Every finding on record at Woodridge Nursing Home

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident, as a result, 1 of 3 sampled residents (Resident #1) suffered physical harm. Findings include:Per record review, Resident #1's diagnoses include frontotemporal neurocognitive disorder. Per review of Minimum Date Set (MDS; a standardized tool used to evaluate residents' needs and improve care planning) dated 8/4/25, Resident #1 has a BIMS (Brief Interview for Mental Status) of 11, suggesting moderate cognitive impairment. Per record review, Resident #2's diagnoses include unspecified symptoms and signs involving cognitive function and awareness, major depressive disorder, unspecified dementia, and restlessness and agitation. A review of the medical record reveals a BIMS of 14, suggesting Resident #2 is cognitively intact. A review of Resident #2's Care Plan dated 6/27/25 reveals Disturbed thought process related to degenerative brain changes as evidenced by confusion, memory loss, and disorientation. with agitation and anxiety. The interventions include observing for mood changes or agitation, identifying triggers for escalation, and minimizing them.Record review reveals that Resident #2 has a history of behaviors. Per a progress note dated 5/10/25, it states that Resident #2 was observed physically pushing a Licensed Nursing Assistant (LNA) backward into the door when she attempted to redirect him/her away from an exit. Later that same day, Resident #2 was observed trying to open a door when an LNA attempted to redirect him/her. Resident #2 shoved the LNA and kicked him in the leg. A progress note dated 8/22/25 states that nursing staff observed Resident #2 pushing a resident with both hands on their shoulders.Per review of a facility incident report dated 9/22/25, Resident #1 was assaulted by his/her roommate, Resident #2, on 9/21/25, and sustained bruising and swelling to the right eye, right cheek, and lip, and an abrasion to the lower lip. Per a progress note dated 9/21/25, a Licensed Nursing Assistant (LNA) reported answering an emergency call light, finding Resident #1 with visible abrasions, blood on the neck and right side of the face, ear, forehead, and lip. The resident indicated that his/her roommate had punched him/her. Review of a progress note dated 9/21/25 states that Resident#1 was observed to have several facial scratches and bruising on his/her face and reported general discomfort. A progress note dated 9/21/25 indicates that Resident #1 rated his/her pain as 4/10, with emphasis on the face where s/he was hit. A progress note dated 9/21/25 reveals Resident #1 to have Right eye, right cheek, right ear, and right lip bruising, mild, abrasion to lower lip. Bruising on the top rear portion of [his/her] head and left wrist.On 9/23/25 at 12:52 PM, per an interview with Resident #1, s/he stated s/he was assaulted by Resident #2. S/he indicated that s/he asked his/her roommate to turn off the TV as it was getting late. Then Resident #2 called him/her some names, swore at him/her and then proceeded to punch him/her in the face at least three times. S/he stated s/he managed to lock him/herself in the bathroom and use the emergency light for help. Per observation, Resident #2 had evident bruising and swelling of the right eye, and an abrasion to the lower lip, and said both his/her back and neck are sore from the assault. S/he stated s/he is using ice on the face and Tylenol for pain. S/he stated the assault scared him/her as it was unexpected.Per interview on 9/23/2025 at 4:12 PM with the Director of Nursing and the Administrator, it was confirmed that Resident #1 was not protected from physical abuse and had sustained injuries because of an assault by his/her roommate.

Based on observation and interview, the facility failed to ensure residents could freely file anonymous grievances. This has the potential to impact all residents. Findings include: Per interview with five residents (Residents #114, #57,1#110, #107, and #133) at Resident Council on 9/9/25 at 1:30 PM, they stated they did not know how to file an anonymous grievance. Resident #110 stated, I often wonder who I could go to if there was a problem with staff. I don't want it getting back to me. Per record review Resident #110 has a BIMS [Brief Interview of Mental Status] score of 15, indicating s/he has no cognitive impairment.Per observation of the second floor there were no blank grievance forms able to be located. The blank grievance forms were found behind the nurses station as shown by the Unit Manager.Per review of the facility's Grievances/Complaints-Filing, Investigating and Resolving policy [last reviewed 5/30/25], there is no mention to filing grievances anonymously.Per interview with the Unit Manager on 9/9/25 at 2:15 PM she stated, There's really no way for them [residents or resident representatives] to file an anonymous grievance.Per interview with the Activities Director on 9/9/25 at 2:28 PM, she confirmed that residents and resident representatives have no way of filing an anonymous grievance.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to maintain a sanitary kitchen. This has the potential to impact all residents. Findings include: 1. A kitchen tour was conducted with the Dietary Manager on 9/8/253 at 9:42 AM.Per observation of the kitchen prep area, the following items were found improperly stored:Harissa seasoning with no date,Expired black sesame dated 3/11/24,White sesame marked 6/18 (no year),Expired sesame seed dated 6/21/24,Marjoram dated11/30/23,Bay leaves dated 5/6/24,All spice dated 11/27/24,The Dietary Manager stated that spices should be discarded a year after opening and confirmed that the above spices were expired.Per observation of the walk in refrigerator, the following items were found improperly stored:A container of Jello with no labels or dates,A container of beef stew with no labels or dates,A container of cream cheese frosting with no use by date,A container of expired buttercream frosting marked good through 9/3/25,A container of expired cooked pasta marked good through 9/7/25,A container of expired purred veggies marked good through 8/27/25,A package of tofu- open and not covered marked good through 8/18/25,A used onion wrapped with no labels or dates,A container of expired sauerkraut marked good through 9/2/25,A container of expired steamed veggies marked good through 8/20/25,A container of expired steamed veggies marked good through 9/5/25,Per observation of the walk in freezer, the following items were found improperly stored:A container of expired ice cream dated 6/24/24,A sheet pan of expired pizza dated 4/26/25,A box of potatoes open to air,A box of hashbrowns open to air,A box of pizza shells open to air,A box of hamburger patties open to air,The Dietary Manager stated that prepared and open food should be labeled with the date it was opened or made and the date that it should be discarded, and containers and packages should be sealed. He confirmed that the above items were either expired or improperly stored.Per observation of the dry storage area, the following items were found improperly stored:A box of gram cracker crumbs open to air,Multiple loaves of undated bread.The Dietary Manager explained that they do not label the loaves of bread with dates.Per interview on 9/10/25 at 9:46 AM, a Dietary Staff stated that there are no dates on the bread and there is no way of knowing what its expiration or use by date is. Per interview at 9:49 AM with a second Dietary Staff, she explained that bread should be labeled with orange tags to indicate the use by date and confirmed that the loaves of bread were not dated.2. During the initial kitchen tour on 9/8/25 and again on 9/10/25. multiple areas of the ceiling in the prep areas and the dish room were observed to be covered with thick dust.The Dietary Manger revealed that the housekeeping staff should be cleaning these areas, and it hadn't been done in a couple months.

Based on observation and interview the facility failed to ensure that all residents were treated with dignity in regard to dining on 2 of 3 units. Findings include: 1. Per observation of lunch service on the Evergreen unit on 9/8/25 at 12:15 PM, 7 residents were in the side room for lunch sitting at one large table, and one small side table. Lunch was being served on trays, with warming dishes, to one resident at a time. As the trays were placed on the table, the warming lids were stacked in the middle of the table. Trash was also put in the middle of the table. At 12:19 PM, while other residents were eating, Resident #39 said that s/he is really hungry. S/he was not served lunch until 12:43 PM. Resident #86, who was sitting in the common area outside of the side room since the start of lunch service was not served lunch until 12:54 PM. Per interview with the Dietary Manager on 9/10/25 at 1:35 PM, he explained that they cannot get all meals to each unit at the same time because there isn't enough staff to bring each food cart up to the unit. Per interview with the DON on 9/10/25 at approximately 3:00 PM, she confirmed that all residents should be served at the same time if they are sitting at the same table. 2. Per observation of lunch on 9/10/25 at 12:05 PM, Resident #132 was sitting while another resident was eating at same table. Per observation on 9/10/2025 at 12:13 PM, all residents had been served lunch except Resident #132. S/he was told by LNA#1 Your tray is coming up, it's just a little late. On 9/10/2025 at 12:31 PM LNA #1 stated, [The]trays got mixed up, they put [his/her] food on the jitney and accidentally sent it to the unit since [s/he] usually eats in [his/her] room. LNA #1 confirmed Resident #132 had not eaten lunch. Per observation on 9/10/2025 at 12:32 PM Resident #132 was given a tray of food on the unit, 27 minutes after the rest of his/her table.

Based on interview and record review, the facility failed to ensure a resident's right to be informed in advanced by the physician or other practitioner or professional of the risk and benefits by proposed care, of treatment alternatives or treatment options, and to choose the alternative or option he or she prefers for two of five residents in the sample. (Residents #4 and #12). Findings include: 1.) Per record review, Resident #4 has active orders for Lorazepam 1 mg [milligram] tab: Give 1 tablet by mouth two times a day for Chronic Anxiety, and Lorazepam Oral Tablet 0.5 mg [milligram]: Give 1 tablet by mouth every 12 hours as needed for increased anxiety/restlessness/agitation for 30 Days inability to redirect, both ordered on 8/28/25. Resident #4 also had an order for Lorazepam Oral Tablet 0.5 MG (milligram): Give 0.5 mg by mouth one time a day for anxiety/agitation. This medication was originally ordered on 3/25/25 and discontinued on 5/22/25. Per record review, there is no evidence that residents were educated on the use and/or risk and benefits of the medications. Per record review of the facility's High Risk Medications policy [last revised February 2023] states, 8. Residents and/or representatives will be educated on the use and risks/benefits of high-risk medications, including adverse effects. Per interview with the Unit Manager on 9/10/2025 10:14 AM she stated the facility does not use consent forms for Lorazepam stating, We only do them for antipsychotics like Seroquel and Olanzapine. She confirmed there is no consent form signed by resident or resident representative for Lorazepam in the resident's EMR [Electronic Medical Record]. On 9/10/2025 at 10:30 AM the DON [Director of Nursing] stated that they [the facility] do not use consent forms for psychotropic medications including Lorazepam. 2. Per record review of Resident #12's medical record, an Antipsychotic Informed consent form states that verbal consent was obtained on 1/7/2024 by Resident #12's responsible party for Olanzipine (Antipsychotic)10 mg once a day. Further review revealed a physician's order dated 9/2/2025 for Olanzapine 10 mg by mouth twice a day for dementia with behaviors. A progress note dated 9/2/2025 states Message left to [responsible party] via phone regarding order updates for increase in Olanzapine AM dose . There is no further documentation indicating that Resident #12's responsible party was ever notified of the increase in Olanzipine. Further record review reveals a physician's order for Citalopram (Antidepressant) 20 mg one time a day for dementia with behaviors. There is also no documented evidence that Resident #12's responsible party was provided the right to be informed in advanced by the physician or other practitioner or professional of the risk and benefits of the use of Citalopram or of treatment alternatives or treatment options. Per review of the facility policy titled Antipsychotics states All residents with a new order for antipsychotic medications will have a signed consent form in the medical record. The facility policy titled High Risk Medications lists psychotropic medications as high-risk medications and states Residents and/or representatives will be educated on the use and risks/benefits of high-risk medications, including adverse effects. Per interview on 9/10/2025 at 11:00 AM the Assistant Unit Manager at 11:00 AM confirmed that there is no documented evidence in the record that the facility obtained informed consent from Resident #12 or her/his responsible party prior to the increase of Olanzapine to 10 mg twice a day from once a day and that there is no evidence of consent or discussion of risks versus benefits of the Citalopram.

Based on observation and interview, the facility failed to ensure that all residents had a homelike environment for multiple areas of the facility, having the potential to impact many residents. Findings include:Per observation during a walkthrough of the facility on 9/8/25 at approximately 10:30 AM, two hallways of the Evergreen Unit had multiple wheelchairs, carts, lifts, medical machines, and bags lining one side of each hall. This was observed multiple times throughout the recertification survey on 9/8/25 through 9/10/25. Per interview on 9/10/25 at approximately 3:00 PM during a facility tour with the Director of Nursing, multiple hallways of the facility had multiple items in the hallway. She confirmed that the hallway should not be a place to store lifts and wheelchairs as there are spots tucked away in the halls for the equipment to be placed.During the tour, three large approximately 15 feet by 5 feet boards were observed across from the nursing stations by the resident common sitting areas. These boards contained multiple data points related to resident care and staffing concerns, including resident falls and other quality measures. While there was no resident specific data on these boards, they did appear to be business related. The DON stated that the board are used to share positive information with the residents, but does understand how they are not homelike.

Based on interview and record review the facility failed to provide respiratory care in accordance with professional standards for five of five residents (Residents #86, #97, #94, #136, and #34). Findings include:1. Per record review, Resident #86 has diagnoses that include acute and chronic respiratory failure, obstructive sleep apnea, and dependence on supplemental oxygen. A 7/18/25 admission note states that Resident #86 has the following active problem requiring attention Recent acute on chronic respiratory failure requires BiPAP [Bilevel Positive Airway Pressure; a non-invasive ventilation treatment] and 1 to 2 L [liters] of oxygen. [S/He] will continue with respiratory support with BiPAP machine we will continue oxygen 1 to 2L. Resident #86 had the following physician orders Standing Order Other: O2 (oxygen) @ 2LPM via NC [nasal canula] PRN [as needed] to maintain O2 sat of above 90% May administer oxygen prn via NC/mask to maintain SP02 [peripheral oxygen saturation] of >90%; If requiring more than 2L notify provider. 2LNC (May wean as tolerated), and BIPAP: Apply at HS [at bedtime] as per home settings every night shift for Sleep Apnea. Per record review, Resident #86's does not have a care plan related to his/her respiratory status, including interventions for oxygen use or a BiPAP machine. Resident #86's MAR (medication administration record) for September 2025 does not show documentation of when or how much oxygen s/he was using under the oxygen order. 2. Per record review, Resident #97 has chronic obstructive pulmonary disease with (acute) exacerbation. Resident #97 has the following care plan focus, [Resident #97] is at risk for shortness of breath r/t deficiencies or abnormalities of pulmonary function (COPD), initiated on 6/23/25. Multiple progress notes reveal that Resident #97 has shortness of breath during September. Vitals signs show four oxygen stats for Resident #97; 61% on 9/1/25, 91% on 9/2/25, 81% on 9/3/25, and 80% on 9/9/25. Resident #97 has the following physician order Standing Order Other: O2 (oxygen) @ 2LPM via NC PRN to maintain O2 sat of above 88% May administer oxygen prn via NC/mask to maintain SP02 of >88%; If requiring more than 2L notify provider. Per record review, Resident #97's care plan does not include interventions for oxygen use. Resident #97's MAR for September 2025 does not show documentation of when or how much oxygen s/he was using under the oxygen order. 3. Per record review, Resident #94 has diagnoses that include COPD, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. Resident #94 has the following care plan focus, [Resident #94] is at risk for shortness of breath r/t [related to] deficiencies or abnormalities of pulmonary function (COPD), initiated on10/28/24. A 9/4/25 provider note states Will need to watch for increasing O2 requirements. Resident #94 had the following physician orders Standing Order Other: O2 (oxygen) @ 2LPM via NC PRN to maintain O2 sat of above 90% May administer oxygen prn via NC/mask to maintain SP02 of >90%; If requiring more than 2L notify provider. Per record review, Resident #94's care plan does not include interventions for oxygen use. Resident #94's MAR for September 2025 does not show documentation of when or how much oxygen s/he was using under the oxygen order. 4. Per record review, Resident #136 has diagnoses that include hypertension and history of cardiac arrest. Per interview on 9/9/25 at 1:37 PM, Resident #136 explained that his/her oxygen tank was empty and s/he does use it as needed. Resident #136 has the following physician order Standing Order Other: O2 (oxygen) @ 2LPM via NC PRN to maintain O2 sat of above 90% May administer oxygen prn via NC/mask to maintain SP02 of >90%; If requiring more than 2L notify provider. Per record review, Resident #136's care plan does not include interventions for oxygen use. Resident #136's MAR for September 2025 does not show documentation of when or how much oxygen s/he was using under the oxygen order. Per interview on 9/9/25 at 2:01 PM, the Unit Manager confirmed that residents should have a care plan if they use oxygen and/or Bipap/CPap machines. She confirmed that Residents #86, #94, #97, and #136's care plans did not include the use of oxygen as an intervention. She stated that Residents #86 and #94's orders should not be PRN as there are on continuous oxygen. She confirmed that she cannot see a way to verify when and how much O2 was administered for these 4 residents based on the MAR. 5. Per record review, Resident #34 has diagnoses that include: Chronic Respiratory Failure with Hypercapnia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body); Interstitial Pulmonary Disease (refers to a group of chronic lung disorders characterized by inflammation and scarring that make it hard for the lungs to get enough oxygen); Chronic Obstructive Pulmonary Disease (COPD is a lung disease characterized by limited airflow); Acute and Chronic Respiratory Failure with Hypoxia (low oxygen in the blood); Bronchiectasis (a condition that occurs when the tubes that carry air in and out of your lungs get damaged, causing them to widen and become loose and scarred); and Heart Failure (failure of the heart to provide sufficient blood flow caused by an impairment of the heart's pumping function) During observations on 9/8/25 at 11:30 AM, Resident #34 was wearing a nasal canula connected to an operational oxygen concentrator (takes air from your surroundings, extracts oxygen, and filters it into purified oxygen to breathe). Resident confirmed s/he uses oxygen to assist with their breathing. Resident #34 has orders for O2 (oxygen) @ 2LPM (liters per minute) via NC (nasal canula) PRN (as needed) to maintain O2 sat (saturation; a measurement of oxygen in blood) of above 90% May administer oxygen prn via NC/mask to maintain SP02 [saturation of peripheral oxygen] of >90%; If requiring more than 2L [liter] notify provider. 2-4 Liter prn to O2 sat 90-92% continuous. A Discharge summary dated [DATE] for Resident #34 states the following: 3 liters per minute nasal canula 24 hours *At nighttime 2L bled into CPAP with a start date of 3/18/16. Further review of the electronic health record (EHR) revealed that oxygen usage was not documented for the Resident. Per interview on 9/9/25 at 4:30 PM, Nurse Manager confirmed oxygen orders and documentation are not in the EHR, and s/he is evaluating orders for all residents on the unit receiving continuous oxygen.

Based on record review and interview, the facility failed to ensure that a Resident's choice regarding his/her Advance Directives (wishes regarding life-sustaining treatment) was documented correctly, ordered, and care planned for 1 of 30 residents sampled (Resident #123). Findings include:Per record review, Resident #123's Electronic Health Record (EHR) has an Advanced Directive stating s/he wishes are do not resuscitate (DNR) and trial course of intubation (a tube to assist with breathing) and ventilation treatment for 5 days, signed 12/30/24 by the Resident. The Code Status in the EHR states DNR/DNI (Do Not Intubate), and the Care Plan (initiated on 2/28/25 and revised on 6/30/25) Focus states Advanced directive, [Resident #123] has established advanced directives-DNR/DNI, Date Initiated: 02/28/2025, Revision on: 03/25/2025), and there is an Order for DNR/DNI with a start date of 2/28/25. The Care Plan, Order, and Resident dashboard don't reflect the Resident's wishes of DNR/Trial of intubation for 5 days per her/his documented Advanced Directives.Per interview on 9/9/25 at 1:50 PM, the Assistant Unit Nurse Manager confirmed Resident #123's Advanced Directive reveal their wishes are DNR and trial of five days of intubation. They confirmed the Code Status, Order, and Care Plan don't reflect the Resident's wishes.

Based on interview and record review the facility failed to ensure one of two sampled residents (Resident #4) were free from chemical restraints. Findings include:Per review of Resident #4's medical record, Resident #4 has a BIMS [Brief Interview of Mental Status] score of 4, indicating the resident has cognitive impairment. Resident #4 has diagnoses of Type II Diabetes, CHF [Congestive Heart Failure], anxiety disorder, and chronic pain syndrome. Resident #4 needs substantial/maximal assistance with ADLs [Activities of Daily Living] and hygiene.Per record review, Resident #4 has an order for Lorazepam 0.5 mg [milligram]: Give 1 tablet by mouth every 12 hours as needed for increased anxiety/restlessness/agitation for 30 Days inability to redirect. The order was placed on 8/28/25 and was to be discontinued on 9/27/25. Per record review of the Medication Administration Record, Resident #4 has received the prn [as needed] medication three times. Per record review of the facility's Pharmacy Services policy [last revised 11/18/24] states, e. Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that.4.PRN orders for psychotropic drugs are limited to 14 days.If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.An interview was conducted with the Unit Manager on 9/9/25 at 2:15 PM. The Unit Manager confirmed the order was for thirty days with no rationale documented, stating We were under the impression that after 14 days they could just renew the prescription for 30 days and then 60 days and then 90 days. I think that's what our policy is.

Based on interview and record review the facility failed to ensure that their policies related to screening for abuse had been implemented for 1 of 5 Employees reviewed (Licensed Nursing Assistant #1). This is a repeat deficiency for this facility, with violations cited during the previous recertification survey dated 11/6/24 and partial survey dated 7/24/25. Findings include: Based on interview and record review, the facility failed to ensure that their policies related to screening for abuse had been implemented for 1 of 5 employees reviewed (Employee #1). The detailed findings are as follows:Licensed Nursing Assistant (LNA) #1, who was a contracted LNA, was hired on 9/3/2025. There was no evidence in the employee file that the Adult Registry review was conducted as required.The facility policy titled Prevention of Abuse Prohibition states that the facility will comply with and review the [NAME] Abuse and Child Protection Registry. Per interview on 9/10/2025 at 5:16 PM the Director of Nursing (DON) provided a copy of an Adult Abuse Registry dated 9/10/2025 stating that Employee #1 had no findings in the Adult Abuse Registry. The DON confirmed that LNA #1 the Adult Abuse Registry check had not been conducted per policy, prior to the LNA working on the floor and that the Adult Abuse Registry check that had been provided was ran that day, 9/10/2025.

Based on observation, interview, and record review, the facility failed to ensure resident's care plans were updated with pertinent information related to their care for two of 30 sampled residents (Residents #40 and #97). Findings include:1.) Per review of Resident #40's medical record, s/he has diagnoses of Parkinson's Disease, hypertension, and muscle weakness. Resident #40 is dependent on staff for hygiene and needs substantial/maximal assistance with ADLs [Activities of Daily Living]. As of 6/16/25, Resident #40 has a BIMS [Brief Interview of Mental Status] score of 0, indicating Resident #40 has cognitive impairment. Per record review of a post fall evaluation on 5/30/25 states, Date / Time of Fall: 05/30/2025 2:38 PM Fall was witnessed. Who witnessed fall: LNA [Licensed Nursing Assistant]. Fall occurred in the hallway. Activity at the time of fall: Being pushed down the hallway in w/c [wheelchair], put foot down on carpet while being pushed and fell out of w/c. Reason for the fall was evident.Did an injury occur as a result of the fall: Yes. Injury details: Hematoma (R) [right] upper forehead, c/o [complain of] (R) rip and hip pain. Did fall result in an ER [Emergency Room] visit/hospitalization: Yes. A rehab screen request note from 5/30/25 states, Leg wrests [sic] were not in use at time of fall. LNA was pushing resident down the hallway when [s/he] out [his/her feet down and fell headfirst out of the chair. Staff do report that even with footrests on [s/he] puts [his/her] feet down and doesn't keep them on the footrests. [S/he] also leans forward in current w/c. [S/he] had a hematoma to the right forehead, c/o right hip and rib pain. Sent to ED [Emergency Department], no sig [significant] findings. Per record review of a general nursing note dated 6/3/25 states, s/p [status post] fall 5/30. Plan of care reviewed with interdisciplinary team. Education provided to LNA regarding transport of resident. Therapy screen also placed as per nursing staff even with footrests on w/c [wheelchair] resident often puts her feet down and has poor positioning in w/c at times. Resident was seen at the ED with no significant findings. Per record review of a general nursing note dated 9/4/25 at 4:22 PM states, Resident needed to be brought back to room for toileting. LNA had footrests in her hand and did not have enough room in the hallway to put footrests on the wheelchair as EVS [environmental services] cart was in the hallway and to make room in the hall, LNA pushed the wheelchair down past the EVS cart to put foot rests on. As she was pushing wheelchair, resident leaned forward and fell out of chair. PT [Physical Therapy] screen placed for broada chair. Per record review of Resident #40's care plan, there are no interventions related to using footrests to prevent the resident from falling documented after the fall on 5/30/25 or 9/4/25. Per interview with the Unit Manager on 9/9/25 at approximately 2:30 PM she confirmed that Resident #40's care plan did not include any information related to using footrests as an intervention to prevent accidents. 2. Per record review, Resident #97 has diagnoses include dementia behavioral disturbance and agitation, and major depressive disorder. Resident #97's care plan reveals that s/he is at risk for elopement, alteration in psychosocial wellbeing, and re-traumatization. A 8/21/25 nursing note reveals that Resident #97 was involved forcefully pushed and grabbed by another resident (Resident #135) and Resident #97 showed visible signs of anxiety including crying and verbally expressed anxiety and fear following physical altercation due to past trauma history. Progress notes after this event show that Resident #97 is anxious, agitated, argumentative, and could be difficult to redirect. An 8/29/25 progress note reveals that Resident #97 was near Resident #135's room and they had a verbal exchange. A 9/1/25 progress note reveals that Resident #97 was tearful this evening. Requesting to have locks on [his/her] door so [Resident #135] couldn't go in there in the night. 'I need a lock, what if [s/he] comes in while I am sleeping? I don't feel safe with [him/her] here, I shouldn't have to hide out in my room all day to get away from [him/her].' A 9/1/25 room transfer note reveals that Resident #97 was moved to a different unit that day for roam control and states that s/he has been roaming often which cause negative engagement with other residents on [his/her] current living unit. Progress notes following Resident #97's room transfer show that s/he continues to have episodes of wandering, agitation, and aggressive verbal behavior that has impacted other residents. Per observation on 9/10/25 at 10:03 AM through 10:16 AM Resident #97 was observed sitting in the common area repetitively yelling and swearing while other residents were in the common area. A 9/10/25 social service note reveals that Resident #97 had an altercation with another resident shortly after the above observation. A facility investigation summary dated 9/12/25 reveals that Resident #97 hit Resident #45, which was observed by staff. Resident #97 was then transferred back to his/her previous room on the memory care unit on 9/10/25. Resident #97's care plan related to wandering was updated on 8/22/25 following the first incident s/he had with Resident #135 on 8/21/25. There were no additional interventions related to Resident #97's psychosocial or trauma care plans that addressed the impact the 8/21/25 had on him/her. Resident #97's elopement, psychosocial, or trauma care plans were not revised following his/her room transfer or 9/1/25, even after s/he showed increased behaviors. There were no new interventions put into place following the room transfer on 9/10/25 to address the impact that Resident #135 had on him/her. Per interview on 9/10/25 at 3:20 PM, the Director of Nursing confirmed that Resident #97 should have care plan revisions for new interventions to ensure their safety immediately. Per interview on 9/10/25 at 3:53 PM, the Unit Manager confirmed that while the care plan focus was updated following the 8/21/25 event, there were no new interventions after 8/22/25.

Based on observation, interview, and record review the facility failed to ensure residents were free from accidents and hazards for two of 30 sampled residents (Residents #40 and #45). Findings include:1.) Per review of Resident #40's medical record s/he has diagnoses of Parkinson's Disease, hypertension, and muscle weakness. Resident #40 is dependent on staff for hygiene and needs substantial/maximal assistance with ADLs [Activities of Daily Living]. As of 6/16/25, Resident #40 has a BIMS [Brief Interview of Mental Status] score of 0, indicating Resident #40 has cognitive impairment. Per record review of a post fall evaluation on 5/30/25 states, Date / Time of Fall: 05/30/2025 2:38 PM Fall was witnessed. Who witnessed fall: LNA [Licensed Nursing Assistant]. Fall occurred in the hallway. Activity at the time of fall: Being pushed down the hallway in w/c [wheelchair], put foot down on carpet while being pushed and fell out of w/c. Reason for the fall was evident.Did an injury occur as a result of the fall: Yes. Injury details: Hematoma (R) [right] upper forehead, c/o [complain of] (R) rip and hip pain. Did fall result in an ER [Emergency Room] visit/hospitalization: Yes. Per record review of a therapy note on 6/3/25 states, Therapy screen request received from nursing s/p fall on 5/30; LNA was pushing resident down the hall, resident unable to hold her feet up and got caught on the carpet, fell out of chair headfirst.Chart reviewed and discussed the resident with nursing. Resident is functionally at baseline; may benefit from broda chair to combat forward leaning and poor [NAME] [lower extremity] support. Therapy to look into getting resident a broda chair. Therapy continues to recommend the following: recline when fatigued/leaning forward and PRN [as needed] use of footrests, i.e., when mobilizing resident. A rehab screen request note from 5/30/25 at 3:00 PM states, Leg wrests [sic] were not in use at time of fall. LNA was pushing resident down the hallway when she out her feet down and fell headfirst out of the chair. Staff do report that even with footrests on [s/he] puts [his/her] feet down and doesn't keep them on the footrests. [S/he] also leans forward in current w/c. [S/he] had a hematoma to the right forehead, c/o right hip and rib pain. Sent to ED, no sig [significant] findings. Per record review of a general nursing note written on 9/4/25 at 4:22 PM states, Resident needed to be brought back to room for toileting. LNA had footrests in her hand and did not have enough room in the hallway to put footrests on the wheelchair as EVS [environmental services] cart was in the hallway and to make room in the hall, LNA pushed the wheelchair down past the EVS cart to put footrests on. As she was pushing wheelchair, resident leaned forward and fell out of chair. PT [physical therapy] screen placed for broada [sic] chair. Per interview with the Unit Manager on 9/10/25 at 10:00 AM she stated footrests were not on when Resident #40 was in his/her wheelchair during the second fall on 9/4/25. She stated, The LNA [Licensed Nursing Assistant] had them in her hand, but they were not on. She was trying to maneuver the resident around a housekeeping cart. The Unit Manager confirmed that both falls were the result of not having footrests on the wheelchair stating, The same thing happened both times. 2. Per record review, Resident #97 has diagnoses include dementia behavioral disturbance and agitation, and major depressive disorder. Resident #97's care plan reveals that s/he is at risk for elopement, alteration in psychosocial wellbeing, and re-traumatization. s/HE has a the following care plan focus, [Resident #97] has behavior problem r/t [related to] h/o [history of] behaviors, impaired cognition, refusals of care. [Resident #97] does at times think [s/he's] joking when [s/he] uses a dry sense of humor and raises [his/her] voice but can become offensive to others. A lot of past trauma with the death of two children and being abused at a young age [Resident #97] is triggered easily, revised on 8/22/25. The last behavior intervention was added on 6/23/25. Nursing notes dated 8/21/25 through 9/1/25 reveal that Resident #97 had an altercation with Resident #135 on 8/21/25, was displaying anxious, agitated, wandering behaviors, argumentative, and could be difficult to redirect. A 9/1/25 room transfer note reveals that Resident #97 was moved to a different unit that day for roam control and states that s/he has been roaming often which cause negative engagement with other residents on [him/her] current living unit. Progress notes following Resident #97's room transfer show that s/he continues to have episodes of wandering, agitation, and aggressive verbal behavior that has impacted other residents. Per observation on 9/10/25 at 10:03 AM through 10:16 AM Resident #97 was observed sitting in the common area repetitively yelling and swearing while other residents were in the common area. A 9/10/25 social service note reveals that Resident #97 had an altercation with another resident shortly after the above observation. A facility investigation summary dated 9/12/25 reveals that Resident #97 hit Resident #45, which was observed by staff. Resident #45 was in a wheelchair. Resident #97's care plan related to wandering was updated on 8/22/25 following the first incident s/he had with Resident #135 on 8/21/25. There were no additional interventions added to Resident #97's care plan related to his/her wandering or behavior, even after s/he showed increased behaviors. Per interview on 9/10/25 at 3:53 PM, the Unit Manager confirmed that while the care plan focus was updated following the 8/21/25 event, there were no new interventions after 8/22/25.

Per observation, interview, and record review, the facility failed to ensure that residents with urinary catheters received appropriate treatment and services to prevent urinary tract infections for 2 of 2 sampled residents (Resident #3 & 27). Findings include: Per record review, Resident #3 reveals medical diagnoses which include:Urinary tract infection (an infection in any part of the urinary system);Neuromuscular Dysfunction of Bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should);Acute Kidney Failure (when the kidneys suddenly can't filter waste products from the blood);Retention of Urine (bladder doesn't completely empty when urinating); andChronic Kidney Disease (a long-term condition where the kidneys do not work as well as they should)Resident #3 has orders for an indwelling Foley catheter (a tube that is maintained in the bladder to drain urine constantly). It is connected to a collection bag that requires frequent emptying. Further record review revealed Resident had a Urinary Tract Infection (UTI) diagnosed on [DATE] after a foley catheter change resulted in Resident's output draining cloudy yellow urine, with a volume of 1300 mL (milliliters), and a fever. According to the Cleveland Clinic, the normal range for 24-hour urine volume is 800 to 2,000 milliliters per day, and healthy urine should be light yellow, like the color of light straw or lemonade(https://my.clevelandclinic.org/health/body/urine). Review of the Care Plan (revised 8/27/25) has a Focus area for an indwelling Foley catheter related to the Resident's urinary retention, and the intervention states Document intake [of fluids] and output [of urine] as per facility policy, which was initiated on 2/9/24 with a revision on 2/12/25. Per interview on 9/10/25 at 2:45 PM, the Nurse Manager stated tracking urinary outputs is a Licensed Nursing Assistant's (LNA) task and would run a report to capture the output data documented for the Resident.Per interview on 9/10/25 at 3:51 PM, the Nurse Manager confirmed that the indwelling Foley catheter output was not located in Residents' charts or being tracked, and she was evaluating other Residents' charts for orders to track output. 2. Per record review, Resident #27 reveals medical diagnoses which include:Obstructive and Reflux Uropathy (occurs when urine cannot drain through the urinary tract);Acute Kidney Failure (when the kidneys suddenly can't filter waste products from the blood); andRetention of Urine (bladder doesn't completely empty when urinating)Resident #27 has orders for an indwelling Foley catheter (a tube that is maintained in the bladder to drain urine constantly). It is connected to a collection bag that requires frequent emptying. In the Electronic Health Record (EHR), there is no documentation of the Resident's output of urine.Per Nurse.com, Urine output provides key insights into kidney function and overall fluid balance. A sudden or gradual decrease in urine output, known as oliguria, can be one of the earliest signs that the kidneys are not filtering waste and maintaining fluid balance as they should (https://www.nurse.com/blog/acute-kidney-injury-urine-output-warning-sign/).

Based on observation and interview, the facility failed to store drugs in accordance with currently accepted professional principles for 1 of 30 sampled residents. Findings include:Per observation on 9/8/25 at approximately 3:00 PM, the following medications were found in Resident #86's room: Clotrimazole External Cream 1 % (Clotrimazole (Topical)), Tacrolimus External Ointment 0.1 % (Tacrolimus (Topical)) and Hydrocortisone External Cream 2.5 % (Hydrocortisone (Topical)). Resident #86 had a roommate.Per interview on 9/8/25 at 3:04 PM, a Licensed Practical Nurse stated that Resident #86 did not have a medication self-administration assessment completed to determine if s/he could have medications in his/her room. She stated that if s/he did, the medications should be in a lock box. Per interview with the Unit Manager on 9/9/25 at 3:54 PM, she confirmed that Resident #86 did not have a medication self-administration assessment and shouldn't have the medications in his/her room. To have medications in the room, a resident would need a medication self-administration assessment determining it to be appropriate and a lock box to place the medications in.

Based on observation, interview, and record review facility failed to ensure a resident was provided adaptive devices used to promote adequate hydration for one of one (Resident #2). Findings include:Per record review, Resident #2 was admitted to the facility with diagnoses that include type 2 diabetes mellitus, essential tremor, and mild cognitive impairment. Review of Resident #2's care plan reveals that s/he has a swallowing problem related to a medical decline and that s/he had choked on a meatball. Care plan interventions include the use of a 2 handled mug with spouted lid. The care plan also indicates a focus initiated on 1/25/2021 of an alteration in fluid balance related to immunosuppressive medication use, history of renal transplant, uropathy, indwelling foley catheter, history of aspiration pneumonia, and diabetes. Interventions include Encourage to drink fluids of choice and ensure access to favorite beverages, diet ginger ale with small amount of cranberry for color.The care plan also states recommend seated in Broda chair for meals. Items within reach, set up is required (meats cut, containers opened). Resident should be squared up to table (not placed at an angle) to allow optimal functional with self-feeding. adaptive equipment used 2 handled mug w/spouted lid; rim plate; rocker/swivel spoon; straw.Per observations made on 9/8/2025 at 12:30 PM, Resident # 2 was observed during lunch in the day room. Her/His tray had a red two handled mug with a spouted lid, 8oz glass of milk, one can of ginger ale with a straw, a coffee mug, a chocolate ice cream, and a plate with a hamburger cut in half, potato wedges, and a vegetable medley. He/She made five attempts to drink coffee from a mug without a lid and/or straw, contents spilled onto tray and clothing protector. A tremor was noted of bilateral upper extremities. Four staff members were present in the day room assisting other residents. At 12:40 PM, Resident #2 attempted to pick up a sandwich and hold it over the plate. At 12:43 PM he/she placed the sandwich back on the plate; 0% of the meal was consumed. At 12:46 PM, Resident # 2 picked up the spoon and chocolate ice cream and spilled the contents on his/her lap and attempted to bring the spoon with ice cream to his/her mouth again, and again it spilled on his/her lap. At 12:51 PM the Resident began using her/his \fingers to eat the ice cream. As s/he reached for the glass of milk, it spilled onto tray. 0% of the drinks were consumed. At 12:53 PM, Resident #2, used the 2 handled mug with the spouted lid to drink. Resident #2 began using her/his fingers to eat the ice cream. The Resident then used a fork to pick up a potato wedge, took a bite and the remainder fell onto the Resident's lap. At 1:01 PM the Resident attempted to drink out of a cup with no lid or straw and spilled it onto the clothing protector and tray.At 1:05 PM when asked if s/he was thirsty, Resident #2 stated yes. At this time the two Licensed Nursing Assistants (LNAs) who were in the room assisting other residents were made aware that the Resident was having difficulty with and that s/he was thirsty. The LNA confirmed that the Resident was supposed to have covered drinks but only gets one cup on her/his tray. On 9/9/2025 at 8:34 AM, Resident# 2 was observed at breakfast in day room. The food on his/her plate was cut by staff. One mug with two handles and spouted lid with orange juice. A carton of milk, a glass of cranberry juice, a can of ginger ale with a straw, and a cup of coffee were on the tray without a two handled mug with spouted lid that the resident was care-planned for. Four staff members in dining area were assisting other residents. On 9/10/2025 at 8:36 AM, Resident #2 was observed at breakfast in day room. One cup with 2 handles and spouted lid with cranberry juice. The following drinks on the tray were not in the care planned two handled spouted mugs: One open carton of milk with no straw or lid, a can of ginger ale with no straw and a cup of coffee with no lid and no straw.During an interview on 9/10/2025 at 8:53 AM with a Licensed Practical Nurse (LPN) who is familiar with Resident #2, the LPN stated that the Resident should have at least two or three of those cups. The LPN proceeded to call the kitchen and requests two more two handled mugs with spouted lids. The LPN stated, The kitchen said they out are of the mugs, but they do need to provide them.Per interview with the Dietary Supervisor on 9/10/2025 at 9:01 AM, she reported that she had sent two additional mugs to the floor 5 minutes prior to interview, and they have many two handled cups with spouted lids. Staff can call the kitchen to have them brought to the floor. She stated, It is the floors responsibility to transfer beverages into modified cups and let us know if they need more than the one provided on the tray. During interview on 9/10/2025 at 2:47 PM, the Speech Language Pathologist confirmed that residents with adaptive equipment for eating/drinking should have multiple cups for different beverages.On 9/10/2025 at 3:01 PM, the Registered Nurse Unit Manager stated that her expectation is two adaptive cups to be on meal trays for residents. One for hot beverages and one for cold beverages.

Based on observation and interview, the facility failed to provide state survey results for residents and resident representatives to readily view. Findings include:Per observation on 9/9/25 at 1:25 PM there were no state survey results available on the second floor where all residents reside.Per interview with Resident #114 during resident council on 9/9/25 at approximately 1:30 PM, s/he stated, It would be nice if we could have access to it [state survey results], I can't get to the first floor because I can't walk. Per record review Resident #114 has a BIMS [Brief Interview of Mental Status] score of 14, indicating that Resident #114 has no cognitive deficit. Resident #114 is dependent on staff for ADLs [Activities of Daily Living] and hygiene.Per interview with the Activities Director on 9/9/25 at 2:28 PM, she confirmed state survey results are not posted on the second floor and are only on the first floor of the building.

Based on interview and record review, the facility failed to implement national background checks on two out of five employees sampled. Findings include: Per record review of five employees' personnel files, RN [Registered Nurse] #1 and LPN [Licensed Practical Nurse] #1 did not have national background checks in their employment file. RN#1 was hired in 8/13/12 and LPN#1 was hired on 8/25/14. RN#1 has worked at the facility for almost thirteen years without a background check. LPN#1 has worked at the facility for approximately 10 years without a national background check.Per record review of the facility's Prevention of Abuse policy [last reviewed 11/18/24] states, A. Before new employees are permitted to work with residents, [The facility]'s human resources shall conduct a comprehensive hiring process which will include in-depth interviewing practices and careful examination of references.B. [The facility] shall comply with CORI Law.C. [The facility]'s Human Resources will contact The [NAME] office of Professional Regulation Nurse and Nurse Aide registry, and any out-of-state nurse and nurse need registries as appropriate prior to hiring employees to determine if there is any sanction, findings or adjudicated finding of patient abuse, neglect, mistreatment or misappropriation of patient property against the prospective employee. D. The appropriate boards of licensure and or certification will be contacted regarding any past or pending abuse findings. The abuse policy does not discuss national background checks for all employees. Per review of licensing agency communications, a memo was sent out to nursing facilities on October 5, 2022, that states, 1. Prior to employing an individual and at least annually thereafter, a Facility must query the following entities regarding the prospective / current employee: .Agency providing a national criminal background check . To check whether the individual is barred from employment based on prior convictions in any state .2. Under [NAME] and federal laws and regulations, a Facility must decline to employ a prospective or current employee with: .Criminal convictions for the abuse/exploitation/neglect of a vulnerable adult or child in any state . In addition to the prohibitions mentioned above, [NAME] laws prohibit long-term care facilities from employing individuals with criminal convictions relating to bodily injury, theft or misuse of funds or property, and/or crimes inimical to the public welfare. A follow up memo was sent out to facilities on 5/1/2023 that further discusses initial national background checks and rechecks for staff: [NAME] [Department of Aging and Independent Living] has determined that re-checks are not necessary if a staff member has not worked or lived in another state since the initial national check was completed.Per interview with the DON [Director of Nursing] on 7/23/25 at 2:45 PM, it was confirmed that the facility did not have national background checks on file and would be contacting the main hospital for the records.A phone interview was conducted with the DON on 7/24/25 at 1:43 PM. The DON confirmed the facility did not perform national background checks on these two nursing staff members during their hiring, stating They are from [NAME], so we didn't do any national background checks. She stated that she was unaware of the memo sent out from CMS [Center for Medicare and Medicaid Services].

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 7 sampled residents (Resident #2). Findings include:Per record review of Resident #2's care plan dated 5/29/2025, Resident #2 is a quadriplegic, has cerebral palsy and decreased range of motion. Resident #2's care plan also mentions that the Resident requires a mechanical lift with assistance from two staff members to move. Resident #2's Brief Interview for Mental Status (a score assessing memory and cognitive function) is 14 out of 15 indicating that Resident #2 is cognitively intact.Resident #2 was observed on 7/23/2025 at 12:50 PM having difficulty repositioning himself in bed raising concern that Resident #2 wouldn't have been able to move away from Resident #1 who is able to mobilize in wheelchair independently per his/her care plan dated 6/25/2025.Per record review, an administration note dated 7/8/2025 states resident exhibiting concerning behavior several times this evening where staff observed [him/her] sitting in his/her wheelchair on [his/her] roommate's side of the room (next to roommate's bed) [Resident #2] and appearing to masturbate. Resident became angry with staff when [s/he] was taken out of roommate's space, and also angry when staff would not allow [him/er] to go back to that side of the room.A Social Workers progress note dated 7/9/2025 reports that Resident #2's roommate (Resident #1) was observed rummaging through [Resident #2's] personal belongings and then [s/he] was found sitting beside [Resident #2's] bed masturbating. SS [Social Services] was told that [Resident #2] was not feeling comfortable remaining in the room with [his/her] roommate. Resident #2 stated he/she felt very uncomfortable and scared.Per interview with Resident #2 on 7/23/2025 at 12:50 PM, they reported the incident made him/her uncomfortable when Resident #1 was next to his/her bed.Per record review, the facility abuse policy titled Prevention of Abuse reviewed on 11/18/2024 states that Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse.Per interview with the Director of Nursing (DON) and the Administrator on 7/23/2025 at 12:30 PM, the DON and the Administrator confirmed that Resident #1 was found next to their roommate, Resident #2, masturbating.

Based on record review and interview, the facility failed to identify, investigate, and report to the State Survey Agency an incident of sexual abuse for 1 of 7 residents (Resident #2). Findings include:Per record review, the facility abuse policy titled Prevention of Abuse reviewed on 11/18/2024 states, [facility] will report any alleged patient abuse sexual abuse, mistreatment, neglect, or misappropriation of resident property to [NAME], APS, and the [NAME] Police Department whenever the facility has reasonable cause to believe that a resident experience abuse, mistreatment, neglect, or misappropriation of property.Per record review, a Social Workers progress note revealed that Resident #2 experienced forced observation of masturbation causing Resident #2 to feel very uncomfortable and scared A Social Workers progress note dated 7/9/2025 revealed that Resident #2's roommate (Resident #1) was observed rummaging through [Resident #2's] personal belongings and then he was found sitting beside [Resident #2's] bed masturbating. SS [Social Services] was told that [Resident #2] was not feeling comfortable remaining in the room with [his/her] roommate.Per interview with the Director of Nursing (DON) and Administrator on 7/23/2025 at 12:30PM, the DON and the Administrator confirmed that they were aware that Resident #1 was found next to their roommate, Resident #2, masturbating. The DON and Administrator also confirmed the facility did not identify the incident as sexual abuse and therefore it was not investigated or reported to the State Licensing Agency.

Based on record review and staff interview, the facility failed to ensure that 1 of 3 sampled residents (Resident #1) was treated with dignity and respect in relation to staff-to-resident interaction. Findings include: Per record review, Resident #1 has resided at the facility since 2022 and has a diagnosis of dementia. Per review of a facility-reported incident reported to the State Survey Agency, a family member reported to the facility their concerns regarding the treatment of Resident #1 by a staff member. The family member indicated that Resident #1 was yelled at by Nurse #1, which caused Resident #1 to cry. The facility investigation revealed an interview with a family member dated 8/29/2024, which reads, I feel this nurse [Nurse#1] does not like [Resident #1] .S/he is rude and blunt. The facility's 5-day investigation report submitted to the State Agency contained statements from several staff members indicating that Nurse #1 had been overheard being loud and rude to Resident #1 and other residents more than once. The 5-day report substantiated the allegations that Nurse #1 did not treat Resident #1 with dignity and respect. On 12/4/2024 at approximately 3:00 PM during an interview with the Director of Nursing (DON), s/he indicated Nurse #1 was verbally instructed not to care for Resident #1 as a result of the investigation. Per the interview on 12/4/24 at approximately 3:00 PM, the Director of Nursing indicated Nurse #1 did not treat Resident #1 with respect and dignity. S/he agreed that the allegations that Nurse #1 acted in an undignified and disrespectful manner to Resident #1 were substantiated.

Based on observation, staff interview and record review the facility failed to meet professional standards of practice regarding wound care for 5 of 9 applicable residents (Residents #1, #2, #4, #5, and #7). The findings include the following: 1. Per record review for Resident #1, the resident was admitted to the facility with chronic leg ulcers. Per observation on 6/22/21 at approximately 10:30 AM, the Licensed Practical Nurse (LPN) was to complete a dressing change to both legs. The LPN and the Registered Nurse (RN) nurse surveyor donned full PPE (gloves/gown/eye protection) and entered the resident's room. The resident's bed stored the necessary supplies required for the treatment. The room was observed as disorganized and cluttered with the breakfast tray present on the bedside table. The resident was recently found to have maggots in a wound. Personal belongings were identified on all surfaces to include the bed. The resident was sitting in a recliner next to the bed. A urinal was 3/4 full of urine that was resting on the window-sill next to the resident, along with bottles of over-the-counter supplements and inhalers. The following wound care was observed: -The resident's dressed feet with exposed toes were resting on the bare floor. The LPN asked the resident to raise his/her feet and covered the floor with a protective/disposable mat. -The LPN removed the old dressing on the left leg using scissors and placed the contaminated scissors on the bed. The old dressing was discarded in a disposable bag that was close to the nurse. -The LPN sanitized his/her hands and donned gloves, then began cleansing the wounds. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN saturated a stack of 2x2 gauze pads with the solution as ordered. The nurse proceeded to wipe down the wounds to the left leg using an up and down motion. After many sweeps of this action the top layer of 2x2's was discarded, and the cleansing motion continued utilizing clean gauze. S/He repeated the process until it was determined that the wound was cleaned to his/her satisfaction. The wound cleansing began at the knee and extended to the toes, including interior/posterior/lateral/medial surfaces. The area in between the resident's toes was not irrigated or cleaned. -The LPN then proceeded to apply Vaseline by massaging it onto the entire leg. The order identified that the Vaseline is to be applied to the surrounding skin on the right and left legs including toes and feet. S/he placed his/her gloved fingers into the jar of Vaseline and removed the ointment and massaged the entire surface of the leg, from knees to tip of toes She massaged the Vaseline until the leg was completely covered. S/He then removed his/her gloves performed hand hygiene, donned new gloves, and opened packages of dressing material that had been stored on the resident's bed. S/he opened boxes of supplies, adjusted dressings size by using the contaminated scissors and placed dressings on the Vaseline covered open wounds. -At the completion of the placement of the specific dressings the leg was wrapped with the materials as ordered. -The LPN then moved to the right leg and proceeded in the same manner. -The resident then rested his/her cleaned dressed feet onto the contaminated wet pad on the floor until both feet had been dressed. S/He then removed the contaminated pad, discarded it appropriately and placed the resident's feet directly on the bare floor. -The resident was observed throughout the day of 6/22/21 beginning on the 8:15 AM tour with his/her feet on the unprotected bare floor. -At one point during the dressing change the resident dropped his/her cell phone onto the floor and the LPN picked it up with his/her contaminated hands and handed the phone back to the resident and continued with the dressing change without changing gloves or sanitizing his/her hands. -Confirmation was made by the LPN on 6/22/21 at approximately 12:04 PM in the presence of the interim Staff Development Nurse that s/he did complete the dressing change per policy. -During observation of wound care by the wound care nurse on 6/24/21 at approximately 1:30 PM s/he confirms that the resident had been diagnosed with maggot infestation on 6/20/21. Per his/her assessment at this time the resident needs to have right foot irrigation to continue for 1 week. The Wound Care Nurse also confirms that the open wounds/[CONDITION(S)] are not to be covered with Vaseline and if the nurse did apply the ointment to the entire leg including the wounds, then that is a problem. The wounds were measured at this time and had not been measured since the specialist assessed the wounds on 6/10/21. The nurse also confirms that the wounds have worsened in some areas, documentation identifies the measurements s/he obtained and describes drainage and various other concerns. 2. Per record review, Resident #2 is identified on the facility Pressure Ulcer (PU) Log (push tool) with a stage 2 sacral PU measuring 2 centimeters (cm) x 0.75 cm. The resident's care plan and progress notes identify that s/he was admitted on [DATE] after a motor vehicle accident resulting in decreased mobility and unresolved [CONDITION(S)]. An observation was conducted on 6/22/21 at approximately 3 PM in the presence of the Unit Manager (UM) and the Registered Nurse (RN) who conducted the wound treatment. The RN prepared the field for the dressing change, performed hand hygiene, donned gloves prior to beginning the dressing change, removed the old dressing and discarded the old dressing, discarded dirty gloves, and without sanitizing her hands, donned clean gloves and assessed the wound and applied a new dressing. The RN applied clean gloves, and without sanitizing her hands s/he measured and treated a new wound that was not previously present. Confirmation at the conclusion of the dressing change on 6/22/21 at 3 PM in the presence of the UM the RN did not wash/sanitize her hands in between donning new clean gloves and accessing clean supplies. 3. Per observation on 6/23/21 at approximately 11:15 AM, while up in a wheelchair, Resident #5 was to have a dressing change prior to a Podiatry appointment. The RN proceeded with the dressing change by sanitizing his/her hands and donned gloves, removed the old dressing to the right great toe and proceeded to assess the wound. With the same gloves, the nurse continued to demonstrate the dryness of the skin on the toe and the foot. S/He passed his/her gloved thumb over the dry toe and the nail bed which is discolored. The RN then applied skin protectant and a protective dressing. The nurse removed his/her gloves and without sanitizing his/her hands, donned clean gloves and proceeds to remove the dressing on the left heel. The old dressing was discarded, and again, the RN brushed his/her fingers over the wound and the dry skin without sanitizing her hands or changing his/her gloves. S/He proceeds to apply the skin protectant and a protective dressing. S/He removes her gloves, and without sanitizing her hands dons new gloves, and applies the soft bootie. The nurse repositions Resident #5's feet in the wheelchair. At the conclusion of the treatment, the RN sanitizes his/her hands. The RN confirmed at 11:30 AM on 6/23/21 that s/he did not perform hand hygiene prior to the application of clean gloves and accessing clean supplies as identified on the Wound Care Policy listed below. 4. During observation of a dressing change on 6/23/2021 at approximately 2 PM for Resident #4, the nurse failed to sanitize or wash hands between glove changes during the dressing change. 5. During observation of a dressing change on 6/24/2021 at approximately 11:30 AM for Resident # 7, the nurse failed to sanitize or wash their hands between glove changes during the dressing change. After the dressing, the nurse confirmed that she did not sanitize or wash hands between dressing changes. Per facility policy of [NAME] Wound Care states the following under section C: Cleansing and Dressing of Skin Impairment(s) Wounds: 5. Perform hand hygiene and don gloves (PPE if required) prior to the beginning of dressing change. 6. Remove and discard old dressing. 7. Remove and discard dirty gloves. 8. Perform hand hygiene and don clean gloves prior to accessing clean supplies. 10. Perform wound treatment as ordered. 12. Discard wound supplies in trash receptacle. 13. Remove gloves and perform hand hygiene. Reference: Lippincott Manual of Nursing Practice (9th & 10th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins. See also F880 and F925.

Based on observation, staff interview and record review, the facility failed to ensure that necessary treatment and services are provided consistent with professional standards of practice to prevent pressure ulcers, for 1 of 7 applicable residents sampled, (Resident #1). The findings include the following: Per review of Resident #1's progress notes dated 6/20/21 the facility received report from RN (Registered Nurse) from the Medical Center Emergency Department (ED), that Resident #1, also has an open area to right buttock near cleft center of right buttock measures 1 centimeter (cm) round, [MEDICATION(S)] dressing applied. The note was documented in the medical record by the LPN on duty at [NAME]. There is no further documentation in the medical record related to the pressure ulcer for the following four (4) days. On 6/24/21 at approximately 3 PM, the Wound Care Nurse (RN) evaluated, measured, treated, and applied a dressing to the now Stage 3 sacral pressure ulcer measuring 0.9 cm (centimeters) by 1 cm. This was confirmed by the wound care nurse. The facility confirms on 6/22/21 in approximately 11 AM, that the Unit Mangers utilize a Pressure Ulcer Quality Assurance form also known as a push tool, to manage/monitor the wounds on each unit. Resident #1 is not listed on the push tool identifying the new sacral wound. Per review of the [NAME] Wound Care Policy last reviewed on 7/28/20 identifies as follows: A. Integumentary Assessment: #6 If an alteration in skin integrity is observed, the wound will be measured and documented in the Wound Progress Note. a.) The Medical Doctor/Nurse Practitioner must be notified of all existing or new pressure injuries. b.) Wound measurements will be obtained weekly thereafter to evaluate wound healing and response to implemented intervention. c.) A wound consult may be requested to assist with dressing recommendations.

Based on observation, administrative staff report reviews and staff interviews, the facility failed to maintain an effective pest control program ensuring that the facility is pest free, as evidenced by dead flies in overhead light fixtures on all three units, the dining room, and the dietary department. The facility also failed to ensure that 1 resident (Resident #9), with diagnosed maggots in his/her wound could not infest other residents. A second resident (#1) was diagnosed with infected maggots in his/her wounds 20 days later. The findings include the following: Per facility tour on 6/22/21 beginning at approximately 8:15 AM the surveyor observed evidence of dead flies in the plastic coverings of several overhead light fixtures in the following locations. Spruce Common Unit: Rm. #128- the light at the window area (facing the courtyard) fixture contains dead flies. Rm. #118- bathroom light found containing dead flies. Rm. #117- bathroom light found containing dead flies. Rm. #131- dead flies in the fixture located by the window. Observation in the Main Dining room identifies some dead flies in the ceiling lights. Maple Grove Unit: Rms. #228, 226, 227 have dead flies in the light fixtures at the window. Rm. #227 dead flies in the bathroom also. Rm. #220 dead flies in the bathroom fixtures. Rms. #219, 212, 214 and 215 dead flies in the window fixtures. Evergreen Unit: Rm. #312-bathroom light fixture has dead flies. Tour of the Dietary Department identified the following and was confirmed by the manager Food Service Supervisor at approximately 10 AM: In the room where the cook stove, prep area and the serving line is located has 12 over head light fixtures. 6 of those 12 lights have visible dead flies. The light fixture above the prep area located by the walk-in freezer has the most dead flies. The clean dish room has 6 over head light fixtures and all 6 of them have visible dead flies. The dirty dish room has 5 over head light fixtures and 3 have visible dead flies present. Per interview with the Infection Preventionist on 6/22/21 at approximately 3:12 PM confirmation was made that on 5/29/21 maggots were identified in the wound of Resident #9. An e-mail was sent to administration by the Infection Preventionist stating the following: [What we need to figure out is how the flies were able to get into the building and able to infest [his/her] wound. [S/He] has been with us for many months, so we know [s/he] got them at [NAME]. I think we need to loop in the Environmental Service Director from the hospital and the nursing home. They may need to do an assessment or even bring in a pest control company to ensure we are preventing flies from entering the building. We need to assess are windows open, screens properly installed, do we need bug lights, etc . We need to be sure that we are controlling the pests to prevent this from happening to [him/her] again or someone else.] The Infection Preventionist also confirmed that on 6/7/21 Environmental Rounds were conducted with the Environmental Service Director from the hospital and the nursing home. During that tour, the group identified [flies in lights in basement halls from the Environmental Director's office, out to the hall. Also flies in lights in medication room and in light in kitchen areas. There is storage under the sink in the kitchen/Rehab suite that should be removed/relocated. Electric room floor was full of dead flies. Should be cleaned and swept periodically.] The report was written identifies locations on Evergreen Unit and Spruce Unit. Per discussion with the Environmental Service Director, s/he confirmed that the facility does have a contract for pest control. During the pandemic when outside agencies were not allowed into the facility, the service only evaluated the outside of the building. The facility requested the contract agency to complete a chemical cleaning on Room #318 (Evergreen Unit) after Resident #9 was diagnosed with an infestation of maggots in his/her wounds. Routine visits by the contracted service restarted on 6/2/21 and is scheduled for monthly visits that consist of outside building inspection and inside review along with discussion with the Environmental Service Director to discuss problems/concerns. Room #128 was thoroughly cleaned by the housekeeping department after the second infestation was identified for another resident, but was not chemically treated as Room #318 had been.

Based upon interview and record review, the facility failed to review and revise the Care Plan of one resident [Res.#1] of 4 sampled residents regarding prevention of falls and injury. Findings include: Res. #1 was initially admitted to the facility in 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Fall Prevention Policy identifies the Prevention procedure as Residents will be individually evaluated for the potential risk of falling so that reasonable and appropriate measures can be developed to address each resident's individual needs in an effort to mitigate the identified risk areas. A review of Res. #1's Care Plan reveals the resident was identified, upon admission, as 'at risk for falls related to Impaired Balance, Weakness, Neurological deficits, Stroke, and Confusion.' The Care Plan includes 6 different interventions to prevent falls, including 'Complete Fall Risk Assessment per facility protocol and revise Plan of Care as needed'. Per review of Nurse's Notes dated 9/11/20, Res. #1 'was found lying on her left side on the floor of dayroom yelling/crying out to staff, she had a laceration on her left forehead . Pressure was applied to laceration to stop bleeding, tissue was re-approximated to wound. A clean dry dressing was applied. The Doctor was updated- he will be here in the A.M. and apply stitches to the wound .[Res. #1] was very upset, yelling, crying at staff .' After the fall, Res. #1 was assessed using the Morse Fall Risk Assessment Scale. The scale rates the resident as a High Risk if they score 45 or higher. Res. #1's score after the fall was 75. Per the facility's Fall Prevention Policy, the resident's Fall Reduction Plan will include: Development of Individualized Care Plans that reflect current, resident-centered interventions including documentation that reflects reviewed and/or updates for each problem with the care plan that the new fall impacted. Review of Res. #1's Care Plan after the fall on 9/11/20 reveals no documentation that a fall had occurred, and no new interventions added to prevent future falls. A Nurse Practitioner Note dated 11/16/20 describes the resident as a [AGE] year-old female with . advanced dementia with a history of behavior disturbance, and history of recurrent falls. The note further states Last night at around 8:30 P.M. [Res.#1] fell , unwitnessed, nurse heard the loud noise. Patient crying out with fall and immediately went to her room to assess, noted large hematoma Left eyebrow area with an overlying abrasion. Also had a small laceration to left thumb. A Nurses Note also dated 11/16/20 reveals 'This writer was able to provide support to [Res. #1's daughter], explaining all safety measures that staff have in place and how mom last fall was May 2020, not as recent as she thought originally. [Res. #1's daughter] asked for options of an alarm and this writer explained that an alarm would not be indicated for mom.' Review of Res. #1's medical record lists the resident's last fall as occurring on 9/11/20, two months prior to this fall on 11/15/20, and not in May 2020. After the fall, Res. #1 was again assessed using the Morse Fall Risk Assessment Scale. The scale rates the resident as a High Risk if they score 45 or higher. Res. #1's score after the fall on 11/15/20 was again 75. Review of Res. #1's Care Plan after the fall on 11/15/20 reveals no new interventions added to prevent future falls. Review of Nursing Notes dated 12/12/20 reveal 'At 07:30 A.M. [Res.#!] was found on the side of her bed sitting up. It appears that she was trying to get up and slid right out of bed.' Nurses Notes dated 12/14/20 further reveal '[after Res. #1's] fall daughter very upset since resident has fallen, and that she has frequent falls. Resident is [AGE] year-old with advanced dementia, poor safety awareness . she is also at a high fall risk if staff were to put her in bed in the afternoon, since she recently had a fall and was sitting on the side of her bed on her floor .' Review of the resident's medical record reveals no fall assessment completed after the fall on 12/12/20, no documentation noted on the resident's care plan, and no new interventions added to prevent future falls. Nurse Practitioner Note dated 12/14/20 relates Res. #1 'has had gradual ongoing decline over the past 8 months with recurrent falls and progressive advanced [CONDITION(S)] . Patient also sustained a mechanical fall on 12/14/2020.' Per review of Res. #1's Care Plan, there is a notation that on 12/14/20 the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Nursing Services [DNS] on 3/23/21 at 11:50 A.M. The DNS confirmed that Res. #1 underwent multiple falls with injuries while at the facility. The DNS stated that Res. #1's Care Plan should have been reviewed and revised to include new interventions to prevent future falls after each fall Res. #1 experienced. The DNS confirmed that consecutive falls on 9/11/20, 11/15/20, and 12/12/20 revealed no new interventions noted or implemented to prevent injuries and/or the next fall from happening. See also F689.

Based upon interview and record review, the facility failed to provide an environment that is free of accident hazards as is possible for one resident [Res.#1] of 4 sampled residents assessed as fall risks, regarding implementing interventions to reduce hazard(s) and risk(s); and monitoring for effectiveness and modifying interventions when necessary. Findings include: Res. #1 was initially admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Anxiety Disorder, Chronic Pain Syndrome, Restlessness and Agitation, and [CONDITION(S)] with Behavioral Disturbance. A review of the facility's Fall Prevention Policy identifies the Prevention procedure as Residents will be individually evaluated for the potential risk of falling so that reasonable and appropriate measures can be developed to address each resident's individual needs in an effort to mitigate the identified risk areas. A review of Res. #1's Care Plan reveals the resident was identified, upon admission, as 'at risk for falls related to Impaired Balance, Weakness, Neurological deficits, Stroke, and Confusion.' The Care Plan includes 6 different interventions to prevent falls, including 'Complete Fall Risk Assessment per facility protocol and revise Plan of Care as needed'. Per review of Nurse's Notes dated 9/11/20, Res. #1 'was found lying on her left side on the floor of dayroom yelling/crying out to staff, she had a laceration on her left forehead . Pressure was applied to laceration to stop bleeding, tissue was re-approximated to wound. A clean dry dressing was applied. The Doctor was updated- he will be here in the A.M. and apply stitches to the wound .[Res. #1] was very upset, yelling, crying at staff .' After the fall, Res. #1 was assessed using the Morse Fall Risk Assessment Scale. The scale rates the resident as a High Risk if they score 45 or higher. Res. #1's score after the fall was 75. Per the facility's Fall Prevention Policy, the resident's Fall Reduction Plan will include: Development of Individualized Care Plans that reflect current, resident-centered interventions including documentation that reflects reviewed and/or updates for each problem with the care plan that the new fall impacted. Review of Res. #1's Care Plan after the fall on 9/11/20 reveals no documentation that a fall had occurred, and no new interventions added to prevent future falls. A Nurse Practitioner Note dated 11/16/20 describes the resident as a [AGE] year-old female with . advanced dementia with a history of behavior disturbance, and history of recurrent falls. The note further states Last night at around 8:30 P.M. [Res.#1] fell , unwitnessed, nurse heard the loud noise. Patient crying out with fall and immediately went to her room to assess, noted large hematoma Left eyebrow area with an overlying abrasion. Also had a small laceration to left thumb. A Nurses Note also dated 11/16/20 reveals 'This writer was able to provide support to [Res. #1's daughter], explaining all safety measures that staff have in place and how mom last fall was May 2020, not as recent as she thought originally.' Review of Res. #1's medical record lists the resident's last fall as occurring on 9/11/20, two months prior to this fall on 11/15/20, and not in May 2020. After the fall, Res. #1 was again assessed using the Morse Fall Risk Assessment Scale. The scale rates the resident as a High Risk if they score 45 or higher. Res. #1's score after the fall on 11/15/20 was again 75. Review of Res. #1's Care Plan after the fall on 11/15/20 reveals no new interventions added to prevent future falls. Review of Nursing Notes dated 12/12/20 reveal 'At 07:30 A.M. [Res.#!] was found on the side of her bed sitting up. It appears that she was trying to get up and slid right out of bed.' Nurses Notes dated 12/14/20 further reveal '[after Res. #1's] fall daughter very upset since resident has fallen, and that she has frequent falls. Resident is [AGE] year-old with advanced dementia, poor safety awareness . she is also at a high fall risk if staff were to put her in bed in the afternoon, since she recently had a fall and was sitting on the side of her bed on her floor .' Review of the resident's medical record reveals no fall assessment completed after the fall on 12/12/20, no documentation noted on the resident's care plan, and no new interventions added to prevent future falls. Nurse Practitioner Note dated 12/14/20 relates Res. #1 'has had gradual ongoing decline over the past 8 months with recurrent falls and progressive advanced [CONDITION(S)] . Patient also sustained a mechanical fall on 12/14/2020.' Per review of Res. #1's Care Plan, there is a notation that on 12/14/20 the resident sustained a 'laceration to forehead, subdural hematoma'. An interview was conducted with the Director of Nursing Services [DNS] on 3/23/21 at 11:50 A.M. The DNS confirmed that Res. #1 underwent multiple falls with injuries while at the facility. The DNS stated that Res. #1's Care Plan should have been reviewed and revised to include new interventions to prevent future falls after each fall Res. #1 experienced. The DNS confirmed that consecutive falls on 9/11/20, 11/15/20, and 12/12/20 revealed no new interventions noted or implemented to prevent injuries and/or the next fall from happening.

Based on record review and interview, the facility failed to ensure that a resident was allowed to return to the facility following a hospitalization for 1 resident sampled (Resident #1). Findings include: Per record review, Resident #1 was admitted to the nursing home in (MONTH) (YEAR), with [DIAGNOSES REDACTED]. The resident had behaviors since admission to the nursing home that included frequent yelling out that was difficult to redirect even after any anticipated needs were met. The resident was not able to communicate verbally to clearly state their needs. Resident #1 was transferred to an acute care hospital on [DATE] with exacerbation of [MEDICAL CONDITION] and Aspiration Pneumonia. Although the resident's [MEDICAL CONDITION] and Pneumonia were resolved by 5/6/19, the nursing home had concerns about managing the behaviors, and asked for a Palliative Care consult. The Palliative Care consult was conducted by the MD on 5/13/19, and documented that the consult intent was to identify goals of care, symptom management, and guide family in decision-making for the resident. This included multiple family members including the DPOA for health care for this resident. According to the notes by the Palliative Care MD, the family wanted the resident to return to the nursing home, and possibly with hospice. A meeting was held by the Administration of the Nursing home, the MD of the resident, the Long Term care Ombudsman and the resident's family on 5/29/19 where a stipulation was made that the family would be required to sign a Memorandum of Agreement outlining the terms on which the nursing home would readmit the resident. The legal representative refused to sign the Memorandum as they felt it was taking away their right to be involved in decision making for the resident. Per interview on 8/13/19 at 2:35 PM, the family legal representative for the resident stated that the resident had lost a lot of strength while in the hospital. They had been receiving Physical Therapy at the nursing home, and was able to ambulate with a walker from the unit to the dining room. By the time the resident left the hospital, they were not able to walk anymore. The family member stated that they were getting therapy again at the level 3 home, and they were hopeful that the resident would regain the ability to ambulate at the prior level of ability. According to the Discharge Explanation included with the 6/14/19 Notice of Transfer/Discharge sent to the legal representative, the nursing home refused to readmit the resident back to the facility, stating that the behaviors were disruptive to the unit where they had resided, that the resident's needs were not able to be met at the nursing home, and they did not have the staffing to provide one on one care for the resident. Per interview on 8/14/19 at 12:30 PM, the Administrator confirmed that he was the one who had written the Discharge Explanation of why they were refusing to readmit the resident. The facility did not issue a 30 day involuntary discharge notice prior to the (MONTH) hospitalization despite the ongoing challenges caused by the disruptive behaviors. In review of the medical record, there was no physician statement at the time of the 6/14/19 discharge notice documenting why the nursing home was not able to meet the resident's needs, or a recommendation for appropriate alternative placement. The resident was not accepted back to the facility, and had to remain at an acute care hospital for almost three months, although there was not a clinical need for them to remain there. The resident was issued an involuntary discharge notice on 6/14/19, and the family appealed the discharge on 6/27/19. The resident was not allowed to return to the nursing home before issuing a discharge notice, nor during the appeal process. Resident #1 was not discharged to another placement appropriate for them quickly, and ended up staying at the hospital until 7/24/19, when s/he was discharged to a residential care home.

Based on record review and staff interviews the facility failed to assure the provision of services to prevent the formation of and promote the healing of a pressure ulcer developed in and worsening in the facility for one resident of 17 in the stage 2 sample, Resident #111. Findings include: Per record review, Resident #111 was admitted to the facility in 2012. It is noted that the resident was admitted to the facility without any pressure areas. In numerous Braden skin assessments, the resident is rated as High Risk for pressure ulcer development. The last quarterly MDS assessment, dated 4/19/17 noted that the resident has a Stage 2 pressure ulcer of the sacrum. There is no documentation, other than the note when it was discovered and there is no revision to the care plan found at that time. The next documentation noted is a progress note by the facility Wound Team on 5/19/17 that the resident has pressure areas noted on the Sacrum and Gluteal fold. The note additionally states that Resident has lost a fair amount of weight over the last multiple months. Resident uses a 'blue' arjo sling for transfers, PT (physical therapy) assesed and changed resident to 'Green' arjo sling going forward. Other: Therapy to look at cushion/seating. In an observation of the dressing change on 7/18/17 there is an Unstageable pressure ulcer with escar noted on the sacrum in the gluteal fold and a stage 1 noted on the L buttock. In record review, of the present pressure ulcers, it is found that the first documentation in notes is a Wound Team Note dated 5/19/17 which does include wound characteristics (stage, wound measurements, color, drainage) and states that there are two areas of concern-a Stage 2 of the Sacrum and the second a Stage 2 of the Gluteal fold. The pressure area may be related to a recent weight loss and spoke of changing the size of the Hoyer lift sling in use. In this note the wound is staged as a Stage 2 pressure ulcer. The next Wound Team note with descriptors is written 6/16/17, a total of 28 days later. In this note the wound is Staged as Unstageable. The next Wound Team note is written on 7/7/17, a total of 21 days later and stages the Wound as a Stage 3 pressure ulcer. The last Wound Team note is written on 7/14/17 and again describes the area as an Unstageable pressure ulcer. The Wound Team notes of 7/7/17 and 7/14/17 both state that the area has worsened. In a review of the Weekly Skin Check evaluations, done by nursing, it is found that the wound is mentioned as an open area of sacrum and buttocks on 5/18/17. There are additional Weekly Skin Checks dated 5/24, 6/13, 6/16, 6/28, 7/7 & 7/14/17 in the record. There are no wound descriptors found in any of these assessments with the exception of notation of two pressure ulcers, Stage 1 & Stage 2, on the 5/24/17 assessment. There is no mention of the pressure ulcers in the 6/13/17 & 7/7/17 assessments. In a review of the facility policy titled Wound Care it states in section A5 The Team Nurse or the assigned nurse will perform a comprehensive body audit weekly according to an assigned schedule and document the results on the Wound-Weekly Observation tool located in the Electronic Medical Record (EMR). If the resident is included in the Skin/Wound Care Rounds, the Wound Team's assessments will be documented within the progress notes as a nurse's note in the EMR. The Wound Team assessment will not be considered part of the weekly body audits. And in section A6 it states,If skin integrity alteration is observed, the resident will be added to the Weekly Wound Rounds, conducted internally, followed by documentation in the form of a narrative progress note titled 'Skin/Wound Team' in the facility EMR. In an interview on 7/18 at 11:50 AM the Licensed Nursing Assistant (LNA) assigned to the care of this resident was interviewed about care related to the pressure ulcer. She stated that the resident only gets up for a short time during the day and when asked how often she is turned every 2 hours I think and when asked about position changes when up in the chair she stated I'm not sure. Well we toilet (him/her) once while (s/he's) up. There is no evidence in the LNA Kardex of any intervention for the pressure area except an update done on 7/17/17 (the first day of survey). There are also no revisions of the care plan relevant to this area of impaired skin integrity other than interventions added on 7/17/17 by the Unit Manager. In an interview on 7/18/17 at 11:45 AM, the Unit Manager confirmed that there was no further documentation available regarding the pressure ulcer for this resident. In an interview at 1:50 PM the Director of Nursing Services stated, when informed of the findings, .that is not acceptable. We have identified issues with the documentation and pressure ulcers are one of the areas we are following. In a recent position paper regarding avoidable vs. unavoidable pressure ulcers in the Wound, Ostomy, and Continence Nurses Society website the following is stated: Accurate and thorough documentation is essential for effective prevention and management of pressure ulcers. Good documentation must be comprehensive, consistent, concise, chronological, continuing and also reasonably complete (Ayello et al., 2009). According to Dahlstrom et al. (2011), initiation of appropriate treatment of [REDACTED].e., location, stage, size), and ongoing measurements and descriptions are necessary to monitor the progression of the wound and effectiveness of interventions. However, based on a retrospective chart review, Dahlstrom et al. found documentation of the characteristics of pressure ulcers was frequently missing key descriptors, such as the stage, location, and size; and therefore, was not meeting quality guidelines. Reference: Wound, Ostomy and Continence Nurses Society. (2017). WOCN Society position paper: Avoidable versus unavoidable pressure ulcers (injuries). Mt. Laurel, NJ: Author.

Based on staff interview and record review, the facility failed to ensure 1 applicable resident (Resident #1) received adequate supervision to prevent accidents. Findings include: Per record review on 12/29/14 at 9:35 AM, Resident # 1 was left unattended in a shower room, resulting in a fall with injury. Per review of facility documentation, Resident #1 was left unattended in a shower chair in the shower room by a Licensed Nursing Assistant (LNA) on 12/1/14. Resident #1 was rated a high fall risk per assessments on 9/30/14. Per the high fall risk care plan initiated on 10/16/14, the resident was to have a personal alarm in place. Per interview with the Director of Nursing Services (DNS) on 12/29/14 at 11:40 AM, the resident was not to be left unattended without the personal alarm in place. During an interview on 12/29/14 at 12:10 PM, the LNA who left the resident unattended stated that h/she was aware of the need for the personal alarm and confirmed that h/she had left the resident unattended for a short time.