**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide showers or bathing alternative, twice per week for 2 (R7 and R56) of 3 residents reviewed for showers in a sample of 36. Findings included: 1. R7's admission Record documents admission to the facility on [DATE] and included diagnoses of muscle weakness, abnormal gait, Parkinson's disease and extra-pyramidal/movement disorder. R7's Minimum Data Set (MDS) dated [DATE] documented R7 needs partial moderate assistance from staff for showering/bathing and does not exhibit the behavior of rejecting care. This same MDS documented R7 had a Brief Interview for Mental Status (BIMS) score of 14, indicating he was cognitively intact. On 10/28/2024 at approximately 10:00 AM, R7 said he does not receive his showers as scheduled and at times goes long periods without a bath. R7 said he was supposed to get two showers per week but sometimes the staff do not come and get him for his shower. R7 said he needs a lot of assistance from the staff to get his showers. R7 said he is supposed to get his shower on Tuesday and Friday. The facility's shower schedule for R7's hall documented R7 was scheduled for showers on Tuesdays and Fridays every week. Shower documentation for R7 revealed over the past three months, staff failed to provide documented evidence of showers for R7 on 8/6/24, 8/9/24, 8/16/24, 9/13/24 and 10/22/24. 2. R56's admission Sheet documented admission to the facility on 5/12/2022 and included diagnoses of heart failure, epilepsy, muscle weakness and adult failure to thrive. R56's MDS (dated 8/9/24) documented R56 needs substantial maximum assistance from staff for showering/bathing and does not exhibit the behavior of rejecting care. This same MDS documented R56 had a BIMS score of 10, indicating moderate cognitive impairment. On 10/30/2024 at 9:34 AM, R56 said she is supposed to get her bath on Wednesday and Saturday. R56 said she has not been getting showers as scheduled. R56 said frequently gets only one shower per week. The facility's shower schedule for R56's hall documented R56 was scheduled for a shower on Wednesdays and Sundays each week. R56's shower documentation for the past three months revealed the facility failed to provide documented evidence of showers for R56 on 8/10/24, 8/17/24, 8/31/24, 10/16/24 and 10/19/24. On 10/30/24 at 9:50 AM, V5 (Certified Nursing Assistant/CNA) said residents are scheduled for two showers per week and the CNAs do the best they can at getting them done, but sometimes showers get missed. V5 said showers are to be documented and turned in to the nurse. V5 said if a resident refused the shower then it is supposed to be documented and turned in to the nurse as well. On 10/30/24 at 9:30 AM, V2 (Director of Nursing) said showers are to be given twice per week and shower refusals are to documented. V2 said no further shower documentation was available for R56 or R7. A facility policy titled Bath, Bed/Shower/Tub, with revision date of February 2018, documented the following in part: The purpose of this procedure is to promote cleanliness and provide comfort to the resident, (staff are to document) The date and time the shower/tub bath was performed and if the resident refused the shower, the reason why and the intervention taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure restorative programs were implemented to prevent a decline in condition for one of one residents (R35) reviewed for position/mobility in the sample of 36. Findings Include: R35's admission Record with a print date of 10/31/24 documents R35 was admitted to the facility on [DATE] with diagnoses that included heart failure, heart disease, insomnia, and obstructive and reflux uropathy. R35's Minimum Data Set (MDS) dated [DATE] documents R35 had a BIMS (Brief Interview for Mental Status) score of 04, which indicates R35 has a severe cognitive deficit. This same MDS does not document any restorative programs or physical therapy. On 10/29/24 at 11:27 AM, V9 (Licensed Practical Nurse/LPN) was observed administering medication to R35. R35 was tearful. V9 questioned R35 why he was tearful and R35 stated that his family wants him to walk but they cannot find a tank (oxygen tank) for him to use. R35 stated he has not walked in he does not know how long and was not sure if he was able. V9 stated she would locate a tank and have someone walk him after lunch. V2 (Director of Nursing/DON) was also present during this interaction and stated she would locate a tank. When V2 returned, she stated she was going to have to have a conversation with (R35) because physical therapy did not have him on their list. On 10/29/24 at 3:20 PM, R35 was sitting in a wheelchair in his room. R35 stated he hadn't walked in a few weeks. R35 stated he did use his walker in his room to ambulate to the bathroom with assist of staff. R35's Order Summary Report dated 10/29/2024 did not document an order for restorative programs. R35's current Care Plan did not document a Focus Area for restorative programs or therapy. On 10/31/24 at 1:00 PM, when asked if she could verify R35 did not have a restorative program on the care plan, V1 (Administrator) stated R35's care plan did document the following interventions under the Covid 19 Focus areas, Encourage doorway exercise activities for modified socialization and Encourage the resident to participate in the facility therapeutic recreation/activity program. R35's PT (Physical Therapy) Discharge summary dated [DATE] documents under Discharge Recommendations and Status, Discharge Recommendations: Shower chair with back, Assistive device for safe functional mobility and Assistance with IADL's (Instrumental Activities of Daily Living). Restorative Programs- Restorative Program Established/Trained=Restorative Ambulation Program. Ambulation Program Established/Trained: Patient is currently able to walk in corridor, walk to dining room, and walk in room, balance is steady, and tier is functional and with Restorative Nursing Program, patient will be able to walk in room with assist of one, and walk in corridor with assist of one, and balance will require the physical support of one, by performing the following Restorative Nursing interventions: allow patient to take his or her time, provide assistance of one and use gait belt. R35's Nursing Restorative Care Program documents R35 has approaches of BUE (bilateral upper extremities) with 2 # (pound) fw (free weights) x (times) 25 reps (repetitions) in all available planes and BLE (bilateral lower extremity) exercises with 2 # ankle weights x 25 reps in all available planes. This same Program documents neither approach was signed off as administered prior to 10/22/24. This indicates R35 had restorative program recommendations made during the physical therapy discharge assessment on 9/25/24 and restorative programs were not started until 10/22/24 and the walking program was not included in the restorative programs. On 10/29/24 at 1:55 PM, V8 (Director of Rehabilitation) stated they fill out a care plan form after someone finishes therapy and the care plan form documents what restorative programs a resident should be receiving and then it is given to the Restorative Aid, (V10). On 10/29/24 at 2:04 PM, V10 (Restorative Aid) showed this surveyor the restorative programs for R35 that documents his restorative programs with the date of 10/2024 and documents restorative programs began on 10/22/24. V10 stated to her knowledge there were no restoratives in place prior to 10/22/24 and if there would have been she would have known about them. V10 stated she got the care plan order from therapy and started it the same day on 10/22/24. V10 stated there were no restorative programs in place for R35 prior to 10/22/24. On 10/29/24 at 3:05 PM, V8 (Director of Rehab) stated R35's physical therapy evaluation documents an initial evaluation on 9/21/24, treatment on 9/24/24, and a discharge assessment on 9/25/24. This surveyor reviewed the discharge assessment and asked if the section labeled Discharge Recommendations and Status meant R35 should be walking with his restorative programs, V8 stated, Yes. When asked why the restorative program didn't start until 10/22/24, V8 stated she turned in the initial restorative programs before 10/22/24. When asked why it wasn't started before 10/22/24 she stated she didn't know and would have to check. On 10/30/24 at 2:23 PM, V8 (Director of Rehabilitation) stated she wasn't able to find any programs for R35 prior to 10/22/24 and no information on why there was no walking program. On 10/31/24 at 12:34 PM, when asked if she would expect restorative programs to start once the recommendations were made by physical therapy, V1 (Administrator) stated she would expect it to start as soon as they got everything together for them. This surveyor reviewed with V1, R35's therapy discharge summary was completed 9/25/24 with a recommendation for restorative programs and they were not started until 10/22/24. When asked if that was an acceptable time frame, V1 stated she would give them thirty days to start the restorative programs once the recommendation was made. On 10/31/24 at 2:00 PM, V8 (Director of Rehabilitation) stated someone could theoretically have a decline in their condition and abilities in thirty days. V8 stated they have now started meeting weekly so residents can get started on restoratives as soon as they are finished with therapy. The facility Restorative Nursing Services policy dated 7/2017 documents, Residents will receive restorative nursing care as needed to help promote optimal safety and independence

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to implement planned fall interventions for 2 (R7 and R52) of 7 residents reviewed for falls in a sample of 36. Findings included: 1. R7's admission Record documented admission to the facility on [DATE] and included diagnoses of muscle weakness, abnormal gait, Parkinson's disease and extra-pyramidal/movement disorder among others. R7's Minimum Data Set (MDS) dated [DATE] documented R7 needs supervision from staff for toileting. This same MDS documented R7's had a Brief Interview for Mental Status (BIMS) score of 14, which indicates R7 was cognitively intact. A nursing note in R7's Electronic Health Record (EHR) dated 9/21/24 at 6:00 AM, documented the following in part: Resident observed lying on floor on back in doorway of room with overturned walker beside him. When asked what happened resident stated that he fell trying to go to bathroom. Resident is alert and verbal per norm. A form titled Illinois Department of Public Health Report with incident date of 9/21/24 at 6:00 AM documented the following in part: IDT (Interdisciplinary Team) reviewed this incident and found on 9/21/24 at 6:00 AM, (R7) got up from his chair in his room un-assisted and attempted to walk to the bathroom and fell . Upon IDT reviewing and investigating this incident, it was determined that (R7) exhibited poor safety awareness .Non-skid strips have been placed in (R7's) room. A bedside commode was placed in (R7's) room near his chair for easier and closer access. Resident's care plan has been updated accordingly. R7's Care Plan documented a focus area of: I am at risk for falls with initiation date of 11/8/2021. This same care plan under the Risk for Falls focus area, listed the following interventions: Bedside commode in resident's room near his recliner for easy access to use the restroom with initiation date of 9/21/2024. On 10/28/2024 at approximately 10:00 AM, R7's room was observed without a bedside commode present. On 10/29/2024 at approximately 10:00 AM and again at 1:45 PM, R7's room was observed without a bedside commode. On 10/30/2024 at 9:15 AM, R7's room was observed without a bedside commode present. On 10/29/2024 at 1:45 PM, R7 said he fell (9/21/24) trying to walk to the bathroom from his recliner. R7 said after his fall, the facility staff did not bring him a bedside commode and never even offered one for his use. R7 denied having any further falls since falling on 9/21/2024. On 10/30/2024 at 9:50 AM, V5 (Certified Nursing Assistant/CNA) stated R7 was not supposed to have a bedside commode as far as she knew. 2. R52's admission Record documented admission to the facility on 1/23/2023 and included diagnoses of dementia, chronic obstructive pulmonary disease and over active bladder. R52's MDS, dated [DATE], documented R52 has a BIMS score of 5, indicating R52 has severe cognitive impairment. A facility incident report dated 7/8/2024 documented R52 was observed on the floor next to his bed with his pillow and blanket. Full body assessment done and no injuries. R52 unable to explain if he fell or intended to lie in the floor. R52 unable to explain what happened. IDT reviewed and decided to implement a concave mattress as a safety measure. R52's Care Plan documented the following focus area of At Risk for Falls, initiated 1/23/2023. This same care plan under the Risk for Falls focus area, listed the following interventions: Scoop mattress (concaved mattress) to be applied to R52's bed with initiated date of 7/8/2024. On 10/29/2024 at approximately 10:45 AM, R52's bed was observed with a non-concaved regular mattress on it. On 10/30/2024 at 9:20 AM, R52's bed was observed with the same non-concaved mattress on it. On 10/30/2024 at 9:30 AM, V2 (Director of Nursing) said a scoop mattress (concaved mattress) has higher edges with a lower middle section. V2 said these types of mattresses help prevent a person from rolling out of bed. V2 said she did not know R52 was supposed to have a concaved mattress and she had never applied one to his bed. On 10/30/2024 at 9:50 AM, V5 (Certified Nursing Assistant) said R52 has not had a concaved mattress on his bed that she can remember. A facility policy titled Fall and Fall Risk, Managing, with revision date of March 2018, documented the following in part: When a resident is found on the floor, a fall is considered to have occurred. Staff will identify interventions related to the resident's specific risks to try to prevent the resident from falling and try to minimize complications from falling. Staff will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling.

Based on interview and record review, the facility failed to develop and implement a plan of care for a resident with Dementia that included appropriate treatment and services to attain or maintain the highest practicable well being for 1 (R77) of 3 residents reviewed for dementia care in a sample of 36. Findings included: According to his admission Record, R77 was admitted to this facility on 10/10/2024 with diagnoses of dementia, bipolar and anxiety among others. R77's MDS (Minimum Data Set) dated 10/17/2024 documented R77 is never understood, has short and long term memory problems, and due to this R77 could not participate in a BIMS (Brief Interview for Mental Status) assessment. R77's Care Plan, with initiation date of 10/11/2024 included focus areas with interventions for the following problems and risks: urinary tract complications, weakness, self care deficit, risk for falls, risk for pain, risk for skin injury, risk for Covid 19, risk for constipation, black box medication warning and anticoagulant therapy. R77's Care Plan did not include a focus area with planned interventions to address R77's cognitive deficit or dementia. On 10/30/2024 at 9:30 AM, V2 (Director of Nursing) said it was her expectation for dementia care to be included in a resident's care plan if they had a diagnosis of dementia. On 10/30/2024 at 12:55 PM, V7 (Care Plan Coordinator) said R77's Care Plan did not address R77's cognitive deficits or diagnosis of dementia, but should have. V7 said it must have gotten missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure timely physician notification of a change in a pressure wound, clarify changes in wound treatment orders, and administer treatments as ordered for a pressure wound for 1 (R1) of 3 residents reviewed for wound care in the sample of 3. Findings include: 1. R1's face sheet documented an admission date of 9/27/17 and diagnoses including: other reduced mobility, obstructive sleep apnea, unsteadiness on feet, morbid obesity, type 2 diabetes mellitus, pressure ulcer of sacral region stage 4, bacteremia, osteomyelitis. R1's 1/16/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. On 1/16/24 at 9:50 AM, V5 (R1's Power of Attorney/ POA) said she was speaking with R1 on the phone about a month prior to this investigation when R1 complained of pain to R1's bottom. V5 said she called the facility and spoke with V2 (Director of Nursing/ DON) about assessing R1's bottom due to R1's complaints of pain. V5 said she was told by V2 at that time that R1 did have a small area on R1's bottom that looked like a paper cut. V5 said R1 had this chronic area on R1's bottom that would cycle through healing and opening. V5 said R1 was sent to the hospital on [DATE] and was told by the hospital R1 had a wound on R1's bottom that was large enough to put your fist in. V5 said this was a surprise because the facility had not reported any new or worsening wounds to R1's bottom. V5 said the hospital had told her that this wound would need to be surgically drained and debrided. V5 said after R1's surgery it was found R1's wound was infected, and osteomyelitis was present. R1's 9/25/23 care plan for Actual Alteration in Skin Integrity Pressure Ulcer to Sacrum documented the following interventions with corresponding dates: 9/25/23 observe for signs and symptoms of breakdown/ infections, 12/15/23 keep off sacrum as much as possible, 12/15/23 cleanse area with soap and water dry well, apply collagen, calcium alginate, and border dressing, 12/21/23 Treatment: Dakins soak (gauze) with flagyl to wound bed cover with calcium (alginate) and boarder (dressing), 1/10/24 to see wound doctor every Thursday, 1/10/24 wound vac at 125 mmHG (millimeters of mercury) continuous medium intensity monitor (amount) of (drainage every shift). On 1/16/24 at 1:13 PM, V3 (Licensed Practical Nurse/ LPN) said R1 had a pressure area on her bottom that would cycle through opening and closing. V3 said R1 had covid in September 2023 and had refused to be assisted to turn and the area had reopened and was being treated. V3 said R1 was not always compliant with care. V3 said she was caring for R1 on 12/19/23 and that she observed a change to the wound on R1's bottom that day. V3 said the wound had a black center and a small open area on that date. V3 said she then reported the change in R1's wound to V2 (DON) on 12/19/23 and was told that R1 would be seen in the facility by V9 (Wound Physician) on 12/21/23. V3 said that on 12/19/23, R1's wound did not have any odor or drainage. V3 said the afternoon of 12/19/23, R1 was transferred to the hospital for altered mental status and returned later on 12/19/23 with a diagnosis of Urinary Tract Infection (UTI) and was prescribed oral antibiotics. R1's 12/19/23 hospital records documented in part . Sent from (facility) with possible UTI and increased confusion . Report of more confusion, history of UTI . Clinical Impression: Acute cystitis without hematuria . R1's progress notes documented R1 was sent to the hospital on [DATE] at 12:47 PM and returned to the facility on [DATE] at 5:40 PM. R1's hospital records documented a 12/21/23 at 2:13 PM note documented in part . Spoke with (Hospital Physician) regarding positive blood culture. (R1) given (intravenous antibiotics) in (Emergency Department) and prescribed (oral antibiotic) at discharge. (Hospital Physician) states treatment appropriate . On 1/16/24 at 1:42 PM, V2 (DON) said the last time she saw R1's wound it was just a small split at top of R1's gluteal fold. V2 initially stated she did not recall being notified by V3 that R1's wound had changed. On 1/18/24 at 3:24 PM, V2 (DON) clarified that she was notified of R1's wound change by V3 (LPN) over the phone on either 12/19/23 or 12/20/23. V2 said she was off work due to illness during that time. R1's Wound Healing Progress Report completed by V2 (Director of Nursing) documented a sacral wound with measurements (length x width x depth) as follows: 11/24/23 1 x 0.1 x 0.1 cm (centimeters), 11/30/23 1 x 0.1 x 0.1 cm, 12/7/23 1 x 0.1 x 0.1 cm, 12/14/23 1 x 0.1 x 0.1 cm. R1's Treatment Administration Record (TAR) documented the following orders: 9/25/23 through 12/15/23 cleanse area to sacrum with soap and water, pat dry, apply a thin layer of medihoney 100% paste, cover with calcium alginate and border dressing every shift; a 12/15/23 through 12/23/23 order to cleanse area to sacrum with soap and water, dry well, apply collagen and cover with calcium alginate and border dressing every shift, keep resident off sacrum as much as possible. On 1/16/24 at 3:00 PM, V9 (Wound Physician) said he was notified of R1's wound when he arrived at the facility on 12/21/23. V9 said R1's sacral wound prior to debridement was very large and open with black necrotic tissue and had a very strong odor. V9 said he debrided R1's sacral wound in the facility and changed the wound care treatment. V9 said he suspected R1 to have gas forming gangrene and was going to treat it with flagyl, dankins, and hydrogen peroxide. V9 said there was a second wound to R1's left buttock that did not appear to be infected. V9 said the second wound to R1's left buttock appeared to be a shear wound and could have happened just prior to V9 entering the facility. V9 said R1 was sent to the hospital on [DATE] after he had seen R1 in the facility where R1's wound was further debrided, and the sacral and buttock wounds became one. R1's 12/21/23 Wound Evaluation & Management Summary completed by V9 (Wound Physician) documented in part .Wound Sacrum Full Thickness .Etiology infection .Wound Size (Length x Width x Depth) 6 x 4 x 3 cm (centimeters) .Undermining 3 cm at 12 o'clock .Dressing Treatment Plan .Alginate calcium apply twice daily for 30 days; Sodium hypochlorite solution (dakins) apply twice daily for 30 days: 1/2; Hydrogen peroxide apply twice daily for 30 days; Metronidazole sprinkle apply daily for 30 days .Wound of the Left Buttock Full Thickness .Etiology infection .Wound Size (Length x Width x Depth) 2 x 3 0.2 cm .Dressing Treatment Plan .Alginate calcium apply twice daily for 30 days; Sodium hypochlorite solution (dakins) apply twice daily for 30 days: 1/2 . On 1/18/24 at 10:46 AM, V9 said he expected the facility to follow his orders. V9 said if the facility would have notified him on 12/19/23 with a picture of R1's wound, he would probably have changed R1's wound treatment orders to include dankins solution twice a day. V9 also stated however, if the facility would have notified him prior to 12/21/23, he did not think it would have changed R1's outcome. V9 said he had treated R1 for several years and R1 was very noncompliant with off loading pressure and the wound to R1's sacrum was unavoidable. R1's 1/14/24 Assessment for Clinically Unavoidable Pressure Sores documented in part . Clinical conditions that are the primary risk factors for developing pressure sores included, but are not limited to, resident immobility and: severe chronic pulmonary obstructive disease, chronic bowel incontinence, continuous urinary incontinence or chronic voiding dysfunction, sepsis, head of bed elevated the majority of the day due to medical necessity, serum albumin below 3.4 g/dl (grams per deciliter), weight loss of more than 10% during last month. On 1/18/24 at 1:09 PM, V14 (Attending Physician) said he could not recall if the facility had notified him of any changes to R1's wound on 12/19/23 or 12/20/23. V14 said if the facility had notified him, he would have ordered to continue the current wound treatment orders and to follow up with V9 on V9's next weekly visit. R1's December 2023 Electronic Medication Administration Record (EMAR) documented a 12/21/23 order for dakins wound solution to buttocks to be administered at 2:00 AM and 2:00 PM and was marked administered by V7 (Registered Nurse/ RN) on 12/21/23 at 2:00 PM. R1's Electronic Medical Record (EMR) documented the order for dakins wound solution to buttocks was entered on 12/21/23 at 1:29 PM by V7 (RN). R1's December 2023 Electronic Treatment Administration Record (ETAR) documented a 12/15/23 order for cleanse area to sacrum with soap and water dry well apply collagen and cover with calcium alginate and border dressing every shift. Keep resident off sacrum as much as possible at 2:00 AM and 2:00 PM and was marked administered by V7 on 12/21/23 at 2:00 PM. R1's December 2023 ETAR also documented a 12/21/23 order for apply dakins soak gauze with flagyl 250 mg (milligram) to wound bed cover with calcium alginate and border dressing at 2:00 AM and 2:00 PM, and was marked as administered by V7 on 12/21/23 at 2:00 PM. On 1/18/24 at 9:12 AM, V7 (RN) was asked which treatment he had completed for R1's wound care on 12/21/23 since there were three different wound care orders documented on the MAR and TAR, and V7 replied he did not know how to look up past charting on dressing changes. V2 (DON) assisted V7 with finding R1's December 2023 EMAR and ETAR. V7 said he did not recall which of R1's treatment orders he had completed on 12/21/23. V7 said he completed R1's wound treatments on 12/21/23 at 2:00 PM as they were charted. V7 was asked what R1's wound looked like on 12/21/23 and V7 replied he could not recall. V7 was asked if R1's wound was open on 12/21/23 and V7 replied he could not recall. V7 was asked who had given him the order to change R1's wound treatment on 12/21/23 and V7 replied he could not recall. On 1/18/23 at 9:21 AM, V2 (DON) said she expected staff would accurately chart any treatment they complete. On 1/18/23 at 9:58 AM, V11 (Certified Nursing Assistant/CNA) said R1's wound had gotten dark a few days prior to R1 being sent out to the hospital. V11 said R1's wound was open prior to V9 (Wound Physician) arriving on 12/21/23. During this interview, V7 (RN) interrupted V11 and told V11 she did not recall and instructed that she did not have to answer any of the surveyors' questions. R1's EMR progress notes from 12/8/23 through 12/21/23 did not document any change or new wounds to R1 or any complaints of pain to sacrum or buttocks. R1's 12/21/23 at 6:15 PM hospital record documented in part . arrived from (facility) with reports of altered mental status . (R1) has known UTI. (R1) was seen in the emergency department on 12/19/23 and diagnosed with UTI. (R1) was sent into the Emergency Department (ED) for worsening altered mental status today. Blood cultures review from ED stay on 12/19/23 revealed a positive culture in the aerobic bottle of Streptococcus dysgalactiae . (R1) does have history of frequent UTIs Differential Diagnosis: Cerebral Vascular Accident (CVA), Transient Ischemic Attack (TIA), UTI, encephalopathy, pneumonia . R1's hospital record documented a 1/5/24 Infections Disease Consultation in part .History of Present Illness: . patient is bed-bound, stage IV pressure ulcer sacral. Patient transferred from outside hospital earlier today for further treatment of suspected osteomyelitis of sacral area and recent bacteremia .patient recently admitted to (outside hospital) on 12/22/23 and found to have E. coli UTI (Urinary Tract Infection) and Streptococcus bacteremia. Patient had sacral wound culture on 12/22 which grew Proteus. Patient underwent debridement of the sacral ulcer on 12/28 and bone culture grew Enterococcus, Enterobacter, E. Coli. Tissue grew Enterococcus and Pseudomonas. Patient started on wound vac .Recommendations: Unfortunately there was not much benefit of long-term treatment of sacral osteomyelitis in bed-bound patient as soon as we stop antibiotics the infection will come back and progress. To assure success in treatment, patient has to be motivated, repositioned frequently with hospital bed, evaluated for nutritional status, and potential diverting colostomy .continue empiric antibiotics but I would recommend 14 days of treatment for soft skin tissue infection rather than full 6 weeks of treatment of osteomyelitis . The facility's revised April 2018 Pressure Ulcers/ Skin Breakdown - Clinical Protocol documented in part . the nurse shall describe and document/ report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds .The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . The facility's revised April 2019 Administering Medications policy documented in part .4. Medications are administered in accordance with prescriber orders, including any required time frame .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; .g. The signature and title of the person administering the drug. 24. Topical medications used in treatments are reordered on the resident's treatment record (TAR) . The facility's revised May 2017 Change in a Resident's Condition or Status policy documented in part .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): d. significant change in the resident's physical/ emotional/ mental condition; e. need to alter the resident's medical treatment significantly; .A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff .c. Requires interdisciplinary review and/ or revision to the care plan .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/ mental condition or status .The nurse will record in the resident's medical record information related to changes in the resident's medical/mental condition or status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from physical restraints for 1 of 6 residents (R1) reviewed for restraint use in the sample of 6. Findings include: On 4/7/23 at 5:45pm, V2 (Director of Nursing/DON) stated the facility is restraint free, with no residents currently having restraints being utilized. On 4/7/23 at 6:10pm, V1 (Administrator) stated the facility is restraint free and that restraints are not used at the facility. On 4/7/23 at 6:25pm, R1 was observed in the North Hall common area watching TV with other residents. R1 was noted to stand up out of her wheelchair and attempt to ambulate, requiring redirection from staff. R1 was alert and oriented only to herself. R1 was noted to be utilizing no restraint devices. R1's Resident Face Sheet documented an admission Date of 03/30/21, and diagnoses including Unspecified Dementia with Behavior Disturbance, Macular Degeneration, Legal Blindness, Bipolar Disorder, and Cognitive Communication Deficit. R1's Minimum Data Set (MDS) dated [DATE] documented a BIMS (Brief Interview for Mental Status) Score of 0, indicating R1 has severe deficits in cognition. The same MDS documented that R1 requires extensive assistance from at least two staff members for transfers, and R1's balance moving from a sitting to standing position is unsteady and is only stable with staff assistance. The MDS Section P, Restraints, documented there are no restraints used for R1. R1's April 2023 Physicians Orders had no orders for restraint devices to be used. R1's Care Plan with a review date of 4/7/23 documents, I have episodes of aggression and agitation which has the potential for injury or negative outcomes to my peers, with the corresponding intervention, Provide increased supervision to assure safety during these episodes til I have calmed. There were no interventions related to the use of restraint devices. A Resident Incident Report in R1's medical record documented, Date/Time of Incident: 04/05/23 at 6:00pm. (V14/Licensed Practical Nurse/LPN) reported when she came in for her shift, (R1) was sitting in a dining room chair on North Hall at the nurses' station. (R1) had a sheet around her midsection and it was loosely tied around the back behind the chair. It was loose to where the sheet was not touching her body and (V15/Registered Nurse/RN) was sitting next to her at the desk while (R1) was playing with the sheet and an activity blanket. The resident's arms were free and the resident was content and making no attempts to stand but was calm. No injuries were assessed. The Physician was notified on 04/06/23 at 8:00am, The POA (Power of Attorney) was notified on 04/06/23 at 8:10am. Additional follow up: (R1's Physician) has been notified and the facility has received a verbal temporary order for a restraint if the resident's behaviors are causing harm to herself or others. After review of all statements, (V1/Administrator) believes, and according to (V15's) statement, she did willfully (she acted based on situation at the time to help protect (R1) from falling or attacking other peer, not that (V15) intended to use as a restraint), she did drape a sheet across the dining room chair, flowing to (R1) midsection a loosely tied the sheet around the back of the chair .Although the resident would have been able to remove the sheet .by definition it would still be considered a restraint. Restraint Policy: Restraints shall only be used for the safety and well-being of the resident(s), and only after other alternatives have been tried successfully. Restraint Assessment completed, order received from PCP (Primary Care Provider) for temporary use of restraint when all interventions have been exhausted, and she is presenting a danger to herself or others. Reassess in ten days for planned D/C (Discontinuation) of order. On 4/11/23 at 3:10pm V15 (RN) was interviewed by phone. V15 stated on 4/5/23 she worked from 6:00am to 6:00pm on the North Hall. V15 stated about ten minutes before her shift ended at 6:00pm, V15 saw R1 ambulating up the hall. V15 stated R1 is not to ambulate unassisted as R1 is, confused, a huge fall risk, and blind. V15 stated she went to R1, who was very wobbly, and R1 almost fell twice but V15 kept her from falling. V15 stated she sat R1 down at a table by the nurses' station in a chair by a peer. V15 stated she got R1 a snack, a drink, and an activity book, but R1 kept trying to get up. V15 stated R1 then started picking up the peer's activity book and pencils and started throwing them, and then started shaking the table. V15 stated she ambulated R1 to a dining room chair right by the nurses' station and sat her in it. V15 stated she tried distracting R1 by talking softly and holding her hand, but R1 was still trying to get up. V15 stated she then got a sheet from the linen closet and placed it across R1's lap and tied it loosely behind the chair. V15 stated the sheet was so loosely fastened R1 could have easily gotten up had she tried. V15 stated she placed an activity blanket in R1's lap. V15 stated R1 calmed right down and there were no further issues. V15 stated V14 (LPN) relieved V15 at 6:00pm, and V14 and V15 removed the sheet from R1, got her wheelchair, which had been in her room, they transferred R1 into it, and V15 went home. V15 stated the next morning, on 4/6/23 at about 4:30am, V15 was called by V1 who stated V15 failed to follow the restraint policy and was being written up and suspended until V15 could be in serviced, which was to be 4/12/23. V15 stated, I wasn't even thinking about the sheet being a restraint. And I was not trying to abuse R1, I love all my residents and would never do that. On 4/18/23 at 9:30am, the Surveyor asked V15 (RN) to recreate the sheet restraint with V8 (Certified Nursing Assistant/CNA) taking the place of R1. V15 demonstrated moving a dining room chair from around the table and moving it closer to the North Hall nurses' station, about six feet away from the nurses seat at the computer. V15 went to the linen closet and came back with a flat sheet, placing the sheet loosely on V8's lap and tying the back once over, not knotted, very loosely, leaving V8's hands and arms free. V15 stated there were no staff who witnessed her place the sheet around R1. V15 stated she did not contact R1's Physician or POA, did not check the chart for a Physician's Order or a Restraint Consent signed by the POA, or a Restraint Assessment. V15 stated she did not contact V2 (DON) stating V2 was already gone for the day. On 4/18/22 at 10:10am, R1 was observed in the facility dining room. R1 had no restraint devices in use. On 4/18/23 at 1:00pm, V2 (DON) stated per the facility policy V2 could temporarily authorize a restraint in emergency situations with a physician's order but acknowledged V15 on 4/5/23 did not contact V2 nor obtain a physician's order. V2 stated when she arrived at the facility about 7:00am on 4/6/23, she immediately assessed R1 for injuries from the restraint and there were none. V2 stated on that day she completed a Restraint Assessment, obtained verbal consent from R1's POA and a physician's order for a least restrictive soft restraint. V2 was unable to explain what that meant exactly but acknowledged it wouldn't include tying R1 with a sheet to a chair. V2 stated she would need to contact V16 (R1's Physician) to clarify the order. An undated Restraint Consent Form listed R1's name at the top, and the Resident Representative Signature and Date line were blank. There was no documentation in the April 2023 Nursing Progress Notes to indicate V2 had obtained verbal consent from R1's POA for any restraint. A Physicians Telephone Order Sheet dated 4/8/23 documented, May use less resistant restraint for resident when behaviors could cause harm to self or others when other interventions exhausted. There was no medical diagnosis on this order to indicate what it was being used to treat or the specific type of restraint to be used. On 4/18/23 at 1:40pm, V14 (LPN) stated she entered the North Hall at about 5:55pm on 4/5/23 to begin her shift. V14 stated she saw R1 sitting in a dining room chair with a flat sheet around her middle, which was tied loosely behind the chair. V14 stated V15 said R1 had been having a lot of behaviors that day and V15 had been trying to calm her down. V14 stated she was Flabbergasted to see R1 restrained in this manner. V14 stated, I knew right then it was wrong, and I should have said something to her (V15) about it, but she is a good nurse and a good person, and I didn't want to get her into trouble. I think she was just frustrated and made a bad choice. V14 stated they removed the sheet, transferred R1 into her wheelchair, and R1 didn't have further behaviors. V14 stated she did not physically assess R1 as the sheet had not been tight enough to injure R1. V14 stated between 11:00pm to 12:00am that evening, V14 decided she needed to report the incident, so she called V2 (DON), who instructed her to notify V1 (Administrator). V14 stated she was told by V1 she should have immediately reported it, and V14 stated she was written up by administration Because they said I violated the abuse policy by not immediately reporting it. On 4/18/23 at 2:10pm, V1 (Administrator) stated she was called at about midnight on 4/6/23 to report R1 having been restrained as referenced above. V1 stated she asked V14 why she had not reported it earlier. V1 stated she began an immediate investigation, calling other staff who had been present on both the 6am to 6pm and 6pm to 6am shifts, and then called V15 (RN) and left V15 a voicemail. V1 stated V15 returned her call at about 4:20am on 4/6/23. V1 stated she told V15 about V14's report. V15 stated she had tried snacks, drinks, coloring books and pencils for redirection, which were not effective. V1 stated V15 told V1 she laid a sheet over R1's lap and loosely tied it behind the chair, placing an activity blanket in R1's lap, which was effective in calming R1 down. V1 stated V15 was written up for violating the facility's restraint policy due to not having a physician's order and the method of the restraint used. On 4/19/23 at 9:24am, V1 provided what she stated was an updated Physicians Telephone Order, undated, which stated, Least restrictive restraint possible when other interventions have been exhausted (soft fabric, loosely tied) in chair no more than one hour at a time. There was no diagnosis on this order. On 4/19/23 at 10:05am, V16 (R1's Physician) stated he was not contacted about R1 being restrained until V17 (Regional Director of Operations) called him on 4/7/23 in the late afternoon or early evening. V16 stated tying a resident to a chair using a sheet is not an appropriate form of restraint. V16 stated one to one supervision should have been utilized if other interventions were not working. V16 stated R1 has had several falls and gait instability. V16 stated going forward, if R1 requires a restraint he will probably order a weighted lap cushion. A Use of Restraints Policy with a revision date of April 2017 documented, The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove the device in the same manner in which the staff applied it .and this restricts his/her typical ability to change positions or place, that device is considered a restraint. Restraints shall only be used to treat the residents medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including Tucking sheets so tightly that a bed bound resident cannot move .(and) placing the resident in a chair that prevents the resident from rising .Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention and a restraint is required to: A) Treat the medical symptom. B) Protect the resident's safety, and C) Help the resident attain the highest level of his/her physical or psychological well-being .Prior to placing a resident in restraints, there shall be a pre restraining assessment and review to determine the need for restraints. Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less restrictive interventions are feasible .The Director of Nurses has the authority to order the use of emergency restraints. The attending Physician must be notified of such and the reason for the order .Restraints shall be used upon written order of the physician and after obtaining consent from the resident and/or representative.

Based on observation, interview, and record review the facility failed to provide an accessible call light for 1 of 5 residents (R58) reviewed for environment in a sample of 39. Findings include: R58's face sheet documented diagnoses to include: fracture of left femur, schizoaffective disorder, insomnia, Alzheimer's disease, encephalopathy, and hypertension. R58's 8/9/22 Minimum Data Set (MDS) documented R58 was not interviewable. R58's Electronic Medical Record (EMR) showed R58 returned to the facility from a hospital stay on 8/2/22. R58's care plans did not show any accommodation for a call light or alternate form for reaching out to staff. On 8/23/22 at 9:56 AM, R58 was lying in bed and no call light was observed in R58's room. The call light outlet in R58's room did not have a call light cord connected to it. No physical bell was observed in R58's room. On 8/24/22 at 10:05 AM, R58 was lying in bed and no call light was observed in R58's room. No physical bell was observed in R58's room. V4 Certified Nurse's Assistant (CNA) said when R58 returned from the hospital he was pulling the call light out of the wall and staff did not replace it. On 8/24/22 at 10:36 AM, V2 Director of Nursing (DON) said when R58 returned from the hospital on 8/2/22 he was found by staff to have the call light cord wrapped around his neck and the call light was removed from his room for his safety. V2 said R58 should have a physical bell in his room. On 8/24/22 at 10:50 AM, V1 (Administrator) said R58 did not have the call light cord wrapped around R58's neck. V1 said R58 was flinging the call light around when R58 returned from the hospital on 8/2/22. On 8/26/22 at 11:19 AM, V1 said when R58 returned from the hospital on 8/2/22 R58 was combative and was flinging the call light around and facility staff had removed it for R58's safety and a physical bell was placed in R58's room. V1 said she expected staff to ensure R58's physical bell was within reach while R58 was in bed. The facility's September 2003 Answering the Call Light policy documented in part . General Guidelines . 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed . be sure the call light is within easy reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident rooms were maintained in a clean and sanitary condition for 2 out 5 residents (R17 and R29) reviewed for environment in a sample of 39 residents. Findings include: 1. R17's Face Sheet documents admission to this facility on 05/12/22. R17's Diagnosis Sheet includes epilepsy with status epilepticus, adjustment disorder with depressed mood, major depressive disorder, heart failure, and chronic kidney disease. R17's most recent admission minimum data set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicated she is moderately cognitively impaired. On 8/23/22 at 10:13 AM brown dried matter was observed on R17's privacy curtain. R17 said she was unsure how long the brown matter had been there but R17 thought about a month. R17 said she thought it was gross it had been there that long. On 8/24/22 at 10:05 AM brown dried matter was observed to be on R17's privacy curtain. On 8/24/22 at 10:51 AM, V12 (Housekeeping Supervisor) said the brown matter dried on R17's privacy curtain was feces. V12 said R17's privacy curtain needed to be taken down and washed. 2. R29's Face Sheet documents admission to this facility on 06/01/22. R29's Diagnosis Sheet includes vascular dementia with behavior disturbance, bipolar disorder, major depressive disorder, and cerebral infarction. R29's most recent admission MDS dated [DATE] documents a BIMS score of 8, indicating she is moderately cognitively impaired. On 8/23/22 at 1:02 PM, R29 stated they don't do a very good job cleaning around here and the place is filthy. R29's room was noted to have a privacy curtain with multiple unknown stains on it, bedsheets with dark brown/ black matter, and the floor was unswept and had other unknown substances dried on it. On 8/26/22 at 11:19 AM, V1 (Administrator) said she expected staff to report to V1 or any housekeeping staff if dried feces was observed on a resident's privacy curtain so the privacy curtain can be taken down and cleaned. V1 said she expected the resident's room to be cleaned, swept, and mopped daily. The facility's June 2009 Cleaning and Disinfection of Environmental Surfaces policy documented in part . Environmental surfaces will be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities . 9. Housekeeping surfaces . will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled . 11 . curtains in resident areas sill be cleaned with there surfaces are visibly contaminated or soiled .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received the required assistance in showering and nail care for 3 of 6 residents (R12, R72, R32) reviewed for ADL's (Activities of Daily Living) in a sample of 39 residents The Findings Include: 1. R12's Facesheet documents R12 was admitted to the facility on [DATE]. The same facesheet documents R12 has a diagnosis of Gastrontestinal hemorrhage, cognitive communication deficit, unspecified dementia with behavioral disturbances. R12's MDS (Minimum Data Set) dated 8/12/22 note that R12 has a BIMS (Brief Interview of Mental Status) of 03, which indicates severe cognitive impairment. Section G of the same MDS note that R12's self performance for bathing is total dependence and support provided is two+ persons physical assist. R12's personal hygiene self performance is extensive assistance-resident involved in activity, staff provide weight bearing support and support provided is one person physical assist. R12 was observed on 8/23/22 at 11:10am and 8/24/22 at 10:56am. His hair was not combed and was sticking up all around his head. R12's fingernails on both hands had moderate amount of brown material underneath them. On 8/24/22 at 1:00pm, R12 said that his fingernails had not been done in a while. Document labeled Bath Care Roster note that R12 received a sponge bath on 8/7/22. Document labeled facility completed care details document that R12 received a shower on 8/15/22. No other documentation was could be provided from 8/7/22 to 8/15/22 of R12 receiving any other showers indicating R12 went 8 days without receiving a shower. 2. R72's Facesheet documents R72 was admitted to the facility on [DATE]. The same document note that R72 has a diagnosis of unspecified dementia without behavioral disturbance, Type 2 diabetes mellitus without complications. R72's MDS dated [DATE] note under section C that R72 has a BIMS should not be conducted due to resident rarely/never understood. The same MDS note under section G that self performance of bathing is total dependence and bathing support provided is two+ person physical assist. Self performance for self hygiene is total dependence-full staff performance every time during entire 7 day period and support provided is two+ person physical assist. On 8/23/22 at 11:15 am, R72 was observed sitting in her wheelchair. R72's hair had not been brushed and was all over her head. R72's fingernails were noted to have a moderate amount of brown material underneath them. On 8/24/22 at 10:15am, R72's hair had been brushed and her fingernails remained to have a moderate amount of brown material underneath them. On 8/24/22 at 10:15am, V17 (family member) said that he had brushed his wife's hair, not staff. V17 said he has to brush it most all of time. Document labeled Bath Care Roster from 5/18/22 thru 8/24/22 note that R72 received a shower on 8/8/22 and document labeled Completed Care Details note R72 had a shower on 8/22/22. No other documentation could be provided from 8/8/22 thru 8/22/22 of R72 receiving any other showers indicating R72 went 14 days without receiving a shower. 3. R32's Facesheet documents that R32 was admitted to the facility on [DATE]. The same facesheet note R32 has a diagnosis of Unspecified dementia without behavioral disturbance, depression. R32's MDS dated [DATE] note that R32 has a BIMS of 5 which indicates severe cognitive impairment. The same MDS section G note that R32 self performance for personal hygiene is extensive assistance-resident involved in activity, staff support for personal hygiene is limited assistance. Section G also note under bathing that the support provided is limited assistance and self performance is extensive assistance. Review of document labeled Bath Care Roster dated 5/24/22 thru 8/24/22 note that R32 received a shower on 8/1/22. Document labeled Completed Care details note that R32 received a complete bed bath on 8/12/22 and no other showers/baths documented to 8/24/22. These documents indicate that R32 went 11 days and then 12 days without a shower. On 8/26/22 at 11:30am, V1 (Administrator) said that it is their policy that residents receive a shower or bath twice weekly. V1 said there is no written policy for baths/showers. V1 said if a resident requests more, they will provide a shower more often. On 8/26/22 at 1:30pm, V14 (LPN/Licensed Practical Nurse) said that the residents are on a bathing schedule and receive a shower or bath twice weekly. V14 also said that if a a resident is heavily soiled, they will usually provide a bath then also. V14 said that the nails are checked and scraped daily by V15 (Activity Director). V14 said that Activities do all except the diabetics and the nurses do them. On 8/26/22 at 1:40pm, V15 said that she checks residents fingernails 2 days a week on Mondays and Fridays. V15 said if they need cleaned or trimmed, she will do them. V15 said she does not do the diabetics, the nurses do them.

Based on observation, interview, and record review the facility failed to maintain a pest free environment. This has the potential to affect all 72 residents living in the facility. Findings include: R9's face sheet documented diagnoses including: nontraumatic subacute subdural hemorrhage, neuralgia and neuritis, major depressive disorder, and Parkinson's disease. R9's 5/20/22 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, meaning R9 was interviewable. On 8/23/22 at 10:17 AM, R9 said there had been bugs in his room for the past couple months. R9 said he had reported to facility management his concerns with bugs in his room and nothing had been done about it. At that time a cockroach was observed running across the floor under R9's bed and another cockroach was observed running across the floor under R9's refrigerator in R9's room. On 8/23/22 at 1:10 PM, V9 Certified Nurse's Assistant (CNA) was observed standing in the 200 hallway and a cockroach was observed crawling up a resident's door frame. V9 donned gloves and tried to kill the cockroach. V9 was unsuccessful in killing the cockroach due to it crawling behind the hallway handrail. V9 said the facility did have a cockroach problem. On 8/23/22 at 11:23 AM, V10 Licensed Practical Nurse (LPN) said the facility has been infested with cockroaches for several months. V10 said management is aware of the cockroach infestation. V10 stated the cockroach infestation was so bad we can't keep food in the facility because cockroaches will get in our food. On 8/24/22 at 11:23 AM, V4 (CNA) said she had seen cockroaches in the facility hallways and in resident's rooms. V4 said the cockroaches were small so V4 did not report them to facility management. On 8/24/22 at 11:35 AM a cockroach was observed in the day room bathroom running across the floor and up the door frame. The facility's August 2015 Pest, Preventing and Managing Infestations of policy documented in part . Staff should be trained to recognize insect and pest infestation, and know what their specific roles will be should an infestation occur General Guidelines . [outside pest control company] will be used and contracted to do preventative management for pest . will complete monthly inspections . will also be used as needed bases and when the monthly prevention is not sufficient . The Resident Census and Conditions of Residents Form (CMS-672) dated 8/23/2022, documents there are 72 residents living in the facility.