Every finding on record at Warren Barr South Loop

Based on interview and record review, the facility failed to report an allegation of missing property for one resident (R2) of three residents reviewed for abuse. Findings include: R2's Brief Interview for Mental Status (BIMS) dated 04/20/2026 shows a score of 13 which indicated that R2 is cognitively intact. On 07/07/2026 at 11:57 AM, R2 stated that on 05/07/2026 around 10:30 am, V16 (Certified Nursing Assistant, CNA) was taking her for a shower. R2 stated when she returned from her shower, her bookbag with her cellular phone, credit cards, state ID, cash, cashier's check, and a library card were gone from her room. R2 stated she reported her missing items to V7 (Licensed Practical Nurse, LPN). R2 stated she inquired about filing a police report to V7, but V7 stated the facility has never done that before. R2 stated she felt filing a police report would have been more sufficient. V10 (R2's family member) advised R2 that she should give the facility more time to perform a thorough investigation. R2 stated she has been waiting for the pending investigation results and has not received any updates regarding her missing items. R2 stated it has been two months since the incident. R2 stated there has been fraudulent activity with her credit card accounts since the incident occurred. Multiple phone call attempts made to contact V16 (Certified Nursing Assistant, CNA). Unable to make contact. Multiple phone call attempts made to contact V17 (Housekeeper). Unable to make contact. On 07/07/2026 at 12:13 PM, V7 stated she informed V1 (Administrator) on the day of the incident, 05/07/2026. V7 stated she searched for the purse with V4 (Guest Services Director). On 07/07/2026 at 2:16 PM, V4 stated she spoke to R2 on 05/07/2026. V4 stated she initiated a Concern Form, but the issue has not been resolved. V4 stated she has not followed up with R2 recently regarding the missing items. V4 stated she submitted the Concern Form to V1. On 07/07/2026 at 3:16 PM, V8 (Housekeeping Director) stated that when she was notified of the missing items, she placed an initial call to the third-party linen company to inform them of the missing items. V8 stated when she found out, she did not check the dirty linen bins, it is normal to wait for the third-party linen source to return the items. On 07/08/2026 at 10:11 AM, V11 (Social Services Director) stated there have been changes with employees within the social services department. V11 stated many of the social services workers are no longer employed there. V11 stated she was not a part of the investigation. On 07/08/26 at 11:50AM, V2 (Assistant Director of Nursing, ADON) stated R2's items coming up missing is something that is serious and warrants an immediate investigation. V2 stated the facility should have sent a reportable immediately because that is considered theft. V2 stated the investigation should have documented interviews. On 07/08/2026 at 11:24 AM, V1 stated he was informed by V7 during morning rounds on 05/08/2026. V1 stated personal belongings missing from residents warrants an investigation. V1 stated he is unable to provide written documentation, other than the initial Concern Form. V1 stated all investigations related to this incident have been verbal only. V1 stated the missing property has not been reported to law enforcement, nor the state. V1 stated the items weren't considered reportable to the state. V1 stated that the facility policy does not state there is a specific time frame for an investigation, only that one needs to be done. But, on 07/07/2026 at 2:56 PM, V1 stated the best practice is maybe once a week to follow up on things. R2's only progress note (related to incident) dated 5/7/2026 at 10:13 PM documents in part Writer endorsed by previous shift that the resident has missing item(s). resident is now requesting to speak with administrator regarding missing item(s). writer will endorse next shift to follow up.R2's Inventory Sheet dated 4/13/26 documents R2 had a visa card, wallet, ID, and a white USBC Android. R2's Care Plan dated 04/15/2026 documents in part R2 will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect) through the next review. The facility policy Personal Belongings List dated 7/8/26 states when a resident or family reports that a personal item is missing, the inventory will be checked to rule out false claims. The facility policy dated 07/03/2026 and titled Abuse and Retaliation Policy documents in part It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. All allegations of abuse and retaliation will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.A final investigation will be submitted to IDPH within 5 working days.If the event that results in allegation of abuse and retaliation also causes the individual to suspect a crime, the facility will also report to the local law enforcement agency.

Based on interview and record review the facility failed to investigate and correct the allegation of missing items for one (R2) of three residents reviewed. Findings include:R2's Brief Interview for Mental Status (BIMS) dated 04/20/2026 shows a score of 13 which indicated that R2 is cognitively intact.On 07/07/2026 at 11:57 AM, R2 stated that on 05/07/2026 around 10:30 am, V16 (Certified Nursing Assistant, CNA) was taking her for a shower. R2 stated when she returned from her shower, her bookbag with her cellphone, cash, credit cards, cashier's check, state ID, and library card.was missing from her room. R2 stated she reported her missing items to V7 (Licensed Practical Nurse, LPN). R2 stated she inquired about filing a police report to V7, but V7 stated the facility has never done that before. R2 stated she felt filing a police report would have been more sufficient. V10 (R2's family member) advised R2 that she should give the facility more time to perform a thorough investigation. R2 stated she has been waiting for the pending investigation results and has not received any updates regarding her missing items. R2 stated it has been two months since the incident. R2 stated there has been fraudulent activity with her credit card accounts since the incident. Multiple phone call attempts made to contact V16 (Certified Nursing Assistant, CNA). Unable to make contact.Multiple phone call attempts made to contact V17 (Housekeeper). Unable to make contact.On 07/07/2026 at 12:13 PM, V7 stated she informed V1 (Administrator). V7 stated she searched for the purse with V4 (Guest Services Director).On 07/07/2026 at 2:16 PM, V4 stated she spoke to R2 on 05/07/2026. V4 stated she initiated a Concern Form, but the issue has not been resolved. V4 stated she has not followed up with R2 recently regarding the missing items. V4 stated she submitted the Concern Form to V1.On 07/07/2026 at 3:16 PM, V8 (Housekeeping Director) V8 stated that when she was notified of the missing items, she placed an initial call to the third-party linen company to inform them of the missing items. V8 stated when she found out, she did not check the dirty linen bins, it is normal to wait for the third-party linen source to return the items. On 07/08/2026 at 10:11 AM, V11 (Social Services Director) V11 stated there have been changes with employees within the social services department. V11 stated many of the social services workers are no longer employed there. V11 stated she was not a part of the investigation.On 07/08/26 at11:50AM, V2 stated R2's items coming up missing is something that is serious and warrants an investigation immediately. V2 stated the facility should send a reportable immediately because that is considered theft. V2 stated with the investigation that there should be documented interviews. On 07/08/2026 at 11:24 AM, V1 stated he was informed by V7 during morning rounds on 05/08/2026. V1 stated personal belongings missing from residents warrants an investigation. V1 stated he is unable to provide written documentation, other than the initial Concern Form. V1 stated all other investigations related to this incident have been verbal only. V1 stated the missing property has not been reported to law enforcement, nor the state. V1 stated the items weren't considered reportable to the state. V1 stated that the facility policy does not state there is a specific time frame for an investigation, only that one needs to be done. But, on 07/07/2026 at 2:56 PM, V1 stated the best practice is maybe once a week to follow up on things.R2's only progress note (related to the incident) dated 5/7/2026 at 10:13 PM documents in part Writer endorsed by previous shift that the resident has missing item(s). resident is now requesting to speak with administrator regarding missing item(s). writer will endorse next shift to follow up.R2's Care Plan dated 04/15/2026 documents in part R2 will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect) through the next review. The facility policy dated 07/03/2026 and titled Abuse and Retaliation Policy documents in part It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation .Must be reported includes theft of personal property, including but not limited to jewelry, computer, phone, and other valuable items .

Based on interview and record review, the facility failed to prevent loss or potential diversion of a controlled substance medication. This failure affects one (R3) resident out of three residents reviewed for medications.Findings include: On 06/16/2026 at 9:59AM, R3 states he goes to a counseling center every two weeks on Thursdays to receive Methadone medications. R3 states each time he goes to the counseling center, he receives 13 bottles of Methadone to bring back to the facility to store for him. R3 states the facility administers him 1 bottle of methadone every day in the mornings. R3 states when he was located on the third floor of the facility about 1.5 months ago, he experienced one of his methadone bottles going missing in the facility. R3 states he complained about it and V2 (Director of Nursing/DON) came to speak with him. R3 states V2 informed him that she would get to the bottom of things. R3 states he told V2 that someone in the facility was taking his Methadone medication. On 06/16/2026 at 2:18PM, V15 (R3's Family Member) states R3 reported to her that one of the nurses gave R3's Methadone medication to another resident at 9:00PM. V15 states R3 usually has 13 bottles of Methadone, but one Wednesday morning, he was missing a bottle and only had 12 bottles. V15 states she inquired to the facility about R3's medication and V15 observed that R3's medication logbook documented that a nurse with V20's (LPN) initials signed that R3's Methadone was given at night. V15 states R3 is not prescribed Methadone at nighttime. V15 states after this incident, R3 was moved to another floor of the facility. R3's facesheet documents that R3 was admitted to the facility on [DATE], with a diagnosis not limited to: opioid abuse, uncomplicated. R3's POS (Physician Order Statement) documents in part the following orders: On 4/30/2026, counseling center incorporated, patient going out to appointment at 10:00AM. The resident must be accompanied by assistant transport. This is a standing order for every other Thursday until discharge. Methadone HCL Intensol Oral Concentrate 10 MG/ML (Methadone hcl) *Controlled Drug* Give 70 mg by mouth one time a day. Do not open the bottle to self-administer!!! There must be supervised self-administration. Do not let the patient open the bottle to self-administer!!! Related to opioid abuse, uncomplicated. Review of R3's medication administration record/MAR dated 05/04/2026, documents that V20 (LPN) cared for R3 on 05/04/2026, during the night shift. R3's Controlled Drug Administration Record for 05/2026, was reviewed and documents that the facility received 13 bottles of Methadone for R3 on 04/30/2026 and R3's first administered dosage was on 05/01/2026. R3's Methadone drug supply was enough to last from 05/01/2026 to 05/13/2026 if administered per physician's orders. R3 was scheduled to go back to the counseling clinic on 05/14/2026 to receive a new 13-day supply of Methadone medication. R3's Controlled Drug Administration Record documents that on 05/04/2026, R3 was administered his Methadone medication at 9:00AM as scheduled, leaving a total of 9 bottles left. R3's drug sheet also documents that on 05/04/2026, V20 (LPN) signed that an unscheduled dose of Methadone was administered to R3 on 05/04/2026 at 9:00PM leaving a total of 8 bottles left. On 06/17/2026 at 11:42AM, V20 (Licensed Practical Nurse/LPN) states on 05/04/2026, she worked the 3:00PM-11:00PM shift and was assigned to care for R3. V20 states during her shift, she did not administer Methadone medication to R3. V20 states she only administered Methadone medication to another resident who was scheduled the same medication that night. V20 states she is aware that she documented on R3's controlled drug administration record that she administered Methadone medication to R3. V20 states she must have been moving too fast and was overwhelmed when she mistakenly documented that she administered Methadone to R3. V20 states there is no possibility that she administered R3's Methadone medication to another resident. V20 states approximately 1-2 weeks after her shift on 05/04/2026, she was contacted by V2 (DON) and V2 asked V20 about why her name was documented on R3's drug sheet. V20 states at this time, V2 informed her that she would be suspended from the facility pending an investigation because R3's Methadone medication was missing. V20 states she also told V2 that she did not administer Methadone to R3 and is not sure why the medication is missing. V20 states she was suspended for two days and was able to return to work after that. On 06/17/2026 at 12:43PM, V2 (DON) states R3 went to his counseling clinic on 04/30/2026 and received thirteen bottles of Methadone and began taking the first bottle on 05/01/2026. V2 states R3 was supposed to have enough bottles of Methadone to last him until his next appointment on 05/14/2026. V2 states she was first made aware of allegations of R3's missing Methadone medication from another staff member. V2 states she also saw that there was a discrepancy on R3's drug administration sheet for Methadone. V2 states V15 (R3's family member) made allegations that the facility was doing something strange pertaining to R3's Methadone medication. V2 states she then started an investigation right away and performed a count of R3's Methadone medication and R3 was missing a bottle of Methadone for Wednesday 05/13/2026. V2 states R3's counseling clinic is closed on Wednesdays and R3 was not scheduled to receive more Methadone medications until Thursday 05/14/2026. V2 states due to this, the facility ordered a one-time dose of Methadone from the facility's pharmacy for R3 so he would not miss his dose of medication. V2 states during her investigation, V20 told V2 that she does not remember giving Methadone medication R3. V2 states she believes that V20 (LPN) was not being truthful when V20 stated she did not administer Methadone to R3 because V20's signature documents that she administered the medication and R3's Methadone medication bottle was missing. V2 states it's possible that R3 took the Methadone medication instead of telling V20 that his Methadone medication was not yet due for administration. V2 states it is the nurses' responsibility to follow the rights of medication to prevent medication errors. Facility document dated 05/13/2026 documents that the facility received Methadone 10mg/ml medication for a total of 7ml from the facility's pharmacy for R3. Review of R3's MAR documents a one-time order for Methadone medication dated 05/13/2026 was administered to R3. Facility policy dated 07/02/2025 titled, Medication Pass documents in part, It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Facility policy dated 08/2020, titled Controlled Substance Prescriptions documents in part, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. The Director of Nursing and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.

Based on observation, interview and record review, the facility failed to ensure proper food item labeling, failed to discard expired food items and proper sanitization of kitchenware. This failure has the potential to affect 158 residents that eat food from the kitchen.Findings include:4/21/26 at 9:12 AM, conducted initial tour of kitchen with V17 (Food Service Director)Observations:*Reach-in refrigerator:-one carton of Almond Milk that was not sealed and not labeled with the open or discard/use by date*Walk-in refrigerator:-a rack containing thawing meats; cooked roast beef, raw Italian sausage, raw turkey breast. The trays had labels that read prep date 4/20. There were no discard dates on the labels.*Milk cooler:-one gallon of milk that was not sealed and not labeled with the open or discard/use by date*Reach-in chest freezer #1-one bag of French fries not labeled with discard date-one bag of Brioche slider buns with manufacturer best by date 4/3/26*Reach-in chest freezer #3-four boxes containing a bag of frozen cookie dough in each; the bags were not sealed and not closed properly; there was freezer frost inside the bags; the freezer thermometer was found inside of one bag-one box containing a bag of egg patties; the bag was not sealed and not closed properly-the bottom of the freezer was dirty with food particles4/22/26 at 10:28 AM, observed V21 (Dietary Aide) wash a kitchen knife in the 3-compartment sink. V21 did not submerge the knife in the wash or rinse compartments of the sink. V21 washed the knife with a rag and rinsed it under the running water. The wash and rinse compartments were observed empty. V21 dipped the knife into the sanitizer compartment for approximately 2 seconds and took it right back out. V21 did not lay the knife to air dry. V21 immediately carried the wet knife to another section of the kitchen and placed the knife into a knife rack.4/22/26 at 10:30 AM, V21 (Dietary Aide) stated dishes should be in the sanitizer compartment of the 3-compartment sink for 10 seconds. V21 stated I washed the knife with a towel under the running water. I did not submerge it in the wash or rinse compartments. I dipped it in the sanitizer for 10 seconds.4/23/26 at 3:37 PM, V17 (Food Service Director) stated when a food item is opened it should be labeled with the opened and discard date. Without the dates it is not known when it was opened and when it should be discarded. If not labeled correctly, there is a possibility that it could be expired and given to a resident. The meats that were thawing should have had the discard date as well as the prep date. It is not known if expired and can potentially be used for the residents. If thawing, meat is kept refrigerated for a week. It cannot be refrozen. The bags in the boxes should have been tied shut, sealed shut. There should not be freezer burn or ice particles inside the bags of food. The freezer thermometer should not be inside of the bag of cookie dough or any food. There could be cross contamination, a choking hazard if pieces fell off the thermometer. The refrigerators and freezers should be free of loose food particles. The dishes should be submerged into each compartment of the 3-compartment sink. The dish should remain in the sanitizer compartment for one minute according to standards for proper sanitization. It will bring bacteria down to safe levels. The dish should air dry. The knife should not have been placed into the knife rack before it dried. Can cross contaminate the other dishes if not allowed to air dry.4/23/26 at 4:14 PM, V2 (Director of Nursing) stated expired food should not be served from the kitchen to the residents. They should be discarded. They may cause the residents to have GI (gastrointestinal) concerns.Facility Kitchen policy, 6/30/25, documents in part: 1.a. Refrigerators and shelves and floors should be clean and free of spillage. 1.e. Refrigerated food should be covered, dated, labeled, and shelved to allow air circulation. 1.h. Open containers of potentially hazardous food or leftovers should be dated and used within 3-5 days in the refrigerator.The Three Tank Sink Washing & Sanitizing diagram above facility 3 compartment sink reads in part: Place ware into detergent sink and wash with pad or brush. After washing, dip ware into middle sink to thoroughly rinse. After rinsing ware, submerge into sanitizer sink for at least 1 minute. Once sanitized, remove ware from sink and place onto drain board to air dry. Return to storage.Facility Manual Ware Washing policy, 10/2019, documents in part: 3. The Dining Services Director insures that all service ware and cook ware are air dried prior and storage.

Based on observations, interviews and review of records, the facility failures related to infection prevention and control are as follows:Failed to follow Water Management Program, Policy and recommendations for identified presence of Legionnaires in the shower room.Failed to maintain clean towels in the laundry room free from possible contamination related to unclean environment.Failed to ensure that inhaler medication and nebulizer mask on the bedside are stored in clean areas to prevent infection for 1 resident (R1).Failed to ensure that a multi-use wrist blood pressure monitor, a pulse oximeter and a thermometer were properly cleaned and disinfected in between resident use for four (R29, R50, R199, and R213) residents in a total sample of 35.Failed to ensure that a staff nurse implement appropriate hand hygiene during medication administration for four (R29, R50, R199, and R213) residents in a total sample of 35.Failed to prevent dirty linen are kept off the floor for 1 (R147) out of 8 residents reviewed for infection control in a sample of 35. Failed to wear personal protective equipment for enhanced barrier precaution for one resident (R7) in a total sample of 35.These failures have the potential to affect 192 residents in the facility in preventing infections.Findings include: On 04/23/2026 at 11:10 AM with V27 (Maintenance Director) at maintenance office stated that facility sent specimen to laboratory for Legionella testing. V27 presented water specimen result from V31 (Outside Vendor Company) that documents water specimen was sent on 03/24/2026. Result was sent and received by facility on 04/02/2026 that reads 3rd Floor East Shower handheld legionella was detected (L. pneumophila scrotype 1). Per V31 (Outside Vendor Company) facility's testing shows a declining performance of water supply controls. Legionella is present in ways that suggest biofilm growth stagnation, or inadequate disinfectant levels. Action items on the following page are recommended as stated in your WMP. Facility was instructed to perform retesting at least 24 hours after corrective flushing is completed. V27 stated that corrective actions were done around 4/9/2026 but no retesting has been done yet. V27 presented documentation that flushes of hot and cold water at least five (5) minutes. V27 stated that they only flush five (5) minutes for both hot and cold water. V27 stated that flushing per outside vendor recommendation which is longer than what the facility did will make sure that Legionella will not spread to other areas. Per V31 (Outside Vendor Company) recommendation after positive legionella results, fixture should be flushed for at least 30 minutes per day for a minimum of 5 days. Where fixture has hot and cold feeds, run cold water first for 10 minutes, followed by hot water for 10 minutes, logging maximum hot water temperature and free chlorine levels. Finally follow running cold water for 10 minutes then measure temperature and free chlorine. Flow should be at low flow (pencil-width diameter) to reduce risk of splashing or exposure. A fillable form was provided but was not used. Water Management Plan to Control Water-Borne Pathogens dated 08/19/2024: Under performance indicators and suggested response for routine Legionella test results: If Legionella growth appears to be uncontrolled. Implement response such as reevaluating if Water Management Plan (WMP) activities such as flushing is being done as intended and WMP activities and controls are working and are effective in controlling Legionella as intended. May contact Water Management Companies for consultation. A verification water testing will be repeated within 48 hours if remedial treatment is performed to ensure that no positive culture from live Legionella bacteria will grow. Per CDC information on Legionnaires' Disease dated 08/06/2025: Legionnaires' disease is a sometimes-fatal form of pneumonia that is on the rise in the United States. Unfortunately, this disease is also underrecognized and underdiagnosed. Clinicians are in a unique position to make sure cases are detected, allowing rapid investigation by public health officials and prevention of additional cases. Legionnaires' disease is a severe form of pneumonia that often requires hospitalization and is fatal in about 10% of cases overall, and in 25% of healthcare-associated cases. Legionnaires' disease is caused by Legionella bacteria. There are at least 60 different species of Legionella, and most are considered capable of causing disease. However, most diseases are caused by L. pneumophila, particularly serogroup 1. While Legionella is found in natural, freshwater environments, it can become a health concern in human-made water systems (e.g., plumbing system of large buildings, cooling towers, certain medical devices, decorative fountains, hot tubs) where conditions allow it to multiply and come in contact with vulnerable persons. People contract Legionella by inhaling aerosolized water droplets containing the bacteria, or, less commonly, by aspiration of drinking water containing Legionella. Legionella is usually not transmitted from person to person; however, a single episode of person-to-person transmission has been reported. Fortunately, most people exposed to the bacteria do not become ill. On 04/23/2026 at 10:25 AM with V26 (Housekeeping Director) at the laundry area a metal table full of towels was seen without cover. V26 explained that the yellow line separates clean areas from unclean areas. Based on the location of the metal table full of towels on top it was located to clean area. V26 confirmed that it was clean towel to be used by residents that is being delivered by outside vendor/company that supplies linens daily. Besides metal table, a white colored bin with trash inside. V26 stated that white is not supposed to be inside the clean area, moving the bin far from the towels on the unclean area. On the same metal table full of towels below navy blue colored foam pads, triangular foams were seen. V26 stated that some are used as foam for wheelchairs, others were used to be placed on the bed of residents. All foams were visually dusty, once touched dust fell on the floor. V26 stated that it (foams) needs to be clean, and it should not be near the towels, it can cause contamination. Per Linen Handling by Laundry Staff Policy dated 06/30/2025 documents that clean linens will maintain that prevent contamination from the environment. Clean linens may be placed in clean linen room protected from the environment. Per facility's census dated 04/21/2026 there are one hundred ninety-two residents residing in the facility. R1 a [AGE] year-old resident, medically diagnosed with viral pneumonia and respiratory disorder among others. On 04/21/2026 at 02:33 PM, R1 was seen in her room sitting on the side of her bed. R1 was alert and verbally able to express thoughts within topic. R1 has a movable table on the side of her bed with two (2) inhalers (printed Ventolin and Breo Elipta) and on top of the drawer nebulizer respiratory equipment with mask placed on high touched surface connected by a tubing. R1 stated that she uses those inhalers every time she needs it and used her nebulizer earlier that day. R1 replied when asked about inhalers. Today? I used it maybe twice. I am not sure. At the nurse station V6 (Registered Nurse) went inside R1's room stated that inhalers on R1's bedside are used as needed due to asthma. V6 stated that nebulizer mask is supposed to be in the bag. Per R1's physician order Breo Elipta is scheduled one time a day for Chronic Obstructive Pulmonary Disease and Ventolin is scheduled every six (6) hours as needed. Medication Administration Record for April 2026 documents that Breo Elipta signed as being administered daily. On 04/23/2026 at 10:22 AM, V2 (Director of Nursing) was made aware, V2 stated that inhalers should not be on the bedside and nebulizer mask should be inside the bag to prevent infection. V2 stated there is no policy, it is facility's practice. On 04/22/2026 at 7:47 AM, V9 (Registered Nurse) walked into R213's room with a multi-use wrist blood pressure monitor, a thermometer, and a pulse oximeter. V9 placed the pulse oximeter on R213's right index finger. After the use of these equipment (wrist blood pressure monitor, a thermometer, and a pulse oximeter) V9 did not disinfect them. On 04/22/2026 At 7:57 AM, V9 did not disinfect the blood pressure cuff, thermometer, and pulse oximeter that was used with the previous resident (R213). V9 walked in with the same blood pressure cuff, thermometer, and pulse oximeter and assessed R29. V9 did not wash her hands, did not apply hand sanitizer nor apply gloves. On 04/22/2026 at 8:21 AM, V9 did not disinfect the blood pressure cuff, thermometer, and pulse oximeter that was used with the previous resident (R29) and utilized the same multi-use wrist blood pressure monitor, a pulse oximeter and thermometer to assess R50's vital signs. V9 did not wash her hands, did not apply hand sanitizer nor apply gloves any point when V9 provided care to R50. On 04/22/2026 at 8:30 AM, V9 did not disinfect the blood pressure cuff, thermometer, and pulse oximeter that was used with the previous resident (R50) and utilized the same multi-use wrist blood pressure monitor, a pulse oximeter and thermometer to assess R199's vital signs. On 04/22/2026 at 9:13 AM, when V9 (Registered Nurse) was asked what V9's rationale was for not disinfecting the multi-use wrist blood pressure monitor, pulse oximeter and thermometer, V9 stated that no resident has a contagious disease at this time and none of the resident that she is assigned to is on transmission-based precaution except one resident which is in a different room. V9 stated that the importance of infection control is to stop or prevent the spread of infectious disease. V9 stated that she agrees that she should disinfect the equipment because it is a preventable measure to prevent the spread of infection. On 04/22/2026 at 12:29 PM, V2 (Director of Nursing) stated that it is best nursing practice to follow proper hand hygiene before and after each medication administration especially between residents. V2 stated that it is important for infection prevention purposes. Facility document dated 07/2/2025 titled medication pass documents in part, follow hand hygiene procedure before and after each resident. R7's face sheet documents that R7's diagnosis is not limited to cerebral infarction, Respiratory Disorder, Acute and Chronic Respiratory Failure, Myocardial Infarction, Emphysema and resident is on tracheostomy. R7's care plan with review date of 07/21/2025 documents in part Tracheostomy, gtube, Enterobacter and Klebsiella (sputum), Potential spread of infection will not occur until the next review date, Change gown and gloves before caring for the next resident. Ensure PPEs are accessible. Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs to staff hands and clothing. Wear a gown and gloves will be discarded in the regular trash can inside resident's room. Signage on door. Staff will wear gown and gloves before resident contact, especially during high-contact activities like dressing, transferring and bathing, or any care that involves exposure to a wound or an indwelling device. Utilize proper hand-hygiene techniques. R7's MDS (minimum data set) dated 02/09/2026, documents that R7 does not score on the BIMS (brief interview for mental status), indicating that R7 is cognitively impaired. On 04/22/2026 at 11:27 AM, surveyor observed there was an enhance barrier precautions signage on R7's door. There was no bin outside the room, with any personal protective equipment. On 04/22/2026 at 11:29 AM, this surveyor observed R7 laying on his bed in a semi-flower position. R7's tracheostomy tubing was positioned to the right side of the neck, while the oxygen was on. Surveyor observed a large amount of yellow secretion, and there was a gurgling sound. Surveyor triggered the call light for assistance. On 04/22/2026 at 11:40 AM, V9(Registered Nurse/ RN) came into R7's room, and assessed the tracheostomy site. This surveyor did not observe V9 donning on her personal protective equipment, despite there being and enhance barrier precaution sign hung by R7's door. V9 repositioned R7's aerosol trach collar in which it related to tubing to the oxygen tank. V9 did not suction R7's airway despite secretion being present. V9 stated she will contact the respiratory team. On 04/22/2026 at 11:47 AM, V16 (Respiratory Therapist) gowned up with proper PPE for enhanced barrier precaution (hand hygiene, gown and gloves) and proceed to assess R7. On 04/23/2026 at 1:40 PM, V2 (Director of Nursing/ DON) stated that enhance barrier precautions should be followed if the staff member encounters any bodily fluids. V2 stated if a staff member is performing activity of daily living (ADL) or a direct care task, she or he should have to be gown up. V2 stated hand hygiene, wearing a disposable gown, and wearing gloves is best practice to avoid spreading microorganisms. V2 stated if these practices are not being followed not only is the person who is performing the task is at risk for exposure. They are also putting the other residents at risk. V2 stated in fact the whole facility will be at risk for spreading microorganisms. On 04/24/2026 at 12:00 PM, V36 (Respiratory Technician) stated anytime she requires to perform any tach care for R7, she always ensures she follows the enhance barrier precaution sign that is posted outside R7's room. Policy titled Infection Prevention and Control with review date of 06/30/2025 documents in part, Enhanced Barrier Precaution (EBP)- an infection control intervention designed to reduce transmission of MDROs (including XDROs) which includes candida aurus, CREs, carbapenemase-producing pseudomonas aeruginosa and carbapenem- resistant acinetobacter baumani (CRAB), MRSA, ESBL, VRE, etc in the nursing homes. The goal is to prevent transmission of MDROs to others. Involves the use of gloves and gowns during high contact resident care activities for residents infected or colonized with MDROS as well as residents with wounds and/ or indwelling medical devices. On 04/22/2026 at 10:35 AM, surveyor walked into R147's room and noticed a foul odor. Surveyor observed a green dirty linen bag with dirty linen on the floor. Surveyor asked V13 (Certified Nursing Assistant) to come into the room. V13 stated that this linen is allowed to be on the floor as long as it is in the bag. Surveyor then observed V13 take the bag out of the room. On 04/23/2026 at 10:30 AM, V2 (Director of Nursing) stated that she is overlooking infection control. V2 stated that bed linens are changed daily, when the resident is not in bed, when they soiled the bed, and when they are given a shower or bed bath. The dirty linens are placed in the green plastic bag. Soiled utility room is utilized to hold the soiled linen bags where then the housekeeping staff takes it down every shift. V2 stated that soiled linen bags should not be placed on the ground because it can spread microorganisms which can spread infections.

Based on review of records and interviews the facility failed to follow influenza and pneumococcal policies for offering and providing timely education prior to obtaining vaccination consent for 4 out of 5 residents (R1, R2, R4 and R16) for a total sample of 35 residents reviewed for immunization. These failures are not in accordance with facility's vaccination/immunization policies for 4 residents (R1, R2, R4 and R16) who did not receive influenza and/or pneumonia vaccine(s) that may help in preventing infection(s).Findings include:Resident records related to immunization reports are as follows:R1, a [AGE] year-old resident initial date of admission in the facility was on 07/16/2025. R1's medical diagnosis includes viral pneumonia and respiratory disorder among others. On 04/21/2026 at 02:33 PM, R1 was asked if she received vaccination. Resident #1 said, No, I did not receive any vaccine. Nobody talked to me about vaccine. R1's immunization record does not indicate influenza and pneumococcal vaccinations were offered.R2, an [AGE] year-old resident initial date of admission in the facility was on 03/23/2026. R2's medical diagnosis includes Parkinson's Disease with Dyskinesia among others. R2's immunization record does not indicate influenza vaccination was offered.R4, a [AGE] year-old resident initial date of admission in the facility was on 02/04/2026. R4's medical diagnosis includes Sepsis among others. R4's immunization record does not indicate pneumococcal vaccination was offered.R16, a [AGE] year-old resident initial date of admission in the facility was on 07/19/2025. R16's medical diagnosis includes End Stage Renal Disease among others. R16's immunization record does not indicate influenza and pneumococcal vaccinations were offered.On 04/21/2026 at 12:23 PM, V5 (Infectious Disease Nurse / Registered Nurse) stated that any refusal should be in the immunization record. It is important to offer vaccines to prevent flu or pneumonia. Vaccination education is needed so that resident can decide properly.All refusals to give consent forms were not signed by either the resident, or responsible party.Influenza Vaccination policy dated 09/16/2024: It is the policy of the facility to annually offer and administer vaccination against influenza to each resident unless otherwise contraindicated or resident refused the vaccine. Influenza vaccination will be offered to residents seasonally. Any newly admitted residents during this period shall be offered the vaccination. Education of the risks and benefits of receiving the vaccination will be provided to resident and/or responsible party. Consent for vaccination will be faxed or emailed to the responsible party for signature if the resident unable to sign. Telephone consent is acceptable but needs to be signed by the responsible party as soon as possible.Pneumococcal Vaccination policy dated 09/16/2024: It is the policy of the facility to offer and administer pneumococcal vaccinations to each resident as recommended by CDC. All residents and responsible parties will receive education about the risks and benefits of the pneumococcal vaccines. Consent for vaccination is obtained by written consent from the resident or responsible party. Consent for vaccination will be faxed or emailed to the responsible party for signature if the resident unable to sign. Telephone consent is acceptable but needs to be signed by the responsible party as soon as possible. Pneumococcal vaccination will be offered upon admission.CDC Pneumococcal Vaccine Recommendations dated 02/25/2026: CDC recommends pneumococcal vaccination for children younger than 5 years and adults 50 years or older. CDC also recommends pneumococcal vaccination for children and adults at increased risk for pneumococcal disease. Stay up to date on which pneumococcal vaccines are recommended for your patients.Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)-United States, 2025-26 Influenza Season Summary of Recommendations: Routine annual influenza vaccination is recommended for all persons aged 6 months who do not have contraindications.

Based on review of records and interviews the facility failed to follow Covid-19 Vaccination policy for offering vaccine for 4 out of 5 residents (R1, R2, R4 and R16) for a total sample of 35 residents reviewed for immunization. These failures are not in accordance with facility's vaccination/immunization policies for 4 residents (R1, R2, R4 and R16) who did not receive updated Covid-19 vaccine that may help in preventing infection.Findings include:Resident records related to immunization reports are as follows:R1, a [AGE] year-old resident initial date of admission in the facility was on 07/16/2025. R1's medical diagnosis includes viral pneumonia and respiratory disorder among others. On 04/21/2026 at 02:33 PM, R1 was asked if she received vaccination. Resident #1 said, No, I did not receive any vaccine. Nobody talked to me about vaccine. R1's immunization record documents that resident received vaccine on 02/02/2022.R2, an [AGE] year-old resident initial date of admission in the facility was on 03/23/2026. R2's medical diagnosis includes Parkinson's Disease with Dyskinesia among others. R2's immunization record documents that resident received vaccine on 10/06/2022.R4, a [AGE] year-old resident initial date of admission in the facility was on 02/04/2026. R4's medical diagnosis includes Sepsis among others. R4's immunization record documents that resident received vaccine on 11/18/2021. R16, a [AGE] year-old resident initial date of admission in the facility was on 07/19/2025. R16's medical diagnosis includes End Stage Renal Disease among others. R16's immunization record documents that resident received vaccine on 12/07/2021. On 04/21/2026 at 12:23 PM, V5 (Infectious Disease Nurse / Registered Nurse) stated that any refusal should be in the immunization record. It is important to offer vaccines to prevent flu or pneumonia. Vaccination education is needed so that resident can decide properly.All refusals to give consent forms were not signed by either the resident, or responsible party.Covid-19 Vaccination Policy dated 07/16/2024: The facility will comply with the applicable CMS, CDC, and/or IDPH guidance on Covid-19 vaccination. The facility will offer Covid-19 vaccination to residents and document administration in the resident's record.CDC on Staying Up to Date with COVID-19 Vaccines dated 11/19/2025: CDC recommends a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2025-2026 COVID-19 vaccine if you are ages 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine.

Based on observation, interview and record review the facility failed to follow their policy by not ensuring call lights were within reach for three (R42, R47, R99) residents of 7 residents reviewed for call lights in a sample of 35 residents.Findings include: 4/21/26 at 12:02 PM, Observed R47 lying in bed. Observed R47's call light on the floor. R47 said I can't talk loud. They don't hear what I'm saying. The doctor told me I have a partial paralyzed vocal cord. I can't use my left arm. I can't walk. Writer asked R47 where the call light was. R47 looked to find the call light and could not find it. R47 said I guess when they sat me up it fell down. 4/21/26 at 12:05 PM, Writer asked V18 (Certified Nursing Assistant) to come to R47's room and asked V18 where R47's call light was. V18 picked up R47's call light off the floor and gave it to R47. V18 said the call light should not be on the floor. The purpose of the call light is to get staff's attention if the resident has a need, like they are in pain or need to be cleaned. V18 stated R47 was not able to reach the call light that was on the floor. V18 stated there is no clip available to clip the call light to R47 or R47's bed sheet. 4/21/26 at 12:38 PM, Observed R99 lying in bed. R99 said they were cold and needed their socks and boots on. Observed R99's call light on the floor. Writer asked R99 where the call light was. After reaching for the call light, R99 said I can't get it. R99 said they did not call for assistance because the call light was on the floor. 4/21/26 at 12:41 PM, Writer asked V7 (Licensed Practical Nurse) to R99's room and asked V7 were R99's call light was. V7 stated R99's call light should be attached to R99, but it was on the floor. V7 stated the call light should not be on the floor. V7 stated there is no clip available to clip the call light to R99. V7 stated the purpose of the call light is for if residents need assistance. 4/23/26 at 4:14 PM, V2 (Director of Nursing) stated any staff member can answer a call light. It is best practice to have call lights within reach for all residents, either by them or clipped next to them. The purpose is so the resident can call for any assistance. If the call light is not within reach, they are not able to call for assistance. According to R47's face sheet, R47 has diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; history of falling. According to R47's MDS, 3/5/26, R47 has a BIMS score of 8 indicating moderate cognitive impairment. R47 requires substantial/maximal assistance or is dependent for mobility. R47 is care planned as being functionally incontinent of bowl and bladder. According to R99's face sheet, R99 has diagnoses that include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; unspecified fall. According to R99's MDS, 3/2/26, R99 has a BIMS score of 15 indicating intact cognitive function. R99 is dependent for sit to stand and chair/bed-to-chair transfer. R99 is care planned as being functionally incontinent of bowl and bladder. Facility Call Light Policy, 6/30/25, documents in part: 5. Be sure call lights are placed within reach of residents who are able to use it at all times. On 04/22/2026 at 10:15 AM, surveyor observed R42 laying on her bed facing the door. R42 asked surveyor what she should do if she needs to go to the bathroom. Surveyor responded with R43 should press her call light. R42 stated that she doesn't know where her call light is. Surveyor observed R42's call light clipped to her pillow behind her, but the button to press was on the floor. R42 stated that she cannot reach her call light. Surveyor asked a nurse to come into R42's room. V8 (Registered Nurse) came in and saw R42's call light on the floor. V8 picks up R42's call light and placed it in R42's hand. On 04/23/2026 at 10:34 AM, V2 (Director of Nursing) stated that nursing staff are expected to round on residents every two hours, every time a call light is pulled or when a family member comes to nurse's station if they needed anything. V2 stated that R42 cannot role side to side by herself in bed and needs assistance for bed mobility. V2 stated that call lights should be within reach or clipped close to them so they can reach it. Otherwise, they cannot make their needs known. R42's care plan documents in part: Keep call light within reach when in bedroom. Facility's call light policy documents in part: Call lights are to be kept within reach of the residents.

Based on review of records and interviews, the facility failed to ensure complete PASRR Level 1 was done to 1 out of 7 residents (R64) for a total sample of 35 residents. These failures affected 1 resident's (R64) determination of proper placement.Findings include:R64, a [AGE] year-old resident with current admission date of 01/31/2025. R64's diagnosis includes psychotic disorder not due to substance abuse, major depressive disorder recurrent and cocaine abuse among others. R64's medications include Trazodone and Paroxetine both are psychotropic medications. On 12/10/2025, R64 was evaluated for PASRR Level 1 that includes major depression and substance related diagnosis for history of cocaine use but did not include psychotic disorder. Per evaluation outcome, no PASRR Level 2 required due to no serious mental illness, intellectual disability and/or related condition.On 04/23/2026 at 09:35 AM, V22 (admission Director) stated that all residents need PASRR Level 1 before admission to facility. Level 1 will determine if Level 2 is needed based on mental health diagnosis. V22 stated that R64's diagnosis of psychotic disorder was not included on PASRR Level 1 evaluation because there is no option to choose psychotic disorder. V22 defined psychotic disorder as mentally unstable and should have been included if there was an option. V22 stated that she did not clarify the issue with the agency that processed PASRR and will ask for clarification. At 12:38 PM, V22 stated that there was an option after rechecking, and it should have been included. V22 stated that since PASRR Level 1 evaluation is incomplete Level 2 should have been done. V22 stated that she will request another Level 1.Behavioral notes of V37 (Psychiatrist) dated 02/18/2026 it documents that R64 demonstrates a noticeable rise of symptom burden, requiring close monitoring with mild psychomotor agitation and retardation.Pre admission Screening and Resident Review PASRR policy (07/16/2025) and procedure (10/24/2025): Both policy and procedure require facility to have PASRR Level 2 done prior to admission if PASRR Level 1 is positive for Mental Disorder or Intellectual Disability.

Based on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care, supervision and/or touch assistance, nail care, shaving, eating assistance for three (R13, R46, R123) residents, who require assistance with ADL's, of nine residents reviewed for ADL care in a sample of 35. The findings include: R123's admission record shows an admission date of 08/14/2023 with diagnoses not limited to, Bipolar disorder; Abnormalities of gait; Lack of coordination; Abnormal posture; Dementia; Hypertension; Other persistent atrial fibrillation; Heart failure. MDS (Minimum Data Set) dated 01/30/2026 showed R123 BIMS (Brief Interview for Mental Status) score to be 10, which indicates moderately impaired cognition. MDS Section GG (Functional Abilities) shows R123 requires supervision/touch assistance for personal hygiene, which includes and is not limited to, combing hair, shaving, washing and drying of face and hands. 04/21/2026 1:45PM R123 observed lying in bed wearing t-shirt and shorts, no socks or shoes on his feet. Observed hair disheveled, fairly long in length- past neckline, beard observed scruffy and long in length, eyebrows observed bushy and long. Fingernails observed long with black residue under nailbed. Toenails observed long in length curving downward. R123 reports he would like his toenails cut, and states not remembering when his toenails were cut last. R123 states he is unable to cut his own toenails. R123 states he would like to be shaven and states he notified someone but is unable to recall whom he notified. 4/22/2026 12:32PM R123 observed eating lunch in his room at his bedside table. Surveyor asked R123 if he has been shaven and R123 stated he has not been shaven but wishes someone would because he feels uncomfortable with his beard. R123 also states he would like to have his toenails and fingernails cut. R123's fingernails observed with dark/black residue under the nailbed. 04/22/2026 1:19PM- Interview with V16 (CNA, Certified Nurse's Assistant) states she usually covers various floors. V16 states she showers residents according to the shower schedule, Monday through Sunday during first and second shift. V16 states she gives residents a full body shower, then inspects fingernails and states she clips them if they are long. V16 states she also shaves residents whose beards get long and uses shavers or scissors to trim eyebrows when they become shaggy or bushy. V16 states she inspects resident toenails during the shower and notifies the Registered Nurse of the residents whose toenails are long and require clipping/cutting. V16 states, the nurses make a list of residents needing their toenails clipped and then they notify the podiatrist, we don't cut toenails, the podiatrist does. V16 states she's unsure of how often the podiatrist comes. V16 states, it may be painful for residents to walk or uncomfortable to wear their shoes if their toenails are too long, they should be trimmed every 3 to 4 weeks. 04/23/2026 1:55PM, interview with V2 (DON, Director of Nursing) states, the CNA's should inspect resident toenails while they provide showers. Residents get their showers twice a week, unless they refuse. If they notice long toenails, they should notify the nurse who then gets a podiatry referral from the doctor. The nurse then notifies the podiatry appointment coordinator and sets up the appointments for those residents. V2 states the podiatrist comes in every other Friday and PRN (as needed). V2 states, when the toenails get too long they can dig into the skin and cause an infection. It can also be uncomfortable and painful when they wear shoes. V12 states CNA's should cut fingernails when they see them long and dirty, because that is not very sanitary. 04/23/2025 2:10PM, record review of R123's care plan dated 02/10/2026 shows in part, R123 has an ADL Self Care Performance Deficit r/t displaced simple supracondylar fracture and requires limited to extensive assistance to complete grooming. 04/23/2026 2:15PM, record review of shower schedule for 5th floor, indicates R123 receives two showers per week. According to R123's room number, his shower days are Tuesday during 7am-3pm shift and Sunday during 3pm-11pm shift. 04/23/2026 2:25PM, record review of podiatry notes. Note dated 08/08/2025 reads in part, follow up evaluation for painful elongated thickened toenails. He is nervous to cut his nails but they are painful. Podiatry note dated 01/06/2026 reads in part, f/u for foot evaluation. Notes pain in his toes from long nails. He is nervous to cut his nails but they are painful. Podiatry note dated 03/20/2026 reads in part, f/u foot evaluation. Notes pain in his toes from long nails. He cannot provide self care. R123 was seen by podiatrist and had his toenails cut on: 08/08/2025, 01/06/2026, and 03/20/2026. 04/23/2026 2:30PM, record review of Restorative Nursing Program policy dated 07/03/2025, reads in part, Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. Resident assistance with ADL's will be based on the functional assessment. 04/23/2026 2:35PM- record review of Shower and Hygiene policy dated 07/03/2025 reads in part, It is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. 04/23/2026 2:40PM- record review of Nail care policy dated 07/03/2025 reads in part, Nursing staff shall check the residents for nail care which includes cleaning and regular trimming. CNA to report to the nurse if there is evidence of pain or if nails are too hard to too thick to cut with ease. Refer to podiatrist for podiatric care and trimming of toenails. 4/21/26 at 12:32 PM, Observed V19 (Restorative) sitting next to R13's bed feeding food to R13. Observed R13 lying in bed. The head of R13's bed was approximately 45 degrees up. R13 was slumped down in bed. V19 stated that V19 pulled R13 up but R13 slid down. V19 stated R13 should be up so R13 does not choke on the food. 4/21/26 at 12:52 PM, Observed R46 lying flat in bed. Observed R46's lunch on the bedside table in front of R46. R46 said they did not offer to pull me up when they brought in my lunch tray. R46 said they need the bed tilted back so they can pull themself up, but they cannot get to the bed controls. The bed controls to tilt the bed are located at the foot of the bed on the foot board. R46 said they cannot use their right side. V7 (Licensed Practical Nurse) and V8 (Registered Nurse) came in to adjust R46 in bed to eat. V8 activated the control at the foot of the bed to tilt the head of the bed down. R46 used their left arm to reach back and grab the headboard to pull themself up. V7 and V8 still needed to center R46 in the bed and adjust them more properly to be comfortable to eat. 4/21/26 at 12:56 PM, V8 (Registered Nurse) stated residents should be adjusted in bed to eat. They should not be flat to eat and should be offered assistance. 4/23/26 at 4:14 PM, V2 (Director of Nursing) stated some residents require assistance during mealtime. Setup of the tray, able to reach the tray, repositioned in bed. The resident needs to be sat upright, greater than 45 degrees and comfortable to eat. When a resident is being fed 1:1, they should not be slumped down in the bed. They should be sat up, at least 45 degrees and comfortable. They should be sat up so there are no complications. The resident is at risk for aspiration while chewing food. I expect the staff members to reposition them to eat at least 45 degrees and comfortable. If they cannot do it themselves, I expect them to get assistance from nursing staff. I expect the staff members to offer to sit them up comfortably, offer assistance. According to R13's MDS (Minimum Data Set), 4/1/26, R13 has a BIMS score of 3 indicating severe cognitive impairment. R13 requires partial/moderate assistance with eating. Helper lifts, holds, or supports trunk or limbs. R13 is care planned for assistance with ADL's (Activities of Daily Living) in bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting. According to R13's Order Summary Report, R13 has an order that reads in part: Aspiration Precautions: Elevate head of bed while on feeding. According to R46's face sheet, R46 has a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. According to R46's MDS, 3/19/26, R46 has a BIMS score of 12 indicating moderate cognitive impairment. R46 requires setup or clean-up assistance with eating. Helper assists only prior to or following the activity. R46 is care planned for assistance with ADL's (Activities of Daily Living) in bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting.

Based on observation, interview and record review, the facility failed to ensure a low air loss mattress device was on the correct setting for 1 out of 2 residents (R4) for a total sample of 35 residents. This failure has potential to affect 1 resident (R4) at risk for a worsening pressure ulcer.Findings Include:On 4/21/26 at 1:23 PM, surveyor entered R4's room. R4 was observed lying in bed. R4 was on a low air loss mattress, setting noted below 80 pounds (lbs.).On 4/21/26 at1.28 pm, Surveyor and V8 (Registered Nurse) entered R4's room, V8 stated mattress not set to the right pressure, V8 changed the setting to 140lbs based on the current weight. V8 stated nurses can change the settings according to the current weight. The purpose of low air loss mattress is to offload pressure points. If it is not in the correct setting it can cause problems.On 04/21/2026 1:37 PM, V19 (Restorative) Stated primarily wound care nurse audits the setting and correct setting according to weight. Sometimes nurses also change the setting.On 04/23/2026 10:54 AM, V33 (Wound Care Nurse) stated that Residents who come with wounds will get low air loss mattress automatically. It will be set according to the weight of the resident. V33 routinely does rounds and monitors the settings. Nurses and Restoratives also adjust the setting, who ever makes the first contact is expected to adjust the settings. If a resident has weight change, they will adjust the settings per resident's weight. When a resident is placed on a low air loss mattress with incorrect setting it can be uncomfortable for the resident. More pressure can cause bruises for the residents.R4's clinical records show R4 has diagnoses not limited to cerebral infraction, aphasia, hemiplegia and hemiparesis, dysphagia, type 2 diabetes, encephalopathy, heart failure and depressive disorder. R4's Minimum Data Set (MDS) stated 4/8/26 shows BIMS score 4, R4 is cognitively impaired. R4's Braden Scale dated 2/22/26 shows score of 8, R4 is at high risk of developing pressure ulcer. R4's current weight is 144 pounds(lbs) documented on 4/7/26.R4's care plan documents in part, (Resident name) has an actual impairment to skin integrity, Off load heels, Turn and reposition at least every 2 hours and as needed.On 04/23/2026 2:00 PM, Reviewed Low air loss mattress user manual in part: Pressure range selection (+/-)- Users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting.

Based on observation, interview, and record review, the facility failed to provide proper tracheostomy care for one resident (R7) in a total sample of 35 residents reviewed.Findings Include:R7's face sheet documents that R7's diagnosis is not limited to cerebral infarction, Respiratory Disorder, Acute and Chronic Respiratory Failure, Myocardial Infarction, Emphysema and resident is on tracheostomy requiring continuous oxygen.R7's care plan with review date of 07/21/2025 documents in part, ensure that call light cord within easy reach, elevate head of bed, as needed, trach-suction secretions as needed, observe color, amount and consistency of sputum, provide over-bed table for positioning comfort while sleeping, remind to deep breath and cough.R7's MDS (minimum data set) dated 02/09/2026, documents that R7 does not score on the BIMS (brief interview for mental status), indicating that R7 is cognitively impaired.On 04/22/2026 at 11:29 AM, this surveyor observed R7 laying on his bed in a semi-flower position. R7's tracheostomy tubing was positioned to the right side of the neck, while the oxygen was on. Surveyor observed a large amount of yellow secretion, and there was a gurgling sound. Surveyor triggered the call light for assistance.On 04/22/2026 at 11:40 AM, V9 (Registered Nurse/ RN) came into R7's room, and assessed the tracheostomy site. This surveyor did not observe V9 donning on her personal protective equipment, despite there being an enhanced barrier precaution sign hung by R7's door. V9 repositioned R7's aerosol trach collar in which it related to tubing to the oxygen tank. V9 did not suction R7's airway despite secretions being present. V9 stated she will contact the respiratory team.On 04/22/2026 at 11:47 AM, V16 (Respiratory Therapist) gowned up with proper PPE (hand hygiene, gown and gloves) and proceed to assess R7. Surveyor asked V9 about the importance of suctioning a resident when the respiratory team is not available. V9 stated suctioning a resident if needed is important because it will decrease the chances of the resident going into respiratory distress. V9 stated it is important for the residents to have the tracheostomy positioned directly to the stoma to receive all the oxygen being administered.On 04/22/2026 at 11:56 AM, V15 (Respiratory Manager) stated the trach collar should be positioned in the opening of the stoma, in the neck, which is a direct airway into the trachea for breathing. V15 stated if the trach is not positioned directly in the opening of the stoma, the resident will not receive the oxygen that is being administered. V15 stated if the resident is not receiving oxygen, it can potentially cause the resident to be under respiratory distress.On 04/23/2026 at 1:30 PM, V2 (Director of Nursing) stated nurses are trained and capable of suctioning residents who have tracheostomy and are on a ventilator. V2 stated if the nurses are not suctioning as needed, residents are open to infection, the trach will not remain clean. V2 stated the trach collar should be covering the trach stoma if they don't, they will not receive medication or oxygen and can go under respiratory distress.On 04/22/2026 at 12:00 PM, V16 stated R7's trach collar was located to the right side of the trach. V16 stated the correct positioning should have been in the center so that R7 could have received the humidified oxygen. V16 stated if R7 does not receive his continuous oxygen, then he can potentially go under distress. V16 said he did notice there were secretions and needed to be suctioned.On 04/24/2026 at 12:00 PM, V36 (Respiratory Technician) stated R7 does require continuous oxygen. V36 stated he tends to have a large amount secretion build up. V36 stated R7 has an aerosol trach collar- mask connected with tubing to oxygen. V36 stated the tracheostomy collar should be positioned in the center over the tracheostomy. V36 stated if R7 is not receiving continuous oxygen, then he can potentially deteriorate the oxygen R7 requires. V36 stated if that were to happen R7 can be under respiratory distress.Policy titled Suctioning with review date of 08/19/2024 documents in part, It is the facility's policy to provide care for residents with suctioning needs. The facility will ensure that staff are trained to handle suctioning of the residents, involving those with oral suctioning needs and those with tracheostomy.

Based on observation, interview, and record review the facility failed to ensure proper pharmaceutical services to meet a resident's needs which includes acquiring and accurately administering a medication for one (R213) resident out of five residents reviewed in a total sample of 35. Findings include:On 04/22/2026 at 7:49 AM, V9 (Registered Nurse) crushed the following two medications and placed them in two separate medicine cups mixed with applesauce: Aspirin 81mg (milligram) 1 tablet via mouth, Diltiazem ER (Extended Release) 120 mg 1 capsule via mouth. When V9 crushed Diltiazem, V9 removed the purple hard part of the capsule, and the particles were released in a medicine cup and mixed with applesauce. V9 proceeded to administer the medication to R213. On 04/22/26 at 10:58 AM, this surveyor informed V9 that diltiazem hydrochloride extended-release capsule is not recommended to be crushed. V9 stated when I tried to change it from capsule, the pharmacy told me it does not come in any other form, it does not come in tablet or liquid. V9 stated that she notified the doctor last week on Wednesday and V9 stated that no new orders were given. V9 stated that V9 did not document this whole situation last Wednesday even though she should have. V9 stated because if it was not documented, it didn't happen. V9 stated that R213 will be assessed and V9 will notify V2 (Director of Nursing), R213's doctor, and R213's family. V9 stated that R213 was stable and was at activities. V9 stated that since the medication is in the calcium channel blocker drug class, V9 wants to assess blood pressure, vital signs and assess for low blood pressure.R213's medication administration record documents in part, extended release 24-hour 120 mg (milligram) Diltiazem HCI (hydrochloride) extended release beads give 1 capsule by mouth one time a day for calcium channel blockers was administered on 04/22/2026.R213's progress note dated 04/22/2026 at 12:03 PM documents in part, the writer (V9) observed no s/s (signs and symptoms) of adverse rx (reaction) after administration of Diltiazem HCI (hydrochloride) Extended-Release Beads. The doctor was notified that residents require med to be crushed prior to administration and gave verbal order to change medication's form from an ER (extended release) capsule to an oral tablet.National Institute of Health (NIH) document retrieved from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=70293a05-d314-43fa-a2b1-398cfb39edf8 documents in part Diltiazem Hydrochloride Extended-release Capsules should be taken on an empty stomach. Patients should be cautioned that the diltiazem hydrochloride extended-release capsules should not be opened, chewed or crushed and should be swallowed whole. Revised 10/25.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for three (R23, R199, and R213) of five residents reviewed for medication administration resulting in a 12% error rate.Findings include:On 04/22/2026 at 7:49 AM, V9 (Registered Nurse) administered Trelegy Ellipta 100mcg (microgram)/62.5 mcg/25 mcg via inhale 1 puff to R213. V9 instructed R213 to inhale and rinse only and did not instruct R213 to spit out. After R213 inhaled, R213 rinsed and swallowed the water provided. On 04/22/2026 at 8:30 AM, V9 stated that R199 was scheduled for a nebulizer treatment. V9 told R199 that she would set a timer on her phone for fifteen minutes. V9 administered the nebulizer treatment to R199 via a respiratory mask. V9 turned on R199's breathing treatment (lpratropium-Albuterol Inhalation Solution) at 9:02 AM. V9 left R199's room and moved the medication cart to the next room. This surveyor remained in the hallway in front of R199's room. This surveyor heard R199 coughing occasionally.On 04/22/2026 at 9:19 AM, R199 was still on the nebulizer treatment and no nurse inside with him.On 04/22/2026 at 9:23 AM, V11 (Restorative Nurse/Licensed Practical Nurse) walked in and turned off the nebulizer treatment. V11 stated that no one else was in there with R199. On 04/22/2026 at 9:38 AM, V10 (Licensed Practical Nurse) administered one drop of dorzol/timol 22.3 mg/6.8mg in R23's bilateral eyes.On 04/22/2026 at 9:39 AM, V10 administered timolol 0.25% opth soln one drop in R23's bilateral eyes.On 04/22/2026 at 9:42 AM, when asked how long should V10 wait between administering different eye drops, V10 responded I believe it is 2-5 minutes. V10 stated that it is important to make sure the eye drops dissolve properly and effectively. V10 agreed that she should have waited longer when the surveyor told her the time that was noted V10 administered the eye drops. On 04/22/2026 at 12:29 PM, When V2 was asked, why should a resident that is prescribed a corticosteroid inhaler rinse and spit after a use, V2 (Director of Nursing) stated that it is best nursing practice to follow per the manufacture's recommendation. V2 stated that it is best practice to administer different eye drops to a resident for 5 minutes apart from each different eye drops medication. V2 stated that when a nurse administers prescribed nebulizer treatment, the nurse should be assessing the resident's oxygen saturation before and remain with the patient at the bedside during the treatment to check for any complications such as respiratory distress.R23's medication administration record documents in part that R23 was administered dorzol/timol 22.3 mg/6.8mg and timolol 0.25% opth soln on 04/22/2026.R199's medication administration record documents in part that R199 was administered lpratropium-Albuterol Inhalation Solution on 04/22/2026.R213's medication administration record documents in part that R213 was administered Trelegy Ellipta 100mcg (microgram)/62.5 mcg/25 mcg on 04/22/2026.Facility provided document dated 06/2023 documents in part, trelegy Ellipta- fluticasone furoate, umeclidinium bromide and vilanterol trifenatate powder, after inhalation, rinse the mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis.Facility document dated 07/2/2025 titled medication pass documents in part, -Pull the lower conjunctival sac and apply a drop of medication. Have resident close eyes to let the medication wash over eye. If 2 or more drops are ordered even though it is from the same medication, there should be at least 3 minutes interval in between drops. -Nebulizer treatments: a) Follow hand hygiene procedure. b) Apply meds in the nebulizer chamber and place mask on resident's face. c)Stay with resident to ensure all meds are given completely.

Based on observation, interview, and record review, the facility failed to provide a accessible functioning call light for one resident (R7) in a total sample of 35.Findings Include:R7's face sheet documents that R7 diagnosis is not limited to cerebral infarction, Respiratory Disorder, Acute and Chronic Respiratory Failure, Myocardial Infarction, Emphysema and resident is on tracheostomy.R7's care plan with review date of 07/21/2025 documents in part, ensure that call light cord within easy reach.R7's MDS (minimum data set) dated 02/09/2026 , documents that R7 does not score on the BIMS (brief interview for mental status), indicating that R7 is cognitively impaired.On 04/22/2026 at 11:29 AM, this surveyor observed R7 laying on his bed in a semi-flower position. R7's tracheostomy tubing was positioned to the right side of the neck, while the oxygen was on. Surveyor attempted to use the call light to ask for assistance, and the call light was pressed at 11:31 AM.On 4/22/2026 at 11:32 AM, V36 (Certified Nurse Aide/ CNA) was observed passing the room and did not answer the call light. Surveyor asked V36 for assistance. V36 stated she was not aware any assistance was needed, since the call light was not on. V36 came into R7's room to test the call light and was then made aware that the call light was not functional. V36 notified the nurse that the call light was nonfunctional. Surveyor asked importance of functional call light. V36 stated it is important for call lights to be functional because that is how the resident will voice any assistance needed. V36 stated if the call light is not functional, anything can happen to the residents.On 04/22/2026 at 11:40 AM, V9 (Registered Nurse/ RN) stated she was not aware that R7's call light was not functional, until today. V9 stated she has notified the V27 (Maintenance Director) and is on his way to repair the call light in R7's room. Surveyor asked V9 about the importance of a functional call light. V9 stated it is important for the call light to always be functional because without one, because that is how the residents let the staff members know if they need assistance. V9 stated anything can happen to the residents such a fall.On 04/22/2026 at 11:46 AM, surveyor observed V27 arrived to R7's room and began to work on the call light.On 04/23/2026, V27 (Maintenance Director) stated if the medical equipment is not working, then he will first troubleshoot the device. V27 stated if the trouble shooting is not the issue, then he will have to repair the entire call light system. V27 stated he had to repair the call light system in R7's room because the cord got pulled away from the device that was attached to the wall. V27 stated due to that matter, the internal parts of the device broke, and the entire system was replaced and repaired. V27 stated he was not aware of R7's call light not functional until the day off the incident. V27 stated he will test the call light weekly, and the last time he tested the call light in R7's room was last week, 04/14/2026. V27 stated the call lights should be always working because they are utilized to help the residents.On 04/23/2026 at 1:22 PM, V2 (Director of Nursing) stated it is best practice to always have functional call lights available because that is how the residents let any staff member know if they need assistance with anything. V2 stated if the call lights are not functioning residents are unable to contact staff. V2 stated it is the expectations of all nurses and or certified nurse aide to check for functional call lights at the beginning of the shift, with no exceptions.Policy titled Call Light Policy with review date of 06/30/2025, documents in part, Nursing staff shall check all call lights daily and report any report defective call lights to the administrator/ maintenance immediately for repair. If call light is not functional, evaluate and provide another means in order for the resident to call for assistance ( i.e. bell) until the call light is fixed. Be sure that when the call light is triggered, it will either alert the staff visually or audibly or both.

Based on interviews and records review that facility failed to provide adequate supervision for one (R1) resident in a sample of four reviewed. This failure has the potential to affect all residents who need an escort while out of the facility on an appointment.R1's current face sheet documents R1 is a [AGE] year-old individual with medical diagnoses that include but not limited to: other encephalopathy, opioid abuse, uncomplicated, malignant neoplasm of overlapping sites of left female breast. MDS (Minimum Data Set) section C dated Sep 29, 2025, documents R1's Brief Interview for Mental Status (BIMS) as 12/15 indicating R1 has moderate cognitive impairment.On 09/30/2025 at 10:24 AM, V3 (Registered Nurse-RN) stated R1 needs an escort to appointments for safety because R1 gets confused and R1 can be in danger of getting lost or being abused if R1 goes to appointments alone.On 09/30/2025 at 12:19 PM, V5 (Work Clerk) stated he schedules appointments for residents and if a resident does not have intact cognitive abilities, an escort is scheduled to accompany the resident to appointments. V5 stated on 09/29/2025, R1's methadone appointment was scheduled for 09/29/2025, at 8:00AM. An escort was scheduled to accompany R1. V5 stated he got a call from V6 (As needed Escort) at 7:42AM stating V6 had an emergency and would not be able to make it to work on time to assist or take R1 to her appointment. V5 stated R1 was picked up by transportation at 7:45AM without an escort. V5 stated he tried to call R1's nurse (does not know who the nurse was) to let the nurse know R1 needed an escort but the phone on R1's unit was not answered. V5 stated he spoke to V10 (Lead receptionist) who stated R1 had already left for her methadone appointment with transportation without an escort.V5 stated all residents on Methadone are sent to the clinic with an escort because the resident comes back to the facility with a supply of Methadone medication to last the resident for a week until the next appointment and Methadone is a controlled substance. V5 stated escorts are scheduled to take a resident to the Methadone clinic for safety reasons and to bring the methadone back to the facility safely.V5 stated it's his responsibility to make sure a resident on Methadone goes to appointment with an escort. V5 stated escorts are trained on keeping residents safe while out of facility for appointment.On 09/30/2025 at 11:15AM, V14 (Certified Nursing Assistant -CNA) stated R1 is confused and forgetful at times, is not able to make decisions, talks about things that are not there, has told V14 that there is someone outside of R1's window when there is no one, and R1 forgets who V14 is although V14 works with R1 regularly. V14 stated R1 can be unsafe in the community by herself because she is forgetful and might not know how to get back to the facility. R1 can get hurt out there in the community if she is by herself.On 09/30/2025 at 2:27PM, V2 (Director of Nursing-DON) stated it is best practice for a resident to have an escort when going to a Methadone clinic because Methadone is a controlled substance, therefore, staff from the facility should be present to make sure the resident's Methadone from the clinic is coming back to the facility safely because Methadone can be abused. V2 stated R1 is alert and oriented times 2-3, meaning R1 has some periods of confusion and should always have an escort for safety reasons when going out of the facility to appointment. V2 stated R1 should not have left the facility without an escort. V2 stated it's the nurse's responsibility to check which resident needs an escort before sending the resident out to an appointment. V2 stated there is an appointment sheet by the nursing station documenting all resident appointments, time of appointment and if an escort is needed. V2 stated V5 (Work Clerk) schedules appointments and indicates on the appointment book who needs an escort.On 09/30/2025 at 1:50PM, V8 (Licensed Practical Nurse-LPN) stated via phone that the CNA who was assigned to R1 had already left at 6:45AM, so the front desk called V8 (Does not remember who) at approximate at 7:05AM and stated R1's ride for an appointment was here. V8 stated he asked the other night nurse (cannot remember name) about R1's appointment and what V8 was needed to do before R1 left for appointment. V8 stated the night nurse told V8 to print R1's face sheet. V8 then asked another CNA (cannot remember name) to get R1 ready for her appointment. V8 stated the CNA got R1 ready, put R1 in a wheelchair and took R1 downstairs to the front desk for pick up to appointment. V8 stated he did not have any information if R1 needed an escort to appointments and during change of shift, the nurse handing over to him for the night shift told V8 that there were no residents with appointments the following morning. V8 stated he is an agency nurse, and this was the first time working at the facility and got a quick orientation from the nurse handing over to him. V8 stated he was not told where to find things like communication book, so he trusted what the nurse he was working with told him and did not know R1 needed an escort to appointments.On 09/30/2025 at 2:48PM, V10 (Lead receptionist) stated he was at the front desk when R1 went to her appointment. V10 stated R1 was supposed to go with an escort but the escort was not available at the time transportation got here. V10 stated he asked V11(Certified Nursing Assistant-CNA supervisor) to accompany R1 to her methadone clinic but V11 is not an escort.On 09/30/2025 at 3:09PM, V11(Certified Nursing Assistant -CNA supervisor) stated R1 was going to appointment and there was a mix up with the escort, so V10 asked V11 to escort R1 to the appointment. V11 stated when R1 got to the appointment, he (V11) stayed outside and never went inside clinic with V11 because he did not know what he was supposed do since this was his first time accompanying a resident to an appointment. V11 stated when he saw R1 come out of the clinic with the transportation driver, he got into the van and drove back to the facility with R1. V11 stated the transportation driver handed something to the nurse but he does not know what it was. V11 stated he did not know what his role was for accompanying R1 to the methadone clinic since he is not trained as a resident escort.Facility's list of residents on Methadone dated 9/18/2025 documents:-R1 must have an escortPolicy titled Appointments and Transportation dated 6/25/2025 documents:-Depending on the resident's medical, physical and cognitive needs and condition, the resident may require an escort while out of the facility for an appointment. If the resident has no representative, family member, friend, etc. to escort him/her during the appointment, the facility will provide one.

Based on interview and record review, the facility failed to follow wound care specialist's recommendation to treat a resident's pressure ulcer and failed to revise the comprehensive care plan addressing a resident's new skin alteration. These failures affected one (R1) out of three residents reviewed for wound care.Finding Include:R1's clinical records show an original admission date of 6/12/25 with included diagnoses but not limited to acute and chronic respiratory failure with hypoxia, anoxic brain damage, and encounter for attention to tracheostomy, and gastrostomy. R1's progress notes show R1 was discharged to hospital on 7/7/25, 7/11/25, 7/19/25, 8/9/25, 8/23/25, and 9/6/25. readmitted back to facility on 7/9/25, 7/15/25, 7/26/25, 8/20/25, and 8/31/25. R1's Quarterly Minimum Data Set assessment dated [DATE] shows R1 is cognitively impaired and is dependent on staff's assistance for his activities of daily living.R1's Wound Assessment Report dated 9/4/25 documented by V23 (Wound Care Nurse Practitioner) revealed R1 was observed with left lateral leg cluster pressure ulcer/injury stage 2 on 8/21/25 (present on admission). Treatment documents in part: Cleanse with normal saline; Betadine and bordered foam; daily and as needed. R1's comprehensive care plan dated 6/13/25 was not revised to address R1's left lateral leg cluster wound. R1's physician orders from 8/21/25 to 9/6/25 shows no treatment order was entered for R1's left lateral leg cluster wound. R1's August to September Treatment Administration Records (TAR) show no documentation of treatments done for R1's left lateral leg cluster wound. On 9/28/25 at 1:52 PM, V8 (Wound Care Licensed Practical Nurse) stated that R1's wounds were all acquired from the hospital and that V23 was seeing R1 weekly at the facility and writes notes weekly. V8 stated that new admissions and re-admissions are seen by the wound care nurse within 24 hours. V8 stated, We call primary doctor to notify of the wounds regardless of if it's old or new then the primary doctor will let us know to follow [V23's] recommendation. We enter treatment orders in PCC [Residents' Electronic Health Record]. All orders will generate in the TAR. Wound care nurse will document in the TAR when treatment is done. Wound care nurses make rounds with [V23] once a week and she let's us know her treatment orders. Then we enter the treatment order in PCC. Wound care will sign the TAR after treatment is done. V8 stated that she is not sure if the facility's wound care team was made aware of R1's left lateral leg cluster wound. Surveyor asked V8 if there were treatment orders in R1's electronic health records for his left lateral leg cluster wound. V8 stated she could not find any documentation. On 9/28/25 at 3:12 PM, V2 (Director of Nursing) stated that resident's who are re-admitted or newly admitted to the facility will be assessed by the admitting nurse and assessed by the wound care nurse within 24 hours for skin alterations. V2 stated that the nurse will get order from the Nurse Practitioner or doctor and then wound care will assess and contact [V23] for recommendations. V2 said that treatment orders will be obtained within 24 hours of admission/re-admission until [V23] comes in and assesses to provide further recommendation. V2 said that the facility's wound care team makes rounds with V23, and all her recommendations will be entered in the resident's electronic health records. V2 said all orders entered will show in the resident's TAR and the wound care nurse will document or sign the TAR if treatment is done. V2 said that if it's not signed off, it's not an active order. V2 further stated that skin care plan is revised as needed and if any new skin issue occurs. It needs to be revised based on the current condition of the resident. V2 said that the care plan is resident specific and individualized, and the purpose of the care plan is to make sure staff is following the plan of care of the residents. V2 stated that the resident's needs, conditions, outcomes, and interventions should all be included in the care plan.The facility's Skin Care Regimen and Treatment Formulary policy dated 7/3/25 documents in part: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. TAR Nursing Documentation includes: a) Routine wound care completed by wound care nurse or designee. b) Ostomy care completed by the wound care nurse or designated nurse. Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated.The facility's Care Plan policy dated 6/30/25 documents in part: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on observations interviews, and record reviews, facility failed to follow their policy to ensure residents have a homelike environment for 3 (R1, R8, R9) out 5 residents reviewed for homelike environment in a sample of 11. Findings include:On 09/09/2025, surveyor observed R1's room had a broken thermostat with no temperatures indicating the temperature in the room. R1's dresser also had a missing handle with drawers that would not close. R1's dresser was also dirty with hardened paste all over it. R8's thermostat was also broken thermostat with no indication of the temperature. R9's thermostat had no temperatures marking on it. R1, R8 and R9's thermostat's analog dial did not have any markings on it to indicate if the thermostat was set to cool or hot.On 09/09/2025 at 10:30 AM, V7 (R1's POA) stated that R1's thermostat is broken and there is no way for us to know what temperature is being set in the room. V7 also pointed to R1's dresser and showed the hardened paste all over the dresser. V7 stated that some drawers would not even close.On 09/09/2025 at 1:14 PM, V3 (Maintenance Director) stated he over looks all the physical plant problem in the facility. V3 stated that there is a thermostat in every patient room which helps resident control the temperatures. The thermostat is an analog thermostat which says what the temperature is set at. V7 stated that every thermometer should have numbered temperatures indicating what the temperatures in the room are set at.Surveyor then asked V3 to join him in R1, R8 and R9's rooms. Surveyor pointed to R1, R8 and R9's thermometer and asked V3 if he knew what the temperature was set at. V3 stated that he doesn't know. V3 stated that this is not what a homelike environment for residents should be.Surveyor also showed V3, R1's dresser. V3 had to take out a wrench from his pocket to fix the drawers on R1's dresser as well as scrape the hardened paste on the dresser. V3 stated that he will get housekeeping right away to clean the dresser and the room.On 09/11/2025, V1 (administrator) stated that all the thermostats are being replace and fixed. V1 stated that V3 is communicating with an outside company on the quotes for this repair. Facility's Resident's rights policy (undated) documents in part: The facility must be safe, clean, comfortable and homelike. Facility's Maintenance policy (07/2025) documents in part: All resident building environment with be maintained by the maintenance department. Any staff who is made aware of a malfunctioning equipment will report the issue to the maintenance department. Cleaning will be done daily while being used by the resident by the housekeeping staff.

Based on interview and record review, the facility failed to ensure hemodialysis services were provided 3 times weekly as ordered by physician to a resident (R5). This failure has the potential to affect 1 (R5) of 3 residents reviewed for Quality of Care /Treatment. The findings include: R5's admission record showed admitted on 02/18/2025 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Arthritis due to other bacteria right knee, Acute and chronic respiratory failure with hypoxia, Gout, Benign prostatic hyperplasia, Type 2 diabetes mellitus, Chronic diastolic (congestive) heart failure, Unilateral primary osteoarthritis right knee, Essential (primary) hypertension. R5 was discharged to facility on 3/10/25. R5's order summary report dated 4/1/25 showed order not limited to: Hemodialysis MWF (Monday, Wednesday, Friday). On 4/1/25 at 2:22 PM V17 (LPN / Licensed Practical Nurse) stated she has been working in the facility for 2 years and is regularly assigned on the 1st floor. She said she had worked with R5 who was receiving HD (hemodialysis) 3x per week MWF (Monday, Wednesday, and Friday) as ordered by physician. She stated every dialysis day, dialysis assessment is printed out, given to resident including Face sheet and POS (Physician Order Sheet). V17 said dialysis resident would come back to facility with paperwork (dialysis assessment) filled out by dialysis center as a form of dialysis communication. V17 said if resident missed dialysis treatment, physician should be informed and documented. V17 stated R5 was scheduled for hemodialysis on 2/28/25 (Friday) but due to transportation issue, hemodialysis was rescheduled on 3/1/25. Reviewed R5's EHR (electronic health record) with V17 and was unable to find documentation that physician was informed regarding missed dialysis on 2/28/25. She said she does not know if R5 received dialysis on 3/1/25, no documentation found. V17 said she is always off every Monday and does not know if R5 received hemodialysis on 3/3/25. On 4/2/25 At 1:34PM V13 (Registered Nurse / RN) stated resident on hemodialysis is sent out to dialysis center to receive hemodialysis as ordered by physician. She said Dialysis assessment should be completed every dialysis day as a form of dialysis communication. V13 said usually she would do progress notes if resident is going out and had received hemodialysis. She said if resident missed or refused hemodialysis, inform physician. Surveyor reviewed R5's EHR with V13 and she confirmed that she worked with R5 on 3/3/25 (Monday), dialysis day. She said she is not sure if R5 received hemodialysis that day. V13 unable to find documentation if R5 received hemodialysis on 3/3/25. No dialysis assessment, no progress notes or documentation found in R5's EHR (electronic health record) on 3/3/25 that R5 received hemodialysis as ordered by physician. On 4/2/25 At 1:54pm V2 (Director of Nursing / DON) stated hemodialysis, should have a physician order in resident's record and should be followed. She said when a resident going out for HD (hemodialysis), Dialysis assessment is printed out by nurses and sent with resident together with Face sheet and POS (physician order sheet) and should be documented in progress/resident's record that resident received HD. V2 said dialysis assessment is a form of communication between facility and dialysis center. She said if resident refused or missed dialysis treatment, physician should be informed and documented. V2 said HD is very important to be received by resident as ordered by physician to remove toxins off their body system and to maintain kidney function. She said if resident missed dialysis treatment, it could potentially lead to fluid overload. She said best nursing practice is to document every dialysis treatment day in resident's health record. V2 said it is standard nursing principle, if it's not documented, it wasn't done. She said R5 is on HD 3x per week Monday/Wednesday/Friday. V2 said on 2/28/25 (Friday), R5 was not able to receive HD due to a transportation issue. V2 said she is not sure if R5 received HD on 3/1/25 and on 3/3/25. V2 stated I don't know why R5 missed dialysis. Surveyor reviewed R5's EHR with V2 and V2 stated unable to find documentation or dialysis assessment if R5 received hemodialysis on 2/28/25 (Friday) and 3/3/25 (Monday) as ordered by physician. MDS (Minimum Data Set) dated 2/27/2025 showed R5's cognition was intact. R5 needed Substantial / maximal assistance with toileting hygiene, shower / bathe self, lower body dressing, chair / bed and toilet transfer. Care plan date initiated on 03/08/2025 showed in part: R5 requires dialysis related to ESRD (End Stage Renal Disease). Assist with arranging transportation to and from dialysis center. Encourage communication with dialysis center. No documentation found in R5's electronic health record that R5 received hemodialysis on 2/28/25 and 3/3/25. No dialysis assessment / dialysis communication found for 2/28/25 and 3/3/25. Facility's Hemodialysis policy dated 7/30/24 documented in part: it is the policy of the facility to ensure that appropriate care for resident on hemodialysis is provided by facility staff. The dialysis nurse will communicate with the facility nurse through a communication sheet or over the phone to ensure continuity of care

Based on observations, interviews, and record reviews, the facility failed to ensure food items were properly labeled and dated, and failed to ensure kitchen staff wore appropriate hair covering. These failures have the potential to affect all 153 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:21 AM, upon entering the kitchen to conduct initial kitchen tour observed V11 (Food Service Director) walking around the kitchen without any hair coverings (no hairnet, no beard or mustache covering). When V11 saw surveyor, he immediately left the kitchen and reentered the kitchen at 9:25 AM wearing a beard protector covering his heard but not covering his mustache and he was not wearing a hairnet to cover the hair on his head. On [DATE] at 9:28 AM, V11 stated anyone who enters the kitchen must wear a hair net and any staff with facial hair should wear a beard guard. V11 stated the purpose of wearing hair coverings is to prevent hair from falling into the food being prepared for the residents. Surveyor brought to V11 attention that he was not wearing any hairnet and asked him to put one on. V11 left the kitchen immediately and returned wearing a hairnet. V11's protector continue to be worn but only covered beard, not his mustache. On [DATE] at 10:35 AM, surveyor brought to V11's attention that he does not have his mustache covered with any hair covering. V11 stated it should be covered because it is facial hair, and all facial hair should be restrained. On [DATE] at 9:35 AM, V11 stated all refrigerated items which are opened should have a label which lists what the food item is, the prepared or opened date and a use by/expiration/end date and most foods have an expiration or use by date of seven days of being opened or prepared. V11 stated it is important for all opened or prepared food items to be labeled with this information so that staff can keep track of the food and knows when to discard expired items. V11 stated, we don't want anything going up to the residents spoiled and we want to avoid food borne illnesses. On [DATE] at 9:45 AM, observed the following items in the walk-in cooler: 1.) Opened package of deli ham wrapped in plastic with no label or dates. V11 stated the opened deli ham package should have been labeled because without a label with dates he cannot tell when the item was opened and once opened it should be discarded after seven days. V11 stated the deli ham would be thrown out right away. 2.) Opened package of sliced American/Swiss cheese wrapped in plastic with no label or dates. V11 stated cheese should be discarded after five days and he does not know when the package was opened because there is no label or opened date marked on the plastic. V11 stated because it is not labeled, he cannot tell how long it has been in there. V11 said, it is going in the garbage. 3.) Large, opened box labeled Folded Cheese Omelet with manufacturer's guidelines printed on the outside of the box printed Keep frozen 0 degrees or below. The outside of box was dated [DATE] and inside the box were defrosted cheese omelets. Observed some of the defrosted cheese omelets to have areas of brown spots on them. V11 stated the omelets in the box were delivered and defrosted on [DATE] because the omelets were needed right away. V11 stated the kitchen usually keep these in the refrigerator, not the freezer and cook them thawed/defrosted. V11 stated he does not know how long the omelets are good for once they have been defrosted, two weeks at the most. V11 viewed omelets inside with brown spots on them and stated, these are going bad, I need to throw them out. V12 (Regional Director of Operations) stated the Folded Cheese Omelets should be cooked from a frozen state, not thawed out ahead of time. 4.) Opened plastic package of sausage links without a label/date. 5.) Opened package of bacon without a label/date. V11 stated both sausage and bacon packages should be labeled and dated with an opened date and use by date. V11 stated it is the responsibility of the staff who opened the package to label and date the items. On [DATE], facility provided list of diet orders for all residents in the facility. The diet order list indicates there are 37 residents receiving nothing by mouth (NPO). Facility provide policy titled, Staff Attire undated which documents in part, the Dining Services Director insures (ensures) that all staff members have their hair off the shoulders, confined in a hair net or cap and facial hair properly restrained and staff will exhibit appropriate personal hygiene. Facility provide signage titled SAFE Brief Personal Hygiene dated 2022 which documents in part, poor personal hygiene (cleanliness and personal appearance) can spread harmful bacteria and viruses to food and surfaces you touch. Washing hands correctly, restraining hair .are a few important activities that can prevent illness from spreading. Examples of poor personal hygiene included but not limited to unrestrained hair. Facility provided policy titled Food Handling Standards and Procedures - Food Safety dated 2024 which documents in part TCS (Time/Temperature Controlled for Safety) foods intended for storage must be labeled with a use by date no more than 7 days from the preparation (prep) date and these food labels intended for storage must include this information: item name, preparation date, use by date (within 7 days of preparation or opening commercially-prepared TCS foods), employee initials. Facility provided signage titled TCS Food and 7-Day Labeling dated 2024 documents in part: 1) TCS foods can grow harmful bacteria if stored or labeled incorrectly, 2) TCS foods include items like meat, eggs, dish, dairy, rice and cut or prepped fruits and vegetables, 3) Labeling TCS foods we prepare helps us know when they were made and when they might spoil, 4) We must label and use TCS food within 7 days from preparation to stay safe, 5) When in Doubt, Throw It Out! - Follow the 7-day rule but trust your senses. If food looks, seems, or smells bad before then, throw it out or ask supervisor if you're unsure. Facility provided signage titled TCS Food Labeling Guide dated 2024 which documents in part, labeling and storing TCS food correctly ensure our ingredients are safe to use in food served to customers.

Based on interviews and record reviews, the facility failed to follow care plan interventions to provide adequate supervision as per facility policy, to avoid fall accidents for 1 (R2) out of 3 residents, in a total sample of 3 residents reviewed accidental hazards. This failure resulted to R2 sustaining a frontal lobe hematoma which led to intraparenchymal hemorrhage. Findings include: R2's MDS Section C (10/4/2024) documents in part: R2 has BIMS (Brief Interview for Mental Status) score of 11. R2 is moderately impaired cognitively. Per R2's Facesheet, R2's diagnosis consist of, bilateral osteoarthritis of the hips, muscle wasting atrophy, difficulty walking, heart failure, history of falling, essential hypertension, cardiomegaly. On 10/23/2024, at 11:25 AM, V10 (Falls Coordinator) stated she is familiar with R2. V10 stated R2 is currently in the hospital. V10 stated that R2 is a max assist. Therapy can assist R2 by himself, but they would know better what her transfer status is. V10 stated that on 10/1/2024, R2 tried to get out of bed unassisted. She was in between the bed and the radiator. Her legs were suspended and against the radiator. Her back was to the edge of the bed and her legs were against the wall. She was on her way down. V10 stated that when the resident changes positions and is on their way down, it is considered a fall. The staff who found her was V11 (Certified Nursing Assistant). Her bottom never touched the floor. She went out on the 2nd and came back on the 4th. V10 stated they concluded from their investigation that R2 tried to get out of bed, but she is unable to walk on her own. The fall was at 8:15 AM in the morning. She did sustain an injury after the fall. She had a left subdural hematoma, but no staff member saw R2 hit her head on the floor. V10 stated that R2's fall interventions after the fall were, R2 was moved closer to the nurse's station. V10 stated that R2 had a prior fall on 08/02/2024. V10 stated that after that fall, R2's fall interventions were updated to; R2 should be up in common areas for meals and when not asleep in bed. V10 stated that breakfast is served at 8:00 AM and R2 was still in the bed around 8:15 AM. V10 stated if R2 was gotten up by a staff member then that would have prevented her from getting up on her own and a fall. Around 7:00 AM is when the morning staff comes, and they do the morning routine of getting the residents up. Given her history, she is someone of high priority to get up in the morning so that she is not alone in bed. V10 stated R2's scheduled nurse and certified nursing assistant (CNA) for 10/1/2024, from 7:00 AM to 3:00 PM was V15 (CNA) and V16 (Licensed Practical Nurse). V10 stated she did not get a witness statement from V16. On 10/23/2024, at 1:30 PM, V11 (Certified Nursing Assistant), stated that she normally works on 4th floor. V11 stated that she works from 7:00 AM to 3:00 PM. V11 stated that breakfast comes around 8:15 to 8:30 AM. V11 stated she assists residents in the morning with changing their clothes, showering and getting them up. V11 stated that when she got to R2's room on 10/1/2024, around 8:15AM, she saw R2's feet were pushed against the radiator and her back was leaning against the bed. V11 stated that she saw R2 around breakfast time. When asked if R2 is a high fall risk, V11 stated I think so?. The nurse who helped R2 was V14 (Licensed Practical Nurse). V11 stated that R2 is a resident who is required to get up for before breakfast, to eat in the common dining area. V11 stated herself and V14 (Licensed Practical Nurse) put R2 back to bed and went back to doing her rounds. V11 stated that she doesn't know who was her nurse. V11 stated that she only went in with V14 because someone called for help because R2 was falling off the bed. On 10/23/2024, at 1:50 PM, V2 (Certified Nursing Assistant) stated that residents get up prior to breakfast. Aides do not get residents up during mealtimes while passing meal trays. V2 stated that they don't just follow the care plan when getting residents up. V2 also stated that if a staff member sees a resident scooting to the edge of the bed, they should get the resident up so that they do not fall. R2's fall care plan documents in part: R2 should be up in common area for meals and when not asleep in bed. R2 will be provided with a bed alarm to alert staff when she attempts to get up unassisted. Date initiated: 08/02/2024. R2's MDS Section GG (08/01/2024) documents in part: For chair/bed-to-chair transfer, sit to stand, and ambulation, R2 is completely dependent. R2's progress note on 10/1/2024, by V16 documents in part: Writer was made aware by nursing supervisor that resident alert and oriented X2 had unwitnessed fall. Writer immediately completed head-to-toe assessment. Vitals are within normal limits. Per nurse practitioner, R2 is to be sent out 911 to outside hospital. R2's progress note on 10/1/2024, by V16 documents in part: This writer contacted local emergency room dept and spoke with a registered nurse who stated the resident is being admitted for subdural hematoma of left frontal lobe. The nurse also stated that R2's hemoglobin level was 6.9 and would more than likely be receiving blood transfusion. Writer informed resident primary care physician, and nursing supervisor. R2's progress note by V13 (R2's Physician) on 10/10/2024: [AGE] year-old female with history or Gastric ulcer, Anemia, HTN. On 10/1/2024, patient transferred to local hospital after unwitnessed fall. She was found to have anemia. She was transfused 2 units of red blood cells with improvement to 8.4. Per records, hemoglobin stable thereafter. For fall, she was found to have intraparenchymal hemorrhage. Neurosurgery was consulted. On 10/23/2024, at 2:00 PM, surveyor asked for full investigation for R2's fall incident. V1 (Administrator) provided the final investigation. Per V1, this is the full investigation. Upon review, there were no interviews from the nurse that was assigned to R2. R2's progress note by V13 (R2's Physician) on 10/15/2024: R2 is an [AGE] year-old female, with a history of Gastric ulcer, Anemia, HTN, who is resides at the facility. On 10/1/2024, patient transferred to local hospital after unwitnessed fall. For fall, she was found to have intraparenchymal hemorrhage. Neurosurgery was consulted. Today, R2's hemoglobin is 6.1. R2 will be transferred to outside hospital due to low hemoglobin for transfusion and anemia workup. Notified nurse on duty to transfer to outside hospital for low hemoglobin 6.1. R2's progress note on 10/16/2024, by nurse on duty documents in part: This nurse called outside hospital and spoke to R2's nurse. R2 is currently in the Emergency Department (ED). Per nurse in ED, a Computed Tomography (CT) of her head was performed, and it showed possible frontal lobe hemorrhage. Another CT head will be completed later on today 10/16/2024. Per ED nurse, hemoglobin was 6.5, blood will be given. Per ED RN, R2 Will be admitted . R2's progress note on 10/17/2024, by nurse supervisor documents in part: Spoke to charge nurse, at outside hospital, who informed writer that patient was admitted for altered mental status. R2's fall risk assessment on 08/02/2024, documents in part: R2 just had a fall. R2's gait is unsteady. R2 is categorized as a high fall risk. R2's hospital record 10/1/2024, documents in part: The patient endorses that she was walking, and she fell and hit front part of her head. The patients' nurse found her and called the ambulance. The CT of the head without contrast showed concerning of 8mm intraparenchymal hemorrhage within the left frontal lobe. Given the patient's CT head finding for intraparenchymal hemorrhage the decision was made to admit the patient to ICU (Intensive Care Unit) for observation. Facility mealtimes policy documents in part: Breakfast is served to the 4th floor between 08:20 AM and 08:30 AM. Facility's final incident report for R2's fall on 10/01/2024, documents in part: R2 had an unwitnessed fall on 10/1/2024, at 8:15 AM. R2 sustained an injury of left frontal subdural hematoma. On 10/01/2024, staff was alerted by alarming sounding. When nurse arrived in the room, she noticed R2 with back against the bed and feet dangling on the floor. Staff assisted R2 back to bed. During emergency room visit, R2 received a CT of brain and results indicated: findings were concerning for an 8mm intraparenchymal hemorrhage within left frontal lobe. V15's statement for R2's fall on 10/1/2024, documents in part: R2 was first seen while I was making rounds. As I came into the facility, R2 was seen scooting to the edge of the bed. Facility's Fall Occurrence policy (07/26/2024) documents in part: Those residents identified as high risk for falls will be provided fall interventions. If a resident has fallen, the resident is automatically considered as high risk for falls. The nurse may immediately start interventions to address falls in the unit. The falls coordinator will add the intervention in the resident's care plan. The falls coordinator will review the incident report and may conduct his/her own fall investigation to determine the reasonable cause of fall. The interventions will be reevaluated and revised as necessary.

Based on record reviews, interviews, and observation the facility fails as follows: to provide respiratory care as per physician's order; to provide interventions for plan of care that would help prevent tracheostomy dislodgement; to provide close monitoring of tracheostomy for a resident with history of multiple incidents of decannulation or dislodgement by following physician's order and/or plan of care. These failures apply to 1 out of 4 residents (R1) reviewed for respiratory care via tracheostomy. These failures that include not closely monitoring, not following physician orders and/or care plan interventions resulted in facility staff not being aware of decannulation or dislodgement of tracheostomy that provides oxygenation essential for 1 resident's (R1) airway. R1 was found expired with tracheotomy dislodgement. Findings include: R1 was initially admitted on [DATE] in the facility. The discharge record from the hospital dated [DATE] documents that R1 uses tracheostomy that was providing oxygen at 28 percent. R1's medical diagnosis related to need for tracheostomy with 28 percent oxygen was respiratory failure. R1 had an order for soft restraints on both wrists dated [DATE] upon admission due to R1 pulling out his tracheostomy. On [DATE] the day after R1 was admitted , V10 (RN/Supervisor) in her progress notes, documented that she was notified by her Certified Nursing Assistant that R1 pulled out his tracheostomy. V11 (Respiratory Therapist) was notified. Per V11 progress notes, V11 documented that she tried to reinsert the tracheostomy to R1 but was unsuccessful. R1 was given non-rebreather oxygen and was transferred to the hospital. Per progress notes of V5 (Licensed Practical Nurse) dated [DATE] it was documented that R1 was sent again to the hospital emergency room for pulling out his tracheostomy. Per notes R1 had broken soft restraint and was able to maneuver R1's hand to removed tracheostomy by himself. Hospital record dated [DATE] documents that R1 developed pulmonary edema or swelling in the lung area. During review of R1's plan of care, the incident on [DATE] when R1 pulled out his tracheostomy the first time was not addressed until the reoccurrence of pulling his tracheostomy on [DATE]. When restorative noted in R1's care plan that due to R1 pulling out his tracheostomy soft restraint will be changed to apply double strap sheep skin limb holder to left upper extremity. Although the care plan instructed to change soft restraint to double strap sheep skin there was no physician order documented until [DATE]. The Care plan also does not document any intervention change after two (2) incidents of pulling out his tracheostomy. On [DATE] at 9:27 AM, V9 (Restorative Nurse/Supervisor) stated that he is the facility staff that is in charge of restraints. V9 stated that R1 came in the facility from the hospital with restraint. And R1 initially uses soft restraints which means a restraint with soft strap. V9 said that he did the initial assessment because when he called the family, he (V9) was informed that R1 needs to have restraints. V9 stated that R1 was strong and vigorous, R1 moves a lot and is restless. V9 stated that he used the soft restraint because it was least restrictive. Once R1 got decannulated (removal of dislodging of tracheostomy) I used the stronger restraint which was the double strap restraint. V9 was asked when did he start using double strap restraint? V9 stated that after R1 removed his tracheostomy on [DATE] he applied double strap restraint because facility has in stock available. Surveyor pointed out to V9 that physician order for double strap restraint was not placed until [DATE] and by placing the double strap restraint, the facility was using restraint without an order by a physician. V9 retracted his statement, V9 said, Double strap was not in stock, so I have to place the order on [DATE]. I have to wait for double strap restraint to come and it was on the 16th of August. V9 stated that double strap restraint should have been implemented on [DATE] but was not done until [DATE]. V9 stated that placing double strap restraint on [DATE] in the care plan was his only intervention. V9 was asked since double strap restraint did not come until [DATE], was there any other intervention done until double strap was available. V9 stated it was only double strap restraint, nothing else. On [DATE] at 2:59 PM, V13 (Certified Nursing Assistant) stated that at around 9:30 PM, with another certified nursing assistant they cleaned up R1. V13 took off the restraint before cleaning R1 and placed back the restraint after cleaning R1. V13 stated that R1 was a little restless during the time he was cleaned up. After that the next time he (V13) saw R1 was around the time nursing staff was performing code blue. On [DATE] at 11:59 AM, V4 (Registered Nurse Agency) stated that V3 informed her that R1 was unresponsive. V4 stated that she saw the left wrist restraint was in place, but the tracheostomy cannula was dislodged when she went to the room after being informed by V3. V4 stated, I have no clue what happened and why it was dislodged. At 2:14 PM, V4 stated that when the aide (V13 Certified Nursing Assistant) did bedside care for R1 around 9:30 PM she did not know that restraint was removed prior to care and was placed back after care. V4 stated I was not with them (V13 and the other certified nursing assistant) when they did bedside care. V4 said, They did not tell me they removed the restraint. V4 stated that it is normal practice for certified nursing assistant to manage restraint in providing care. V4 stated that restraint on R1's left wrist was in place during CPR (cardiopulmonary resuscitation). On [DATE] at 12:29 PM, V3 (Respiratory Therapist) stated that about 10:00 PM, when she walked into the room of R1. V3 noticed that R1's chest was not rising. V3 stated that she called a code blue and informed the nurse on duty (V4/Agency Registered Nurse). V3 stated that it was only when she lifted the neck of R1 that she saw that the tracheostomy was decannulated. V3 stated that the whole tracheostomy was out or not inserted in the stoma (A tracheostomy is a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing). V3 stated that she reinserted the tracheostomy and started cardiopulmonary resuscitation (CPR) and continue until 911 paramedics came. V3 stated that when she checked R1's oxygen saturation, there was no result seen on the oximeter equipment. V3 stated that she did not recall if the restraint was in place during that time. V3 stated that she started her shift at 7:00 PM and it was the only time she saw R1 when R1 was unresponsive around 10:00 PM. V3 stated that like nurses on the floor, respiratory therapist needs to see residents that need respiratory care at the beginning of the shift (7:00 PM). But that particular day she (V3) needed to see three (3) residents on the other side of the hallway (pointing to the opposite hallway) right away. When V3 was asked how the tracheostomy became decannulated? (when out of the stoma). V3 said, I really can't say. On [DATE] at 12:30 PM, V3 reiterated that she did not work on bedside respiratory care on R1 until 10:00 PM. V3 again reiterated that it was not only the cannula inside the tracheostomy that was dislodged but the entire trach. At 1:58 PM, R3 was seen at the bedside. According to V3, R3's tracheostomy is similar to R1's. R3 has Velcro around his neck that holds the tracheostomy collar. A tracheostomy collar was connected to the oxygen concentrator at the opening of the tracheostomy that provides oxygen to R3. V3 removed the mask (tracheostomy collar) that immediately made R3 respond by coughing and displaying difficulty of breathing. V3 stated that R1 was large in build, that was the reason that the tracheostomy was not easily seen dislodged. V3 presented a tracheostomy that was in an unopened package. The tube inside the transparent plastic that was inserted into the stoma or opening in the throat area (trachea) was around two (2) to three (3) inches. Physician orders for R1 were as follows: Dated [DATE] - Vital signs every shift. Per Medication Administration Review (MAR) last vital sign was checked in day shift of [DATE]. On [DATE] at 9:19 AM, V3 stated that all respiratory therapist documentation was in the point click care (PCC) under Respiratory Therapy Daily Flow sheet. And suctioning of R1 was scheduled the same as other residents which is every six (6) hours and as needed. V3 was asked that under Respiratory Therapy Daily Flow sheet dated [DATE] there was no care documented from 1:17 PM to 10:01 PM (around 9 hours) and was there respiratory care was done for R1? V3 stated, As I told you before, I needed to see 3 residents first. R1 was seen for respiratory care around 10:00 PM. Per Physician Order dated [DATE] - Suctioning of tracheostomy was scheduled every four (4) hours not every 6 hours. Per respiratory administration record documentation, R1 was not suctioned on [DATE] at 8:00 PM as ordered by the physician. Per hospital records dated [DATE] (initial admission of R1) documents R1 requires a lot of suctioning for copious secretions. Review of all Respiratory Therapy Daily Flow Sheets dated [DATE] are as follows: Time 1:00 AM by V17 (Respiratory Therapist Agency) documents, R1 on humidified tracheostomy collar 28%, suction and trach care given, resident emergency equipment at bedside. Time 7:38 AM by V18 (Respiratory Therapist) documents, R1 received an aerosol trach collar 30% fraction of inspired oxygen. Emergency equipment is at the bedside, respiratory equipment is properly plugged into the emergency red outlet. I will continue to monitor R1 throughout the shift. Time 1:17 PM by V18 documents the same notes as above. Time 10:01 PM by V3 (Respiratory Therapist) documents, observed R1 unresponsive and decannulated. The nurse was notified. CPR was started, 911 was called. On [DATE] at 10:04 AM, V2 (Director of Nursing) stated that compared to nursing staff, the task of respiratory therapist was to provide respiratory care. Respiratory care includes suctioning of the tracheostomy. Ventilators and tracheostomies are primary duty of a respiratory therapist in the facility. V2 stated that restraints are handled by nursing staff. V2 stated that R1 was sent out to the hospital for CT scan on [DATE] due to fall. When asked how can a resident with restraint fall? V2 stated that she was not present during the time R1 fell , she (V2) would not know. Per V2 full sets of vital signs are done by nursing staff. And R1 vital signs was not documented between 3:00 PM to 11:00 PM because R1 expired on that day. Clarificatory question was asked, since R1 was found unresponsive around 10:00 PM almost the end of the shift which is 11:00 PM. Why was there no full set of vital signs recorded? V2 stated, I don't know. I will check if there is vital signs. Physician order of R1 on vital signs dated [DATE] documents that R1 needs vital signs every shift. Per Medication Administration Review (MAR) last vital sign was checked in day shift of [DATE] which was 7:00 AM to 3:00 PM and no vital signs documented for evening shift 3:00 PM to 11:00 PM. V2 was informed that there was no documentation between 1:17 PM to 10:01 PM (around 9 hours) that respiratory care was done. V2 stated that best practice is to have respiratory care done between 1:00 PM to 10:00 PM to check the resident. V2 stated that R1 was restless and agitated, it can be seen in R1's record. V2 stated that tracheostomy may have dislodged because of R1's agitation and being restless. V2 was asked would frequent monitoring and tracheostomy care per physician orders help in making sure that it was in place? V2 stated that nursing staff does not do tracheostomy care because it is being done by respiratory therapist. V2 said, Nurses just look at the trach but do not do actual care. Because respiratory therapist are the one who do actual care of trach and ventilator. V2 was informed that on V4's documentation dated [DATE] at 9:30 PM, it was documented that restraint and tracheostomy were in place. But V4 stated that she was not present when the 2 certified nursing assistants were cleaning R1. In fact, V4 stated that she was not informed by V13 (Certified Nursing Assistant) that he took the restraint off prior to care and placed it back after the care. V2 stated that, documentation in the progress notes dated [DATE] at 9:30 PM are statements coming from certified nursing assistant to the nurse. V4 was just informed by the certified nursing assistant who did the bedside care. V2 stated that best practice is for respiratory therapist to monitors residents often, ensuring that tracheostomy of all residents are in place. V2 pointed out that respiratory therapist has separate documentation related to complying with physician's order. Upon reviewing respiratory administration record, R1 ordered to be suction related to his tracheostomy every four (4) hours dated [DATE] at 8:00 PM was documented as NN (see Progress Notes). R1's progress notes does not have any documentation on suctioning on [DATE] at 8:00 PM. R1's plan of care dated [DATE] on tracheostomy sows, risk for ineffective airway clearance, impaired breathing mechanics due to respiratory failure. Intervention includes ensure that tracheostomy ties are secured at all times. Tracheostomy Dislodgement article prepared by the Department of Surgical Education, at [NAME] Regional Medical Center Surgical Critical Care Evidence-Based Medicine Guidelines Committee dated [DATE], reads: Tracheostomy tube dislodgement is associated with multiple potential complications including loss of airway, subcutaneous emphysema, pneumothorax, pseudotract formation, stomal stenosis, sternoclavicular osteomyelitis, and trachea-innominate fistula. The most devastating complication of tube dislodgement is anoxic brain injury and patient death. Facility policy on Suctioning dated [DATE], reads: It is the facility's policy to provide care for residents with suctioning needs. After request of V1 (Administrator) for policies related to tracheostomy care and monitoring. None was provided.

Based on observation, interview, and record review the facility failed to follow policy procedures, failed to assess wounds timely, failed to ensure that wound care orders are transcribed as directed, failed to implement care plan interventions (monitor dressing, report loose dressing, report signs/symptoms of infection), failed to ensure that Nurse's Notes were documented - as indicated on the TAR (Treatment Administration Record) and/or failed to follow physician orders for three of three residents (R1, R2, R3) reviewed for wound care. These failures resulted in R1 sustaining Staph (Staphylococcus) Bacteremia (presence of bacteria in the bloodstream which can occur due to tissue infection) on or about 8/2/24 which was treated with Vancomycin (Antibiotic) until 8/5/24. On 8/12/24, R1's sacrum pressure ulcer developed a foul odor (indicative of infection). Findings include: On 8/1/24, IDPH (Illinois Department of Public Health) received allegations that daily wound care was not being provided as ordered. The following concerns were identified: R1 was admitted to the facility on [DATE]. On 8/14/24 at 9:32am, surveyor inquired about concerns with R1's wound care, V10 (Significant Other) stated He got a big sore on his butt, and he got one on his elbow. You can smell them, so I assume they're infected. They (staff) are supposed to change the dressings daily and when I come back days later, it's the same ones on there. R1's diagnoses include encephalopathy, malignant neoplasm of larynx, tracheostomy, and dependence on ventilator. R1's (3/21/24) care plan states resident has actual impairment to skin integrity. Intervention: apply treatment as ordered by Physician. Monitor dressing to ensure it is intact and adhering. Report loose dressing to staff/treatment Nurse. Report abnormalities, signs, and symptoms of infection to medical doctor. R1's progress notes include (8/2/24) WBC (White Blood Cell): 12.78 (high), received orders to send out to hospital. (8/8/24) Staph bacteremia treated with IV (Intravenous) Vancomycin (Antibiotic) until 8/5/24. Sacral decubitus ulcer status post debridement. Patient returned 8/8. R1's (8/8/24) wound assessment reports include the following assessments and treatment orders: 1) Left elbow (unstageable) pressure etiology 1.5 x 1.4 x 0.10cm (centimeters). 25-49% granulation, 50-74% slough. Treatment: Daily and PRN (as needed). Cleanse with 0.125% Dakins solution (a topical antiseptic/antimicrobial solution used to treat/prevent skin infections). Apply Hydrogel and bordered gauze. Odor post cleansing: none. 2) Sacrum cluster (stage 4) pressure etiology 11.0 x 18.0 x 3.5cm. 90% granulation, 10% slough. Exposed tissue: muscle/fascia, adipose, subcutaneous. Treatment: Daily and PRN. Cleanse with NS (Normal Saline). Dakins moistened fluffed gauze, ABD, bordered gauze. Odor post cleansing: none. 3) Right ischium (stage 3) pressure etiology 0.5 x 2.0 x 0.1cm. 60% epithelial, 40% granulation. Treatments: 3 times per week and PRN cleanse with 0.125% Dakins solution. Apply skin prep and hydrocolloid. Odor post cleansing: none. R1's (8/8/24) POS (Physician Order Sheets) include the following treatments that were not transcribed as directed on the wound assessment reports: 1) Left elbow: cleanse with NSS (Normal Saline Solution) and pat dry [incongruent with actual order - 0.125% Dakins solution], apply Hydrogel to wound bed, cover with foam or dry dressing [incongruent with actual order - bordered gauze] daily/PRN. 2) Sacrum: cleanse with full strength Dakin and pat dry [incongruent with actual order - NS]. Apply Dakin gauze on the wound base then cover with foam/dry dressing once daily/PRN [ABD is excluded]. 3) Right ischium: cleanse with NS and pat dry [incongruent with actual order - 0.125% Dakins solution]. Apply skin prep on the wound base, cover with hydrocolloid 3 times weekly/PRN. R1's (6/24/24) functional assessment affirms resident is dependent on staff for ADL (Activities of Daily Living) care. R1's (6/24/24) BIMS (Brief Interview Mental Status) affirms resident is rarely/never understood. On 8/12/24 at 2:05pm, surveyor inquired about R1's wounds. V3 (Wound Care Coordinator) stated He has quite a few, he has a sacral and left elbow pressure wound everything else is vascular. Surveyor inquired about R1's pressure wound treatments. V3 responded The left elbow is hydrogel daily and the sacrum is Dakins (full strength) daily. V3 affirmed that she was prepared to change R1's dressings at this time and subsequently entered R1's room (with surveyor), the odor was notably foul. Surveyor inquired about the smell in R1's room. V3 replied I smell an odor. R1's left elbow dressing was dated 8/8 [4 days prior however the dressing is supposed to be changed daily]. Surveyor inquired about the date on R1's left elbow dressing. V3 gasped, paused momentarily, and stated 8/8. V3 removed R1's left elbow dressing, cleansed the wound with NS [0.125% Dakins was prescribed], applied Hydrogel, gauze and border dressing. V3 subsequently turned R1 to the side, the foul odor became almost unbearable (smelled like decomposition). R1's right ischium wound was noted to be open without a treatment (hydrocolloid) in place. R1's (undated) sacrum (foam) dressing appeared to be saturated, disintegrating and not adhered to the skin, the gauze was noted to be square, flat, and appeared gray. Fluffed gauze was clearly not present (as ordered) and/or covering the large, deep, sacrum wound with muscle exposed. Surveyor inquired about the appearance of R1's sacrum dressing. V3 responded I see saturated gauze, and the dressing looks old and soiled. Surveyor inquired about the appearance of R1's sacrum wound which was large, deep and muscle exposed. V3 replied It is a stage 4, prior to that it was covered in eschar which was debrided. V3 cleaned R1's sacrum wound with full strength Dakins solution [NS was prescribed], placed Dakins soaked (kerlix) gauze in the wound and applied several large border dressings. V3 placed the (adhesive) edge of a sacral border dressing on top of R1's right ischium wound [hydrocolloid was ordered]. On 8/12/24 at 2:29pm, V2 (Director of Nursing) entered R1's room (as requested). Surveyor inquired about the odor in R1's room V2 stated I smell something, odor. I smell an odor; I don't know where it's coming from. On 8/12/24 at 2:35pm, V4 (Restorative CNA/Certified Nursing Assistant) entered R1's room (wearing a mask) and surveyor inquired about the odor in the room. V4 stated I got sinuses right now. Surveyor inquired if V4 smelled a foul odor. V4 responded Yeah, I think I do. Surveyor inquired if there were concerns with the appearance of a resident's dressing and what's the requirement. V4 replied Immediately, I tell the Nurse. On 8/12/24 at 2:47pm, V5 (CNA) affirmed that she was assigned to R1. Surveyor inquired about the smell in R1's room. V5 stated I smell poop. Surveyor inquired about the appearance of R1's sacrum dressing when changed last. V5 responded It was soiled because he had a big bowel movement around 1:30pm. Surveyor inquired if V5 told anybody about R1's soiled dressing. V5 replied No, I charted it and went to lunch. Surveyor inquired why concerns regarding the appearance of R1's dressing were not reported to the Nurse. V5 stated I know wound care was up here doing rounds. Surveyor inquired about staff requirements for identified concerns regarding skin integrity impairments and/or dressings. V5 responded, I usually notify the Nurse and chart it. R1's (August 2024) TAR (Treatment Administration Record) affirms the left elbow and sacrum treatments were documented 8/9 and 8/12 [R1's left elbow dressing was dated 8/8 and sacrum dressing was disintegrating - during 8/12 surveyor inspection], the 8/10 and 8/11 entries are blank. R1's right ischium treatment (scheduled for 8/10 administration) was also blank therefore none of the treatments were administered as ordered. On 8/14/24 at 11:30am, surveyor inquired why a treatment was not on and/or administered to R1's right ischium (stage 3) wound on 8/12/24 (as ordered). V3 (Wound Care Coordinator) stated Let me double check and look up in here (reviewed the electronic medical record) and affirmed I did not place the hydrocolloid on there, you're right. Surveyor inquired what R1's left elbow and sacrum were cleansed with during (8/12/24) treatment administration. V3 responded I cleaned the elbow with normal saline and cleaned the sacrum with Dakins. [neither wound was cleaned as directed]. Surveyor inquired about R1's right ischium and left elbow physician order sheets which are incongruent with treatment orders on the (8/8/24) wound assessment reports. V3 reviewed R1's electronic medical records and affirmed Cleanse with Normal Saline was entered in the physician orders for both treatments [not Dakins 0.125% as prescribed] and stated (V11/Wound Care Nurse) put that order in. Surveyor inquired if V3 notified the physician on 8/12/24 regarding R1's sacrum wound odor [change in condition post 8/8 assessment - odor: none]. V3 replied No, I did not notify the doctor. Surveyor inquired what a blank entry on the TAR indicates. V3 stated It wasn't signed out. Surveyor inquired how R2's left elbow dressing change was documented as administered on 8/9 when the dressing was clearly dated 8/8 (on 8/12/24). V3 responded It was signed out on the 9th and the dressing was dated 8/8. Surveyor inquired why R1's (8/12/24) sacrum dressing change was documented as administered on the TAR when it was clearly not (prior to surveyor observation) because it was saturated, disintegrating, and odiferous. V3 replied I'm not sure who signed it. Surveyor inquired if treatments documented on the wound assessment reports (by the Wound Physician and/or Wound Nurse Practitioner) are orders. V3 affirmed they are and affirmed the treatment orders are subsequently entered electronically in the POS by facility staff. R2's (6/27/24) POS includes right AKA (Above Knee Amputation): monitor steri-strips, cover with ABD pad dressing every other day/PRN. R2's (July 2024) TAR affirms the right AKA dressing change was scheduled on 7/1/24, the entry is blank. R2's dressing changes were also scheduled on 7/27 and 7/31, NN was documented. On 8/13/24 at 10:05am, surveyor inquired what NN documented on the TAR indicates. V2 (Director of Nursing) stated It means see Nurses Notes. Surveyor inquired why NN was documented on R2's TAR on 7/27/24 and 7/31/24. V2 reviewed R2's Nursing progress notes and stated It says see wound care notes on the 27th. On the 31st she put the same thing, see wound care notes again. I'll have to ask her (V8/Registered Nurse) why did she do that. It should be in the progress notes. R3 was admitted to the facility on [DATE]. R3's (7/19/24) progress notes include sacral wound (stage 4) with dry dressing intact. All meds (medications) verified with doctor [actual wound assessment and/or treatment orders received are excluded]. On 8/12/24, surveyor requested R3's initial sacral wound assessment. Surveyor received R3's (7/22/24) skin evaluation [documented 3 days after admission]. R3's (7/23/24) sacrum wound assessment report states odor post cleansing: none. R3's (7/20/24) care plan states resident has actual impairment to skin. (7/26/24) Resident is on IV antibiotics related to SSTI (Skin Soft Tissue Infections) prophylaxis. R3's (8/8/24) sacrum wound assessment report states odor post cleansing: mild [change in condition post 7/23/24 assessment]. On 8/15/24 at 2:19pm, surveyor inquired about staff requirements for residents admitted to the facility with wounds. V12 (Wound Care Physician) stated The Nurse does the initial assessment, and the patient needs to be admitted so they contact the medical director or physician that's on call for orders. Surveyor inquired what Dakins solution is used for. V12 responded If someone thinks that there's an infection that's going on, there's bacterial overload or generally if there's inflammation. Surveyor inquired about potential harm to a resident if daily wound dressings are not administered as ordered. V12 replied It depends on the wound. Surveyor inquired if a resident has a stage 4 wound with muscle exposed and the dressing is not changed daily what's the potential harm. V12 stated There's potential for harm, I can't be specific about it. Every wound is different, if a wound has exposed structures and the dressing is not changed every day it may last another day and still be efficiently done. If it does not get done the whole week, there may be risk for infection. Surveyor inquired what wound odor is indicative of. V12 responded Most likely it would be infection that was occurring. The Skin Care Regimen policy (revised 1/24/24) states it is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for residents with skin breakdown. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. TAR Nursing Documentation includes routine wound care completed by wound care nurse of designee. Refer any skin breakdown to the skin care team and physician including wound physician/NP (Nurse Practitioner) for further review and management.

Based on record reviews and interviews the facility failed as follows: failed to follow preventive measures in placing intervention of skin moisture barriers as per facility policy; failed to follow Wound Nurse Practitioner recommendation for dietitian to consult and assess in a timely manner; failed to provide interventions of multivitamin and zinc sulfate per Wound Specialist Assessment; failed to provide protein supplement due to delay of nutritional assessment; and failed to ensure orders by Wound Nurse Practitioner for laboratory testing and antibiotic therapy was carried out. All failures apply to 1 out of 4 residents (R1) in a total sample of 4 residents reviewed for prevention and treatment of pressure injuries. These failures affected 1 resident (R1) and resulted in R1 sustaining pressure injuries and R1's transfer to hospital due to sepsis/infection of pressure injuries. Findings include: R1 is [AGE] years old, initially admitted in the facility on 5/7/2024. R1's medical diagnosis includes anoxic brain damage, reduced bed mobility and seizures. V13 (Agency Licensed Practical Nurse) progress notes dated 6/25/2024, documents that R1 transported to the hospital by two (2) paramedics going to the emergency room (ER). V14 (Licensed Practical Nurse) progress notes dated 6/25/2024, documents that R1 was admitted to the hospital with diagnosis of sepsis. On 7/16/2024 at 2:28 PM, V9 (Family of R1) stated that on 6/22/2024 her brother V10 (Family of R1) visited R1 in the facility. During the visit V10 smelled a foul odor on R1 and requested the nurse to change the dressing. V9 stated that she spoke to V8 (Wound Coordinator / Licensed Practical Nurse) and that V8 assured her that it was not an infection. V9 stated that R1 was admitted in the hospital for sepsis of the wound and was treated with a lot of antibiotics until currently. On 7/19/2024 at 1:08 PM, V10 confirmed and stated that he saw the wound, it looked really bad and smelled of foul odor during his visit on 6/22/2024. V4 (Nurse Practitioner for Wound) progress notes dated 6/25/2024, the day R1 was transferred to the hospital, showed R1's wound was worsening, it has malodorous, and R1 has elevated temperature. History of R1's skin documentation are as follows: Per initial assessment by the facility dated 5/8/2024, R1's skin was intact. R1 was transferred to the hospital on 5/13/2024 due to coffee brown emesis and came back from the hospital to the facility on [DATE]. On 5/16/2024, R1 was seen and was assessed initially by V4 (Nurse Practitioner for Wound). V4 documented that R1's skin was intact, though there are few blanchable redness on the perineal areas. V4 recommended that facility follows preventive measures which includes application of topical moisturizer daily and incontinent / moisture barrier cream every shift and as needed. Physician Order Sheet (POS) of R1 documents that both skin barrier treatments which are topical moisturizer scheduled daily and incontinent / moisture barrier cream scheduled every shift were not included in the order after R1 was readmitted on [DATE]. On 5/31/2024 per facility assessment, R1 sustained three unstageable pressure ulcers. They were located on the sacrum with measurement of 5 by 3 centimeters, left gluteal (buttock) with measurement of 3.5 by 3 centimeters, and right gluteal (buttock) with measurement of 5.5 by 4.5 centimeters. On 6/4/2024 per V4's progress notes and wound assessment, R1 was seen and assessed with wounds the same measurements as per facility assessment. Per V4 all wounds have slough (a mass or layer of dead tissue separated from the surrounding or underlying tissue). V4 recommends that R1 needs nutritional consult for presence of wounds due to risk for wound complications. On 6/11/2024 per V4's progress notes and wound assessment, V4 reiterated again her recommendation of the need for R1's nutritional consult for presence of wounds due to risk for wound complications. Per progress notes R1 was seen by V12 (Registered Dietitian) on 6/17/2024. Eighteen (18) days after R1 was identified on 5/31/2024 with three (3) unstageable pressure injuries; and after multiple recommendation by V4 on 6/4/2024 and 6/11/2024. V4's wound assessments of R1 dated 6/25/2024 documents that R1's sacrum wound extends to the left gluteal area and was worsening. On V4's progress notes with the same date, it was documented that the wound of R1 is warm to touch and was worsening. Wound has large area of eschar, and R1 has a fever, with malodorous smell. V4 recommends antibiotic therapy for infection depending on the outcome of laboratory test results. V13 (Agency Licensed Practical Nurse) progress notes on change of condition dated 6/25/2024, documents that R1's temperature 100.9 Fahrenheit and pulse rate of 114 beats per minute were out of the normal range. On 7/17/2024 at 10:39 AM, V8 (Wound Coordinator / Licensed Practical Nurse) stated that R1 was initially admitted on [DATE] and was transferred to the hospital on 5/13/2024. R1 returned back in the facility on 5/15/2024 and the wound care team with V4 (Nurse Practitioner for Wounds) saw R1 on 5/16/2024. During this time R1 had no pressure ulcer when assessed on 5/16/2024. R1 has a Braden score of 5 that means R1 is at high risk for alteration of skin integrity. V8 stated that cream barriers help to prevent resident from developing pressure ulcers. V8 was asked related to cream barriers not included in the physician order after re-admission on 5/16/2024. V8 after reviewing R1's treatment administration record (TAR) for the month of May 2024 stated, I am not sure why it was not placed there upon re-admission. It would help if that was in the order, applying topical cream is more focus than just changing a diaper. V8 also said that there is no specific assessment in a schedule basis if a resident does not have wound. The wound care team did the assessment on 5/31/2024 because R1 has skin alteration, and it was the first time R1's pressure ulcers were identified. V8 stated that R1's pressure ulcers were unstageable because there was slough that makes the wound not able to be determined for its depth. V8 stated that on 6/25/2024 when wound care team saw R1's pressure ulcers that was the time it got worst. Per V8 there was the merger of two (2) pressure injury sites of the sacrum extending to the left buttock. Upon changing the dressing R1's pressure ulcers had foul odor and granulating tissue had decreased. V8 clarified that granulating tissue are good tissue that helps the wound heal. During this time V4 ordered labs that included STAT (to be performed right away) CBC (complete blood count), CMP (comprehensive metabolic profile), ESR (erythrocyte sedimentation rate), pre-albumin, and culture of the wound. V8 was asked if all of these orders were carried out and performed. V8 reviewed all orders of R1 and said, I don't see all the orders only CBC, CMP and urine culture. V8 said that V4 also ordered antibiotic therapy but was not sure if it was done. V8 said that R1 was transferred to the hospital and was admitted with diagnosis of sepsis. Per World Health Organization (WHO) fact sheet dated 5/3/2024, sepsis is a life-threatening condition that happens when the body's immune system has an extreme response to an infection, causing organ dysfunction. The body's reaction causes damage to its own tissues and organs, and it can lead to shock, multiple organ failure and sometimes death, especially if not recognized early and treated promptly. On 7/17/2024 at 11:54 AM, V2 (Director of Nursing) stated that nursing staff has no formal skin assessment done as scheduled. Best practice is for nursing staff to assess resident during ADL (activities of daily living) care on their shower day and CNAs (Certified Nursing Assistants) to notify nurses immediately when there is a change on a resident skin. V2 said she is not familiar with R1. On 7/17/2024 at 1:45 PM, V8 provided a form titled Wound Specialist's Assessment of Ulcer Avoidability / Unavoidability for R1. V8 stated that V2 (Director of Nursing) instructed V8 to give the form to writer. The form document as follows: Wound sites of R1: Sacrum, Left Buttock, and Right Buttock with date of onset for all pressure injuries on 5/31/2024. Under interventions, R1 needs the following medications and supplements: Multivitamins, Zinc Sulfate, Nutritional Supplements, and use of pain medication to allow repositioning. Form further documents that because of the above risk factors and because despite the provision of above preventive interventions, the sore still developed, the sore is therefore considered unavoidable. Because the sore which was acquired from the hospital/other home and was provided with above proper interventions still deteriorated, this ulcer is therefore unavoidable. Upon review of R1's record the following were established: - Per physician order record and history, R1 was never given multivitamins and zinc sulfate. R1 was not receiving Pro Stat, protein supplement from the time pressure injuries were identified on 5/31/2024 and was ordered; and not until 6/17/2024. Despite V4 (Nurse Practitioner for Wound) recommendation on 6/4/2024, 6/11/2024 and 6/18/2024 for nutritional consult. R1 was not seen by dietitian until 6/17/2024. On 7/18/2024 at 10:15 AM, V4 (Nurse Practitioner for Wounds) stated that cream barrier helps to prevent moisture build up and prevent skin alteration. When R1's pressure injuries were identified they were unstageable because it cannot be determined how deep the wound is due to present of slough. When slough is removed it will either be stage 3 or 4 and never be stage 1 or 2 because of the depth of the wound. When asked if unstageable is considered late stage of the wound? V4 stated that it can be late stage of pressure injury because there are stages 1 and 2. Unless there is an underlying factor underneath the wound. V4 stated that protein intake is very important to the healing of the wound and also zinc in the diet. Protein helps with amino acid build up and helps with tissue rebuilding. Yes, I recommended to evaluate R1's nutrition by the dietitian since I first saw the wounds on 6/4/2024. It will take time to absorb nutritional supplement. V4 was asked since it takes time for nutritional supplement to be absorbed will it be beneficial to start R1 as early as possible? V4 did not address the question, and said nutrition is not enough to prevent wound from deteriorating. Document titled Wound Specialist's Assessment of Ulcer Avoidability / Unavoidability for R1 was presented to V4 to verify and acknowledge the form. V4 stated that she was aware of the form. V4 was informed that under interventions multivitamins, zinc sulfate was supposed to be given to R1 but were not ordered in the physician orders. And Pro Stat was not ordered until 6/17/2024 although R1's pressure injuries were identified on 5/31/2024. V4 stated that she does not know that because she does not check each and every order of resident. V4 was asked to verify the date of the form and stated that it is 5/18/2024. V4 was asked that in the form pressure injuries of R1 are unavoidable but in R1's progress notes with the same date (5/18/2024) all 3 (three) pressure injuries are improving? V4 stated that it is the facility staff who fill in the unavoidable form and she just signed it. Surveyor also pointed out another discrepancy to V4 that under the form/document, pressure injuries were acquired from hospital or other homes. V4 said that all pressure injuries were facility acquired and not acquired elsewhere. V4 stated that on the day that she assessed R1 on 6/25/2024, R1's pressure injuries had malodor that was pretty intense and when there is odor to the wound there is infection. I (V4) ordered labs that includes CBC with differential, CRP, ESR and antibiotic treatment; and cannot remember if she ordered a wound culture. V4 was informed that the physician order sheet does not reflect all lab orders and R1 has no order for an antibiotic. V4 stated that it seems that there is lack of coordination. V4 stated, I told the girls (wound care team), PCP (Primary Care Physician) and DON (Director of Nursing) about R1's wound status and those orders. V4 stated that the information she gave directed the nursing staff to assess R1 and R1 was ordered to transfer to the hospital. R1 was admitted in the hospital for sepsis of the wound. On 7/18/2024 at 12:25 AM, V8 admits filling out the form (Wound Specialist's Assessment of Ulcer Avoidability / Unavoidability for R1) that V4 signed. V8 stated that dietitian was informed that R1 needs dietary consult but does not know why it took her until 6/17/2024 to see R1. On 7/18/2024 at 12:43 PM, V12 (Registered Dietitian) stated that resident needs protein if they are not getting enough protein via tube feeding. Amino acid helps with rebuilding tissue or regenerating tissue. R1 needs also zinc and multivitamins. V12 stated that after R1 sustained pressure injuries it was on 6/17/2024 that she (V12) saw R1 for nutritional consult. V12 then stated that R1 was at risk for malnutrition due to prolong use of enteral feeding. Per article of National Library of Medicine, dated 3/24/2022, it reads that proteins provide the main building blocks for tissue growth, cell renewal, and repair during wound healing. Skin Care and Regimen and Treatment Formulary policy dated 1/24/2024, reads: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Under prevention, the facility will provide topical moisturizer to be applied daily and as needed. Facility will also provide incontinent / moisture barrier cream every shift and as needed. Facility policy does not provide assessment schedule for early identification of wounds. V1 (Administrator) and V2 (Director of Nursing) were requested for policy and/or procedure of skin assessment schedule. V1 and V2 stated that facility does not have any policy or procedure related to skin assessment schedule.

Based on observation, interview and record review, the facility failed to ensure that two (R1, R2) residents remain free from abuse. This failure resulted in R1 and R2 being sexually abused by V3(CNA). Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual first admitted on [DATE]. R1's medical conditions include but not limited to: acute and chronic respiratory failure with hypoxia, anxiety disorder due to known physiological condition, muscle wasting and atrophy, not elsewhere classified, right upper arm, left upper arm, right thigh, left thigh, dysphagia, oropharyngeal phase, dysphagia following cerebral infarction. R1's BIMS (Brief Interview for mental status) score dated 12/19/2023 documents R1's (BIMS as 13/15, indicating R1 has intact cognition. On 1/26/2024 at 12:10pm, R1 was observed in bed watching TV with his daughter at the bed side. R1 has a tracheostomy and is difficult to understand when he speaks. R1 can express himself using hand gestures and reading lips. V7(R1's family member) was in the room and assisted Surveyor in understanding R1 when R1's words would not come out properly/clear. R1 said on Tuesday, 1/23/2024, a Black guy with a Ponytail (who was later identified as V3-Certified Nursing Assistant) was putting lotion on his buttocks and as he was putting it on; he was also putting it in his private parts (R1 showed with hand gesture, moving his hands up and down what V3 was doing as he put lotion) and playing with it. R1 stated he told V3 to stop and get out of his room. R1 stated he was very upset and angry when V3 was doing this to him because he felt violated. R1 stated he has been at the facility for one year now and no CNA has ever done this to him before. R1 stated another CNA (No name, no date provided) was also rough with him during Activates of Daily Living (ADL) care and hit him on his hands as he was providing care. R1 said he was angry when the CNA hit his hands. R1 stated he was safe at the facility as long as V3 does not take care of him. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is dependent on staff for toileting, hygiene and needs substantial/maximal assist with lower body dressing and personal hygiene. R1's care plan dated 03/23/2023 documents R1 has actual skin integrity related to PMH (Past Medical History) of: Resp. Failure, Pressure Injuries, Impaired Mobility, Incontinence, and a Braden score of 14 places him at risk. Interventions: Apply moisture barrier cream after each incontinence episode, may keep at bedside. R2 is a [AGE] year-old individual first admitted to the facility on [DATE]. R2's medical conditions include but not limited to: muscle wasting and atrophy, not elsewhere classified, right shoulder/left shoulder, right/left lower leg, other lack of coordination, acute respiratory failure with hypoxia, and human immunodeficiency virus [HIV] disease. R2's MDS Section C dated 10/25/23 documents R2's Brief Interview for Mental Status (BIMS) as 15/15 indicating R2 is cognitively intact. On 1/26/2024 at 12:45pm, R2 said V3 played with him about three days ago while providing ADL care. R2 said the CNAs usually turn him and put skin breakdown prevention cream on his buttocks and no one has ever applied it to his penis, going up and down. R2 said this was the first time this has happened to him, and he has been at the facility for two years. R2 was fearful that surveyor works for the facility and stated they do not want to talk much about it because V3 is a tall strong guy and he. R2 is a sickly person who cannot defend himself and if V3 knows R2 told the surveyor about what happened, he, V3 might retaliate. R2 was tearing up and crying as he told this to surveyor. R2 said he does not want V3 to come back to his unit and work there because R2 was scared of him. R2 said he wants to file a complaint with the police so he can be safe here if V3 comes back to work at the facility. R2 said he was safe at the facility as long as V3 does not take care of him. R2's current care plan document R2 is at risk for skin related issues and was initiated 11/02/2022. Interventions are documented as: Apply barrier cream every shift and as needed (PRN), CNA may apply and may keep at bed side. R2's MDS Section GG - Functional Abilities and Goals, dated 10/25/2023 document R2 needs Substantial/maximal assistance with eating, showering/bathing self and upper body dressing, Personal hygiene, and R2 is Dependent on toileting hygiene, lower body dressing, putting on/taking off footwear. On 1/25/2024 at 12:37pm, V5(CNA) said when she provides care, she never goes back and forth when cleaning residents or putting lotion on their private parts and she does not swipe back and forth, she repeats the motion in going in one direction. V5 said this is how she was taught in CNA school and is how she provides care. V5 said stroking residents in their private parts is not ok because it can be perceived as sexual abuse by the resident. V5 said on 1/25/2024, R2 told her that on Tuesday, 1/23/2024 that a male CNA (V3) stroked him on his private parts. V5 said she reported this to V9(Licensed Practical Nurse -Agency) about it. On 1/26/2023 at 1:15pm, V6(Certified Nursing Assistant-CNA) said R2 told her what V3 had done to him, stroking his private parts while providing care. She (V6) told the nurse on duty V7 (Licensed Practical Nurse -LPN) the same day, but she does not remember the exact date R2 told her. V6 said she only puts barrier cream on the buttocks, never on the penis, and when she cleans the penis area, she never strokes the resident because she was taught in school never to go back and forth on private parts. On 1/26/2024 at 2:35pm, V4 (Staffing coordinator) said that she was doing her rounds and when she come to R2's room, he said that he did not want the male CNA to provide care to him anymore. (V3 was identified as the staff R2 was referring to) and said the way V3 was providing ADL care was very rough and he did not want him. R2 said V3 was rolling him over too quickly, and R2 did not want V3 to take care of him. V4 said R2 told her about V3 at about 9:00am yesterday, 1/25/2024. V4 said R2 did not tell her which day this happened, all he said was that he does not want V3 to take care of him. V4 said she came down and told V1(Administrator) about a little after 9:00am that R2 had complained about V3 being rough. V4 said V3 was escorted out of the building pending investigations. On 01/26/2024 at 3:20pm, V9 (Licensed Practical Nurse-LPN-Agency) said she was passing medications in the morning yesterday, 1/25/2024, during the evening shift about 8:30pm. R1's family arrived and started talking to R1. V9 said she stepped out and gave the family space, then after a while, R1's wife came out screaming to her (V9) and said R1 was sexually abused and no one had told her about it. V9 said she further inquired from R1's family member what happened and R1's family member said that a male CNA had (Jagged) rubbed R1's penis back and forth, masturbating R1. V9 said she called V1(Administrator) at about 9:00pm and informed him, then she let R1's family speak with V1. V9 said when she went back to the unit, she found the police and the fire fighters in R1's room, and the fire fighters asked for the face sheet for R1, and the police pulled V9 to the side to ask her what happened. V9 said she really did not know what happened since she did not get a chance to speak with R1 or his family about the issue before the police arrived. V9 stated the police stayed until about 10:00pm, and the fire fighters took R1 to the hospital after the family requested him to be sent out. V9 said she did not get a chance to speak with R1 about the incidence before he was sent out. V9 said R1's family are the ones who called the police. On 1/28/2024 at 11:06am V13(MDS /Clinical Care Coordinator-RN), said R2's MDS dated [DATE] section GG & H Documents R2 is always incontinent for urinary, bowel, and his care plan last updated 1/28/24 documents R2 needs one person assist with all ADLs except transfers and eating. V13 stated R2's MDS Section C dated 10/25/23 documents R2's Brief Interview for Mental Status (BIMS) as 15/15 indicating R2 is cognitively intact, which means R2 can understand and make decisions for himself. On 1/28/2024 1:15pm V15(Licensed Practical Nurse) said V6 (CNA) come to her just before lunch on 1/25/2023 and told her that R2 did not want to have V3 as his CNA because R3 was rough with R2 during ADL care. V15 said and she told V4 (CNA Supervisor/Staffing coordinator) not to assign V3 to R2. V15 said V4 told her she will go talk to R2. V15 said she left it at that and went to pass medications and when she got to R2, he said that V3 was rough while he was bathing R2, and he did not want him to provide ADL care to him anymore. Reviewed R1's current Physician Order Sheet (POS) and it does not document an order for cream to penis, and it is not listed in current ALD care plan. Reviewed R2's current Physician Order Sheet (POS) and it does not document an order for cream to penis, and it is not listed in current ALD care plan. R1's Police report number dated 1/25/2024 is JH128282. R2's Facility Reported Incident Report to IDPH dated 1/25/2024 documents: On 1/25/2024 at approximately 9:20am, V4 (CNA Supervisor/Staffing Coordinator) was completing CNA rounds on R2 when R2 alleged that 2-3 days ago, V3 (CNA) provided rough ADL care and repositioning. R1's Facility Reported Incident Report to IDPH dated 1/25/2024 reported sexual and physical abuse by V3. Facility policy titled Abuse and Neglect, dated 7/14/23 documents: -It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, and mistreatment. -Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in ham may be considered abuse. -Sexual abuse is defined as non-consensual sexual contact of any type with a resident. -Mental abuse includes but not limited to humiliation, harassment, threats to bodily harm, punishment, isolation (involuntary, imposed seclusion) or deprivation to provoke fear or shame.

Based on observation, interview and record review, the facility failed to supervise one cognitively impaired resident (R2) who is at high risk for falls and has a history of repeated falls; failed to update the fall risk care plan; and failed to implement fall prevention interventions as care planned for one resident (R2) of three residents (R2, R3, R8) reviewed for falls. As a result of these failures, R2 fell with R2 sustaining a right posterior occiput (head) laceration, one centimeter, which required emergency transfer to the hospital for 2 staples of the laceration repair. Findings include: R2's Admission Record documents, in part, diagnoses of anoxic brain injury, metabolic encephalopathy, hypertension, type 2 diabetes mellitus, muscle wasting and atrophy, dysphagia, lack of coordination, abnormal posture, reduced mobility gastrostomy status, and weakness. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 10 which indicates the R2 has moderate cognitive impairment. R2's MDS, dated [DATE], documents, in part, one fall with major injury, and a staff assessment for mental status coded as moderately impaired by cues/supervision required. On 8/21/23 at 12:00 pm, R2's room door observed closed with R2 alone in R2's room with the television (TV) on with a high pitched, constant noise from the test pattern on the TV. R2 observed awake, alert, nonverbal and in bed with a bed alarm in place (green light on with a wire connected to bed sensor pad under R2's buttocks). On 8/21/23 at 12:02 pm, V13 (Fall Coordinator/Licensed Practical Nurse, LPN) stated that the purpose of the bed alarm is that it alerts staff if the resident is getting out of bed unassisted. V13 stated that R2 has unsteady gait and is a fall risk. When asked if staff outside R2's closed room door would be able to hear the bed alarm with the high-pitched TV noise, V13 stated, Yes, usually we can hear the alarm with the door closed. V13 provided oral care for R2, then left R2's room. This surveyor asked R2 about the fall incident, on 7/17/23, when R2 fell out of the wheelchair and had to go to the hospital for emergency care, R2 nodded R2's head up and down indicating yes. When asked about more details of this fall incident, R2 nodded R2's head side to side indicating no. In R2's General Progress Note, dated 7/17/23 at 11:00 pm, V26 (Agency LPN) documents, in part, (R2) activated chair alarm. (V26) quickly responded to (R2) but could not break (R2's) fall. (R2) was noted lying on right side. 911 called. Head to toe assessment was completed with open area to back of head. Small amount of blood noted. V26's signed Employee/Resident Statement, dated 7/17/23 at 9:15 pm, documents, in part, that R2 had a fall at the nurse's station and that V26 did not witness R2's fall. V26 documents that V26 responded to R2 who was on the floor in right side position. V26 documented that V26 was in another resident's room when R2's fall happened. V26 documents that the last time that V26 saw R2 was at 9:00 pm. On 8/22/23 at 3:08 pm, V26 (Agency LPN) stated that as an agency nurse, V26 works at multiple facilities. When asked if V26 remembers R2, V26 stated that V26 sees many different residents on a daily basis and cannot remember R2. This surveyor read verbatim V26's authored progress note in R2's electronic medical record (EMR) from 7/17/23 at 11:00 pm, and V26 stated that V26 does not remember R2 or R2's fall incident on 7/17/23. When asked, in general, what are fall precaution interventions for a resident who has had multiple falls, confusion and poor safety awareness, V26 stated that there must be supervision. V26 stated that if the resident is alert, then V26 would bring the resident out to a common area, and that staff would have to keep an eye on the patient. R2's emergency department hospital records, document, in part, that R2 sustained a right occipital region 1 centimeter laceration from a mechanical fall. R2's procedure of laceration repair with 2 staples was performed by V42 (Hospital Physician) on 7/18/23 at 2:45 am. On 8/23/23 at 11:01 am, V13 (Fall Coordinator/LPN) stated that V13 is responsible for performing the fall risk assessment for resident to determine if they are at low or high risk; will add interventions to the residents' care plan for the fall risk residents; will make sure that the fall interventions are appropriate to each fall incident; and the care planned fall interventions are in place. V13 stated that V13 is notified of all fall incidents that occur in the facility. V13 stated that with each fall incident, staff interviews (witness statements via paper forms) are conducted to figure out why a fall occurred. V13 stated that V13 will take data from the resident and staff interviews to determine a course of action to prevent a future fall incident. V13 stated that V13 was notified of R2's unwitnessed fall (7/14/23) from the bed to the floor. V13 stated that with the 7/14/23 fall incident, R2 was care planned for the intervention of floor mats to the sides of the bed. V13 stated that on 7/17/23, approximately 20 minutes after R2's fall incident at 9:15 pm, V2 (DON) notified V13 of R2's fall with injury. V13 stated that V13 then phoned the nurse's station after speaking to V2 and talked directly to V26 (Agency LPN) who was caring for R2. V13 stated that V26 reported to V13 that R2 was sitting up in R2's wheelchair at the nurse's station so V26 could see R2 and that R2 kept standing up unassisted. V13 stated that V26 reported that V26 was in another resident's room when R2 fell at the nurse's station. V13 stated that witness statements were collected from staff about R2's fall incident on 7/17/23. When asked what were R2's fall interventions prior to the 7/17/23 fall, V13 stated for staff to keep R2 at the nurse's station, room close to the nurse's station, purposeful rounding, call light in reach, floor mats and bed/chair alarm. When asked the reasoning for keeping R2 at the nurse's station, V13 stated, It's the hub of the floor. Activities going on. Staff coming in and out. And when staff aren't working in rooms, that's where they go. When asked about positioning R2 in a wheelchair at the nurse's station, V13 stated that it's in eyesight and that a nurse or any staff can see R2 as well. When asked what fall intervention was care planned for after R2's 7/14/23 fall, V13 stated that it was floor mats. This surveyor showed V13 the fall risk care plan for R2 asking V13 where the fall mats intervention is, and V13 viewed the care plan (initiated date 7/6/23). V13 stated that there is another care plan for R2 and printed a duplicate care plan (initiated date 7/6/23) from R2's EMR with no intervention listed for R2. V13 stated, That's it. There's nothing more. V13 stated that V13 performs an investigation of each fall incident to determine the root cause and will add new interventions to the resident's care plan after each fall incident to prevent that type of fall from occurring again. R2's Care Plan, date initiated 7/6/23, documents, in part, that R2 is at high risk for falls related to cognitive impairment, gait problems, poor safety awareness, muscle weakness, recent fall in last 2-6 months, recent fall in last month and traumatic brain injury with interventions as follows: Keep (R2) in common areas when (R2) is not sleeping or sleepy (7/5/23); I (R2) would like staff to move me close to the nurses station for closer observation (6/28/23); and I (R2) have periods of forgetfulness. I would like staff to frequently reorient me to my surroundings (6/28/23). R2's Care Plan (7/6/23) does not include floor mats. Also, this surveyor observed R2 awake and alert on 8/21/23 at 12:00 pm inside R2's room with a closed door and high-pitched TV noise which is not a common area as care planned for. Employee/Resident Statements, dated 7/17/23 at 9:15 pm for R2's fall in front of the nurse's station, were collected from V26, V34 (CNA), V35 (Agency CNA), and V43 (CNA). V35 and V43 documented that they did not witness R2's fall and that they were performing resident care for other residents. V34 documented that V34 did not witness R2's fall and that V34 was on a bathroom break. On 7/14/23 at 5:13 am, V29 (LPN) documented, in part, in R2's incident note, that at approximately 4:10 am, V29 noted noise from within R2's room, went to inquire and found R2 in a sitting position on the side of the bed towards the door. R2's Fall Risk Evaluation (performed with R2's fall incident), dated 7/14/23, documents, a score of 13 which indicates that R2 is high risk for falls. R2's incident report, dated 6/28/23 at 1:40 pm, documents an unwitnessed fall incident for R2. R2's Fall Risk Evaluation (performed with R2's fall incident), dated 6/26/23, documents, a score of 16 which indicates that R2 is high risk for falls. R2's progress note, dated 5/16/23 at 9:51 pm, indicates an unwitnessed fall incident for R2. On 8/21/23 at 2:15 pm, when asked about R2's fall history, V2 (Director of Nursing, DON) stated that R2 had a previous fall in the facility, was unsure of how many previous falls, but stated that R2 did not have a fall incident previously with an injury. V2 stated that on 7/17/23, R2 was sitting across from the nurse's station in the wheelchair and had been brought out in the common area to be monitored. V2 stated that frequent monitoring is important especially since R2 had a previous fall incident. On 8/24/23 at 3:50 pm, V33 (Attending Physician) stated, Every time there is a fall, the nurses will call me. I give them instructions. I was not there for R2's falls so I sent (R2) out for evaluation. I talk to the nurses. They do follow my recommendations of fall precautions. When asked about R2's fall on 7/17/23 with injury, V33 stated, I was notified on 7/17/23 of the fall, and I ordered for (R2) to be sent out to the hospital. When asked what is V33 expecting of nursing staff in following fall precautions, V33 stated, To make sure there is close monitoring. Especially a resident with multiple falls, have close monitoring and frequent rounds. Make sure the bed rails are in proper position, so the resident won't get out of bed or when transferring to a wheelchair to make sure that that don't have a fall. It's a nursing expectation. This surveyor informed V33 that R2's fall with injury on 7/17/23 was when R2 was in a wheelchair in the common area at the nurse's station. When asked what type of supervision should nursing staff provide R2 while at R2's at the nurse's station, who has poor safety awareness, confusion and frequent falls, V33 stated, To keep their eyes on (R2). In the communal area, (R2) should be close the nurse's station and somebody should be with (R2). Eyes closely on (R2). When asked if nursing staff are not following these fall precautions, like direct supervision, for R2 who fell and experienced a laceration to the back of head that required 2 staples for closure, could this cause harm to R2, and V33 stated, Yes. R2 frequently falling could cause a laceration. Nurses need to pay attention to residents, so they don't fall. A laceration should not occur. Nurses have to be more aware of falls and provide early intervention. Facility policy dated 7/17/23 and titled Fall Occurrence, documents, in part, Policy Statement: It is the policy of the facility to ensure that residents are assessed for risk of falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Procedure: . 2. Those identified as high risk for falls will be provided fall interventions . 3. If a resident had fallen, the resident is automatically considered as high risk for falls . 7. Ultimately, the Falls Coordinator may change the interventions provided by the nurse if the Falls Coordinator's investigation identifies a more appropriate interventions for the individual fall. 8. The Falls Coordinator will add the intervention in the resident's care plan. Facility policy dated 7/27/23 and titled Care Plan, documents, in part, Policy Statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations . Procedures: . 5. These will be periodically reviewed and revised by a team of qualified person after each assessment. Facility job description titled LPN Floor Nurse and dated 12/1/19, documents in part, Reports to: Director of Nursing & Assistant Director of Nursing. Summary/Objective: In keeping with our organization's goal of improving the lives of the Guests we serve, the Licensed Practical Nurse (L.P.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The L.P.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations, and established nursing policies and procedures. Essential Functions: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity and freedom of choice. 2. Provides supervision to C.N. A's and all subordinate staff which includes checking their work to ascertain that assignments have been completed . 9. Responsible for all nursing care of assigned Guests while on duty . 14. Must be knowledgeable of individual care plans and support the care planning process by reporting specific information and observations of the Guest's needs, preferences and report any behavioral changes . 18. Follow established safety precautions when performing tasks and using equipment and supplies . 21. Ensure each Guest receives person centered care. Facility job description titled Certified Nursing Assistant and dated 5/20/22, documents, in part, Reports to: Floor Nurse, Unit Manager and Staffing Coordinator. 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 Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Provides quality nursing care to Guests in an environment that promotes their rights, dignity and freedom of choice . 11. Follow established safety precautions when performing tasks and using equipment and supplies . 15. Ensure each Guest receives person centered care.

Based on record review and interview the facility failed to implement appropriate care plan interventions to prevent serious injury for one of five residents (R5) reviewed for injury of unknown origin. This failure resulted in R5 sustaining a 5 x 3cm (centimeter) avulsion (trauma where all layers of the skin have been torn away, exposing underlying structures) to the skin overlying the Achilles tendon which required suture repair. Findings include: R5's diagnoses include but not limited to anoxic brain damage, contracture of muscle multiple sites, lack of coordination, and muscle wasting of (left) lower leg/ankle/foot. R5 was discharged (4/7/23) from the facility. R5's (3/16/23) BIMS (Brief Interview Mental Status) affirms resident is rarely/never understood. R5's (3/16/23) Functional Assessment affirms (2 persons) physical assist is required for bed mobility. R5's (12/23/22) care plan includes actual skin alterations. Interventions: pad bed rails, wheelchair arms or any other source of potential injury if possible. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. R5's (3/10/23) incident report states nurse entered room and noted resident left lower extremity dangling out of bed with moderate bleeding noted to back of extremity and heel. Nurse Practitioner notified and gave order to transfer resident out 911. R5's (3/10/23) hospital history and physical states patient presents with left ankle laceration after cutting at (Facility Name). On exam 5 x 3cm avulsion to skin overlying Achilles tendon, with minor Achilles involvement. Consulted orthopedic surgery who sutured and placed patient in a splint. R5's (3/10/23) incident investigation states upon interview with staff, resident has involuntary spasms with left lower extremity and may have had an involuntary spasm with may cause resident to injure his extremity by hitting it against the bed frame. On 8/3/23 at 1:32pm, surveyor inquired about R5's (3/10/23) incident and V62 (Licensed Practical Nurse) stated When I came into the room during rounds, I noticed that he (R5) had a large laceration to the left leg by his Achilles he got from moving involuntarily on the side of the bed rail. He (R5) used to have a spasm where he would draw his leg up and scrape his leg on the rail. We sent him to (Hospital Name) for traumatic injury. On 8/3/23 at 3:49pm, surveyor inquired if R5's care plan includes involuntary movement and/or interventions to prevent harm while in bed. V64 (Care Plan Coordinator) reviewed R5's skin alteration care plan (which excludes involuntary movement) and stated it seems like they have appropriate interventions like pad bed rails, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface (referring to 12/23/22 entries) however bed bolsters (to prevent R5's leg/foot from touching the bed frame) are excluded. On 8/3/23 at 4:15pm, surveyor inquired about R5's (3/10/23) incident investigation. V2 (Director of Nursing) stated He has involuntary muscle spasms which cause him to move his lower extremities involuntarily. He had rubbed it on the bed frame, and it cause it to open up. It wasn't sharp but it was metal, there was blood all over the bed frame that he rubbed his heel on to open up the area. Surveyor inquired how R5 was injured if padded side rails were in use V2 responded He had 2 (upper) side rails he didn't have all 4 side rails up. Surveyor inquired if R5's injury was sustained from the side rail V2 replied It was the bed frame, so I don't know why people keep saying it was the side rail it was the bed frame and he kept rubbing. He was alert and oriented times zero, he's a traumatic brain injury. Surveyor inquired if R5's care plan interventions included bed bolsters V2 stated I don't even know about that I could check. On 8/3/23 at 4:30pm, surveyor inquired about appropriate interventions for R5 and/or a resident with involuntary leg movement. V61 (Physician) stated Maybe close observation, just make sure that fall precautions, padding things like that are in place. This patient has anoxic brain injury with muscle spasms so if you have muscle spasms try to make sure he doesn't hit any of the bed rails or if at risk for fall make sure he doesn't have a fall. Surveyor inquired about potential harm to a resident (lying in bed) with involuntary movement if preventive interventions are not implemented V61 (Physician) responded I would say if any involuntary movement such as muscle spasms or seizure I can't think of any life-threatening harm but maybe localized things like the skin or maybe fall. If bed rails are not up, he may fall from the bed and get injured.

Based on observation, interviews and record review, the facility failed to a) follow facility policy to notify the physician of an abnormal lab result that delayed treatment for one resident (R3) of 4 residents reviewed for notification of a change of status. This failure resulted in R3 being transferred to the emergency room and later expiring of sepsis and pneumonia; The facility failed to b) notify the physician and document medications including antibiotics that were not given to a resident (R2) that was hospitalized for sepsis; and the facility failed to c) ensure respiratory treatments or monitoring were accurately documented for (R2) who was not a resident of the facility at that time. Findings include: a) R3 is [AGE] years old. R3's diagnoses include but are not limited to paraplegia; hyperlipidemia; atherosclerosis of coronary artery bypass graft(s); neuromuscular dysfunction of bladder; dysphagia; protein-calorie malnutrition; chronic respiratory failure with hypoxia; dementia; hematuria; tracheostomy; gastrostomy; muscle wasting and atrophy (left and right ankle, foot, lower leg, thigh, upper arm); pressure ulcer of head and back. MDS (Minimum Data Set) dated 10/25/2022, indicates R3 is totally dependent on one to two person assist with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, bathing and R3 is always incontinent of bladder and bowel. R3's POS (Physician Order Summary) indicates order date of 10/24/2022 by V11 (Pulmonologist Nurse Practitioner) for sputum culture one time only for 1 day; start 10/24/2022; end 10/25/2022. Laboratory Report sputum culture for R3 with a collection date 10/24/2022, specimen received date 10/25/2022, final report dated 10/27/2022 9:57AM, indicates Pseudomonas aeruginosa (type of bacteria) heavy growth. R3's POS (Physician Order Summary) indicates order date of 10/31/2022 by V18 (Nurse Practitioner) for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl, antibiotic) Give 500 mg via G-Tube two times a day for PNA (pneumonia) for 7 Days; start 10/31/2022 17:00; end 11/6/2022. This order for treatment is 4 days after the culture result was received by the facility. Review of R3's progress notes reveals that prior to 10/31/22 R3's physician was not notified of the sputum culture result obtained by the facility on 10/27/2022. On 11/30/22 at 12:37 PM, V2 (Director of Nursing) stated The NP (Nurse Practitioner) or the primary physician should have been made aware of the results as soon as the results were received on 10/27/22. I don't see documentation of notification of the NP or the physician. The nurse should have contacted the physician for new orders on 10/27 to start treatment right away for the organism (bacteria). On 12/1/22 at 9:12 AM, V11 (Pulmonologist Nurse Practitioner) stated I ordered the sputum culture on 10/24. If it's results show an infection, facility staff will notify infectious diseases physician, or me. I was not notified. Facility staff could have notified me, infectious diseases, or the primary doctor. On 12/1/22 at 10:16 AM, V7 (Infection Preventionist) stated The physician and/or the NP (Nurse Practitioner) have to be notified so we can order treatment or make changes to the current treatment. If there are issues notifying the primary, then the medical director is notified. R3's sputum culture is an abnormal lab. The provider determines if there will be a treatment/or a new order. If they are not notified, they would not be able to make that determination. The nurse receives the labs when they come in. I do not see documentation that the physician or NP was notified of the results. On 12/1/22 at 11:51 AM, V15 (Medical Doctor) stated I don't remember if I was notified of the sputum culture. On 12/1/22 at 2:24 PM, V18 (Nurse Practitioner) stated I ordered the cipro on 10/31 for a positive sputum culture. I reviewed the culture on 10/31 in R3's charting. Usually, the nurse will notify who orders the lab. Usually that will be the Pulmonologist. ID (Infectious Disease) will usually follow up on the result. It doesn't look like ID saw the patient. The culture looked like it needed to be addressed when I reviewed the records. Excerpts taken from R3's hospital record Emergency Documentation 10/31/2022: -He appears to have low-grade temperature as well as tachycardia clinically patient seems to be septic. -Presenting with tachycardia and hypoxia along with a low-grade fever point towards sepsis as well as source of infection such as pneumonia, UTI bacteremia and sepsis. Patient is given intravenous fluid for hydration along with empiric antimicrobial agent including Zosyn as well as vancomycin. -Clinical work-up/Interpretation Results: 10/31/2022 15:49 CDT, WBC 18.6 x10 (3)/mcL. -Multiple entries: Suctioned pt., thick/yellow secretions. -In the ER, he was hypotensive, febrile at 39 C, tachycardic (elevated heartrate) at 125, tachypneic (rapid respirations) at 24. He was on 10 L/min via trach collar. Lab work notable for a white count of 18, hemoglobin 9.7, BUN 55, lactic acid 4.2, procalcitonin 1.7. UA with positive leukocyte esterase, WBC, and bacteria. He was given vancomycin and Zosyn in the ER. R3's Certificate of Death indicates date of death : 11/7/2022, cause of death: sepsis due to pneumonia. According to the Centers for Disease Control and prevention, sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death. Facility policy Critical Laboratory Value Reporting, revised date 7/27/22, documents in part: It is the policy of this facility to establish an effective system for reporting critical laboratory values and STAT laboratory results to the physician who is responsible for the care of the resident. 1. The facility will immediately notify the ordering/attending physician when STAT laboratory results are available or when lab results are clinically considered critical (when lab values indicate an imminent life-threatening condition). 2. When a critical laboratory result is received from the laboratory or detected by the nursing staff, the result will be communicated to the physician immediately. The result will/may be communicated via telephone and will be faxed afterwards. Facility policy Notification for Change of Condition, revised date 7/28/22, documents in part: The facility will provide care to residents and provide notification of resident change in status. 1. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: b. a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); c. a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) Facility policy Antibiotic Stewardship Program Policy, effective date 7/27/22, documents in part: 4) Utilize a communication tool for residents suspected of having an infection that includes clinical history (new symptoms and complaints), physical exam findings (vital signs, localizing pain, pulse oximetry, etc), and other relevant information (previous antibiotic exposure, previous culture and sensitivity test results, current medications, and medication allergy history). May use tools such as SBAR to guide nursing-physician interactions. b) R2 was [AGE] years old initially admitted on [DATE] with medical diagnoses of anoxic brain damage, aphonia (loss of ability to speak through disease of or damage to the larynx or mouth), displaced commuted fracture of shaft of humerus, left arm, fracture of left clavicle. Per minimum data set (MDS) dated [DATE] documents that R2 can rarely or never be understood. On 11/29/2022 at 2:19 PM, R2 was in his room with V13 (R2's Brother) R2 has a tracheostomy, gastric feeding tube and urinary catheter. V13 stated that R2 cannot communicate verbally, and that as far as he knows, the wound on R2's buttocks continues to be present. V13 further stated that R2 was transferred from another room. On 9/18/2022 R2 was sent to the hospital with diagnosis of sepsis. V16's (Licensed Practical Nurse) notes dated 9/18/2022 documents: R2 was transferred to the ER (emergency room ) with admitting diagnosis of sepsis. Per facility census report R2 was not in the facility from 9/19/2022 to 11/3/2022. Multiple complete blood count (CBC) laboratory results document elevated white blood cell (WBC) count that is present when a person has an infection. Normal values for WBC is between 4.8 to 10.8. On these following dates R2's WBC were elevated: 8/28/2022 WBC was 17.2, 8/30/2022 WBC was 14.5, 9/4/2022 WBC was 15.5, 9/6/2022 WBC was 17.1, 9/9/2022 18.2, and on 9/18/2022, the day R2 was transferred to hospital, R2 was diagnosed with sepsis WBC was critical 28.1. Review of R2's medication administration record (MAR), multiple medications including 3 antibiotic orders were either documented as not given or no documentation as given. Levaquin 500 MG was not given on 9/11/2022, 9/13/2022. Daptomycin intravenous (IV) antibiotic 500 MG daily was not signed as given on 11/5/2022. Imipenem-Cilastatin intravenous (IV) antibiotic 500 MG 4 times a day was not signed as given on 11/5/2022. Micafugin Sodium intravenous (IV) antibiotic 150 MG daily was not given on 11/8/2022 due to unavailability. R2's infection includes urinary tract infection (UTI), blood infection, and sepsis. On 11/29/22 at 2:46 PM, V6 (Licensed Practical Nurse) stated that for residents that have new orders for an antibiotic, there is a convenience box on the first floor that nurses can acquire antibiotics, without waiting for the pharmacy to deliver the medication. V7 (Infection Preventionist) stated that on the 1st Floor medication room there is a convenience box that nurses can take antibiotics/medications without waiting for pharmacy to deliver. On 11/30/2022 at 11:39 AM, V2 (Director of Nursing) said, There is a convenience box in the facility where antibiotics/other medications are available. In case the nurse needs antibiotics before pharmacy can deliver. In case the nurse was not able to give antibiotic medication, the nurse must notify pharmacy to order it as STAT (fast delivery) and notify the physician that it was not given. There should be documentation that the physician was notified. I do not know why R2 was diagnosed with sepsis when she was transferred to the hospital. As to R2's Levaquin antibiotic, it should have been given or at least documented, and as to R2's Daptomycin IV (intravenous) antibiotic, I don't know why it was not signed on 11/5/2022 on the TAR (treatment administration record). But the nurse should indicate if it was not given, and the nurse still needs to sign it. Again, a physician should have been notified. I will check the notes if nurses notified the doctor. c) On 12/1/2022 at 11:25 AM, V10 (Respiratory Manager) said, Regarding respiratory administration record documenting that respiratory staff were signing or documenting on the days that R2 was not in facility, it was a mistake, they should have not signed it. The proper way is to perform first what was ordered by the physician before signing. I know, if the order was performed first, there is no way you will miss if the resident is in the facility. But I can say that the orders that were on the record were being performed by my staff. R2's Treatment Administration Record (TAR) for the month of September documents the following: Analyze fraction of inspired oxygen (FIO2) daily and as needed every shift and change inner cannula every shift and as needed were signed on 9/19/2022 when R2 was in the hospital. According to the CDC website: Healthcare professionals should treat sepsis with antibiotics as soon as possible. Antibiotics are critical tools for treating life-threatening infections, like those that can lead to sepsis. However, as antibiotic resistance grows, infections are becoming more difficult to treat. Antibiotic side effects range from minor, such as rash, dizziness, nausea, diarrhea, and yeast infections, to very severe health problems, such as life-threatening allergic reactions or C. difficile (also called C. diff) infection, which causes diarrhea that can lead to colon damage or death. However, when antibiotics are needed, the benefits outweigh the risks of side effects or antibiotic resistance. Improving the way healthcare professionals prescribe antibiotics, and the way we take antibiotics, helps keep us healthy now, helps fight antibiotic resistance, and ensures that these lifesaving drugs will work for you or others when they are needed most, like for treating infections associated with sepsis. Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP) dated August 9, 2022. 41356

Based on observation, interviews and review of records, the facility failed to follow It's policy ensuring prompt identification, documentation and to obtain appropriate treatment for 1 resident (R2's) wound deterioration in a sample of three (3) residents reviewed for pressure ulcers and skin breakdown. These failures resulted to 1 resident's (R2) wound deterioration as to the size and stage of right buttock pressure ulcer in a sample of three (3) residents reviewed for pressure ulcers. Findings include: On 11/30/2022 at 11:19 AM, with V8 (Wound Coordinator), R2's right buttock pressure ulcer was seen approximately about 2 inches x 3 inches in terms of length and width. The pressure wound has redness and exposure of bone-like color on the upper left area. V8 said I am not sure if it is stage 3 or stage 4. R2's Wound Assessments are as follows of R2's pressure ulcer on the right buttock: Facility's initial skin evaluation, by V8 (Wound Coordinator), dated 8/20/2022, documents that R2 had a Stage 2 pressure ulcer measuring 0.5 by 0.5 (length by width) centimeters. Per V8's notes, R2's Braden score was 11 which means that R2 is at risk for further alteration of skin integrity. R2's August 2022, treatment administration record (TAR), documents that treatment for R2's right buttocks pressure was started on 8/22/2022, 2 days after buttocks pressure ulcer was discovered and it was discontinued on 8/29/2022. Per the same TAR, R2 does not have a treatment order in place from 8/29/2022 to 9/12/2022 (15 days). R2's Wound Assessment, in Wound Rounds, by V8 dated 8/29/2022, documented that the right buttock pressure ulcer was healed. A photo of the right buttock pressure ulcer shows that skin was not intact with exposure of underlying tissue and redness was present. R2's Wound Assessment, in Wound Rounds, by V8 dated 9/15/2022, documented that the right buttock pressure ulcer increased exponentially in size from 0.5 by 0.5 to 6.3 by 7.0 (length by width) in centimeters. Staged from stage 2 to stage 3. V17 (Wound Medical Doctor) initial assessment dated [DATE] also documents the same on R2's right buttock pressure ulcer size 6.3 by 7.0 (length by width) in centimeters stage 3. Per V16's (Licensed Practical Nurse) notes dated 9/18/2022, it was documented that R2 was transferred to ER (emergency room ) with an admitting diagnosis of sepsis. R2's Wound Assessment, in Wound Rounds, by V8, dated 11/4/2022 documented that right buttock pressure ulcer size was 8.0 by 6.5 (length by width) in centimeters stage 3. Per facility census, R2 left the faciity on [DATE] and returned to facility on 11/18/2022. R2's Wound Assessment, in Wound Rounds, by V8 dated 11/19/2022, documented that the right buttock pressure ulcer size 6.3 by 7.0 (length by width) in centimeters is stage 3. V17's (Wound Medical Doctor) assessment dated [DATE] also documents right buttock pressure ulcer increased in size 7.5 by 9 by 1 (length by width by depth) in centimeters, and increased from stage 3 to stage 4, and was documented by V17 as deteriorated. Per minimum data set (MDS) assessment dated [DATE] on bowel and bladder: R2 was assessed as always incontinent as to his bowel. R2's treatment administration record (TAR) for August, September, and November, for right buttock pressure ulcer treatments, were never signed as treatment being performed. On 11/30/2022 at 11:39 AM, V2 (Director of Nursing) said, Well as to R2's pressure ulcer, we need to do our assessment on a daily basis. I mean nursing staff on the floor needs to check resident skin daily. I don't know if they checked R2's skin daily, I will have to investigate. V2 also said, to R2's right buttock pressure sore, I don't know why there was no order for 15 days. I know I can see on the TAR (treatment administration record) that there was no order for treatment between those dates (8/29/2022 to 9/12/2022). But again, I need to investigate to tell you what really happened. But best practice is to have treatment orders for any pressure ulcer. On 11/31/2022 at 1:10 PM, V8 (Wound Coordinator) said, On August 29, I assessed it as healed. When a wound is healed, I don't see the wound anymore. That is the reason there was no order for treatment from August 29 to September 12. Yes, on September 15th, R2's right buttock pressure ulcer became stage 3. The nurses on the floor did not inform me. V8 was asked if there should be an interdisciplinary coordination between the Wound Care Team and the nurses working on the floor. V8 said, I know that care plan for pressure ulcer needs to be done at the time when it was first seen, and it needs to be updated every time there are changes to the wound. R2's pressure ulcer on his right buttocks was first identified on 8/20/2022, and it should have been care planned as soon as possible. I understand that the care plan needs to be updated too. R2's care plan for wounds was dated 8/22/2022. The right buttock pressure ulcer was identified on 8/20/2022. There was no update on R2's wound care plan although R2's right buttock pressure ulcer increased in size and increased in stage. From stage 2 to stage 3 on 9/15/2022, and from stage 3 to stage 4 on 11/21/2022, when V17 (Wound Medical Doctor) documented the wound as deteriorating. Facility submitted R2's Wound Assessment, in Wound Rounds, by V8 dated 8/29/2022, which documents that the right buttock pressure ulcer was healed. With a photo of the right buttock pressure ulcer shows that skin was not intact with exposure of underlying tissue redness. V2 stated, there is redness to that area. (Pointing at the picture). But there are some areas that are not red. On 12/1/2022 at 1:27 PM, V17 (Wound Medical Doctor) said, a closed pressure ulcer is described as full skin epithelization and there is no exposed tissue. A closed pressure ulcer is different from healed pressure ulcer. There must be an order for a stage 2 pressure ulcer like cream or dressing. A stage 2 pressure ulcer needs treatment, it is on a case-to-case basis. Pressure ulcer may worsen if there is no treatment. As to R2, I did not assess her until 9/15/2022 where I staged her (R2's) right buttocks pressure ulcer as stage 3. On my initial assessment it was already a stage 3. I cannot say what the facility did before or if there was treatment done before I saw R2. After I saw R2 on 9/15/2022, my next assessment was 11/21/2022, and the wound was a stage 4. Facility's Skin Care Treatment Regimen Policy as revised on 7/28/2022, in part reads: It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Under procedure. Charge nurses must document in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician. Refer any skin breakdown to the skin care coordinator for further review ad management as indicated. Policy also includes treatments necessary for all stages of pressure ulcers from stage 1 to 4.

Based on observation, interviews and record review, the facility failed to prevent, assess, provide timely care, and update resident's care plan related to a facility acquired pressure ulcer/wound (R1) and a change in status of a current pressure ulcer/wound (R2). These failures resulted in acquiring, deterioration or worsening of a pressure ulcer/wound for 2 residents (R1 and R2) of 3 residents reviewed for pressure ulcers/wound prevention and treatment. These failures resulted in 1 resident's (R1) deterioration of a facility acquired pressure ulcer/wound, with subsequent transfer to the hospital with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1 is [AGE] years old with medical admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/2022 R1, V2 (R1's Daughter) stated that R1 developed a Stage 4 pressure ulcer while in the facility. V2 also stated that R1 was rushed to the hospital due to septic shock related to the pressure ulcer on 10/19/2022. Per R1's notes dated 10/19/2022 by V7 (INFECTIOUS DISEASE NURSE PRACTITIONER) documents as follows: R1 temperature was 101 degrees Fahrenheit. Per V2 (R1's Daughter) who was present at the bedside. R1's sacral wound (The sacrum is a bone that is at the back of the pelvic bones) started on Saturday (10/16/2022). V7's skin assessment of R1: Sacral wound was hot to touch, malodor (foul smelling), necrotic tissue, purulent drainage, gray drainage, [CONDITION(S)], and [CONDITION(S)] around peri-wound skin. Under assessment: [CONDITION(S)] R1 hypotensive, febrile, more lethargic than usual. Wound and possible aspiration pneumonia believe to be source. Discussed case with wound MD (V9). Ordered R1 sent to hospital for evaluation. On 11/9/2022 at 12:44 PM, V7 (INFECTIOUS DISEASE NURSE PRACTITIONER) stated Given how it looked and the amount of necrotic tissue infection was identified, I informed V9 (Wound Doctor) and both of us agreed that R1 needs to go to (Operating Room) OR. Just by looking, I didn't even need to do an assessment this needed an OR intervention. Initial skin assessment provided by V10 (Wound Care Coordinator / Licensed Practical Nurse) documents as follows: R1 does not have pressure ulcer upon admission on 9/30/2022. Under notes, due to Braden score 13 and current comorbidities, R1 is at risk for skin alterations. Per R1's notes dated 10/3/2022 by V13 (Physician Assistant) documents as follows: R1 high risk for developing contractures, pressure ulcers, poor healing per fall if not receiving adequate therapy and pain control. R1's notes dated 10/15/2022 by V11 (Licensed Practical Nurse) documents as follows: R1 was observed with skin alteration to his sacrum. Writer cleaned site and applied dry dressing. Medical Doctor, V1 (Director of Nursing), V12 (Assistant Director of Nursing), and wound care made aware. V2 (R1's Daughter) at the bedside. On 11/9/2022 at 1:45 PM, V10 (WOUND COORDINATOR / LPN) stated, R1 did not have a sacral pressure ulcer when first admitted to facility on 9/30/2022. I (V10) did not know about R1's sacral pressure ulcer until 10/18/2022 when I was informed by facility staff that day. The wound had a lot of necrotic tissue and was measured 7 centimeters by 7 centimeters and was assessed as unstageable due to having a lot of slough and necrotic tissue. When I found it, it was already that size and condition. V10 stated, R1's notes by V11 (LICENSED PRACTICAL NURSE) sacral wound was already identified on 10/15/2022. V10 said, Nobody informed me (V10) about R1's pressure ulcer on the sacrum. So, after reviewing R1's health records, no assessment was done. As to R1's care plan, the pressure ulcer was not addressed until I (V10) modified it today 11/9/2022. I (V10) dated 10/18/2022 because that was the time, I identified R1's sacral pressure ulcer. I should have not modified it, since R1 was already discharged . Upon review of R1's care plan history. It was documented that V10 created a care plan for R1's pressure ulcer on 11/9/2022. Upon review of R1's full care plan, R1's pressure ulcer was not care planned upon initial identification dated 10/15/2022. On 11/9/2022 at 3:12 PM. V1 (DIRECTOR OF NURSING) stated that she was not sure if she was informed by V11 (LICENSED PRACTICAL NURSE) about R1's sacral wound. After checking her phone, V1 said, It's here she (V11) texted me. I was informed by V11 about R1's pressure ulcer on the sacrum. I don't have any knowledge if any of nursing team saw R1's sacral pressure ulcer. There is only one assessment dated [DATE]. The next day R1's sacral wound was bad, and he (R1) was sent to the hospital. As to R1's care plan, I told V10 not to modify it. I agree it should have been care planned once the pressure ulcer was identified. Facility Wound Assessment Details Report by V10 documents as follows: R1's Assessment 10/18/2022, facility-acquired pressure ulcer, unstageable, 10/18/2022 date identified (although notes by V11 documents that it was identified on 10/15/2022). Tissue 20% bright pink or red, 80% necrotic hard adherent. Measured in centimeters as 7.00 by 7.00 total area of 49 centimeters. R1's Minimum Data Set, dated dated dated [DATE] documents as follows: R1's brief interview for mental status score was 5 indicating that R1's cognitive status was impaired. R1's needs one-person extensive assist on bed mobility. R1 does not have unhealed pressure ulcer during assessment. But R1 is at risk of developing pressure ulcer. On 11/10/2022 at 1:51 PM. V11 (Licensed Practical Nurse) said, I remember R1, I first saw his pressure ulcer on 10/15/2022 on his sacrum. It was black and red around it. I don't know how to stage pressure ulcers, but it was bleeding. I cannot remember the actual size of the wound because I did not measure it. I only used 1 boarder gauze to cover it. I cleansed it with normal saline and placed a wet to dry dressing. I informed the doctor, V1 (Director of Nursing), V2 (Assistant Director of Nursing) and the wound care team. Besides my notes, I do not remember if I did any assessment. The next time I came back was on Wednesday 10/19/2022. By that time R1 was already in the hospital. Per R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply gauze to wound bed cover with dry dressing. R2 is [AGE] years old with medical admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/2022 at 11:35 AM. R2 was lying in bed and V8 (R2's DAUGHTER) was at the bed side. The bed had a LAL (low air loss) mattress. There was a thick draw sheet in between the mattress and R2. V8 said, I don't think they are doing a good job on my mother's wound. If they are doing a good job, how did it get so bad? On 11/9/2022 at 1:45 PM. V10 (WOUND COORDINATOR / LPN) stated, Yes, R2 has sacral pressure ulcer that was healed and reopened again . Upon looking at R2's health record. V10 said, On 9/19/2022 R2's sacral pressure ulcer was healed and reopened again on 10/28/2022. In the most recent assessment dated [DATE] it deteriorated because R2 refused treatment. It was assessed by V9 (Wound Doctor) and was found to be deteriorating. I personally did not care plan R2's sacral pressure wound. I agree that because R2 was refusing wound treatment it needed to be care planned. If she (R2) keeps on refusing wound treatment her sacral wound will continue to deteriorate. On 11/9/2022 at 3:12 PM V1 (DIRECTOR OF NURSING) said, Any resident that has a pressure ulcer and is refusing treatment must be care planned. Education is needed for R2 to understand the importance of proper treatment. On 11/10/2022 at 12:42 PM. V9 (Wound Doctor) said, My assessment for the buttocks wound and facility's assessment for the wound is the same. R2's wound extends from sacrum to the buttocks, or midline of the buttocks. If it is on bone prominence it is pressure, but because I also see shearing, I classified it as skin tear. But since the sacral area is a bone prominent area you could classify it as pressure sore. R2 was resisting care, and it takes 3 of us to turn her (R2). Part of the problem is convincing R2 to let staff reposition her. Preventive measures to prevent the wound from deteriorating are off-loading, repositioning, and behavioral interventions. I am not familiar with the care planning the facility used. But these interventions are important. For general wound care, it depends upon the patient status. Infection can be prevented by repositioning, off-loading, maintaining clean area of the wound, dietician intervention. It is essential for planning of care. Per R2's wound assessment by V9 dated 11/3/2022 documents as follows: Per nursing report, R2 has been refusing treatment and wound has deteriorated. On exam, 2 nurses and 1 tech were at the bedside, trying to convince R2 to be repositioned and have exam and treatment done. Discussed with R2 how her non-adherence has led to deterioration of wound. Wound measures in centimeters 6 by 8 by 0.1 with surface area 48 centimeters. Wound has exudate of light serous, 20% slough, 60% granulated tissue and 20% skin. Wound deteriorated. Compared to wound assessment dated [DATE] documented as follows: Wound measures in centimeters 5 by 7 by 0.1 with surface area 35 centimeters. Wound has exudate of light serous, 100% granulated tissue. Facility wound assessment also documents deterioration. Wound assessments are as follow: On 9/19/2022 sacral wound classified as pressure was healed. On 10/28/2022 wound on the sacral re-opened measuring in centimeters 5 by 7, 35 centimeters area, and 100% bright pink or red. On 11/4/2022 sacral wound measures in centimeters increase in size to 6 by 8, 48 centimeters area with 20% slough white fibrinous, 20% skin intact and 60% bright pink or red. R2's care plan does not address the sacral pressure ulcer and/or R2's behavior in refusing care as it relates to the pressure ulcer.

Based on interview and records review, the facility failed to provide adequate and sufficient care for 1 resident (R2) in a sample of 4 residents (R1, R2, R3, R4) reviewed for falls. This failure resulted in R2, a resident who requires two person-assist for bed mobility falling out of bed and sustaining a femur fracture. Findings include: R2's Face Sheet documents resident is a [AGE] year old with diagnoses including, but not limited to: History of Falling, Spinal Stenosis, Lumbar Region Without [CONDITION(S)] Claudication, Acute Respiratory Failure with [CONDITION(S)], [CONDITION(S)], Unspecified [CONDITION(S)], Unspecified Transient Alteration of Awareness, Adult Failure to Thrive, Acute Kidney Failure, Unspecified Obesity, Unspecified Acute Embolism and [CONDITION(S)] of Unspecified Deep Veins of Unspecified Distal Lower Extremity, Presence of Unspecified Artificial Knee Joint. Facility's Final Reportable (8/17/22) regarding R2's documents in part: On 8/13/22, certified nursing assistant (C.N.A) was providing ADL (activities of daily living) care to R2. Upon turning R2 to the left side, R2's legs and lower body begin to slide off the bed. To prevent R2 from falling to the floor, C.N.A. lowered R2 to the floor while calling for help. R2 complained of left knee pain and prn (as needed) pain medication administered. Doctor notified and ordered R2 to be transferred to the hospital for further evaluation. On 8/17/22 the facility received clinical updates and R2 was noted to have a left periprosthetic distal femur fracture. On 09/14/2022 at 9:50 am, V2 (director of nursing) stated, R2 sustained a fall on 08/13/2022 resulting in a femur fracture. R2's fall occurred while a certified nursing assistant was providing ADL care at R2's bedside. The C.N.A. tried to prevent R2 from falling, however, was not successful. R2 had all fall preventative measures in place as per R2's care plan. If a 3 is coded on a resident's MDS for bed mobility, the resident requires at least two CNA or staff members to provide care. On 09/14/2022 at 12:05 pm, V4 (physical therapy director) stated, on 07/16/22 physical therapy picked R2 up post fall incident (R2 had a fall at the facility on 7/15/22). R2 remained at previous baseline of two-person max assist with transfers and bed mobility. On 09/15/2022 at 10:04 am, V7 (fall prevention coordinator) stated, R2's second fall occurred on 08/13/22. R2 was in bed, getting ADL care and R2 was positioned properly in the bed. While R2 was getting the care R2's leg dropped over the side of the bed. R2's top leg dropped over R2's lower leg and dropped over the side of the bed. With R2's leg dropping like that, the leg made R2 start sliding out of the bed because R2 has bilateral lower weakness. The C.N.A. who was providing care to R2, went around to the other side of the bed to try and prevent the fall. The C.N.A could not prevent the fall, and instead ended up guiding R2 to the floor. The CNA was not able to prevent the fall, so she guided her to the floor and called for help, staying with R2 the entire time. The floor mats were already at R2's bedside. R2 sustained a left peri-prosthetic distal femur fracture. Due to the density of R2's bones, arthritis and R2's age and previous fractures, R2 sustained a femur fracture. The impact of R2 being led to the floor could have resulted in R2 sustaining a femur fracture. R2 complained of pain and aches in R2's left leg and R2 was sent out to the hospital. In order to implement other post fall interventions, we had to wait till R2 returned from the hospital so that we can assess her, however, R2 never returned. On 09/15/2022 at 2:17 pm, V3 (restorative director) stated, Prior to the first fall that took place on 07/15/2022, R2 required extensive assistance with almost everything. R2 required assistance from 2 or more staff members for ADL care and bed mobility. When R2 was receiving ADL care on 08/13/2022, the day that the second fall occurred, R2 required 2-to-3-person assistance. When R2 was receiving ADL care due to a bowel movement or bed bath, R2 should have had two CNA's present at bedside for R2's safety. The reason why R2 needed the presence of two CNAs while getting cleaned is because R2 would not be able to help because R2 required extensive assistance. R2 was assessed as being a 3, which means that R2 required the assistance of 2 or more CNAs. I think the assistance of 2 CNAs would have been sufficient. R2 was not able to perform anything independently. On 09/15/2022 at 2:44 pm, V9 (certified nursing assistant) stated, I was giving R2 a full bed bath when I noticed that R2's legs started to slide off the side of the bed. I scurried to the other side in an attempt to lessen the impact of R2's fall, while at the same time calling for help. A nurse did arrive and did a full assessment, and we used a mechanical lift to get R2 back into the bed. I was the only C.N.A. that was present while I was giving R2 a bed bath. To my knowledge, R2 was one person assist for bed mobility. R2 requires extensive care, but R2 is a one person assist. I have given bed baths alone to R2 in the past. On 08/13/2022, the day R2 fell was not the first time I have given R2 a bed bath by myself. I was not aware that R2 was assessed as needing the assistance of two or more CNAs for bed mobility. If I was aware that R2 scored a 3 on the MDS for bed mobility, I would not have been giving a bed bath to R2 by myself. I was only aware that R2 required a two-person transfer, that is why I never transferred R2 without a second person. I only remember that R2 was a two person assist for transfers, but I was not made aware that R2 required at least two people for bed mobility, as I have done a bed bath for R2 by myself on many occasions. On 09/15/2022 at 3:12 pm, V10 (certified nursing assistant) stated, R2 required two-person assistance for bed mobility and transfers. I never cared for R2 by myself because R2 was too heavy and too difficult to care on my own. It was not safe to care for R2 by just one person. I never did R2's ADL care by myself I always requested another C.N.A. because R2 was difficult to deal with not only because of R2's increased weakness, but because R2 was sundowning as well. On 09/16/2022 at 12:14 pm, V11 (primary physician) stated, If the resident is listed on the MDS as two-person assist, R2 should get help from two people. I saw R2 multiple times in the facility. If this resident is assessed as needing assistance from two people, then two people should have been assisting R2 to prevent falls and injury. Having two people assisting a resident who is scored as requiring two people increases the resident's safety. Minimum Data Set Section G (MDS) (dated 04/22/2022) scored R2 as (3) requiring 2-to-3-person physical assistance for bed mobility. M.D.S (dated 07/23/2022) scored R2 as (3) requiring 2-to-3-person physical assistance for bed mobility. Fall Care Plan (dated 07/16/2022) notes R2 is a high risk for falls related to limited mobility, unsteadiness, generalized weakness, decreased sitting stability increased bilateral lower extremity weakness and most recent falls. Fall Risk Assessment (dated 07/15/2022) prior to fall incident on 08/13/2022 scored R2 as (17) a high risk for falls. Post Fall Investigation (dated 08/15/2022) documents R2 sustained a witnessed fall on 08/13/2022. The investigation documents that the root cause of the fall was due to increased bilateral lower extremity weakness now affecting stability when turning side to side in bed. Resident also failed to identify edge of bed, leading to poor position, destabilizing resident and she was unaware to correct/compensate D/T (due to) weakness. Progress Note (dated 08/13/2022 at 4:43 pm) documents, Resident is a/o x 3. Complaining of left knee pain. E. ambulance services pick up resident by stretcher and she was taken to R. hospital with 2 attendants. Son at bedside. Fall Occurrence Policy (revised 05/17/2022) states that it is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place and interventions are reevaluated and revised as necessary.

Based on Record Review and Interview the facility failed to provide accurate pressure ulcer assessments and place preventive measures on plan of care with interventions for the sacral pressure ulcer to 1 resident (R3) reviewed in the sample of 3 (R3, R6 and R9). These failures resulted in a R3's Facility aquired sacral pressure ulcer deteriorating and increasing in size. Findings includes: R3 was [AGE] years old, originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview for Mental Status (BIMS) dated 3/24/2020 reads that R3 has a score of 9 meaning that R3's cognition was not fully intact. R3 was discharged on [DATE]. On 12/1/2020 at 2:45 PM, V9 (Wound Care Coordinator / LPN) stated, On 3/26/2020, a staff nurse informed me that R3 had an open area on the back side, when I assessed R3 I saw an open blister, bright red, no exudate, no drainage. I informed V10 (Nurse Practitioner) because she was in-charge of R3's medical care including wound treatment. Preventative measures should include turning and repositioning every 2 hours, low air loss mattress, ensuring that R3 was not soiled or wet every 2 hours. All of these interventions must be included in the care plan. R3's pressure ulcer on the sacrum was facility acquired. On 12/2/2020 at 11:10 AM., V3 (Assistant Director of Nursing) stated, R3 came to the facility due to stroke and needed therapy. R3 had [DIAGNOSES REDACTED]. and diarrhea, R3's sacral pressure ulcer most likely worsened from the diarrhea. Proper interventions should be low air loss (LAL) mattress, lab draw, turn and reposition Q2H, making sure resident is clean and dry every Q2H. All of these interventions should be in the care plan and should be included in the physician order. I was not aware that there were no physician orders or care plan done related prevention of the wound from deteriorating. R3 went home per family's request. Facility provided R3's 2 wound assessments dated 3/26/2020 and 4/1/2020. Wound assessment dated [DATE] reads: the wound was located on the sacrum, classified as blister, facility acquired, wound size in centimeter (cm) 8.00 X 9.00 X 0.00 (length x width x height), skin intact 50%, bright pink or red 50%, in the photo the wound was open and covers only the tail bone or sacral area. Wound assessment dated [DATE] reads: the wound was located on the sacrum, classified as blister, facility acquired, wound size in centimeter (cm) 7.00 X 7.50 X 0.00 (length x width x height), bright pink or red 100% and in the photo the wound covers not only the tail bone or sacrum but also a large area of the buttocks. In comparison of both photos wound assessment dated [DATE] shows that R3's wound area was multiple times larger than the wound assessment done on 3/26/2020. On 12/2/2020 at 11:44 AM. After showing both wound assessments dated 3/26/2020 and 4/1/2020 for comparison. V17 (Regional Consultant) stated, This is not right, I think these assessments are not right. R3 had pressure ulcer on the sacrum and based upon the wound assessment dated [DATE] and 4/1/2020 the pressure ulcer deteriorated. As I remember, it was classified as a blister but the area became larger from 3/26/2020 to 4/1/2020. It should at least be included in the care plan to address this wound regarding preventing it to worsen. R3 was not seen by a Wound Doctor, and V10 (Nurse Practitioner) was in charge of her medical care including wounds. On 12/2/2020 at 12:20 PM., V10 (Nurse Practitioner) stated that R3 had pressure sore on the sacrum and was not eating well. R3's wound became worse because R3 was declining. On the medical point, there needs to be interventions like reposition Q2H, keeping clean and dry, proper treatment, low air loss mattress in order to prevent pressure sore from worsening. Regarding care plan, I am not in-charge of doing the care plan. But there should be interventions to prevent further deterioration of the pressure ulcer either in the care plan or as an order. I understand that even if a resident has co-morbidities it is still necessary to provide interventions to prevent pressure ulcer from progressing. R3 was not in hospice, but I advised her to be in hospice. It was my understanding that R3 will be admitted to hospice after discharge to home. On 12/3/2020 at 10:05 AM., V35 (Registered Dietitian) stated, I am familiar with R3 and that is my assessment on 3/20/2020 as shown in my notes. That is my only assessment, if I did not do another assessment, the nursing staff did not inform me about R3's sacral pressure ulcer. When R3's wound assessments dated 3/26/2020 and 4/1/2020 that includes photo of R3's sacral pressure ulcer was presented to V35. V35 stated, For me it is only a blister, and I do not need to address R3's nutritional needs related to her wound because it is only a blister. Because it was identified as a blister it is a blister, it doesn't matter how it looks like, for me it is a blister. When R3's Full Care Plan was presented to V35 and was asked about the lack of nutrition intervention for R3's sacral pressure ulcer in the Care Plan. V35 stated, Because it was only a blister then I do not need to do a nutritional care plan for the wound. When R3's Order was presented to V35 and was asked about the lack of nutritional supplement to help pressure ulcer healing. V35 stated, Protein supplement will be helpful for resident with pressure ulcer for healing of tissue. But since it was only a blister it was not recommended and was not included in R3's order. Yes, R3 has poor appetite. R3's Full Care Plan was reviewed and nutrition for sacral pressure ulcer was not addressed and not even mentioned. R3's Orders does not include nutritional supplement to facilitate or help with pressure ulcer. R3 has 2 Skin Evaluations dated 3/19/2020 and 3/26/2020. In the initial skin evaluation dated 3/19/2020, R3's sacral area skin was intact. On the next skin evaluation that was done on 3/26/2020 when sacral pressure ulcer was first discovered. The notes written by V9 (Wound Coordinator / Licensed Practical Nurse) reads: Writer notified by staff nurse that R3 has a new alteration to the sacrum. Wound care team assessed resident and observed open blister, treatment in place. V10 (Nurse Practitioner) was notified, according to resident incontinent and Braden Score 16 (The Braden scale assesses a patient's risk of developing a pressure ulcer) R3 remain at risk for further skin alteration. However, skin preventive measures remain in progress. After further review of R3's electronic health record, skin preventive measures does not reflect on R3's notes, was never care planned or placed as an order from 3/26/2020 when sacral pressure ulcer was discovered up to 4/2/2020 when R3 was discharged from facility to home. And based on the wound assessments photos on both 3/26/2020 and 4/1/2020. After only 5 days, R3's sacral pressure ulcers has increased in size multiple times. Although the facility on both assessments categorized R3's pressure ulcer as blister, wound assessment on 4/1/2020 sacral area not only covers the sacrum but also the large area of the buttocks. Facility Policy on Skin Care Treatment with review date 8/5/2020 provided multiple procedures to prevent worsening of pressure ulcer that the facility failed to provide. It reads: It is the policy of this facility to ensure prompt identification, documentation and obtain appropriate topical treatment for [REDACTED]. Charge nurse must document in the nurse's notes and / or the wound report form any skin breakdown upon assessment and identification. Resident who are not able to turn and reposition themselves will be turned and reposition every 2 hours unless specified in the POS. Resident with Stage 3 and / or 4 pressure ulcer will be placed in specialized air mattresses like low air loss mattress with an incontinent brief if they are incontinent only, incontinence pad which will also act as repositioning aid, and either a flat sheet or a fitted sheet which are all necessary to prevent infection control issue.

Based on observation, interview and record review, the facility failed to adequately assess a resident identified at high risk for pressure ulcers, in an effort to ensure wounds are identified and treatment is implemented promptly, for 1 of 1 residents (R148), in a sample of 49, who was identified to have a facility acquired pressure ulcer to the right heel. This facility failure, resulted in a deterioration of R148's skin integrity and the development of a Stage 3 pressure ulcer to the right heel. Findings include: R148 is [AGE] years old with [DIAGNOSES REDACTED]. R148's Braden Scale dated 1/03/2020, documented that R148 was a moderate risk (score 13) for pressure ulcer development. R148's Minimum Data Set ((MDS) dated [DATE], under the section titled, Functional Status, facility staff indicated that the resident required total dependence of two+ persons physical assist, during transfers and toileting; and extensive assistance of two+ persons for bed mobility. On [DATE], R148 was transferred to the hospital. According to the hospital records, R148 was treated for [REDACTED]. The hospital Nursing Progress Notes, Admission Summary dated [DATE], on assessment, R148 was identified to have an unstageable wound on the heel of his right foot. The hospital Consultation Note dated [DATE], documented the following: R heel Necrotic tissue; Length 4.5 cm (centimeters), Width 2.5cm; Depth 0cm. On review of the electronic health record, there was no documentation that facility staff identified the wound on R148's right heel. This wound was not identified until the resident was transferred to the hospital on [DATE]. R148 was discharged from the hospital on [DATE], with treatment orders and instructions for facility staff, for the wound on the right heel. R148's Wound Assessment Details Report dated 1/6/2020, documented that the facility wound care department, performed a full body assessment and noted sacrum and ischial wounds. There was no documentation of the wound to the right heel. Upon the resident's return to the facility, staff failed to assess, identify and implement treatment for [REDACTED]. The wound to the right heel, was not identified by facility staff until 1/28/2020. According to the documentation, on 1/28/2020, R148's right heel measurement was recorded as- 2.20 cm X 2.10 cm X 0.10 cm (L x W x D). During an observation of the dressing change on 2/05/2020, the wound to the right heel measured - 2.00 cm X 1.00 cm X 0.10 cm (L x W x D). Skin/Wound Note dated 1/28/2020 indicated, Resident seen by wound MD (medical doctor) new site heel, orders placed in (facility computer program) preventative measures and tx (treatment) orders remains in place. On 2/5/2020 at 2:52 PM, V7 (Wound Care Nurse/Licensed Practical Nurse, LPN) stated that R148's wound on right heel was discovered on 1/28/2020. V7 (LPN) stated that wound care nurses do assessments daily. On 2/6/2020 at 10:19 AM, V8 (LPN) said that if Certified Nursing Assistants (CNA) notice anything on residents during the showers, CNA's are supposed to notify the nurses. V8 further stated, nurses will then perform a full body assessment and will notify the doctors of any findings. On 2/6/2020 at 12:19 PM, V8 (LPN) stated that during R148's admission to the facility she noted a wound on both heels. V8 stated that when R148 arrived to facility, she (V8) needed to remove the hell protectors and the dressing in order to assess R148's lower extremities. V8 said that she notified the Wound Care Department about R148's wounds. On 2/6/2020 at 11:00 AM, V13 (CNA) stated that she noticed the wound on R148's right heel on readmission to the facility, but she forgot to report it. On 2/6/2020 at 10:37AM, V12 (Wound Care Nurse/LPN) stated that she performed a full body assessment on R148 upon readmission. V12 stated that she didn't notice any wound on R148's right heel. V12 said that the wound was identified on 1/28/2020 when she was doing rounds. V12 stated that skin assessment is done by wound care nurses only on the wounds have already been identified. Floor nurses do weekly skin assessments. On 2/6/2020 at 10:51 AM, V10 (Wound Care Physician) stated, I started taking care of him when he came in. He was admitted with wounds. I was notified that (R148) had the right heel pressure ulcer Stage 3, can't remember when. But I did see (R148's) right heel last on [DATE]20. We are treating it with [MEDICATION NAME] Blue. Daily assessment on the skin identifying wounds like these should be documented. I was notified, yes but I don't know how staff works, they are not my employees. Staff should follow the skin protocol. That is their job and in their job description. I can only assess what I see that day at that time, and the wound can develop within hours. So, I expect - float heels on bed; air boot or heel protector and wound treatment should be implemented in order to prevent and manage pressure ulcers on the feet. These are protocols in the facility. Facility Policy Skin Care Treatment Regimen Revised August 2, 2019 states It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [REDACTED]. Procedures: 1. Charge nurses must in the nurse's notes and/or the Wound Report form any skin breakdown upon assessment and identification. 5. Refer any skin breakdown to the skin care coordinator for further review and management as indicated.

Based on observations, interviews and record reviews, the facility failed to develop effective interventions to prevent a resident from multiple falls in which two resulted in serious injuries. R3 reviewed for falls with injuries out of 4 residents reviewed for falls in a sample of 21. R3 sustained an injury to left forehead requiring sutures and sustained a Left Rib fracture. Findings include: On 1/09/2020 at approximately 1:10pm, V32(Local Fire Department) reported, When we arrived, the resident was lying on the floor in blood. They left him in the same spot where he fell . The staff didn't try to get him up. There was blood on his head and the floor. He was alert and denied pain. This guy was coherent. He knew what was going on around him. The nurse called 911 for us to pick him up. The engine company (It's called that not paramedic), picked patient up and placed him in a wheelchair. V32 stated that R3 told him that the nurse blocked him in his room by placing the medication cart in front of his door. V32 reported, The patient told me he wanted to go to the hospital and not return. R3 was transferred to community hospital B. On 1/9/2020 at 2:45pm, V24(RN) stated, It's been a while since I worked on the evening shift. I worked on 12/25/2019. I took care of R3. The CNA informed me that R3 was on the floor in his room. I went to his room and resident was laying on the floor on his left side. I did an assessment: He stated his left rib area was hurting, took vital signs. They were stable. We put him in bed. Don't remember if I gave him pain medication or not. Received doctors order to send patient to hospital. On 1/9/2020 at approximately 3:00pm, V23(RN) stated, The fall incident with R3 happened in November, 2019. I did rounds on my shift. The CNA told me the resident was on floor. I first saw resident face down. I saw blood on the floor. I turned R3 to the side and saw laceration on R3's left eyebrow. Didn't know if resident had a spinal injury. I did not move resident. Resident was alert and oriented to name. R3 said he tripped. I asked the resident if he was in pain, he denied any pain, took vital signs and they were stable. I put pressure dressing on forehead. I called for another nurse. I left the room to call 911. When ambulance arrived, they placed resident on a stretcher from the floor. I notified the doctor. Requested to interview CNA's(V27 and V28) who reported R3 falls on 11/24 and 12/25/2019. On 1/09/2020 at 3:30p.m., V1(Administrator) stated that they no longer worked at the facility and attempted call both CNA's but they had not returned call. On 1/09/2020 at 3:40pm, V25(Physician) stated, R3 had prior history of falls prior to admission to this facility. R3 was admitted from hospital for weakness. He had falls since he's been here. I'm aware of R3's head injury on 11/24/2019 and his left rib fracture happened on 12/25/2019. The first fall was not preventable because staff was not familiar with the resident. After the first fall, interventions were put in place such as bed alarm, R3 was moved closer to the nursing station and other interventions. Resident was ok to get up with staff assistance. The nurse told me, R3 said he was going to fall on the floor and hurt himself. Despite interventions put in place, R3 continued to have falls. I ordered another psychiatric evaluation but resident was not here long enough to receive it. V25 responded to question about R3 left on floor until Emergency Medical Services arrived. He said, It's not uncommon for a patient to be left on floor/ground depending on the situation. The nurse may have not moved resident to prevent further injury to head or spine, as long as staff is by his side for support. On 1/10/2020 at 12:20pm, V30(Nurse Practitioner) stated, R3 had some falls while in the facility. R3 had [DIAGNOSES REDACTED]. He denied R3 was taking anti-psychotics. R3 denied hearing voices and he did not verbalize any delusions to me. He was somewhat withdrawn. He was continued on [MEDICATION NAME] because that's what he was taking in the hospital. [MEDICATION NAME] can be given for ADHD(Attention Deficit [MEDICAL CONDITION]) or ADD([MEDICAL CONDITION]). [MEDICATION NAME] may also be prescribed for failure to thrive, low body weight. He was not eating well. Did the hospital figure out why he had so many falls? MDS (Minimum Data Sheet) indicates R3 was admitted on [DATE], with history of falls with minor injury, Medications received: 2 days admission: Anticoagulant (i.e., [MEDICATION NAME]). MDS section for balancing and transfer indicates: Surface to Surface transfer (transfer between bed and chair or wheelchair=2=Not steady, only able to stabilize with staff assistance. Moving from sitting to standing=8= activity did not occur, walking =8= activity did not occur, turning around=8=activity did not occur. Wheelchair indicated. Family or Significant other participated in assessment. MAR(Medication Administration Record) dated 11/25 and 1/26/2019 indicates R3 received [MEDICATION NAME] Sodium 40 MG/4.0ML subcutaneously in Right Upper Quadrant and Left Upper Quadrant of abdomen respectively: This medication is given to prevent clots. On 1/9/2020 at 4:15pm, V26(LPN/ Fall Coordinator stated, Anytime a resident has a fall, I will conduct a full investigation of the fall. I will do my own investigation to determine root cause. The Root Cause Analysis is done electronically. I will modify the nurse's care plan and put in new fall interventions or change interventions. R3's thought process was jumbled, confused. He started having some delusions. R3 seemed alert and oriented to name, place and time but the more you speak to him, he seemed more confused. The first fall was due to weakness. He tried to get up out of bed. He was seen by the psych nurse practitioner after the first fall. He stated someone was trying to get him. He was paranoid. R3 was to be seen by the psychiatric doctor for another evaluation. R3 was impulsive He fell on the floor a couple of times. We put him closer to the nursing station, placed bed alarm and explained safety awareness. He was not started on any medication. Explained to R3 to pull call light. He nodded his head as if he understood but he did not do it when he needed help. V26 presented a chronological fall history for R3. R3 experienced eight falls between 11/24/2019 and 12/26/2019. 11/22/2019: R3 admitted to facility 11/24/2019: R3 fell , laceration to forehead, sent to hospital ER. Intervention, R3 educated on using call lights and to ask staff for assistance. To be seen for Psych Evaluation. 12/3/2019: R3 fell from wheelchair- no injury. Mat placed in wheelchair to minimize sliding. 12/10/2019: R3 fell attempting to transfer self from wheelchair to bed without waiting for staff assistance. No injury revealed by in-house X-rays, PT/OT to evaluate strength and mobility. Educated to change positions slowly especially from sitting to standing and ask for staff for help. 12/25/2019, Resident fell from bed. R3 presented with delusions and was noted calling 911 stating that Two guys are outside of the door trying to kill me. R3 sent to ER. 12/26/2019 at 4:05am, R3 returned from ER with [DIAGNOSES REDACTED]. A chair and bed alarm put in place for safety. Resident to be evaluated by in house Psychiatrist. 12/26/2019 at 8:31am, Resident observed laying on the floor next to his bed. R3 stated, I'm trying to leave, I don't want to live in this place anymore. Resident sent to ER for Evaluation. 1:05pm: R3 returned from ER with no injury. Resident moved to room closer to nursing station for closer observation. Resident to be visually checked more frequently while in bed. 12/26/2019 at 6:40pm, Resident fell from bed stated he was attempting to reach his phone when he slipped out of bed. R3 sent to ER for evaluation. 10:56pm: Resident returned from ER with no injury. Resident to be provided with activities that can provide a distraction and minimize the potential for falls. Resident's bed should be in lowest position while in bed for safety. (Per Policy, all residents's on blood thinners that have unwitnessed fall must be sent to the ER for evaluation.) Facility's Psych Provider (V30/Nurse Practitioner) Initial Evaluation Note documents: History and Physical dated 11/25/2019, indicates R3 [DIAGNOSES REDACTED]. Cognitive Impairment: Mild, Mood=anxious/depressed. Present History: Patient denies mental illness despite [MEDICAL CONDITION] listed in records; patient denies current antipsychotic treatment. Medication: [MEDICATION NAME] 5mg BID. Community Hospital A ER(emergency room ) Physician's notes dated, 11/24/2019 documents, R3 was admitted to the ER at 9:48am and discharged back to nursing home at 4:51pm. Physician notes Indication: Trauma; head injury after mechanical fall. History [MEDICAL CONDITION] residual weakness. Noncontrast CT of brain was obtained. Impression: No [MEDICAL CONDITION](bleeding). Small left frontal scalp laceration/hematoma. Impression: In order to achieve hemostasis, patient [MEDICAL CONDITION] repaired at bedside with 3 interrupted sutures. Approximately 2cc [MEDICATION NAME] with epi injected around laceration site prior to repair. X-ray of pelvis Impression: No acute fracture. According to Hospital B emergency room (ER) Intake Sheet dated 12/25/2019, R3 was admitted to the ER at approximately at 5:58pm and was discharged back to the facility on [DATE] at 12:34am. ER Physician's History and Physical documents: 72 y/o male Previous medical history of [REDACTED]. Of note on 12/3/2019 had similar presentation with fall from wheelchair. Patient has residual Left sided weakness from [MEDICAL CONDITION]. Patient states he was trying to stand from his bed to get to his wheelchair and in the process slipped and lost balance, then fell on this left side and flank, also hit his head. Denies (L[NAME]-loss of consciousness). Appearance: Left facial droop. Patient Physician Exam denotes reason: FALL. Exam: Left rib pain, 3 views. Clinical indication: [AGE] year old male with left rib pain. X-ray Findings: There is an acute appearing nondisplaced left eighth rib fracture near the constochondral junction. Impression: Acute appearing left eighth anterolateral nondisplaced rib fracture. Correlate with point tenderness. CT of Head: Impression: No acute [MEDICAL CONDITION] or depressed skull fracture. There is a concern for stroke, further evaluation with MR. ER Nurse's note dated 12/25/2019 documents: Nurse from Warren Barr contacted. Nurse was notified that patient has a nondisplaced rib fracture and is going to be discharged . According to Hospital B ER admitting intake sheet dated 12/26/2019, R3 was admitted to the ER at 7:46pm, for accidental fall at nursing home. R3 was discharged back to nursing home at 10:20pm. Physician note documents: Patient to ER for mechanical fall. Patient states he dropped his cell phone, bent over to pick it up and accidentally tripped over and struck left parietal (side) of head against the siderail. Denies L[NAME], history of [MEDICAL CONDITION]; left sided weak. Patient states he does not feel safe where he is staying. Patient requested social services for possible transfer. Hospital B ER Physician's Notes dated 12/26/2019 remarks: Differential Diagnosis: [REDACTED]. Notes. Patient just seen at community hospital ER for complaint of fall just yesterday. Patient with multiple falls sent from Warren Barr again today with complaint of fall. Hospital B History of Present Illness documents: The patient is a 72 y/o male who presents with fall. The course of pain is decreasing. Location of pain: head. The degree of headache: negative. The other degree of pain is negative. The degree of bleeding is negative. Existing injuries prior to trauma were left 8th Rib Fracture. Re-examination: Head CT: Negative for any acute process. Patient to go back to Warren Barr and continue usual medical regimen. Reviewed cautions for falling and patient awaiting transportation. Hospital B ER intake document dated 12/26/2019 remarks; R3 arrived in ER at 10:00pm. R3 in ED(Emergency Department) at facility(Warren Barr South Loop Nursing Home) for mechanical fall today. Patient dropped his cell phone, bent over to pick it up, and slipped on his side. Patient states he hit the left side of his head against the siderail. Denies L[NAME]. No noted injuries. Patient and per EMS(Emergency Medical Service Driver) states patient had a total of 3 fall episodes today, 2 of which he slid down from his bed while sleeping and fell , the 3rd time was when he dropped his phone and tried to pick it up. Patient currently receiving physical therapy [MEDICAL CONDITION] which are left side residual weakness. Patient states normally ambulates on his own but with a limp. Per EMS, patient was seen yesterday here at community hospital B for same complaints of fall. Discharge note dated 12/26/2019 at 10:20pm documents: ambulance here to take patient back to Nursing Home. On 1/3, 1/7, 1/8, 1/9 and 1/10/2020, R16, R17 and R19 are at risk for falls. Residents were interviewed and observed in their rooms. Residents denied any fall concerns. Fall Occurrence Policy dated (MONTH) 30, 2019 documents: It is the facility policy to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission, readmission, quarterly, significant change, and annually.

Based on observation, interview and record review the facility failed to follow their plan of care and the Skin Care Treatment Regimen Policy and Procedure by not providing incontinent care at least every 2 hours, failed to provide wound dressings as ordered, failed to provide nursing preventative interventions to avoid new wounds, failed to identify new wounds, failed to consult the wound doctor for changes in wound condition and failed to monitor skin/wound weekly for 3 of 10 residents (R2, R7 and R11) reviewed for wound care protocol and prevention. This failure resulted in R7's development of new facility acquired pressure sores and the deterioration of the existing sacral pressure sore. Findings include: 10/29/18 at 1:50 pm, V29 (Certified Nursing Assistant, CNA) removed R7's adult brief. R7's multiple wounds exposed on sacrum, left and right buttock with no dressings on and liquid stool on sacral wound and left buttock wound. Skin reddened on the edges of sacral and left and right buttock wound with small amount of blood. V29 stated that R7 did have a dressing on her buttocks covering the wound but it came off about 9am when she had a bowel movement then so I left it off because I know wound care will come see her. 10/29/18 at 2:05pm, V8 (Wound Care Director) stated that V29 just told me R7's wound dressing has come off. The CNA should inform the staff nurse right away and the staff nurse could put a dressing on. If a resident sits in stool with an open wound, they risk infection and the wound deteriorating. 10/29/18 at 2:25pm during dressing change, V8 stated that, there was a change in condition in the left buttock wound and it is reverting to pressure wound, and has dead tissue, instead of a skin tear as noted. I would recommend the area be debrided (removal of dead tissue). V8 then asked family member for consent so the wound care doctor may see R7. There is also a new area on the right buttock, on left knee that wound care is not familiar with and looks like pressure wound, as well as a pressure area on her left ear that was not identified on wound care notes. R7 had gauze and a dressing over the left knee area that was not dated. V8 stated she does not know how long it was there, just that wound care had not identified this area on their weekly notes. V8 stated then that R7 is on a regular mattress. 10/31/18 at 10:46am, V8 stated that R7 was readmitted with a stage 3 pressure sore on sacrum on 9/23/18 and air mattress should have been in place when R7 was admitted but it was overlooked. Prompt care when a resident has urine or a bowel movement is an intervention in place to prevent worsening of wounds or new wounds. On 10/12/18, a skin tear was noted to left buttock but I would have called that a deep tissue injury based on appearance. We are supposed to take weekly wound measurements on all wounds. There was no weekly measurements from 10/12/18 to 10/30/18 for sacrum or left buttock. On 10/12/18, Left buttock skin tear measures length of 3.5 centimeter (cm) by width of 5 cm by .10 cm depth with no undermining. The Left buttocks deteriorated. The floor nurses are responsible for daily skin checks and to inform wound care of any new areas. R7's wound care plan did not have left buttock skin tear or any treatments until 10/29/18 when I added it with the new wounds. V8's progress notes dated 10/29/18 notes during routine dressing change, R7 noted with new pressure areas of break down to Left Ear, Right Buttocks and Left knee. Left buttock wound noted as worsening. R7 referred to wound specialist. V8's progress note 10/30/18 indicates surgical debridement performed today by wound care Doctor. V31's (Wound Care Doctor) note dated 10/30/18 notes the dates of onset for a stage 4 pressure ulcer on Left ear, right buttock unstageable deep tissue injury and a pressure stage 2 on left knee as 10/29/18. Left buttock and sacrum are unstageable deep tissue injury from pressure. Left buttock wound measures Length-14 centimeter (cm) by Width of 13cm by depth of 0.1cm. Exudate/drainage, 20 percent % dead tissue. Surgical Excisional debridement procedure was performed on Coccyx and Left buttock to remove dead tissue. A [MEDICATION NAME] agent ordered for right buttock and left ear. R7 requires total assistance with activities of daily living. Preventative measures include prompt incontinence and turning and repositioning every 2 hours. 11/08/18 at 10:11am, V31 stated that left buttock was debrided and R7 has purulent drainage that I was surprised and possible infection. There is also a tunnel there now and I recommended infectious disease follow R7. R7 developed new pressure areas on right buttock, left ear and left knee. Having stool on open wounds could contribute to wound deteriorating or becoming infected and R7 should have prompt incontinent care. V8's progress note dated 11/7/18 at 7:28pm note that Coccyx & Left Buttock debrided with V31 which were found with an abscess that was ruptured. New orders for Infectious Disease consult received & carried out. V59's (Infectious Disease Nurse Practitioner) note dated 11/7/17 indicates reason for consult as [MEDICAL CONDITION] of sacral ulcer. [MEDICATION NAME] (antibiotic) started for 3 weeks. 10/13/18 progress note by V23 (Licensed Practical Nurse/Wound Care Nurse) notes during routine dressing change, resident was noted with skin tear to left buttock and Left thigh back. Physician orders [REDACTED]. Treatment Administration record (TAR) from 10/14/18 to 10/30/18 note this was done daily by nursing. Facility policy labeled Skin Care treatment notes use a [MEDICATION NAME] agent daily on dead areas for stage 3 and 4 wounds. TAR also notes [MEDICATION NAME] is ordered and given for left buttock. 10/31/18 at 10:46am, V8 stated that [MEDICATION NAME] is not an appropriate order for the left buttock wound. Wound care plan intervention dated 9/19/18 notes to monitor/document location, size and treatment of [REDACTED]. Skin Care Treatment Regimen Policy and Procedure revised last on (MONTH) 1,2017 note that it is the policy of the facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for [REDACTED]. Charge nurses must document in the nurse's notes and or the Wound Report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the patient's physician. Refer any skin breakdown to the skin care coordinator for further review and management as indicated. Residents who are not able to turn and reposition themselves will be turned and repositioned every 2 hours. Stage 3 and 4 including pressure ulcers may be referred to wound care specialist for further clinical and treatment consultation in accordance to the facility protocol and standard of care. Residents with Stage 3 or 4 will be placed in specialized air mattress like Low Air Loss Mattress or Alternate Pressure Mattress. Per facility face sheet, R2 was admitted to the facility 7-20-18, and has [DIAGNOSES REDACTED]. R2's MDS (Minimum Data Set) dated 10-14-18 indicates a BIMS (Brief Interview for Mental Status) score of 1, indicating severe cognitive impairment. This MDS also indicates R2 requires the extensive assistance of two or more staff members for bed mobility and to transfer, is incontinent of stool, and has a urinary catheter. R2's (MONTH) (YEAR) physician's orders [REDACTED]. Reason for isolation--KPC ([DIAGNOSES REDACTED] pneumoniae carbapenemase) of urine. 10-29-18 at 12:35 pm, Surveyor asked V29 (CNA) to do an incontinence check on R2. R2's elbows were both bent, and her hands were curled into fists. R2's legs were contracted. R2 was not wearing any heel protectors. V29 donned gloves (without first washing her hands), and unfastened R2's brief. R2 had fresh stool in her brief, and was not wearing a dressing covering her sacral ulcer, which also had stool in it. V29 stated she'd last changed R2's brief at 10:00 am, and R2's wound dressing had fallen off. V29 stated I just left it off, because the Wound Nurse will be coming around. V29 then proceeded to clean R2 from her rectal area toward her vaginal and urethra area, from back to front. V29 did not change her gloves after cleaning the stool from R2's rectal and perineal area. V29 used the same, soiled gloves to apply moisture barrier cream to R2's buttocks, and apply a new bed pad and replace R2's top sheet. 10-29-18 at 1:08 pm V8 (Wound Nurse) stated R2 first developed an unstageable sacral ulcer, discovered by a CNA (Certified Nursing Assistant) on 10-2-18, despite frequent turning and repositioning and having an air mattress. On 10-23-18, this wound measured 5.0 x 6.0 cm (centimeters) x 2 cm deep. This wound was debrided at the bedside on this day by V31 (Wound Care Physician). V8 stated this is the only wound R2 has had since admission to the facility, that R2 has not ever had any foot wounds, but that R2 should be wearing heel protectors due to her immobility. V8 stated if a resident's wound dressing falls off/is missing during incontinence care, the CNA should notify the Wound Nurse or the resident's staff Nurse for immediate replacement, to keep the wound clean, and protect the wound from urine, stool, and bacteria, which may worsen skin breakdown. 10-29-18 at 1:47 pm, Surveyor requested V8 perform a dressing change for R2. V8 stated she hadn't gotten to the residents on R2's floor yet, as this floor is usually the last or next to last. Wound care makes rounds on daily. R2 still did not have a dressing covering her sacral ulcer. In addition, R2 was not wearing heel protectors. V8 stated the CNA should have notified either her or the resident's staff Nurse immediately to replace R2's soiled dressing--the wound should not have been left open since 10:00 am. R2's care plan updated 10-30-18 contains the focus R2's unstageable (pressure ulcer) is currently stage 4 following debridement. This care includes the intervention Sacrum: Cleanse with NSS (normal saline solution). Pat dry with gauze. Apply skin prep to peri-wound. Apply santyl. Cover with secondary dry dressing. Change daily and prn (as needed). R2's care plan also includes the focus on indwelling catheter care, including the intervention I would like staff to clean my peri area from front to back. 10-30-18 at 11:10 am R2 was seen still not wearing heel protectors. 10-31-18 V22 (Restorative Aide) stated Wound Care Nurses are responsible to provide immobile residents with heel protectors. 11-7-18 at 2:00 pm V3 (Director of Nursing) stated CNA's performing incontinence care should first explain the procedure to the resident, wash his/her hands, don gloves, and clean the resident. Female residents should be cleaned front to back, so as not to introduce stool/urine into the vagina or urethra, to prevent infection. After cleaning the resident, the soiled gloves should be removed, and the CNA should again wash his/her hands and don new gloves prior to applying skin barrier cream to the resident's peri rectal area and applying a new incontinent brief. If a dressing falls off/gets soiled/is missing during incontinence care, the CNA should immediately notify the Wound Nurse or staff Nurse so that it may be replaced. Facility policy titled Hand Hygiene revised 10-25-18 indicates Hand hygiene is performed during the following situations: Before and after direct resident contact. Before and after entering isolation precaution settings. Before and after assisting a resident with personal care. After contact with a resident's mucous membranes and body fluids or excretions. Per facility face sheet, R11 was admitted to the facility 5-10-18, with [DIAGNOSES REDACTED]. R11's MDS (Minimum Data Set) dated 5-17-18 indicates a BIMS (Brief Interview for Mental Status) score of 00. indicating severe cognitive impairment. This MDS also indicates R11 had one stage 2 and one stage 3, along with 2 unstageable pressure ulcers on admission, and requires the extensive assistance of two or more staff members for bed mobility. 11-5-18 at 1:40 pm V8 (Wound Nurse) stated R11 was first assessed by V52 (Wound Nurse) 5-11-18. R11 had an unstageable wound to her right elbow, 3.2 cm (centimeters) L (Length) x 3.4 cm W (Width) x undeterminable D (Depth). The treatment was to cleanse the area with normal saline and apply [MEDICATION NAME], then cover with a foam dressing daily. R11 also had an unstageable sacral wound, measuring 9.5 cm L x 13.3 cm W x undeterminable depth. Treatment was the same as for R11's right elbow. R11 also had a left hip stage 2 wound, 1.9 cm L x 1.4 cm W x undeterminable depth. Treatment was to cleanse the area with normal saline and apply a [MEDICATION NAME] dressing every 3 days. R11 also had a right trochanter (hip) wound, stage 3, measuring 5.8 cm L x 4.4 cm W x undeterminable depth. Treatment was to cleanse the area with normal saline, apply Xeroform dressing, then cover with a dry dressing daily. This right hip ulcer was mostly healed, with area within its borders which had re-opened. R11's Treatment Administration Record dated (MONTH) (YEAR) indicates dressing changes on R11's wounds were done, as ordered. V53's (Dietician) consultation 5-16-18 recommended continuation of R11's mechanical soft, thin liquids, no concentrated sweets diet. On 5-17-18, V53 added prostat 30 ml (milliliters) by mouth daily, to promote wound healing. On 5-26-18, R11's left hip ulcer was deteriorating. It had now become unstageable, with 80% necrotic tissue and 20% pale pink tissue. R11's sacral wound was the same as upon admission to the facility. V8 stated R11 was qualified to have the Wound Physician team consult and treat her, due to having been admitted with a stage 3 wound that had re-opened, along with a sacral ulcer that was staying the same,despite treatment, and a left hip wound that was deteriorating. The Wound Care Nurses or Staff Nurses can notify the Wound Care Physician team for consult and treatment of [REDACTED]. ulcers, with the 5-12-18 intervention R11 is being followed by the facility's Wound Doctor/Specialist weekly. There aren't any Wound Care Physician notes in R11's medical record, and the facility confirmed the Wound Care Physician team had not been put on consult for R11. 10-31-18 at 11:29 am V11 (Former Nurse Practitioner) stated she saw R11 on 5-11-18, and recommended Wound Care team (Wound Nurses) and Nutrition to follow. Surveyor asked V11 why she did not order the Wound Care Physician team to consult and treat R11. V11 stated the Wound Care Physician team is supposed to be notified upon a resident's admission to the facility by the staff Nurse or Wound Care Nurse if that resident presents with wounds requiring such consultation.

Based on observation, closed record review and interview the facility failed to assess, analyze the circumstances of falls, evaluate for the effectiveness of interventions, attempt alternative-interventions and supervise residents to minimize the risks for recurring falls and serious injury for 3 resident (R6, R4 and R5) in the sample of 6 residents. Finding includes: 1. R4 was observed on 06/09/11 with bilateral side rails up. Resident was not verbal. Incident and Accident report: 05/22/11 7:05am - Certified Nurse Aide (CNA) states resident (R6) was sitting on edge of bed with alarm attached to gown. Stating she needs to use washroom. Resident placed on commode by CNA. Bed 2 called for assistance, CNA heard a loud thump coming from washroom. Witnessed resident lying on floor on back. CNA immediately came and got nurse. 05/23/11 4:55pm - Resident observed lying on her right side, on the floor at the foot of the bed with alarm sticking out from under her right shoulder area, making a ticking sound. Noted with a pool of blood surrounding her head area with blood gushing from the right side of head. First aide initiated. 05/25/11 9:30am - Resident observed on floor. She was lying outside the bathroom floor. Wheelchair in bathroom. CNA reported she was last seen sitting in dayroom. Upon assessment a moderate amount of dark red blood seen to left side of the head. The nurse notes dates: 05/15/11 9:15pm - Assigned CNA reported to writer that resident was lying on floor in her bedroom. Immediately writer assessed moderate amount of dark blood coming from left side of the patient head. Area cleansed with normal saline solution and area patted dry. Laceration assessed at 3-5cm . R6 jumping and exhibiting facial grimacing to touch. Physician notified. At this time writer received order to have her transferred to Z1 hospital. At 10:30 pm - Ambulance arrived on unit and successfully transported resident to Z1 emergency room . 05/15/11 at 3:00am - Resident received 3 sutures to laceration on left side of head. No active bleeding observed at site. 05/22/11 at 1:00am - CNA making rounds, noted resident sitting on bed with gown off, alarm attached to gown. Sutures to left side head dry and intact. 05/22/11 at 5:30am - CNA states resident was sitting on edge of bed with alarm attached. Stating needs to go to washroom. Bed 2 calls for CNA's help. While attending to her, heard thump in washroom. Witness resident lying on back (on floor). CNA immediately got nurse. Suturse to left side of head dry and intact. 05/23/11 4:25pm - Resident observed lying on her right side, on the floor at the foot of her bed with alarm sticking out from under her right shoulder area making a ticking sound. Noted with a pool blood surrounding her head area with blood gushing from right side of head. Pressure immediately applied to right side of head and 911 called. Pressure to open area on right side of head maintained with ice pack to area and resident covered with blanket to aid in preventing of shock. Neuro checks done, right pupil 4mm/sluggish and left pupil 3mm/brisk. Resident responsive to verbal and tactile stimuli, moaning and crying. Resident roommate stated that she was trying to get up again and fell . 05/23/11 4:40pm - Resident transported to Z1 emergency room . Left eye open, moaning and crying. Swelling and bruising noted on right side face near eye area and bleeding. Paramedics transported. 05/24/11 7:15am - Resident admitted to Z1 hospital with [DIAGNOSES REDACTED]. pain and inability to ambulate. 05/29/11 7:00pm - Resident readmit with multiple bruises to bilateral upper and lower extremities. 3 sutures to right eye brow. The Fall risk assessment (Criteria for Assessment) was score 28 (05/22/11, 05/23/11, 05/29 /11 and 06/01/11) and high risk. E3 (Director of Nurse) on 06/29/11 at 11:30 am in the conference room stated," The residents care plan and assessment should have been revised or updated. The resident should have been reassessed to prevent further fall and effectiveness of the intervention. R6 was not reassessed and care plan not updated or revised. 2. The nurses' notes for R4 date: 12/16/10 denoted at 5:45am nurse was called to residents room by Certified Nurse Aide (CNA). Resident was on the floor with blood running from her left eye . Assessed resident while on the floor. Resident was responsive to verbal stimuli wavering her arms and legs. With assistance from the nurse and CNA resident was placed back in the bed. Starting cleaning from the inner corner of left eye cleansed the blood off to determine the origin of bleeding. Discovered a laceration on the left eyelid. Approximately 1 inch long. Applied pressure with gauze to stop bleeding. 12/16/10 6:00 am notified physician of resident laceration and received order to send to Z1 emergency. 12/16/10 6:05 am Notified ambulance service to transfer to hospital. 12/16/10 6:30am Continue monitoring resident. Noted bleeding had stopped. 12/16/10 6:50am Transferred by paramedic to Z1 emergency room . 12/16/10 1:00pm Writer called Z1 hospital to check on status of resident. Spoke with emergency room charge nurse who said resident was transferred to Z2 hospital for trauma. 12/16/10 1:05pm Writer called Z2 hospital and spoken with nurse (Z3) who is caring for resident. Gave report that resident has a subdural bleed and being admitted for further evaluation. R4 was score high risk for fall. The care was not revised or updated to prevent further falls. 3. The accident and incident report for R5 dates: 03/05/11 10:55pm Resident noted sitting on her bottom on floor next to bed. Was assessed per nursing. Resident had no complaint of pain or distress. No bruises or fractures noted at this time. 03/06/11 2:40am - During rounds noted on floor in room between beds in seated position leaning on right elbow. Assessed no apparent injuries noted. Assessed pain, no sign and symptoms. Assisted to bed. Alarms remain inplace. Close observation for reminder of shift and no further falls. The Nurse notes dates: 03/06/10 2:40 am - During rounds, noted by CNA on floor in room with alaram between bed. assessed with [REDACTED]. 03/06/11 6:05am - Per verbal report from Z1's report right shoulder dislocated. notified nurse practioner for medical doctor with new order to transfer to Z5 emergency room for multiple falls. 03/06/11 9:30am - Ambulance with 2 attendants. Resident placed on stretcher without incident. 03/06/11 5:00pm Received a call from Z5. Resident will return to facility tonight. [DIAGNOSES REDACTED]. 03/24/11 10:50pm - Rounds made and noted resident with leg over side rail and attempting to get out of bed. 03/24/11 11:05 pm - Rounds made and noted resident with leg over the siderail and attempting to get out of bed. 03/30/11 11:30am - Refused to sleep. Climbing out of bed. Complaint of pain. The Z4 laboratory report date 03/05/11 denoted right shoulder and humerus - examination reveals what appears to be anterior subcoracoid dislocation of the head of the right humerus with no definite evidence of fracture. Clinical correlation is requested. The fall risk assessment denoted resident on 03/05/11 and 03/06/11 was at a score of 25 high risk. E1 (Administrator) on 06/02/11 at 3:25pm in the conference room stated," The doctor came to visit resident. He touched her shoulder. She became agitated. He ordered X- Ray. The X-ray showed dislocation of right shoulder. I do not know what happen to her shoulder. She had prior fall before admission. She was unable to tell what happen. She could follow simple commands." The facility did not reassess and revise or update the care plan after each fall. The fall prevention policy and procedure: (1). Fall assessment for all residents upon admission and quarterly and updated as necessary. (c). The effectiveness of each resident careplan as it related to prevention will be documented on each at least quarterly. (d). Fall assessment will be reviewed at least quarterly and update if necessary. (2). All residents assessed, ass high risk for fall will be monitored closely. (e). Review and revise nursing care plan.