that point. V5 stated she was not sure if R1 was supposed to have bed alarm on and did not place R1 on bed alarm after returning from the bathroom. V5 stated around 2am on 1/16/2020, she was called by V3 (Nurse) to come to R1's room, she also saw other staff members rushing towards R1's room. V5 stated on getting there, R1 was on the floor bleeding. On 1/21/2020 at 2:44pm, V4 (Night Nurse Supervisor) stated she was rounding on the floor when she was alerted to R1's fall. V4 stated she assisted in providing first aid to R1 because of the extent of her injuries. V4 stated if resident is high risk for fall, they are supposed to have bed in low position, mat on the floor, and alarms on if ordered. V4 stated she was not sure if R1 had a floor mat on 1/16/2020 because R1's bed had been pushed aside to accommodate staff providing first aid to R1. On 1/21/2020 at 3:25pm, V3 (Nurse) stated she was not familiar with R1 and could not recall if she ever took care of R1 prior to 1/16/2020. V3 stated on 1/16/2020 at 2am, she was walking in the hallway when she heard R1 crying with pain. V3 stated she opened R1's door and found R1 on the floor on her left side by the foot of the bed face down and bleeding. V3 stated R1 was saying, I fell , I fell . V3 stated R1's cry drew her attention to R1's room and she did not hear a bed alarm activation. V3 stated R1 was supposed to have an alarm on. V3 stated she does not really work with R1 and was not sure if R1 needed help to the bathroom. V3 stated R1 had gone to the bathroom herself and was returning to bed when she fell . V3 stated she called the physician and was asked to send R1 out because of the injuries. V3 stated R1 is a high risk for fall. On 1/22/2020, at 12:27pm, V11 (Physician) stated she saw R1 on 1/17/2020 and today (1/22/2020) at the hospital. V11 stated R1's injuries are very extensive. V11 stated R1 was not going to have surgery due to her age ([AGE] years old). V11 stated she expects the facility to care extensively for R1 when providing care because R1 has dementia and would not be able to comprehend instructions. V11 stated she would expect nursing staff to carry out any order written in the POS. On 1/22/2020 at 12:42pm, V2 (DON) further stated bed alarm orders and other fall prevention interventions should be followed if it was active in the POS and the care plan. V2 stated nursing staff are expected to familiarize themselves with resident's care plan. 2. R3's EHR shows R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's MDS dated [DATE] shows R3 requires extensive assistance of one to two persons physical assist with bed mobility, transfer, personal hygiene, and toilet use. R3's care plan created 1/6/2020 shows, R3 is at risk for falls due to status [REDACTED]. The care plan intervention included: Bed alarm ordered and check for proper functioning when in use. Review of R3's fall risk evaluation dated 9/8/19 showed R3 with a score of 11=High Risk for fall. Review of R3's fall risk evaluation dated 12/10/19 showed R3 with a score of 18=High Risk for fall. Review of R3's fall risk evaluation dated 1/14/2020 showed R3 with a score of 13=High Risk for fall. On 1/21/2020 at 1:30pm, R3 was observed in bed. R3's bed was high and R3 did not have bed alarm on or floor mat around her bed. R3 was alert but slightly confused. On 1/21/2020 at 1:33pm, V9 (CNA) stated R3 is high risk for falls and was supposed to have bed alarms on and floor mat around her bed. V9 stated she did not know why R3 did not have these things on. Review of facility's policy titled, 'Fall Management' with a revised date 6/4/14 shows, the facility observes the physical and cognitive function of each resident to identify factors that place them at risk for falling. A care plan is developed defining those risks and interventions are implemented. The policy also shows 3. A score of 10 or higher is indicative of a risk for falls. 5. The facility will observe for the use of safety devices always selecting the least restrictive device to meet the individualized needs of the resident. 6. The care plan is developed to address the areas identified on the review and on the observations of the resident.

Based on interview and record review, the facility failed to utilize wheelchair foot pedals during a wheelchair transport for one of one residents (R143) reviewed for locomotion in the sample of 51. This failure resulted in R143 receiving a fractured left fibula. Findings Include: R143's Face Sheet dated 5/8/19 documents [DIAGNOSES REDACTED]. R143's MDS (Minimum Data Set) dated 2/5/19 documents R143 has severe cognitive impairments, is non-ambulatory in R143's room and requires extensive assist of one for locomotion in a wheelchair while on and off the unit. R143's Clinical Notes dated 3/4/19 documents, R143 complained of R143's leg being in excruciating pain. R143 stated R143's leg went under the wheelchair while R143 was being pushed up the hallway. X-rays ordered, awaiting results. R143's Radiology Report dated 3/4/19 by V11 DO (Doctor of Osteopathic Medicine) documents, The visualized osseous structures demonstrate a subacute incomplete nondisplaced fracture involving the proximal left fibula. Mild to moderate joint space narrowing is noted. R143's Clinical Notes dated 3/5/19 documents R143 was sent to the Emergency Department to be evaluated and returned the same day with a knee immobilizer to the left leg, for a fractured left fibula. R143's Serious Injury Incident Report dated 3/11/19 documents R143 was on the way to the dining room when R143 felt a pain in R143's leg, x-rays revealed a proximal subacute fibula fracture. The Trigger Investigation Report included in the Serious Injury Incident Report documents R143 stated R143 was performing a normal routine of rolling in the wheelchair then staff provided assistance as requested and on way into the dining room, R143 heard a pop. A witness statement dated 3/4/19 from V12 CNA (Certified Nursing Assistant) documents, R143 was wheeled into the dining room and began to cry. R143 stated that while R143 was being pushed in her chair, R143's foot went underneath the chair and R143 heard a pop. R143 couldn't rate the pain but stated, it hurt really bad. Another witness statement dated 3/4/19 from V7 CNA documents, V7 assisted R143 by pushing R143 into the dining room and during the transport, R143 began to complain of pain in R143's foot. R143 stated the pain is real bad. On 5/8/19 at 12:14 PM, V1 Administrator stated that during the investigation, V1 could not prove that V7 did anything on purpose to hurt R143 however the incident didn't sit well with me {V1} so we {facility} let him {V7} go for not keeping {R143} safe during transportation. V1 stated that R143 did not have foot pedals on the wheelchair at the time of the incident. On 5/08/19 at 12:22 PM, V3 ADON (Assistant Director of Nursing) stated R143 could propel R143's self in the wheelchair so R143 did not have foot pedals. V3 stated V3 don't know if {R143} is cognitive enough to know to keep her {R143's} feet up when staff were propelling {R143}. V7 CNA should have gotten some {foot pedals} for {R143's} chair prior to pushing {R143}. Some residents have the foot pedals in their rooms but if not, they {staff} can ask therapy to get a set. All residents who are propelled by staff are to have foot pedals on their chair.

Based on observation, interview, and record review, the facility failed to ensure a resident's [MEDICAL CONDITION] medications were available and scheduled per the physician orders, resulting in several significant medication errors. This failure resulted in R2 experiencing prolonged [MEDICAL CONDITION] activity and a hospital admission to the intensive care unit. This applies 1 of 4 residents (R2) reviewed for medication availability in the sample of 6. The findings include: R2's Electronic Medical Record (EMR) showed R2 was admitted to the facility on (MONTH) 19, 2019 and transferred to the hospital on (MONTH) 23, 2019. R2 remained hospitalized during the survey. On (MONTH) 5, 2019 at 12:05 PM, V11 (R2's Mother and Caregiver) stated R2 has a longstanding history of [MEDICAL CONDITION] since he contracted encephalitis in 2001 when he was a child. V11 stated R2 lived at home and she managed his medications. V11 stated R2 is high-functioning, and at home she sets up all of his medications for him and would remind him to take them. V11 stated when R2 was discharged from the hospital to the facility for strengthening, the hospital waited until R2 received all of his [MEDICAL CONDITION] medications before he was transferred. R2's (MONTH) 19, 2019 Nursing Admission Assessment Comprehensive showed R2 was admitted to the facility at 10:30 PM, and he was alert, ambulatory with assistance, and continent of bowel and bladder. R2's (MONTH) 2019 Physician order [REDACTED]. In the medication room on the floor where R2's room was located, there was a computerized medication storage unit stocked by the pharmacy where nurses may access medications that are not available in their medication carts. The listing for the unit showed only one of R2's [MEDICAL CONDITION] medications ([MEDICATION NAME]) was available. R2's (MONTH) 2019 Physician order [REDACTED]. R2's (MONTH) 19, 2019 hospital discharge orders showed to administer one 97.2 mg tablet of [MEDICATION NAME] (R2's second [MEDICAL CONDITION] medication) every morning, and one and a half tablets of 97.2 mg [MEDICATION NAME] at night. R2's (MONTH) MAR indicated [REDACTED]. Neither of the doses were signed off as administered on (MONTH) 20, 2019. R2's (MONTH) MAR indicated [REDACTED]. MAR indicated [REDACTED]. Another entry from the next day at 9:00 PM for the single tablet dose showed Not Administered (Medication Not Available). R2's hospital discharge orders showed to administer [MEDICATION NAME] 100 mg (R2's third [MEDICAL CONDITION] medication), one tablet in the morning and one and a half tablets in the evening. R2's (MONTH) MAR indicated [REDACTED]. R2's (MONTH) MAR indicated [REDACTED]. R2's hospital discharge orders showed to administer [MEDICATION NAME] nightly (R2's fourth [MEDICAL CONDITION] medication). R2's (MONTH) 2019 MAR indicated [REDACTED]. R2's hospital discharge orders showed to administer lacosamide (R2's fifth [MEDICAL CONDITION] medication) every 12 hours. R2's (MONTH) 2019 MAR indicated [REDACTED]. R2's hospital discharge orders showed to administer cannabidiol (R2's sixth [MEDICAL CONDITION] medication) 2.2 ml twice daily for one week, then to increase the dosage to 4.4 ml twice daily. R2's (MONTH) 2019 MAR indicated [REDACTED]. For (MONTH) 21, 2019, R2's MAR indicated [REDACTED]. For (MONTH) 22, R2's MAR indicated [REDACTED]. For (MONTH) 23, the MAR indicated [REDACTED]. R2's (MONTH) 22, 2019 nursing progress note from 6:23 PM showed notified by (Certified Nursing Assistant) that resident was having [MEDICAL CONDITION] . writer made aware [MEDICAL CONDITION] lasted about 5-10 minutes . R2's 4:34 PM nursing note from (MONTH) 23, 2019 showed Resident noted with altered mental status today after having [MEDICAL CONDITION] activity on 3/22 . R2's (MONTH) 23, 2019 note showed resident had [MEDICAL CONDITION] activity noted by his mother, [MEDICATION NAME] for 5 minutes (5:38 PM), as reported per resident's mom . The note showed an ambulance arrived at 5:44 PM on (MONTH) 23 for transport to the hospital. On (MONTH) 5, 2019 at 12:40 PM, V11 (R2's Mother) stated when R2 was stabilized at the hospital after leaving the facility, he was transferred to another hospital and admitted directly into the intensive care unit. V11 stated R2 couldn't talk and just stared, he couldn't walk, and now he's incontinent . that's how out of it he is. V11 stated R2 said Hi Mom for the first time on (MONTH) 3, 2019, 11 days after leaving the facility. On (MONTH) 5, 2019 at 2:15 PM, V4 RN (Registered Nurse Manager) stated medications should be given as prescribed by the physician because they are part of a resident's health process. V4 stated some medications have to stay at specific times, like [MEDICAL CONDITION] medications and [MEDICAL CONDITION] medications. V4 stated if medications are not available, pharmacy should be called and the physician should be notified that the medication is not available to get further guidance. On (MONTH) 9, 2019 at 1:30 PM, V2 (RN, Director of Nursing) stated it is very important to give [MEDICAL CONDITION] medications as ordered and the way the physician wants it to avoid relapse. V2 added [MEDICAL CONDITION] medication levels need to be maintained. On (MONTH) 11, 2019 at 9:15 AM, V12 (R2's Neurologist) stated he has been seeing R2 for many years and described R2's [MEDICAL CONDITION] activity as very brittle and his medication regimen as critical. V12 added R2's [MEDICAL CONDITION] activity as such that if his medications are taken an hour late, it is ok, but 90 minutes is pushing it. V12 stated there is no question that R2 not receiving his medications on schedule was a contributing factor with his [MEDICAL CONDITION]. V12 stated that without giving medications, lacosamide, [MEDICATION NAME], and [MEDICATION NAME] levels drop quickly in the body. V12 added there is definitely a high probability R2's [MEDICAL CONDITION] could have been prevented if he had received his medications on schedule and the lack of medication played a dominant role in R2 being transferred to the hospital. On (MONTH) 9, 2019 at 12:15 PM, V3 (Pharmacist) stated it is important to take [MEDICAL CONDITION] medication as ordered by the physician as it is prescribed. The facility's 7.0 Medication Shortage/Unavailable Medications policy (revised (MONTH) 1, 2013) showed 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. The policy further showed 2.3 If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery .

Based on interview and record review the facility failed to follow the care plan to use a sit to stand device to transfer a resident (R27) from a shower chair to a wheelchair. The facility also failed to follow their CNA Checklist to have a nursing assessment done before moving a resident after a fall for one resident (R27) of eleven residents reviewed for falls in a total sample of 28 . This failure resulted in R27 sustaining multiple fractures and being hospitalized . Findings Include: R27 is a [AGE] year old resident admitted to the facility on [DATE]. R27 has [DIAGNOSES REDACTED]. R27 is not currently in the facility. R27's Care Plan effective date 1/3/17 documents ADL's (Activities of Daily Living) R27 requires extensive assistance with ADL performance and cueing/supervision with physical help of 1-2 (person)due to decreased strength, balance and endurance. Transfer Status Sit to Stand Machine. The Fall Risk assessment dated [DATE] scores R27 as 10, high risk for falls. On 6/7/17 at 3:20 PM E9 CNA (Certified Nursing Assistant) stated that E10 CNA was giving R27 a shower. R27 sometimes can stand stand for short periods of time and sometimes we use sit to stand machine, When I came in the shower room R27 was standing getting ready to pivot to wheel chair from the shower chair. There was no sit to stand machine. R27's left leg twisted, it didn't turn toward the wheel chair. R27 started to go down, we lowered her to the ground. I went to go get the mechanical lift. We used the call light. R27 had on briefs and socks I can't remember if a towel was on the floor. R27 complained that her left leg hurt and she couldn't breath. When the nurse came we already had her in the sling of the mechanical lift. The nurse came and assessed R27's leg and took vitals. On 6/7/17 at 11:45 AM E2 DON Director of Nursing stated that the nurse should assess residents prior to being moved after a fall. Witness Statement of R27 dated 4/19/17 at 12:00 PM written by E4 RN (Registered Nurse Unit Manager) documents R27 stated she was in the shower and was being moved from shower chair to wheelchair and left foot caught in towel. Legs gave way so two CNA's lowered her to the ground. CNA got lift to pick her up and brought her to her bed. Nurse came in, had pain to left leg ( foot, ankle and leg) movement pain is 9 out of ten., do not move. X-ray was done, nurse gave pain medicine but didn't sleep all night. Witness Statement of E10 CNA dated 4/20/17 documents in part; When drying R27 off, another CNA (E9) came into shower to assist. Resident (R 27) stood up holding on to the bar with one hand and locked wheel chair with the other hand. Back side dried off and brief applied. Resident then started to turn to sit in the wheel chair when stated help me and resident started to bend knees so the two CNA's assisted her to the ground. The resident became very anxious, call light in shower pulled, resident insisted get me up, I cant breath CNA got lift to get resident up and put her in bed. Nurse notified to see resident. Progress Note dated 4/19/17 12:07 AM written by E11 RN writer informed by CNA that resident was lowered to floor in shower room during transfer to wheelchair Writer went to further assess resident (R27) who was lying in bed. Resident complain of left lower leg foot pain. PM Supervisor notified of incident. Vitals stable, fall was witnessed and resident did not hit head. Z1 Medical Director notified, Primary Care Physician did not respond to pages. New orders for STAT X-rays of left knee, tibula/fibula, ankle and foot. Family notified. Pain medication administered. Will continue to monitor. X-ray report from Z2 dated 4/19/17 documents in part; Impression: undisplaced oblique fracture left lateral malleolus with over lying soft tissue swelling and undisplaced oblique supra condylar fracture of left femur. Progress Notes dated 4/19/17 written by E12 LPN (Licensed Practical Nurse) documents in part; Dr ordered that the resident should be sent to a hospital of choice. Ambulance picked up the resident at about 2:30 PM. The facility CNA Checklist, undated, documents in part; discuss post fall management; report to the nurse intermediately, do not move the resident until the nurse gives you instruction.

Based on observation, interview, and record review, the facility failed to perform a skin assessment when a shower was refused for 1 of 3 residents (R3) reviewed for pressure ulcers in the sample of 6. This failure resulted in R3 developing a pressure sore to the right heel and identified as a black, necrotic, and unstageable pressure ulcer measuring 1 centimeter (cm) x 1.5 cm. Findings include: On 12/1/15 at 11am, E4(Wound Care Nurse) and Z1(Wound Physician) performed wound care to R3's right heel pressure ulcer. The wound is covered with black tissue and Z1 removed the black tissue with a scalpel. Z1 stated R3 had a wound to the right heel a few months ago, but it healed. Nursing Admission Assessment 7/9/15 assesses R3 at risk to develop pressure ulcers based on the Braden Scale Assessment for Pressure Ulcer Risk. Wound Physician Note 8/4/15 documents an unstageable deep tissue injury to R3's right heel measuring 1.5 centimeters (cm) x 2 cm and recommendations for a sponge boot, float heels in bed, and off-load pressure to the wound are given. Nurse Note 11/30/15 documents wound care was in progress to other wounds when E4 turned R3 and noted what appeared to be an open blister with a black hardened wound base. Physician and family were notified, treatment orders received from the physician, and orders carried out. Treatment Record documents a weekly skin check was completed on 11/26/15. The last shower sheet 11/29/15 documents R3 refused a shower and a skin check was not completed. Last Braden Scale 9/29/15 is not filled out and there are no other Braden Scales since admission. Wound Physician Note 12/1/15 documents R3 is spending less time up in the wheelchair as recommended, now has a wound to the right heel, and R3 has had a wound to this site in the past. Recommendations are for a sponge boot, float heels in bed, and off-load the wound. Care Plan for the right foot brace 7/21/15 has an intervention to monitor for redness/skin integrity. Care Plan at risk for skin breakdown 7/22/15 is not updated when the right heel pressure ulcer is identified on 8/4/15 and no new interventions are put into place. Skin Care Plan 10/20/15 includes an intervention to check under the right foot brace during skin checks and monitor skin daily during skin checks and report changes. The skin care plan does not include interventions recommended by the wound physician on 8/4/15. On 12/1/15 at 11:40am, R3 stated there were no foam boots or heel protectors before 11/30/15. R3 stated her heels rest and rub on the bed and R3 cannot move the right leg or foot independently. On 12/1/15 at 11:45am E4 stated the heel elevator device was given to R3 on 11/30/15 when the wound was discovered. R3 did not have any other devices in place to elevate the heels and R3 cannot move the right foot and leg on her own. On 12/1/15 at 1:15pm, Z1 stated R3 did not develop the necrotic black heel wound in 12-24 hours. The wound was there on 11/30/15 but overlooked by staff who got R3 dressed or showered. On 12/2/15 at 1:20pm, E11(Nurse Aide) stated R3 refused a shower on 11/29/15 and a body check or skin check was not completed. On 12/3/15 at 10am by phone, E12(Nurse Aide) stated if R3 got a shower at night, E12 would have completed a shower sheet. E12 stated R3 had a dressing on her sacrum and a skin tear on the arm, but E12 did not see any other areas of skin breakdown. Skin Management policy - The Braden Scale is the designated risk assessment for (the facility). The Braden Scale will be conducted on admission, when a resident is readmitted , quarterly or following a change of status. A head to toe observation of the residents' skin will be conducted on admission, readmission, weekly, and during care. Areas of concern will be reported to the nurse and the physician. The care plan is developed based on the individual risks and needs of the resident. Interventions are developed based on the assessment information and are interdisciplinary in content. Preventive measures may include but are not limited to off-loading pressure points.

Based on interview and record review the facility failed to safely transport 1 of 3 residents (R1) reviewed for wheel chair mobility. This failure resulted in R1 being transferred to the local hospital with a [DIAGNOSES REDACTED]. Findings Include: The Incident Report dated 11/4/14 documents that E4 (Certified Nursing Assistant) was pushing R1 down the hall in a wheelchair while the resident pushed a portable oxygen cylinder. There were no leg rests on the wheelchair at the time of the transport and R1 fell out of the chair and hit her head on the floor. R1 was noted to have a contusion above the left eye, bleeding from the lower lip, and swelling to the right hand. The MD was notified and orders were received for a stat x-ray of the skull, the results were negative for fractures and the resident was monitored closely for safety. On 11/5/14 R1 had complaints of a worsening headache, dizziness, and pain in the right hand. R1 was transferred to the local hospital and was admitted with a [DIAGNOSES REDACTED]. On 11/18/14 at 2:25pm E4 stated "I was bringing the resident from therapy back to her room. The resident was in the wheelchair and had oxygen in a carrier with wheels. There was no oxygen holder on the back of her wheelchair and there was no one around to help me so I asked the resident to push the oxygen while I push her. The resident's feet were dragging because she did not have a foot rest and she fell out of the chair and hit her head on the floor. She had a knot on the side of her head and I went and told the nurses." On 11/18/14 at 2:45pm E3 (Clinical Manager) stated "I did the investigation for this incident and I concluded that the CNA used poor judgment. The CNA was educated on utilizing her staff members with transfers involving a wheeled oxygen carrier. This resident did not have a holder on the back of the wheelchair so the CNA should have used a second person to push the oxygen. I also educated her on using leg rests while transporting residents in wheelchairs. The resident was able to stand and pivot but she did use leg rests as well and there were no leg rests being used at the time of the fall." On 11/18/14 at 1:25pm E2 (DON) stated "Oxygen should be in a carrier on the back of the wheelchair when residents are being transported in a wheelchair, and foot rests should be on at all times unless the resident is self-propelling." On 11/18/14 at 1:35pm Z1 (MD) stated" I was notified on 11/5/14 that the resident had a fall from the wheelchair. I did not know that she was pushing an oxygen cylinder at the time of the fall. I was told that the resident had some general pain throughout which is somewhat normal for the resident. The next day I got a call of a worsening headache with no change in mental status and the resident was sent out to the hospital. This resident does not have any history of intracranial bleeding so any bleeds would be most likely related to the fall from the wheelchair." The facility's policy on Oxygen Safety documents that trained personnel shall provide and enforce regulations for the storage and handling of cylinders should be secured at all times.

Based on interview and record review, the facility failed to prevent an avoidable fall while providing care in the shower room for 1 of 4 residents (R1) reviewed for falls, and/or failed to safely transfer resident. These failure resulted in R1 being sent to the hospital for evaluation and assessed to have a right fractured rib and right fractured hip. Findings include: 1). On 11/7/14 at 2pm, E6 (CNA) stated that on 2/8/14, she assisted E4 (CNA) with R1's shower. E6 stated that she was behind R1's shower chair and E4 lifted R1 forward. E6 stated that she removed the sling from under R1 and then R1 was "dropped" into the shower chair. On 11/12/14 at 10:05am, E4 (CNA) stated that she could not remember what happened during R1's shower. E4 stated that it was a long time ago. E4 stated that she remembers giving R1 a shower. E4 stated that R1 stated that her chest hurt after the transfer. E5's witness statement dated 2/8/14 reads "After R1's shower, CNA said that R1 complained of knee pain. R1 stated that it hurt when she breathed in & R1 complained of chest pain. E5's statement reads R1's family member came to visit and wanted x-rays. Z2 (Physician) gave an order to send R1 to the hospital." E3's (RN) called R1's family member on 2/8/14 at 10:45pm and asked R1's family member what R1 reported to the hospital regarding the incident. R1's family member stated that R1 said that on 2/8/14, E4 (CNA) reached under R1's arms and around R1's chest and pulled her up to reposition her during the shower. R1 stated that she heard a pop in her chest and a crack in her knee. R1's clinical notes dated 2/8/14 read R1 is alert and oriented. On 2/8/14, Z1's emergency room clinical notes read "[AGE] year old female (R1) presents to the ED (Emergency Department) for chest pain around 1:30pm after being lifted out of the bath tub at the the nursing home. R1 reports pain across lower chest that is worse when taking a deep breath. R1 reports hearing a crack in her right knee when being lifted up with current right knee pain. Physical Exam notes: Chest wall positive for marked rib tenderness bilaterally, marked swollen anterior right knee, tenderness mid thigh and lateral hip, knee pain with movement, left foot drop. Primary impression: Possible right femoral neck fracture. Additional impression: Internal derangement right knee, musculoskeletal chest pain, right rib fracture." Z4's (Consultant Physician) clinical notes dated 2/9/14 read R1 is a [AGE] year old female who presents from a nursing home after apparent fall. R1 is bedridden but in the process of transferring R1 for a shower, she may have fallen. R1 clearly had some pain in her ribs and her hip. On initial x-rays, it looks like R1 has a subcapital fracture of the right femur with possible impaction. Imaging report: Hip x-ray, there is a capital fracture of the femur with impaction." Z1's report on 2/8/14 reads "Clinical information: Blunt trauma to the chest. Impression: possible undisplaced right rib fracture." The facility's IDPH (Illinois Department of Public Health) final report of the incident dated 2/14/14 reads "It is possible that R1 may have sustained a fracture during repositioning with a gait belt in the chair."

Based on observation, interview and record review the facility failed to implement measures to promote the healing of a pressure ulcer for one of three residents (R2) reviewed for pressure ulcer treatment in a sample of 4. This failure resulted in R2 developing a pressure ulcer that became infected, delayed healing and increased in size and depth from a Stage I to a Stage IV. Findings include: R2 is a [AGE] year old resident with [DIAGNOSES REDACTED]. The Braden Scale, 8/15/13 and 11/5/13, both place R2 at risk for the development of pressure ulcers. The facility Wound Assessment Details Report, 9/18/13, documents R2 developed a facility acquired Stage I area to the coccyx measuring 4.0 by 3.7 by 0.0 centimeters (cm) on 9/6/13. The facility Wound Assessment Details Report, 10/9/13, documents R2 developed an unstageable soft necrotic facility acquired pressure ulcer measuring 2.5 by 2.0 by unknown depth in centimeters. The facility Care Plan Report, 11/8/13, documents R2 has an unstageable pressure ulcer to the coccyx. Interventions include, labs, pressure reducing mattress and cushion when sitting, avoid friction, keep linen and clothes free of wrinkles, educate R2 as needed, treatment as ordered, report changes, encourage nutrition, encourage R2 to change position as often as possible, keep skin clean and dry, barrier cream, monitor skin daily, keep pressure off of affected area as much as possible, and treat pain. There is no care plan to limit sitting to sixty minutes or specific instructions for off- loading, including bedrest at any time between September 2013 through 1/3/14. The Physician Order Sheets, 10/23/13, starting continuously, document R2 as activity as tolerated. The Physician Orders 12/11/13 and 12/27/13 document orders for use of antibiotics for an infected ulcer. The Wound Care Specialist Initial Evaluation, completed by Z5, 10/9/13 documents R2 with a unstageable pressure ulcer to the medial coccyx measuring 2.5 by 2.0 by unmeasurable cm of depth. Debridement was completed. Recommendations were to limit sitting to 60 minutes, off-load wound and repositioning. The Wound Care Specialist Evaluations, all completed by Z5, after the initial evaluation are as follows: 10/16/13- unstageable necrosis measuring 2.5 by 2.2 by unmeasurable cm of depth to the medial coccyx. Recommendation include limit sitting to 60 minutes and off-load. 10/23/13- Unchanged measurements but wound progress deteriorated. Additional information documents R2 needs to limit sitting in a chair to 60 minutes. Now with additional tissue damage to surrounding skin. Debridement was completed. Other recommendations include a gel wheelchair cushion. 10/30/13- unstageable necrosis to the medial coccyx area measuring 2.6 by 2.4 by unmeasurable area in cm. Additional information includes R2 is getting a new offloading cushion. Recommendation again include to limit sitting to 60 minutes. Debridement was completed. 11/6/13- unstageable necrosis to the medial coccyx area measuring 3.0 by 2.5 by not measurable area in cm. Findings noted deterioration which was due to a generalized decline of R2 and non-compliance with wound care. Recommendations were for R2 to not sit in a chair for a week to aid in healing. "This was discussed with staff." 11/13/13- unstageable necrosis to the medial coccyx measuring 3.5 by 2.5 by unmeasurable depth in cm. Additional information documents "still in chair prolonged periods. Needs offloading. Foul odor to tissue, increased necrosis. May need hospitalization for surgical debridement and infectious work up." Debridement completed. Recommendation again include to limit sitting to 60 minutes and off-load wound. 11/20/13- unstageable necrosis to the medial coccyx measuring 3.5 by 3.0 by depth unmeasurable in cm. Additional information documents "debrided thin layers covering bone. Culture grew [MEDICATION NAME]. Antibiotics to be ordered by primary care physician." Procedure documents, "wound debrided via surgical incision and muscle removed along with infected tissue." Recommendation include to limit sitting to 60 minutes and off-load. Area not improved. 11/27/13- Stage IV Pressure Ulcer to medial coccyx measuring 3.5 by 3.0 by 2.0 cm. Additional Information documents "Continued non-compliance with offloading, limit sitting. Patient up prolonged periods. MUST LIMIT SITTING/PRESSURE ON WOUND. Antibiotics end 11/30/13." Recommendations include to limit sitting to 60 minutes. 12/4/13- Stage IV Pressure Ulcer to medial coccyx measuring 3.0 by 2.8 by 2.0 cm and wound progress as not improved. Additional information documents, "Facility finding balance between offloading and sitting in chair due to fall risk." Recommendations were to limit sitting to 60 minutes and off-load. 12/11/13- Stage IV Pressure Ulcer to medial coccyx measuring 2.8 by 2.9 by 1.5 cm and wound progress as improved. Additional information documents R2 complying with offloading. Recommendation to limit sitting to 60 minutes to off-load wound. 12/18/13- Stage IV Pressure Ulcer to medial coccyx measuring 2.2 by 2.4 by 1.1 cm and wound progress as improved. 12/27/13- Stage IV Pressure Ulcer to medial coccyx measuring 2.0 by 1.9 by 1.0 cm and wound progress as improved. Recommendation is to off-load wound. On 1/3/14 at 10:00am, Wound Care was completed by E3 (Wound Nurse). R2 had a pressure area to the coccyx area which was measured by E3 as 2.0 by 2.2 by 1.0 cm. Tunneling was noted to the wound when E3 packed the pressure ulcer with dressing. On 1/3/14 at 10:15am found R2 in a wheelchair in the hallway of the dementia unit. On 1/3/14 at 11:05am, 11:15am, 11:30am, 11:40am, 11:45am, 11:55am and 12:12pm found R2 in the activity/dining room area in the wheelchair asleep. On 1/3/14 at 12:50pm, R2 remained at the dining room table asleep after lunch was served. On 1/3/14 at 11:35am, E8 (Nursing Assistant) stated R2 was placed in the wheelchair before breakfast, placed in bed for wound care then gotten back up. E8 stated R2 had been up in the wheelchair since approximately 10:15am. E8 stated the protocol for R2 is to lay down after lunch and get up at approximately 3-4pm. E8 stated all residents with wounds are encouraged to go to bed after lunch. On 1/3/14 at 11:25am, E7 (Nursing Assistant), state she was familiar with R2 and is a regular caregiver for R2 for the last several months. R2's protocol is to be turned and repositioned every 2 hours. E7 stated R2 currently is compliant with care but approximately 4 months ago didn't like to go to bed and would try to get up without assistance. E7 stated R2 is a one person assist to transfer and would be going to bed again after lunch and get back up at approximately 2 pm. E7 was unaware of any other pressure ulcer interventions for R2. On 1/3/14 at 11:22am, E6 (Nurse) stated R2 has a pressure ulcer to the coccyx. R2 is to use a cushion in the wheelchair and lay down after meals. E6 stated R2 on occasion has issues laying down and will want to get up On 1/3/14 at 11:05am, E3 (Wound Care Nurse) stated E2 (Director of Nurses) manages the wound care and there is a weekly conference to discuss residents wounds at the facility. E3 stated Z5 recommended sitting up for no more than 60 minutes in a chair as an intervention to heal the pressure ulcer to R2's coccyx. E3 stated if a resident is non-compliant the facility talks to the family and resident or asks the physician to talk with the family. IF still non-compliant education is completed. A Care Plan is also initiated. E3 stated there is no documentation in the care plan for R2 to limit sitting or be placed on bedrest for a week. E3 stated the staff would be aware of R2's interventions by physician order. E3 stated there is no physician order in the clinical record to limit sitting. On 1/3/14 at 12:52pm, E2 stated R2 has a protruding sacral bone. IT started as redness and a cushion was placed in R2's wheelchair. E2 was aware the wound has declined and was being seen by Z5. E2 stated R2 wasn't always complaint with laying down. E2 stated back in September R2 would only remain in bed for short periods of time. R2 is positioned per standard of care which is every 2 hours. IF a resident is non-complaint with care a care plan is initiated and wounds are discussed weekly. The facility protocol for pressure ulcers is the wound care nurse will evaluate and the physician, E2, unit manager and family is notified. Problem solving is completed an interventions are initiated as appropriate. A care plan is initiated if there is a new or special order for care. The Nursing Assistants are aware of care needs via a Caregiver Alert Card placed in each residents closet. IF a resident is to be up one hour at a time it would be on the Caregiver Alert Card. On 1/3/14 at 12:58pm, E2 accompanied the surveyor to R2's room. The Caregiver Alert Card was present in R2's closet but no repositioning needs or instructions other than use of a wheelchair cushion were presents. E2 stated E9 (Unit Manager/Nurse) would be able to provide specific care needs for R2 and would be aware if R2 had a sitting restriction of 60 minutes. On 1/3/14 at 1:00pm, E9 stated a weekly meeting is held and all wounds are discussed. R2's interventions include antibiotics, gel cushion in the wheelchair, lay down after meals and walking with Restorative Therapy. R2 is to reposition herself in her wheelchair every hour. E9 stated she was unaware of the recommendation to restrict R2's sitting to 60 minutes. On 1/3/14 at 2:00pm, E12 (Medical Director) stated all pressure ulcers are to be followed every day, repositioning is to occur and follow facility protocol is to be followed to promote healing. E12 was not aware R2 had a wound that was not healing, not aware of Z5's recommendations or that R2 was not complaint with care causing the pressure ulcer to worsen. The facility "should follow the recommendations of Z5. (R2's) behavior should be addressed and the recommendations should be followed. The facility should take advantage of the behavioral improvement and take care of the wound (R2) has." On 1/3/14 at 3:00pm, E1(Administrator) and E2 were asked to provide documentation the facility reviewed the recommendations of Z5 and made implemented measures to assist with the healing of the pressure ulcer to R2's coccyx, including management of non-compliance behaviors. No documentation was provided. The facility policy, Skin Management, 8/10, documents the facility is committed to the prevention of pressure ulcers through the identification of at risk residents and the specific factors that place them at risk. The initiation of intervention based on these factors will be designed to decrease the risks. There is no documentation in the clinical record of the facility implementing interventions or creating a plan of care to address the risk factors R2 exhibited which caused the wound to worsen, including limited sitting or individualized repositioning measures and behavioral interventions to address non-compliance. Z5 was unable to be reached on 1/3/14 for an interview.

Based on interview and record review the facility failed to accurately assess and document functional transfer ability and safely transfer one resident (R5) of three residents reviewed for transfers in a sample of 10 residents. This failure resulted in R5 requiring treatment at the local hospital for a right arm acute transverse fracture. Findings Include: R5 had been a resident of the facility since 2010. R5 was discharged from the facility on 11/3/12. Annual Minimum Data Set ((MDS) dated [DATE],Quarterly MDS dated [DATE] and discharge MDS dated [DATE] were reviewed for functional and mobility status. 7-Day ADL (Activities of Daily Living) ADL Coding Summary dated 10/28/12 to 11/3/12 indicates R5 MDS coding was a 3(Extensive assistance/resident involved in activity, staff provide weight bearing support) for self performance and a 3(2 + persons physical assist) for transfers. Quarterly MDS dated [DATE] section G indicates Bed Mobility coded as a 3/3 for bed mobility - how a resident repositions and moves in bed. This code indicates R5 required extensive assist with 2 person physical assist with bed mobility. On 1/22/13 at 1:50pm E5, (Certified Nursing Assistant) CNA stated "I reposition R5 by myself at night." Incident Investigation Conclusion dated 11/2/12 indicates R5 was a one person assist with a gait belt for transfer and repositioning. Nursing Home Resident Record -Continued/Nurse's Notes dated 11/2/12 at 4:43pm indicates R5 was observed sitting up in a wheelchair alert, with bruise to right upper arm and shoulder, breast and chest. Nurse's Note further indicates physician was notified of bruising and X-rays were ordered for right upper arm, shoulder and right ribs. Mobile Radiology Report Date of Service 11/02/12 indicates R5 with an acute transverse fracture proximal humerus with modest medial displacement of the distal fracture fragment. Review of the nurse's notes dated 11/3/12 indicates R5's physician was notified of mobile X-ray results with subsequent orders to send R5 to the local hospital emergency room for evaluation. Hospital Radiology Report of Examination, Service date 11/03/12 indicates reason for visit right arm injury with findings of overriding fracture of the proximal humerus with medial displacement of distal fragment. Severe osteoporosis is present. R5's Fall Prevention and Restorative Care Plan dated 8/20/12 indicates R5 requires a gait belt for transfers and mobility. Fall Care Plan dated 8/20/12 also indicates R5 requires a mechanical lift for transfers. On 1/17/13 at 3:15pm E3, Restorative Nurse stated " I don't know why R5's care plan has mechanical lift as an intervention. I don't believe R5 was ever evaluated for or used a lift for transfer." On 1/22/13 at 10:35am E3 said that I usually talk to staff to get first hand information from the staff that care for the resident for the MDS assessment. I wasn't able to find or talk to any staff that day regarding care and mobility for R5 for the period of 10/28/12 to 11/3/12 so I just coded R5 as an 8 - the activity didn't occur - because I didn't have a clear picture of what R5 was able to do. Usually I would look for another staff to provide information about the resident before doing the MDS. I just put 8's on the MDS that the activity didn't occur, but that assessment would not be accurate. On 1/17/13 at 12:00pm E2 Director of Nursing (DON) stated "Nurses and restorative complete care and transfer list, the Care Card placed on the residents inside closet door. That directs the CNA's how to care and transfer the resident. We believe R5's bruising and injury happened during a transfer on the day shift on 11/3/12." E2 was asked to provide R5's Care Card, but said that the facility didn't have it. On 1/17/13 at 10:30am E4 Certified Nursing Assistant) CNA, stated R5 was not helping or bearing weight at all during transfers on 11/2/12, further stating "R5 had stopped walking all together on and off for a couple weeks. E4 said that on 11/2/12 myself and another CNA staff transferred R5 with a gait belt twice, once in the morning and once after lunch. R5 provided no assistance during either transfer and was unable to bear weight. We held the gait belt and lifted R5 up under both of her arms. We didn't remove the wheelchair arm rests on R5's chair, so R5 had to be lifted over the arm rest. E4 said that R5's arm rest are removable from the wheel chair. E4 further stated "If a resident can't bear weight at all we should use a mechanical lift. E4 said that we didn't use a mechanical lift because it wasn't indicated on R5's Care Card so we still used 2 persons and a gait belt to transfer. Facility Incident Investigation - Final Written Report Conclusion Addendum dated 11/9/12 indicates R5 right arm fracture occurred during transfer of R5. On 1/18/13 at 2:55pm Z1,Physician stated "The last couple of times or the last visit with R5 she was not able to walk. If two staff can't hold her well they should use a lift. The proper way would be to use a lift. R5 was heavy, she was probably dead weight if she was no longer standing. It could certainly cause a break in the arm if someone has osteoporosis and strong force or pressure was on their arm during transferring " Attending physician progress notes [REDACTED]." On 1/23/13 at 11:10am E1,Administrator stated "If a resident could transfer an hour before but an hour later they can't bear weight, they should be transferred with a mechanical lift - despite what their previous assessment was."

A. Based on record review and interview the facility failed to follow physician orders [REDACTED]. The facility also failed to assess R4's skin condition weekly as indicated in their policy. R4 was found with an open stage 2 pressure ulcer requiring treatment on the left and right buttocks 15 days later. Findings include: According to R4's care plan at risk for skin breakdown dated 8/12/10 denotes maceration to the left and right buttocks. A review of the care plan also indicates as an intervention check for wetness, change and keep R4 clean and dry. In R4's care plan dated 4/17/10 R4 is identified as incontinent of bowel and bladder . In a review of R4's current minimum (MDS) data set [DATE], R4 is assessed in section H as incontinent of of both bowel and bladder. According to R4's closed record pressure ulcer risk assessment dated [DATE] R4 scored an 18 (12 or higher is at risk for pressure ulcer development). A review of the physician telephone order dated 8/1/2010 indicates the physician was notified of R4's maceration of the left/right buttocks and gave treatment orders to include clean daily with normal saline and pat dry, apply hydrogel and protective dressing daily and as needed, and to apply urinary indwelling catheter for wound promotion, and indwelling catheter care every shift. A review of R4's clinical record treatment administration record, denotes no entries of the urinary catheter being applied until 8/18/10. On 9/30/10 at 4:30pm E8(nurse), said that she observed the maceration on R4's left/right buttocks on 8/12/10, E8 said that she notified the physician and received treatment orders, along with the order for apply the indwelling urinary catheter. E8 said that after receiving the telephone orders she notified the nurse on duty, and placed the orders on the chart. E8 said that the primary nurse is responsible for applying the indwelling urinary catheter for R4. E8 also said that since the area was macerated the primary floor nurse was responsible for doing the weekly skin assessment and it should be documented in the nursing notes. E8 said that she observed the open area of R4's left/right buttocks while providing care to R4's wounds to the right ankle and leg. E8 said that she did a wound assessment, notified the physician and received treatment orders, and notified the family of the findings and treatment plan. According to the closed record R4's skin maceration was observed on 8/12/10, and according to the closed record R4's buttocks were reassessed on 8/27/10. According to R4's clinical record physician telephone orders dated 8/27/10 denotes treatment of [REDACTED]. According to the facility's skin management policy indicates that a head to toe observation of the residents skin will be conducted weekly. According to the facility's skin ulcer policy ulcers will be assessed weekly and as needed to identify the effectiveness of the treatment plan and the progression of the healing process. The policy indicates the assessment of treatment efficacy determines the status of the wound healing when the wound is observed. The policy also indicates that pressure ulcer weekly assessments are to be documented in the clinical record. On 10/1/10 at 11:15am Z1 (physician), said that the insertion of the indwelling catheter is to keep the area dry and to prevent further skin breakdown and to promote wound healing. Z1 said that he would expect the facility to place the indwelling catheter within an adequate time frame of no more than 24 hours. Z1 said that indwelling catheter could have provided some defense against R4's wound development. B. Based on interview and record review the facility failed to adequately assess one sampled resident R9, identified with a stage 4 pressure sore of the sacrum area. This failure resulted in R9 having an identical assessment of the wound for two weeks and resulted in decline in the status of the pressure sore. Findings include: According to R9's clinical record dated 9/15/10 8:37pm the wound assessment details report indicated R9 has a wound in the sacrum area stage 4, that measures 5.40cm x 4.30cm x 1.50cm. The wound was also noted to be healing with 100% granulation tissue. According to the wound assessment detail report dated 9/23/10, a sacrum area stage 4, measured 5.40cm x 4.30cm x 1.50cm and the wound was also noted to be healing with a 100% granulation tissue. The current plan and comments on 9/23/10 at 3:11pm denotes no changes noted will continue to monitor. According to R9's clinical record dated 9/10/10 written by Z3 (physician), wound etiology pressure, stage 4 measuring 7.0cm x 5.0cm x 2.5cm, the wound is described as granulation tissue 100%, and wound care assessment dated [DATE] denotes wound etiology pressure, stage 4 measuring 7.0cm x 5.0cm x 4.0cm, the wound is described as thick adherent yellow necrotic tissue 10%, slough [MEDICATION NAME] 10%, and granulation tissue 80%. According to the wound care assessment of 9/24/10 written by Z3(physician), denotes trunk wound etiology pressure, stage 4 measuring 7.0cm x 5.0cm x 3.0cm, the wound is described as thick adherent black necrotic eschar tissue 20%, thick adherent yellow necrotic tissue 10%, slough [MEDICATION NAME] 10%, and granulation tissue 60%. This last assessment denotes that R4 required surgical excisional debridement of muscle. On 9/29/10 at 12:30pm both E9 (nurse), and E10 (nurse), said that they physically did the assessments on R9. E9 said that sometimes measurements are different from different people. E9 was unable to answer why, R9 required debridement if she had 100% granulation tissue. During the daily status meeting on 9/29/10 E2 (director of nursing), said that residents with 100% granulation tissue would not require debridement. On 9/30/10 at 11:45am both E2 and E9 said that during the assessment of the wounds the nurses used a portable hand held device to record the data, and during the assessments the nurses didn't follow the appropriate procedure and save the actual data as it was taken. E2 said that this device was used during the assessments of all the residents in the facility with wounds. E9 said that she has called the manufactuer to provide an in-service on use of the device. E9 said that she couldn't be sure if she used the portable device appropriately during the assessments.

Based on record review, interviews, review of facility's policy on pressure sores and review of hospital records the facility failed to provide treatments and services in the areas of pressure sores as follows: 1. Provide treatments to each pressure sore as ordered by the physician. 2. Perform weekly assessments (per facility's protocol) to all pressure sores to determine if the treatment therapy is effective and the pressure sore is improving. 3. Comprehensively assess each newly developed pressure sore before treating it. 4. Provide an explanation to resident's family/POA (power of attorney) related to the debridement process in a language he/she understands. 5. Obtain a written consent from family/POA before the debridement procedure is done. 6. Accurately and consistently document pressure sore sites. These failures resulted in 1 sampled resident (R2) who developed pressure sores in the facility to have signs and symptoms of [MEDICAL CONDITION]/ infection. R2 was transferred to a local hospital with an axillary temp of 104.2 F in spite of antibiotic therapy. R2 required wound debridement to the left foot (not identified or treated by facility staff), was found [MEDICAL CONDITION] ( [MEDICAL CONDITION] resistant Staph aureus) in the left leg. R2's right foot was not salvageable due to extensive gangrene consuming the entire right heel that was wet and malodorous. Right above the knee amputation was planned/discussed, however R2 expired before this could be done. R2 was transferred to a local hospital on [DATE]. On this day R2's heel had not been treated in 8 days, as well, R2's left medial leg had missed 3 treatments/ 3 days apart. The last time R2's left lower leg was treated was [DATE]. R2's left heel had never been identified or treated by the facility. R2 expired 3 days ([DATE]) after transfer from the nursing home to the local hospital with a secondary [DIAGNOSES REDACTED]." These failures resulted in an Immediate Jeopardy. E1 (administrator), E2 (Director of nurses), and E9 (clinical nurse) were notified of the Immediate Jeopardy on [DATE] at 2:45pm. The Immediate Jeopardy was noted to have begun on [DATE] when R2 showed signs/symptoms of [MEDICAL CONDITION] which resulted in R2 being sent to the emergency room of a local hospital. The findings include: 1) On [DATE] at approximately 11:35am Z1 stated to surveyor per telephone interview "(R2) had a small area on the right heel that got worse because they didn't treat it ". Z1 added, "(E4-wound care nurse/coordinator) had told me she would be gone for a few days, but the nurse will continue to take care of R2's foot." Z1 continued, "When I came to see (R2), there was a dressing on (R2's) foot dated [DATE], when they (facility staff) removed it the entire heel was black and draining pus." Z1 finally stated, "(R2) was transferred to the hospital on [DATE]. They wanted to do an amputation above the knee on (R2), but I really didn't want them to do that. The Doctor explained to me that (R2's) whole lower leg had no circulation, and he gave me a couple days to think about it, but (R2) died that Friday." Closed Record review indicated that R2 was an [AGE] year old resident who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 was admitted to the facility with no open areas or skin breakdown. On [DATE] during a routine podiatrist visit, R2 stated to Z5 (podiatrist) "My heel hurts." Z5 assessed R2's heels and documented finding a 3.3 x 3.1cm wound on R2's right heel. Review of the facility's nurses notes dated the same day [DATE] also documents R2 with a 3.5 x 2.5cm open blister on R2's right heel. Z3 (physician of R2) was notified and orders given to apply [MEDICATION NAME] to R2's right heel and cover with Kerlix daily until healed. Review of the facility's TAR (treatment administration sheet) indicates R2 received treatment to the right heel from [DATE] until [DATE]. There was no treatment given to R2's right heel from [DATE] until [DATE]. A total of 8 treatments were missed. R2 was sent to a local hospital on [DATE] due to deterioration at the right heel site and a temperature of 104.2 degrees. There was also no other assessment performed to R2's right heel to determine improvement or lack of improvement since [DATE]. Further documentation dated [DATE] (3 days later) indicates that Z4 (wound doctor) assessed R2's right heel and documented the size as follows: 5.0 x 5.0 x not measurable with a scant amount of serous drainage. Z4 also identified a newly developed pressure sore on R2's left medial posterior ankle. Z4 sized this new site as follows: 2.0 x 2.0 x 0.1cm with a small amount of serous drainage. Record review further indicates that E4 also assessed this site on [DATE] and staged it as a 2 and sized it as follows: 2.0 x 2.0 [MEDICAL CONDITION]. However, review of the facility's TAR indicates that E4 had treated R2's left lower leg on [DATE] before an assessment was performed. The treatment to R2's left lower leg was changed by the physician on the next day ([DATE]). The new treatment was as follows: Dc previous treatment order to left medial posterior leg. Left medial posterior leg : "cleanse with normal saline, pat dry, and apply Polymen and protective dressing every 3 days." Review of the facility's TAR indicated this treatment was done by E4 as ordered on [DATE] however there was no further treatment to this site until [DATE]. This review indicates that R2 had missed a total of 3 treatments 3 days apart. There was also no assessment performed by the facility staff since [DATE] in all records reviewed. Z4 performed a debridement on this site (left lower medial leg) as documented by E4 on [DATE] at 9:18pm. Documentation included in part : "manual debridement performed bedside. pain med refused. pt tolerated procedure well. order changed due to drainage related to debridement." There was no evidence that a consent was obtained from Z1 (who was present during the procedure) or any family member of R2 for this procedure to be done nor was there evidence of documentation that the procedure was explained to Z1 using language that was understood including ''sharps being used or cutting away the tissue of the wound." There was no evidence that the risk involved, including bleeding and infection was explained to Z1. There was also no evidence that R2 was premedicated prior to this procedure. R2 is identified as confused with history of dementia. Surveyor again interviewed Z1 on [DATE] at approximately 12:50am regarding the explanation of the debridement procedure to R2's leg. Z1 stated, "I was there (nursing home) visiting one day when a doctor and a nurse was there with (R2)." Z1 continued, "The Doctor told me he was just going to clean up the sore on (R2's) leg a little." Z1 continued, " He (wound doctor) took some kind of instrument and pressed it on (R2's) sore and some kind of drainage ran out." Upon further interview Z1 stated, "No, I didn't see him cut anything. He (wound Doctor) never mentioned the word cutting to me." Z1 added, "No one ever asked me anything about a consent to do that or the danger." On [DATE] at 1:05pm - 1:20pm Z4 was interviewed by phone regarding the debridement on R2's left lower leg on [DATE]. E4 stated in part, " (Z1), (E4) and another assistant was present during the debridement procedure." Z4 continued, "I showed (Z1) the curette I was using and told (Z1) it was sharp, I explained that I would be removing dead tissue! Surveyor again asked Z4 if the word "sharp" was used when describing the process. Again Z4 stated, "Yes." Z4 stated, "I always have to explain the risk with sharp debridement to the family." Z4 continued, "Whenever I'm asked to see a patient in the nursing home, I'll get the patient's name, then when I get there I will review the chart and look for a consent. This has always been my policy." Upon further interview Z4 stated "Yes, I require a consent, the nursing home staff can get a verbal consent by phone if the family is unable to come into the nursing home, I'll accept that." Z4 added, "(Z1) was here in the nursing home when the debridement was done, so a written consent could have been gotten." Z4 again explained verbal consent is accepted if the family cannot get into the nursing home and the staff call and get a phone consent. Surveyor questioned Z4 about a consent for debridement and premedication for R2. Z4 stated, "No there was no consent in the chart, I guess I missed checking for it and R2 was not premedicated except I used [MEDICATION NAME], a topical anesthetic." Z4's interview is in conflict with Z1's account of explanation of procedure and risk . Upon questioning by surveyor, E4 ( who was also present at the time of the debridement) did not remember what words were used to describe the debridement to Z1. However, there was no evidence or documentation regarding the explanation given to Z1 nor was there evidence or documentation that Z1 understood it. Further record review of nurses notes dated [DATE] indicates that the facility staff had found an open area on R2's scrotal sac and left buttock measuring 15cm x 1.5cm. Z3 was notified of these areas and gave an order for [REDACTED]. On [DATE] at 8:45pm, during administration of an antibiotic, R2 was found warm to touch and not easily aroused by the facility's nurse. R2 had a temperature of 104.2 axillary, heart rate of 104 and pulse of 28. Z3 was notified and order was given for x-ray of the left heel, left heel wound culture and Keflex (antibiotic) by mouth 4 times a day x 10 days. Surveyor noted an order for [REDACTED]. During interview Z1 (administrator) stated "I think it should be right, It's probably an error." On [DATE] at approximately 3:50pm, E2 (Director of nurses) was interviewed regarding identification, treatments and assessments for R2's pressure sores. E2 stated, R2's right heel was identified on [DATE] and R2's left lower leg was identified [DATE] and assessed on [DATE] by E4. E2 then provided surveyor with a computerized form dated [DATE] indicating that R2's left lower medial leg was assessed by E4. E2 with surveyor then began a search in R2's clinical record to locate an assessment for R2's right heel as well as weekly assessments for R2's pressure sores. After a 20 minute search through R2's closed clinical record and other documentation, E2 left the conference room where surveyor was stationed and went to further search for the missing documentation. After approximately an additional 10- 15 minute search E2 stated to surveyor, "I don't see anything else unless (E4) has other documentation in a separate file." E2 was unable to provide a right heel assessment on this day after approximately a 30 minute search. E2 was unable to provide an explanation for the 8 days that R2 did not receive treatment to the right heel or the 3 treatments missed to R2's left lower medial leg even though this site was recently debrided. Also, E2 could not provide an explanation for the treatment not given to R2's buttock. On [DATE] E2 provided surveyor with a computerized documentation of a right heel assessment by E4 dated [DATE]. Upon questioning E2 stated, "The assessment was in the computer." Later this day at 12:40Pm - 1:55pm E4 was interviewed. During interview and record review with surveyor, E4 confirmed that R2 had not received treatments to the right heel from [DATE] until [DATE] a total of 8 days missed. E4 confirmed that R2 missed treatments to the left lower leg from [DATE] - [DATE] (3 treatments/3 days apart missed). E4 admitted that she had treated R2's left, lower medial leg on [DATE] before it was assessed on [DATE]. E4 confirmed that pressure sores in the facility are assessed weekly and should be assessed before they are treated. Further clinical record review with surveyor, E4 confirmed that R2's right heel had not been assessed since [DATE] and that R2's right lower leg had not been assessed since [DATE]. Upon further interview and record review with surveyor, E4 added, "The next time I saw R2's right heel was on [DATE] the wound had deteriorated, and had pus/drainage." E4 continued "I called (Z3) and got an order for [REDACTED]. I also made a mistake and wrote left heel instead of right on the physician's orders [REDACTED]." Record review indicates that on [DATE] at 8:45pm, during administration of an antibiotic, R2 was found warm to touch and not easily aroused by the facility's nurse. R2 had a temperature of 104.2 axillary, heart rate of 104 and pulse of 28. R2 was sent to a local hospital emergency room . R2's heel wound had not been seen or treated since [DATE] and left lower medial leg since [DATE]. The facility has a policy that pressure ulcers will be assessed weekly and as needed to identify the effectiveness of the treatment plan and the progression of the healing process. The facility practice of not assessing pressure sores is in conflict with facility policy. On [DATE] Z3 (Doctor of R2) was interviewed per telephone regarding notification of changes in R2's pressure sores and change in R2's condition on [DATE] when R2 became septic. Z3 stated, "I remember getting a call from the nursing home about something, but I don't remember what it was about." Surveyor continued to prompt Z3's memory including orders given to facility staff as well as medical specifics about R2. Z3 finally stated, "I don't have (R2's) chart in front of me." Upon further interview Z3 stated, "Yes, I heard (R2) had passed away." Hospital records dated [DATE] indicate that R2 arrived at the local hospital emergency room with [DIAGNOSES REDACTED]." Cultures of R2's pressure sores were done and indicated that the left, lower medial leg contained a heavy growth [MEDICAL CONDITION]. A consultation was done on [DATE] related to R2's pressure sores. Documentation included in part: "Notable findings are extensive gangrene of the right heel consuming the entire right heel. This is wet and malodorous with blistering skin." Listed under impressions documentation is as follows: "There is impending gangrene of the left heel. R2 has extensive gangrene of the right heel. There is impending gangrene of the left heel. The right foot is not salvageable. The patient is a poor candidate for attempts at limb salvage. R2 will likely need amputation of the right foot and at the very least a debridement of the left heel." Listed under Recommendations in part is: 4. The option for management of the right leg include right above the knee amputation versus ongoing temporizing measures with wound care. Comfort care or Hospice will be a consideration. Record review of the "State of Illinois Certificate of Death" indicates that R2 expired on [DATE] at 7:00pm ( 3 days after admission to this local hospital). The significant condition contributing to death but not resulting in the underlying cause in part 1 is listed as "Infected right foot." The facility presented an abatement plan on [DATE] at 5:55pm via facsimile at regional office. This abatement plan was reviewed on [DATE]. Review of this plan lacked required components to abate this deficiency. E1 was notified on this day at approximately 9:20 with requirements needed to abate. On [DATE] the facility presented the following abatement plan. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a level 2 severity . the facility still needs to evaluate the changes they have implemented and need to assess training inservices. The facility submitted the following plan: - The facility QA'd (quality assurance) wound care completed on [DATE] to address omission of dressing /treatment, dressing/treatment of [REDACTED]. - Facility QA'd skin and wound care process completed [DATE] to review of skin and wound care to ensure resident clinical condition demonstrates the need and/or treatments/services promote healing. - House wide audit of TARs (treatment administration record) completed on [DATE] to ensure all other residents' treatments administered per physician order [REDACTED]. - House wide skin audit completed [DATE] with no new skin areas noted. - Cross reference of all POS (physician order [REDACTED]. - Audit of care plans to ensure accurately reflect current plan of care and accurate site completed [DATE]. - House wide audit of Braden scales started [DATE] to ensure accuracy of wound history. - Staff nurses will be responsible for wound care coverage in the absence of Wound Care coordinator. - Wound care Coordinator/designee will review documentation of treatments rendered for completion upon Wound care coordinator return. - Certified wound specialist or designee will provide additional training and education to the Wound Care coordinator and Director of nurses on wound care. Wound care coordinator will be registered for the next available Wound care certification program that is local and available. designee will establish a calendar with dates reflecting the floor nurse assignment for wound care coverage [DATE]. - LNs inserviced by nurse managers or designees on providing treatments as ordered and as assigned, documentation of treatments on TAR, transcribing treatment orders to TAR, completing weekly wound assessments, accurate documentation of wounds site, and obtaining written consent and use of verbiage family can understand completed on [DATE]. - LNs will be in-serviced on assessing the wounds response to treatment started on [DATE]. - Nurse assistants inserviced by nurse managers on skin management and prevention of skin breakdown, reporting of skin break down completed [DATE]. - Facility will review and revise as indicated the wound policy/guidelines and debridement policy. Any changes in policy/guidelines will be reviewed with medical director at QA meeting. - Wound doctor will follow-up on and participate in post plan of care on wounds that he/she completed mechanical debridement. -Wound report will be reviewed by QA at Qa meeting. Facility will obtain written consent prior to wound Dr. performing mechanical debridement within the facility. The facility has developed a QA audit tool to monitor compliance. Director of nursing or designee will complete audit daily for 2 weeks, three times a week for 2 weeks, then weekly x 4 weeks to ensure facility is improvising treatments as ordered and as assigned, documentation of treatments on TAR, transcribing treatment orders to TAR, completing weekly wound assessments, accurate documentation of wound site, and obtaining written consent and use of verbiage families can understand, 8 weeks assessment of wound response to treatment. Will review weekly wound report wound documentation to ensure accuracy and completion and Braden scale for wound history accuracy. Results of audit will be reviewed by QA committee. QA committee will determine continued frequency of monitoring.