**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure two staff member were at bedside during incontinence care for one resident who was high risk for falls and required two person assistance with turning and repositioning. This affected one of three residents (R4). This resulted in R4 sustaining a fall, being transferred to the local hospital with a diagnosis of scalp hematoma. Findings include:R4 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease, weakness, and difficulty walking. R4 fall risk evaluation dated 7/29/25 documents a score of 10. Facility fall prevention policy dated 8/2024 documents a score of 10 or greater indicates resident is at high risk for falls. R4'sR4's incident report dated 8/7/25 documents while receiving Activities of daily living (ADL) care patient slid out of bed.R4's functional ability and goals assessment dated [DATE] documents under toileting: Hygiene and roll left to right substantial/maximal assistance which indicates helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.R4's task list date 7/30/25 documents turn and reposition resident two person assist at all times.On 9/4/25 4:49pm V2 (DON) said she was present during the fall for R4. V2 said she was assisting V19 (CNA) with R4's care. V2 was on one side of the bed and V19 (CNA) was on the other side of the bed. V2 said she stepped away from the resident to move or get the garbage can at the same time V19 (CNA) wiped R4 causing her to jerk and start to slide off the bed. V2 said she was unable to stop R4 from falling. On 9/5/25 at 3:43PM, V19 (CNA, Certified nursing assistant) said she was assisting V2 (DON) with incontinence care for R4. V19 said R4 is total care and requires two people for all care. V19 said R4 was on her side and was cleaning her buttocks. V2 (DON) was on the other side and went to get the garbage can by the door when R4 starting to go forward because she could hold her weight. R4 fell to the ground.On 9/4/25 at 4:30PM, V16 (restorative nurse) said R4 requires two staff members be present during care for safety. V16 said staff should never leave the bedside when providing care and all items should be at bedside prior. V16 said staff should have never left the resident bedside during care. V16 said she provided reeducation to staff about ensuring all items are at bedside prior to starting care. R4's progress note dated 8/7/25 documents: While receiving ADL care patient slid to floor, head to toe and ROM assessed without deformities or complaints of pain, patient positioned back to bed with 2 person assist using a mechanical lift, lump to left frontal lobe noted, pain medication administered by mouth for pain, ice pack applied to head. Doctor and nurse notified, new order: send to hospital for evaluation and treat. R4's hospital discharge paperwork dated 8/7/25 indicates fall with scalp hematoma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to follow their policy and procedure to ensure staff provided incontinence care at least every two hours for a resident identified as dependent on staff for toileting. This affected one of three (R131) residents reviewed for neglectful care and services. This failure resulted in R131 being exposed, soiled with feces, crying, verbally distraught, begging for help and feeling uncomfortable. Findings Include: R131 was diagnosis with mixed/urinary incontinence, rash and other nonspecific skin eruption, malignant neoplasm of vulva and obesity. Minimal Data Set (MDS) section C (cognitive patterns) dated 5/8/25 brief interview for mental status documents a score of thirteen which indicates cognitively intact. Section GG (functional abilities) documents R131 was dependent with toilet hygiene (helper does all of the effort). Resident does none of the effort to complete the activity or the assistance of two (2) or more helpers is required for the resident to complete the activity. Care Plan initiated on 1/31/25 and 5/8/25 documents: R131 has a self-care deficit in bed mobility related to decrease ability to position or reposition self in bed and turn from side to side without staff assist. At risk for abuse and neglect. On 5/13/25 at 4:53pm, R131 who was assessed to be alert to person, place and time said, she was left in her feces from 2am until the police arrived. R131 said, she called V37 to report staff was not answering her call light and she needed to be cleaned up after a bowel movement. R131 said, her vaginal area was exposed and there was so much diarrhea. R131 said, she felt bad and just wanted some help while starting to tear up. R131 said, she was falling in and out of sleep due to her nightly medication and was not provided incontinence care until the police arrived. Facility provide statement for R131 dated 5/14/25 documents: I woke up. I had a mess on my hands because I was in diarrhea. I pressed the call light to be changed. No one was coming so I called my son and V37. I just remember being uncomfortable and needing to be changed. On 5/15/25 at 10:03am, V37 (family) said, R131 called him crying, upset, verbally distraught begging for help early Monday morning at 2am complaining of staff not answering her call light on the night shift. Not changing her after she had a bowel movement. R131 has a wound from radiation in her groin. V37 said, R131 called him back multiple time between 3am -5am to report staff still hadn't come to her change/provide incontinence care. V37 said, he called the facility with no answer. V37 said, after the multiple calls from R131 due to her not receiving care, he called the police for a well check. R131 was left soiled and saturated in urine and feces for four hours. The facility tried to say R131 tore of her adult brief. R131 does not have any behaviors. Facility provided concern form dated 5/12/25 (9:37am) documents: V37 stated he had concerns regarding care. Wasn't able to reach anyone. Stated he called police. All parties notified. Facility provide statement for V37 dated 5/14/25 (2:41pm and 4:08pm): V37 said, that he received a phone call from R131 early Monday morning and that she mentioned she was waiting for someone to come and change her. V37 also mentioned that he called the police because he said he [NAME] like R131 was being mistreated. Police Report dated/time report 5/12/25 at 6:31am documents: Last known secure 5/12/25 at 3:00am. On 5/12/25 at 6:52am, police responded to nursing home in reference to a citizen assist complaint. V37 informed them that he was requesting a well-being check on his wife, R131. V37 stated that he tried calling the facility several times and no one was answering. Additionally, V37 informed Southwest Central Dispatch (S.W.C.D) that he spoke with R131 who stated she was sitting in her own feces and had open wound. V37 explained that he was unhappy with the care R131 was getting. Upon police arrival, police observed a female subject standing behind a nurse's cart, dressed in scrubs. In the hallway for two hundred rooms. Police inquired, if she was the nurse for the wing, at which point she informed police she was and assisted police with the location of R131's room. Upon entering R131's room, police could smell the strong odor of feces. Police then observed a female subject, later identified as R131, lying on the bed closest to the entry door of the room. R131 did not have any undergarments on, was lying on her back, and her vaginal area and groin area appeared to have a large amount of feces on it. R131 was holding a bed sheet that also appeared to have feces on it. Police spoke with R131, who explained the following in summary but not verbatim: She/R131 had been lying in that condition since May 12 2025 between the hours of 2:00am -3:00am. R131 further advised that she called her husband to report the condition and also her son. Police asked, R131 if she had a call button located near her, to contact staff. R131 informed police there was call button beside her bed, but no one had come to assist her. Police relocated back into the hallway and spoke with the female subject standing behind the nurse cart, dressed in scrubs. Police informed her of R131's condition, at which time the female subject standing behind a nursing cart, dressed in scrubs advised that she was not a CNA (certified nurse's assistant). Police relocated to the administrative area and knocked on the doors. Police was met by a male subject, dressed in what appears to be a doctor coat. Police informed him of R131 condition and what the female subject standing behind a nurse cart, dressed in scrubs explained to police. The male subject dressed in what appears to be a doctor's coat immediately relocated to R131 room and then contacted another individual. Upon the arrival of a second female staff member, she did not enter R131's room and began working on her schedule paperwork. Police inquired with the female staff member if she needed police assistance getting another staff member to assist her, due to R131 sitting in her feces since 2:00am. After some time had passed a third female staff member arrived at the location where the second female staff member was. The third female staff member explained that she was gathering an undergarment adult brief for R131. Police inquired with the third female staff why R131 did not have an undergarment on at this moment. The second female staff member answered and advised that it was due to R131 having behavioral problems. Upon the second/third female staff entering R131's room, the second female staff member began question R131 about her notifying the police and who she contacted about her condition. Police advised R131 that she did not have to answer the questions, at which time the second female staff member became agitated and informed police that R131 was obligated to answer her questions, due to the second female staff member being in charge of the floor. Police advised the second staff member that R131 had been lying in her feces for some time and that assisting R131, prior to question R131, would be her best interest. On 5/15/2025 at 11:27am, V28 (social service) said R131 did not have any behaviors related to refusing incontinence care nor is any charted in the care plan with seventeen pages. V28 said, she would assume R131 would want to be changed after a bowel movement like anyone else. On 5/15/2025 at 3:15pm V35 (nurse) said, she was assigned to R131's unit on the night shift (11pm -7am) for 5/11/25. V35 said, she was an agency nurse and had never worked with R131 before. V35 said, there wasn't an evening (3pm -11pm) nurse on R131's unit to get report from. V35 said, when she started her shift at 11pm, there were two certified nursing aides that introduced themselves to her. V35 said, she thought those two aids were assigned to her unit. V35 said, two hours into her shift she realized a lot of call light were going off. V35 assumed the aides were in other resident's room providing care. V35 said, R131's family called to complaint that R131 was soiled. V35 said, she went into R131's room at 1:00am. V35 said, R131 was soiled with feces and needed to be changed. V35 said, she needs another staff member to assist with R131 due to her size. V35 said, she did not have any staff to assist her with R131 incontinence care. V35 said, there wasn't any aides on her unit. V35 said, she started to check all of her assigned resident to make sure they were alive. V35 said, she called V10 (manager on duty/nurse) and informed her that there was no CNAs on her shift and only one nurse on the opposite unit. V35 said, residents were soiled and neglected. V35 said, the facility put her licensed and the residents at risk. On 5/15/25 at 5:06pm, V10 (IP Nurse) said, she worked upstairs on the second floor on the 3-11 shift. V10 said, she was the manager on call from Sunday night (5/11/25). V10 said, she was short staff on the night shift of 5/11/25 going into the early morning of 5/12/25 on R131's unit. V10 said, on R131's unit there was only one nurse and one certified nursing assistant working on the 11-7am for the long term care unit/R131's unit. V10 said, two (2) nurse and (4) four CNA are needed for the long term care unit. One nurse and two CNA should have been on R131's unit. On 5/16/25 at 1:16pm, V48 (CNA) said, she was short staffed on the night shift on (5/11/25) Sunday night. V48 said, she worked with V47 (CNA), and they provided incontinence care for R131 two to three times that night with the last time being around 4:30am- 5:00am. V48 said, she did not see the police. V48 said, she did not chart the care provide to R131. Facility provided witness statement from V47 dated 5/14/25 documents: V47 was a CNA on the night 5/11/25. V47 was not assigned to R131. V47 did not take care of R131 on 5/11 night shift. Statement given by V47 via phone on 5/15/25 at 11:20am. On 5/16/25 at 4:20pm, V9 (nurse) said, she was the nurse on the south unit. V9 said she worked the day and evening shift on 5/11/25. V9 said, she was in the facility charting until 1:30am -1:45am because she sent a resident to the hospital. V9 said, at the end of her double shift she was not providing any patient care. On 5/16/25 at 12:13pm, V2 (Administrator) said, if staff was aware that R131 needed incontinence care and failed to provide it, that failure is neglect. V2 said, residents should be changed every two hours and as needed. V2 said, she did not view the camera to determine if staff responded to R131's call light. Surveyor requested to view the video footage of staff entering and exiting R131's room. V2 did not present any video footage for review during the survey. On 5/16/25 at 1:47pm, V4 (ADON) said, she came into the facility on 5/12/25 at 2:00am, that morning. V4 said she was informed around 11:45pm that a nurse was needed on the south unit on long term care side. V4 said, she spoke agency nurse, who informed her that the south unit nurse had just left. The nurses are not supposed to leave without being relived or giving report to another nurse. The long term care unit had two nurses when she reported for work, ideally it should be three nurses assigned to the long term care unit. V4 said, she did not interact with the police. Abuse policy dated 9/2017 documents: This facility affirms the right of our resident to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Neglect means the failure of the facility, it employees or service providers to provide goods and service to a resident that are necessary to avoid physical harm, pain or mental anguish or emotional distress. Further, neglect means a facility's failure to provide or willful withholding of adequate medical care, mental health treatment, psychiatric rehabilitation, personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R111 diagnoses include but are not limited to fracture of lumbar vertebra, diabetes, protein calorie malnutrition, and attention to gastrostomy. R111 is not verbally or physically responsive when spoken to or while staff providing care. On 05/14/25 at 10:35 AM V15, CNA, said, I check and change R111 every 2 hours. We check and change everyone every 2 hours. On 05/14/25 at 12:53 PM V30, wound nurse, accompanied surveyor to see R111. R111 in his bed laying mostly on his right side. R111's right ear was resting on his shoulder and pillow. A visible 4x4 foam dressing was over his left ear. V30 said R111 has deep tissue injuries to his left ear, elbows, sacrum, ischium, feet, and left lateral neck/head areas, skin tears and lacerations over his right hand. V30 said interventions for pressure relief include a horse shoe shaped neck pillow, heel boots, and an air mattress set to his weight. The neck pillow was not on R111 neck and was at the top of the mattress. V30 said interventions include turn every 2 hours for all residents who can't reposition themselves. V30 did not make any movement or response during observations and conversations at this time. On 5/15/25 at 1:55PM V30, Wound care, said R111's right ear wound was identified on 5/1/25 and present on readmission. V30 said the wound was unstageable. On 5/12/25 the right ear measured 0.7 x 1.0 x 0.1 deep, and at stage 3. V30 was asked specifically what intervention were put in place for V30's ear pressure ulcer. V30 said interventions include turn and reposition, every 2 hours, wedges in his room help him be elevated off his sides and bottom, and an air mattress, protein supplements were added. V30 said these wounds were present since before his readmission. V30 said R111 has always had an air mattress originally delivered on 12/26/24. V30 said interventions are appropriate for R111. V30 said they are repositioning R111 enough. The surveyor asked if the facility completed a tissue tolerance test for R111. V30 said a tissue tolerance test has not been done to V30's knowledge. The surveyor asked V30 if R111's care plan includes the use of his neck pillow. V30 said it's not on there. V30 was asked if bolsters are on the care plan and V30 said they are not on there. V30 said they have heel boots and turn and reposition every 2 hours on the care plan. V30 said R111 has about 18 skin impairments (without counting). V30 said we complete unavoidable documents we fill them out and the nurse practitioner reviews and signs them. V30 said R111 has unavoidable documentation for his sacrum and left ear but not the right ear because it did not develop in the facility. On 5/16/25 at 11:42 AM V32, MDS Nurse, said the purpose of the care plan is how they know what care and services to provide to the residents. V32 said the action part of the care plan is the interventions, what we are doing. V32 said the care plan is individualized based on resident needs and preferences. V32 said anyone providing care to the resident has access to the care plan. On 5/16/25 at 11:52AM V44, Doctor, said R111's prognosis is poor. R111 is a bedbound patient. R111 said interventions for pressure relief should be followed. The surveyor discussed the unavoidable assessment completed by the facility for R111's ear with the intervention for heel protectors. R111 said, I don't see that applying to an ear wound. V30 provided a list with R111 skin impairments including left ear unstageable pressure ulcer acquired in house and right ear stage 3 pressure ulcer. There are 18 impairments on the list for R111. On 5/16/25 at 11:46AM V30 said we use Braden scale for everyone. V30 said R111 is at high risk for pressure ulcers. Review of R111 wound progress notes date 5/12/25 identify sacrum pressure ulcer, right knee, right hand, right lateral foot, and left leg vary from pressure to venous. Wounds on bilateral ears and left side of head and breakdown on various sites of body. Right ear pressure ulcer stage 3 size 0.7 x 1 x0.1, peri wound skin is fragile. Left ear pressure unstageable size 2.8 x 1.9 x 0.1 granulation and eschar present. Peri wound fragile. Pictures include in document of left ear. Care plan provided to the surveyor by the facility for R111 reviewed and does not include use of wedge/bolster, neck pillow. There is no intervention for turning or repositioning or frequency. There is no intervention specific to R111 left and right ear to relieve pressures, except for treatment. An Unavoidability/Avoidability Determination for R111 ulcer site left ear, unstageable onset 4/21/25. Diagnosis identified Severe PVD, Urinary and Bowel incontinence, and history of pressure ulcers. Interventions include moisture barrier after each incontinent episode, pressure relief mattress, low air loss, turn and reposition every 2 hours, supplements, and tube feeding. The policy for Skin Management: Treatment/General Wound Treatment dated 4/2024 states, in part, treatment guidelines have been developed to serve as a general protocol for selecting the type of treatment or dressing to be used. The facility recognizes that the selection of treatment protocol is individualized based on the resident condition and practice patterns .implement prevention protocol according to resident needs. Mobility: turn and reposition as needed using a person centered approach. Based on interview and record review, the facility failed to prevent one resident with a tracheostomy, who was identified as high risk for skin breakdown and dependent on staff for care, from acquiring a wound, and failed to follow their policy to develop and implement interventions individualized based on the resident's condition for one resident at high risk for skin breakdown with 18 impaired skin areas. This affected two of three residents (R111, R122) reviewed for pressure sore. This failure resulted in R122 sustaining an open wound to the left side of the neck measuring 7 cm x 1cm x 0.5 cm at the tracheostomy collar. Findings include: 1. R122 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, type II diabetes, abnormal posture and tracheostomy status. R122's Minimum Data Set, dated [DATE] documents R122 is dependent on staff for rolling left to right and for all activities of daily living. R122's Braden scale for predicting pressure sore risk documents score of 8. A score of 9 or below indicates very high risk for skin breakdown. On 5/15/25 and 5/16/25 at 10:46 AM, R122 was observed in bed with head leaning to left side. R122 had tracheostomy collar in place. A tracheostomy collar is a soft, clear mask that fits over the tracheostomy tube to deliver oxygen that has a green thin strap that goes around the neck. R122's skin and wound evaluation dated 5/4/25 documents in house acquired laceration to left side of neck measuring length 6.5 (centimeters, CM) x 0.7 CM). R122's wound assessment report dated 5/6/25 documents: Resident was in bed for wound evaluation. Resident has Respiratory Failure, and Cerebral Infarction. Resident is status trach/vent, incontinent, and poor bed mobility. Resident has laceration injury to the neck due to trach collar. Injury was picked up and is being treated. Primary Etiology: Skin Tear/Laceration. Stage/Severity: Stage 3. Size: 7 cm x 1 cm x 0.5 cm R122's wound note dated 5/13/25 documents: Resident has laceration injury to the neck due to trach collar. Injury was picked up and is being treated. Primary Etiology: Skin Tear/Laceration Stage/Severity: chronic On 5/16/25 at 12:27PM, V43(Wound NP) said R122's wound was classified as a laceration due to the shape of wound being straight and linear. The opening was caused from resident moisture causing the skin to became softer and easier for foreign force to cause breakdown. R122 trach collar was determined to be the cause of opening along with moisture. V43 said it was classified as laceration and skin tear which are the one in the same and can be used interchangeable. V43 said the wound stage three on initial note was done in error. On 5/16/25 at 10:59AM, V3 8(Respiratory Manager) said R122's had a wound to left neck which could have been caused by friction from the trach collar. V38 said staff are supposed to ensure the strap is placed on pad the to ensure it does not irritate the skin. On 5/15/25 at 2:20 PM, V30 (wound nurse) said R122's wound is a laceration from the tracheostomy collar. Laceration is a cut in the skin from trauma like friction from the tracheostomy collar. Facility policy reviewed 9/23 Pressure injuries documents: to prevent or reduce the incidence of pressure injuries, standards of practice should be implemented. A pressure injury may be defined as any lesion caused by unrelieved pressure that results in damage to the underlying tissue, although friction and shear are not primary causes of pressure injuries, friction and shear are important contributing injuries to pressure Injuries. A pressure injury is localized damage to the skin and or underlying tissue usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. [NAME] l device related pressure injury. Use staging system to stage. This describes the etiology of the injury. Medical device related pressure injuries result from the sue of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R59 has diagnoses with Dementia, history of falling and unspecified fracture of left humerus shaft with routine healing. Brief interview for mental status dated 3/6/25 documents a score of eight which indicates moderate cognitive impairment. Fall risk evaluation 2/27/25 documents score of twelve. Scoring a ten of higher makes resident high risk for falls. Minimal data set dated [DATE] documents: roll to left and right; R59 requires substantial/maximal assistance (helper does more than half the effort), lying to sitting on side of bed: R59 is dependent. On 5/14/25 at 3:15pm, R59 who was alert to self only said, she fell out of bed but could not elaborate on the events prior to the fall. On 5/14/25 at 3:22pm, V22 (nurse) said R59 had two unwitnessed falls from the bed. R59 was observed on the floor face down both times. V22 said she was not sure how R59 fell. V22 said she got report that R59 did not move. V22 said R59 did not have any injuries the first fall. The second fall R59 complained of arm pain. V22 said R59 was sent to the hospital both times. On 5-15-25 at 1:54pm, V46 (restorative directive) said R59 was high risk for falls. R59 was dependent on staff for repositioning in bed. R59 was unable to turn and reposition herself. V46 said she is not sure how R59 fell since she was unable to reposition self without staff assistance. V46 said R59's fall intervention was ineffective to prevent her from falling out of the bed. R59 was given a fall mat after the first fall which was an ineffective because R59 had a second fall from the bed. Fall mats do not prevent falls from the bed. Fall mats decrease the chance for injuries if the resident falls onto the floor. V46 said R59 sustained abrasion to the scalp and left toe with the second fall. V46 said she does not know what R59 hit to obtain the abrasions nor is it documented. Nursing note dated 4/8/25 document: Resident (R59) observed laying in a prone position (flat on their stomach, with their face downward or turned to one side), on the floor next to the bed. Resident states, I fell out the bed. Left upper extremity edema, no visible injures, bed was at the lowest position and call light still attached to the resident. Fall incident dated 4/8/25 documents: R59 has poor bed mobility, positioning and requires assistance from staff. R59 has old left arm fracture with routine healing. Will maintain be in the lowest position. Floor mat given. Round at a minimum of every two hours and prompt or assist for change in position, toilet, offer fluids and ensure resident is warm and dry. Hospital after visit summary dated 4/8/25 documents: fall from bed. Nursing Note dated 5/5/2025 documents: Resident (R59) observed laying prone position on the floor near bed. R59 states, I rolled out bed. Left upper extremity edema, abrasion to left top of head. Complains of pain 8/10. Fall event dated 5/5/25 documents: During rounds, the nurse on duty observed the resident laying prone position on the floor on the floor mat. Injury: Abrasion top of scalp and left third toe. Hospital paperwork dated 5/25 documents: Resident presented to the emergency department at this time for evaluation after experiencing a fall out of her bed. According to the patient, the patient was sitting on the edge of the bed and fell off of the bed. R59 has a history of dementia. Physical Exam Finding: Left upper extremity with diffuse swelling, contracted, sling. Closed head injury, Abrasion of scalp. Fall Prevention and Management Policy dated 5/2015 documents: The facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. Based on interview and record review the facility failed to provide effective supervision for a resident with a diagnosis of right-side hemiplegia, lack of coordination, abnormal posture, displaying agitation while in dining room, and failed to ensure effective interventions to include supervision and monitoring were implemented to prevent a resident from falling out of bed. This affected two of three residents (R59, R65) reviewed for safety, supervision, and falls. This resulted in R65 falling from the wheelchair, R65 was sent to the local hospital for treatment of a clavicle fracture, and resulted in R59 sustaining a closed head injury, abrasion to the top of the scalp and left upper extremity (arm) with diffuse swelling. Findings include: 1. R65 face sheet shows diagnosis of hemiplegia and hemiparesis following non traumatic subarachnoid, type 2 diabetes, aphasia, lack of coordination, abnormal posture, unspecified dementia. R65 incident report dated 3/13/2025 denotes in-part fall, date of incident 3/13/25, location dining room, during lunch resident was in the dining room while his room was being cleaned. Resident became agitated and he reached for the door and fell. Resident unable to give description. Was this incident with incident witnessed, N documented. Description took vital signs, informed Doctor, and family. Neuro check initiated with normal findings. The resident initially denied pain, but after 30 minutes c/o (complain of) pain to left arm. MD was updated and ordered Xray of left shoulder, arm, and elbow. Pain level -one. Mental status- confused/ fearful, orientated to person. Non complaint to safety guidance. Resident had a misunderstanding with his sister who was visiting and was agitated and hard to redirect. On 5/14/25 at 2:17pm V21 (LPN) said she was the Nurse for R65 on 3/13/25 when R65 fell in the dining room. V21 said on this day, R65 room was being deep cleaned and R65 had to get up from bed and come to the dining room until the room was finished being cleaned. V21 said R65 was in a manual wheelchair. V21 said R65 usually stays in his room and watch his movies. V21 said R65's sister did visit that day, and during that visit R65 was agitated because he wanted to go back to his room. V21 said R65 sister was upset that R65 was agitated. V21 said R65 sister was not in the dining room when R65 fell, she was lingering in the hallway. V21 said she asked several times if she could put R65 back in his bed because of the agitation. V21 said R65 reached for the door in the dining room, to open the door and that's when he fell from the wheelchair. V21 said the Director of Nursing at that time allowed her to watch the video and she observed what happened on the video. V21 said she watched the video, but she can't recall if someone was in the dining room when R65 fell. V21 said she does recall that she observed two aides in the hallway. V21 said staff are supposed to monitor the dining room. Facility presented assignment sheet for 3/13/25 (day of R65's fall). V52 (CNA) was identified as one of the aides that was standing in the hallway. On 5/14/25 V52 said herself and V54 were in the hallway, and the other aides were setting up for lunch services. V52 said she thinks a nurse was in the dining room when R65 fell, but she doesn't recall. V52 said R65 was having behaviors because he wanted to go back to his room. V52 said you could hear R65 banging on the door. V52 said herself and the other aide were planning to put R65 back to the bed, but he had the fall prior to them putting back to bed. V52 said R65 does not usually get out of bed, he prefers to be in his room and watch his movies. V52 said staff are supposed to monitor the dining room when residents are in there. 5/16/25 at 1:42pm V53 (CNA) said she was not in the dining room when R65 fell, she was taking her 15 minute break. V53 said the dining room supposed to be monitored, she thought it was. V53 said she doesn't know who was monitoring the dining room. 5/16/25 at 2:14pm V9 (LPN) said she was not in the dining room when R65 fell, she was passing medications. R65's emergency room after visit summary dated 3/14/25 denotes you was seen diagnosis clavicle fracture. Upon exit of this survey the facility failed to identify who was monitoring the dining room when R65 fell from the wheelchair. Facility fall policy prevention management policy with last review date 8/2024 denotes in-part this facility is committed to maximizing each resident physical. Mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for prevention strategies, and facilitate as safe an environment as possible. All falls shall be reviewed, and the residents existing plan of care shall be modified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and implement effective interventions for one resident at risk for malnutrition. This affected one of three residents (R113) reviewed for weight loss. This failure resulted in R113 sustaining a 34.8 percent unplanned weight loss in less than 6 months. Findings include: R113 was admitted to the facility on [DATE] with a diagnosis of diabetes, muscle wasting, dysphagia, seizures and gastrostomy status. R113 's Minimum Data Set, dated [DATE] documents substantial/maximal assistance with eating. On 5/15/25 at 2:00PM, R113 weight was taken via mechanical weight lift by staff. Weight scale was set to 0 prior to weighing. Resident weight was 133 pounds. R113's weight on 12 /25/24 documents 201 pounds; 2/5/25 documents weight of 199 pounds, 2/19/25 documents 132.2 pounds; 3/5/25 documents 132.8 pounds, 3/7/25 document 132.8 pounds; 4/1/25 documents 131.6 pounds; 5/6/25 document 129 pounds, 5/14/25 documents 129 pounds R113's 12/20/24 dietary note documents: R113 receiving continuous feeding with nothing by mouth status. R113's eternal feed order dated 1/16/25 documents eternal feeding 1.2 bolus 250 ml two times a day. (900 calories, 40 grams of protein) R113's dietary note dated 2/23/25 documents: enteral feeding 250 ml bid bolus (nutrient content 900 calories, 40.5 gm protein, 363 ml free water and water flush 250 ml four times a day. (total water 1363 ml) excluding oral intake. has puree 1:1 pleasure feeding order intake 50-75%. Weight history: 2.5.25 199, 12.9.24 201, 11.6.24= 199, 10.9.24 = 200 Height 59 Body Max Index 40.2 estimated Kcals needs: 1420-1704 adjusted BW (25-30); estimated protein needs: 54-65 (1.0-1.2); estimated fluid needs: 1420-1704 (25-30 ml); Skin: intact; Plan: Continue Enteral Nutrition and water flush as ordered. Monitor tolerance to Tube Feeding and follow up as needed. R113 dietary evaluation documents high risk for malnutrition. Question accuracy of 199 weight on 2/5/25. Estimated caloric needs 1510-1812 calories. Under intake variable intake 50- 75 % is fed by staff. Under comments: significant change continues, artificial nutrition with no new orders or interventions documented. R113's dietary note dated 4/26/25 documents: EN: feeding 250 ml bid bolus (nutrient content 900 calories, 40.5 gm protein, 363 ml free water and water flush 250 ml Four times a day. (total water 1363 ml) excluding oral intake. has puree 1:1 pleasure feeding order intake 50-75%. Weight t history: 4.1.25= 131.6, 2.7.25= 132.8, 2.5.25 199, 12.9.24 201, 11.6.24= 199, 10.9.24 = 200 Height 59 inches Body Max Index 29.6. Weight loss 34% in 180 days discussed in Nutrition at Risk meeting 4.9.25 and 3.12.25 and secondary to acute kidney failure estimated. Kcals needs: 1495-1794 kcal; estimated protein needs: 54-65 gm (1.0-1.2); estimated fluid needs: 1495-1794 cc; Skin: intact; Plan: Continue Enteral Nutrition and water flush as ordered. monitor tolerance to Tube Feeding and follow up as needed. On 5/16/25 at 10:09 AM, V45 (dietician) said R113 had a significant weight loss of 34 percent based on weight of 199 pounds to 131 pounds. V45 said R113 was on continuous artificial feeding and orders was changed in January to receive feeding twice a day which is about half of her caloric intake due to R113 eating by mouth. V45 said in February she questioned the weight and asked for reweight which indicate same weight. V45 said she begin to question the accuracy of all R113 weight from august 2024 through January 2025 saying she was unsure if R113 ever weighed 200 pounds and was always around 130. After a significant weight change depending on resident, we will monitor weights weekly, implement supplements or caloric counts. V45 was unable to provide any additional information related to any interventions or monitoring down for R113 weight and requesting to review her notes. At 11:29AM, V45 was not able to present any new information related to R113, except that she reviewed her hospital weights which did not match but said they do not use hospital weights calculate weight changes. V45 said R113's weight was stable at 130 pounds and no further interventions were placed. On 5/16/25 at 1:09PM, V50 (Nurse Practitioner) said he was not able to recall any concerns related to R113 having a significant weight loss. V50 recalls receiving reports of R113 not eating good possible to mood. V50 was shown R113 weights and was unable to explain the change or any interventions put in place. Facility weight management policy reviewed 6/24 documents: to establish a policy for the consistent, timely monitoring and reporting of resident's weights. Weekly weights will also be done with a significant change of condition, food intake decline or with physician order. The director of nursing will forward dietary recommendations to the physician or nurse practitioner will follow up with recommendations within 24- 48 hours.

Based on interview and record review, the facility failed to prevent one resident (R3) who was admitted to the facility with healed scar tissue to sacrum and identified as moderate risk for skin breakdown from developing a facility acquired pressure ulcer measuring 2 centimeters (cm) length X 1.5cm width x 0.3cm depth within three days after admission for one of three residents reviewed for wounds. Findings Include: R3 diagnoses include paraplegia, moderate protein-calorie malnutrition, diabetes and osteomyelitis in the left foot. Brief interview for mental status dated 9/13/24 documents a score of fourteen which indicates cognitively intact. R3's face sheet documents: admission date 9/6/24. On 12/03/24 at 11:16am, R3, who was assessed to be alert and oriented to person place and time, said she was left soiled with stool on the overnight shift twice when she was admitted which caused her to have an open wound on her buttock. R3 said she did not have an open wound on her buttock upon admission. R3 said she was devastated. She said she never thought she would be left soiled in feces. Wound care note dated 9/7/24 documents: admission: R3 was admitted to facility with admitting diagnosis of rehabilitation related to Osteomyelitis. Head to toe skin assessment completed by wound team: Resident noted with healed scar tissue to sacrum. Barrier cream applied/initiated. Resident is incontinent of bowel and bladder, needing assistance with turning and repositioning. Resident may have a chair cushion, heel boots and will be turned/repositioned. Although interventions will be in place resident will continue to be at risk for further skin breakdowns due to unidentified factors. Pulmonary initial evaluation dated 9/10/24 documents: R3 was also found to have osteomyelitis of her foot. On 12/06/24 at 11:11am, V35 (treatment nurse) said she completed R3's skin assessment on 9/7/24. R3 had a healed scar tissue on her sacrum area. R3 was given barrier cream at that time. R3 did not have an unavoidability charting upon admission. Unavoidability charting is completed when the resident has a change in condition or worsened wound. R3 did not acquired unavoidability charting because she did not have any issues with her sacrum wound. R3 was found to have a facility acquired wound during rounds on 9/9/24 by V36 (treatment nurse) and V37 (wound doctor). Skilled Wound Expert Skin and Wound Note date of service 9/9/24 documents: Wound: 2, Location: sacrum, Primary Etiology: Pressure, Stage/Severity: Stage 3 Wound Status: Present on Admission, Odor Post Cleansing: None, Size: 2 cm x 1.5 cm x 0.3 cm. calculated area is 3 sq cm. Wound Base: 75-99% granulation, 25-49% slough Wound Edges: Attached, Peri wound: Intact, Fragile, Exudate: None amount of None. On 12/06/24 at 1:30pm, V36 (treatment nurse) said, R3 had a facility acquired a wound that was notice during round on 9/9/24 with V37. R3 was at moderate risk for skin breakdown to being very moist and incontinent of bowel and bladder. R3 was alert and able to report if she had any issues or concerns. Braden Scale for predicting pressure sore risk dated 9/6/24 documents a score of thirteen with indicates: Moderate risk related to very moist: Skin is often, but not always moist. Unavoidability/ Avoidability Determination dated 9/19/24 document: R3's wounds were unavoidable. Unavoidability/Avoidability Determination dated 10/28/24 document: R3's wound were avoidable. Facility policy Skin Care Prevention revised 9/2023 documents: Resident will receive appropriate care to decrease the risk of skin breakdown. Clean skin at time of soiling and at routine intervals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, interview, and record review, the facility failed to find appropriate roommates for R1, appropriately notify R1 of room change and consider room preferences and follow up with R1's discharge planning. This resulted in R1 being placed in a room with two residents (R11 and R12) that have behaviors and are severely cognitively impaired causing R1 to lose sleep and experience mental distress. Findings include: R1 is a [AGE] year-old female who originally admitted to the facility on [DATE] and moved to the long-term care side of the facility on 10/4/2024. R1 continues to reside in the facility. R1 has multiple diagnoses including but not limited to the following: surgical amputation, type II DM, need for assistance with personal care, HTN, heart failure, CKD V, and left BKA. Per Minimum Data Set (MDS) dated [DATE] shows R1 has a Brief Interview for Mental Status (BIMS) score of 12 meaning resident is cognitively intact. On 10/23/24 at 12:50PM, R1 was interviewed regarding roommates and discharge planning. R1 said the facility staff moved her to the long-term care side of the facility without getting her consent or being acclimated to the room or roommates. R1 said she did not want to come to this side of the building and would have rather transferred to another facility instead. R1 said, I told the staff I did not want to move rooms, but they transferred me here anyway. I have not spoken with a social worker since moving to the long term care side of the building, and even before that I barely saw any social workers. R1 said, I have two roommates that are severely cognitively impaired. R1 said R11 will talk all night saying things like 'do not touch me', 'give me my whiskey', and 'where is my food stamp card'. R1 said R11 is constantly saying things that does not make sense and sounds as if she is hallucinating. R1 said R12 will constantly yell out all day and night and scream bloody murder. R1 said, The staff will move (R12) into the dining room during the day, so I try and sleep during the day when she is out of the room. R1 said both of these residents prevent R1 from sleeping. R1 said, The staff is aware that I do not want to be in the room with (R11) and (R12). The staff does not care, they get to go home at night, but I am stuck in this room with (R11) and (R12) that scream all night. It is to be noted that during observation on 10/23/24, resident's eyes were puffy. R1 was in bed cuddled up with blanket at 12:50PM and was sleeping when this surveyor entered the room. On 10/24/24 at 12:17PM, R1 was observed to be sleeping in bed. R1's name was called twice but was in a deep sleep and did not respond back to surveyor. At 12:40PM, R1 was interviewed again. R1 said she is not getting any sleep because of R11 and R12 screaming all night. R1 was observed to have puffy eyes and to be upset about loss of sleep. On 10/28/24 at 1:15PM, R1 told this surveyor that on 10/25/24 R1 had a care plan meeting with the interdisciplinary team where R1 let them know R1's concerns with R1 roommates and discharge planning. R1 observed to have wet eyes talking to this surveyor about having a hard time sleeping. R1 said R1 met V6 (Social Worker) for the first time on 10/23/24 after speaking with this surveyor. It is to be noted that during the course of this survey, 10/23/24-10/30/24, R1 was visited on four different occasions and each time R1 expressed that she cannot sleep due to R11 and R12 yelling all night. R1 was observed to look tired and distraught on all visits from surveyors. On 10/23/24 at 2:10PM, V1 (Administrator) and V2 (Director of Nursing) were interviewed regarding social services. V1 said, We recently had a lot of changes in the social service department. All the social service workers are very new. On 10/23/24 at 3:30PM, V6 (Social Service Worker) was interviewed regarding R1. V6 said, I have not spoken with (R1) since I started working here and I am unaware of her discharge goals and plans. Per social service progress notes, it is to be noted that prior to 10/24/24, the last time discharge planning was discussed with R1 was on 7/25/24. R1's care plan states in part but not limited to the following: R1's tentative plan is for the resident to return home upon completion of skilled services. As necessary, meet with the R1 on a regular basis to help with preparation for discharge. It is to be noted that at no point in R1's care plan does it show R1's plan of care is to move to long-term care within the facility. It is also to be noted that on 10/30/2024, R1 was observed to still be in room with R11 and R12. Room change notification form shows R1 was notified of the room change on 10/4/2023 at 11:30AM, which is the same day R1 moved to the long-term care side of the facility. Resident Rights policy dated 8/1/2022 with revision date of 2/2024 states in part but not limited to the following: The objective of the accommodation of resident needs and preferences is to create an individualized, home-like environment to maintain and/or achieve independent functioning, dignity, and well-being to the extent possible in accordance with the residents own needs and preference. Room Change/Transfer within Facility policy dated 12/2017 with review date of 12/2023 states in part but not limited to the following: To assure that residents are appropriately notified of room transfers. When a resident is being moved to a new room at the request of the facility, the resident shall receive an explanation in writing of why the move is required. The resident will be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. 2. Based on interview and record review, the facility failed to ensure timely signing of a Certificate of Death. This failure applies to one resident (R7) who expired in the facility 9/17/24 and resulted in mental anguish to R7's family and delay of funeral services for R7. Findings include: R7 admitted to the facility 5/30/24 and had diagnoses that included pneumonia, severe protein-calorie malnutrition, and multiple pressure ulcers. According to progress notes, on 9/17/24 R7 went into cardiac arrest while participating in resident activities. Emergency Medical Services were called to the facility to provide advanced life saving measures, however R7 was unable to be revived and was pronounced deceased without transfer. On 10/30/24 at 1:58pm, V33 (Funeral Home Staff) said when R7 expired in the nursing facility, the funeral home recovery team reported to the facility and requested R7's face sheet that included R7's demographics such as name, birthdate and physician's contact information. The funeral home reached out to R7's Primary care Physician (V29) to have the Death Certificate signed within 24 to 72 hours of V7's transfer. V33 said when the Funeral home called V29, V29 refused to sign the Death Certificate because V29 said they were not the primary physician. V33 called V34 Pulmonology Consultant as listed on the face sheet and V34 said they could not sign the Death Certificate because they were not the primary physician for R7. V33 mentioned notifying R7's family and made several calls to the facility regarding the issue. On 11/4/24 at 9:52am V34 said a few weeks ago, the Funeral Home contacted V34 to sign the death certificate, however V34 explained that because V34 only saw V7 in the facility under pulmonology consultation, it was not appropriate to sign the death certificate. V34 said V33 was angry and offered to assist with reaching out to V29 (primary physician) however V33 mentioned that they had previously reached out to V29 but refused to sign. During the interview, V33 said they called the facility several times since R7 was transferred leaving several messages for the administrative staff and did not get any response. Finally, V33 called the facility on 10/17/24 and spoke with the receptionist (V35) and informed V35 that the Funeral Home had been attempting to get a physician to get the death certificate signed. V33 notified V35 that the family would be filing a formal complaint. Later that day, the signed death certificate was received dated 10/17/24. V33 said that the delay in signing the death certificate also delayed proceeding with funeral arrangements for R7's family. On 10/29/24 at 11:13am, V36 (Family Member of R7) said that when V33 informed them of the delay in getting the death certificate signed, several messages were left with administrative staff, however no one returned their calls. V36 said regarding this issue, It took a mental toll on all of us because it was like we couldn't even get the process of grieving, or the funeral arrangements made without the death certificate. On 10/30/24 at 2:23pm V35 (Receptionist) said they received a call from a family member of R7 who was upset and mentioned suing the facility for refusing to sign the death certificate. V35 transferred the call to an administrative staff member but could not recall who. V35 said later, the funeral home called the facility, relaying the same concern and then V35 notified V2 Director of Nursing directly. On 10/30/24 at 2:23pm V2 Director of Nursing said, the funeral home reached out to the facility a few weeks ago, saying V29 had been refusing to sign the death certificate. V2 spoke with V29 and got it signed later that day. On 10/30/24 at 10:30am V29 said they were notified at the time V7 expired in the facility and signed the death certificate when the facility called. The death certificate was reviewed and was noted to be signed by V29 on 10/17/24, 30 days after V7 expired in the facility. V29 provided a fax confirmation that the signed death certificate was sent to the funeral home on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Based on interview and record review, the facility failed to immediately assess and call 911 for transfer of a resident with active seizures to the hospital. This failure affected one (R4) of three residents reviewed for change in condition and resulted in R4 having active seizure activity for three hours before 911 was called for resident to receive emergency treatment. Findings include: R4 is [AGE] years old who was admitted to the facility on [DATE] with the diagnoses history of seizures, atrial fibrillation status post [NAME] 03/2024, cerebral vascular accident pulmonary embolism, hypertension, respiratory failure and dependent on ventilator and required tracheostomy, tube feeding placement, pneumonia, and proctitis. On 10/29/2024 at 09:56AM V18 (Agency Registered Nurse) said that she worked on 10/3/24 and started at 3:00PM and provided care to R4. V18 said that R4 started having seizures at 05:30PM; a respiratory therapist called her and notified that R4 was having jerky movement. When V18 got to the room, R4 was having head jerking movement initially and then hand movements. R4 was having seizures continuously but V18 did not recall why she did not chart when it started, duration, and vital signs during seizures. V18 said, she notified the charge nurse V23 (Assistant Director of Nursing) and gave R4's scheduled medication and called Telehealth physician with V23's assistance. After scheduled medication was given to R4, he was still having seizures and was sent to the hospital via 911. On 10/29/2024 at 3:31PM V23 (ADON/Assistant Director of Nursing) said, on 10/03/2024 she was doing her rounds on the long-term unit when V18 (Agency Registered Nurse) called for assistance and R4 was having seizures. When V23 got to the unit V18 was at the door of R4's preparing his scheduled medication. When V23 went to the room with V18, R4 was having head jerking movements, and V23 assisted the nurse with calling Telehealth physician. V23 used her computer to communicate with the physician. After 7:00PM the facility uses Telehealth answering service for the primary physicians. V23 observed V18 giving R4's scheduled medication and waited 30 minutes after medication given. R4 continued to have seizures on and off. V23 called 911 and sent the resident the local hospital. V23 said If V18 had notified her sooner that resident was having continuous seizures longer than 30 minutes, V23 would have called 911 right away. V23 said she instructed V18 to monitor resident's seizures, vital signs, and complete documentation on R4's condition. V23 called report to the hospital and completed the discharge paperwork for V18. V23 said she expects staff to follow instructions and complete assessments, charting and report change of condition timely. On 10/30/2024 at 11:24PM V24 (Respiratory therapist) was interviewed. V24 said, on 10/02/2024, during the 7:00PM to 7:00AM shift, R4 exhibited signs of seizure activity. V24 communicated this assessment to the nurse on duty. R4 was noted having shakes in the upper torso, face and head when V24 was obtaining vital signs and said the movements didn't appear to be a respiratory issue. V24 was unaware if the nurse on duty provided any interventions and noted R4 was not transferred out of the facility during the shift. V24 said, I asked the nurse a few times whether (R4) was going or staying, and the nurse said they were [waiting] to get the DON's (Director of Nursing) decision. R4's electronic health record was reviewed, and V24 completed Ventilator/Aerosol Flowsheet assessment on 10/02/2024 at 10:10PM and included Ambu bag present bedside, resumption of convulsions unseen. Progress notes and Ventilator flowsheets available to review did not indicate when V24 initially assessed R4 to be noted with abnormal movements. No progress notes or physician notification was documented until 10/03/2024 when V23 (ADON) and V18 (Registered Nurse) called telehealth and received orders to transfer R4 to the hospital for evaluation. Hospital records of 10/3/24 indicated R4 was admitted for seizures. R4's 911 emergency services records documents: chief complaint of seizures with three hours of duration. 911 was called at 8:54PM and Telehealth called at 8:42PM and nurse reported R4 having seizures since 6:30PM to telehealth physician and resident left the facility at 9:19PM. Medication administration audit report reviewed, and scheduled medication was signed out at 8:02 PM. On record review Ventilator/Aerosol Flowsheet assessment was not completed for 10/03/2024 on the 07:00PM shift and Respiratory therapist was in the room assisting the 911 emergency services and disconnected R4 from the ventilator to be transferred to the hospital at 9:19PM. R4's hospitalization records reviewed and R4 was admitted for seizures and required Neurologist consultation and Electroencephalogram on from 10/04/2024 to 10/07/2024 under sedation and was also treated for pneumonia, urinary tract infection, and chronic sacrum wound osteomyelitis. On 10/31/2024 at 11:54 AM V2 (Director Nursing) said she expects her nurses to assess resident, take vitals, chart, check laboratory test results, and call physician with change of condition such as check low blood sugar, low oxygen saturation, or low blood pressure or seizures. If a resident continues to have active seizures to call 911 and send the resident to the hospital. On 10/30/2024 at 1:30PM V 26 (Medical Director) said he expects the facility to call 911 and send resident to the hospital when residents are having active seizures. The goal is to stabilize residents, obtain vital signs, blood glucose levels, and then transfer out to the hospital. There are medications that can only be given at the hospital. On 10/29/2024 at 2:42PM V2 (Administrator) provided facility policy titled Change of Condition reviewed dated 11/2023, Which reads: 1. Nursing will notify the resident's physician or nurse practitioner when: B-There is a significant change in the resident's physical, mental, or emotional status. E-It is deemed necessary or appropriate in the best interest of the resident. B. Based on interview and record review, the facility failed to appropriately transcribe an IV antibiotic order for one (R8) of three residents reviewed for medication administration. Findings include: R8 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. It is to be noted that R8 was transferred to the hospital on 8/14/2024, 9/25/2024, and 10/2/2024. R8 has multiple diagnoses including but not limited to the following: Cerebral infarction, type II DM, respiratory failure, ESRD and dependence on renal dialysis, right AKA, left BKA, pneumonia, and TIA. Per hospital after visit summary dated 9/28/2024, R8 returned to the facility with a chief complaint of left arm swelling. Discharge medications list states in part but not limited to the following: Cefepime in dextrose 5% 2 gram/50 ml piggyback IVPB - 50 ml by IVPB route every other day. Given Monday, Wednesday, and Friday with dialysis, dose of 2000 mg. It is to be noted that the medication of Cefepime was never transcribed as a physician order upon facility admission of 9/28/24. On 10/28/24 at 10:45AM, V5 (Nursing Unit Manager) was interviewed regarding admitting residents from the hospital. V5 said the nurses are made aware of any IV antibiotics in report from the nurse at the hospital and on the discharge paperwork when the resident arrives to the facility. At 2:22PM, V2 (Director of Nursing) was interviewed regarding R8 and transcribing medication orders. V2 said when we admit a new resident, we contact the physician to verify and reconcile the orders. The nurse that is admitting the resident then will put in the medications into the physician orders. The night nurse then checks double checks the orders and the nursing manager the following day triple checks them again. It is to be noted that R8 was never started on the IV antibiotic of cefepime during their stay in the facility from 9/28/24-10/2/24. Per hospital records 10/2/24-10/25/24 shows that R8 only received part of his antibiotics in the nursing facility despite all IV antibiotics being on his discharge paperwork. R8 now has some drainage from his stump. Admission/re-admission Policy dated 9/28/22 states in part but not limited to the following: Physician order sheet should reflect any standing orders specific to the resident as well as medications and treatments that are ordered throughout the stay. A. Based on interview and record review the facility 1.) failed to implement effective interventions to prevent accidental removal of tracheostomy cannula and accidental extubation for a ventilator dependent resident; 2.) failed to follow their Hypoglycemia Policy and procedure by not initiating intravenous access to provide intravenous fluids and failed to call 911 immediately upon determining that intervention for hypoglycemia was not effective. These failures applied to one (R3) of three residents reviewed for nursing care and resulted in R3 being found decannulated and in cardiac arrest on 10/2/24 and on 10/23/24 when R3 was assessed as deceased and in rigor mortis (irreversible sign of death) by paramedics. Findings include: 1.) Respiratory progress notes dated 10/2/24 at 2:04am showed that R3 was found decannulated and without pulse. On 10/30/24 at 11:24pm V24 Respiratory Therapist said they worked the night shift 10/1/24 from 7pm to 7am. V24 said towards the beginning their shift, V24 received in report that R3 was fidgeting and pulling the tubing attaching the tracheostomy to the ventilator machine. Because of this, the ventilator alarmed many times during the previous shift. V24 said this behavior was noted to start at least a week prior. V24 said when this was noted and the ventilator alarm sounded, V24 would go into R3's room, try to calm R3 and notified the nurse of the behavior. On 10/2/24, V24 responded to an alarm at approximately 1:45am and found R3 with the tracheostomy cannula removed from R3's neck. V24 explained that the cannula is the tubing that is placed in the neck of an individual who is unable to breathe independently, and the ventilator mechanically provides breathing support. Since the cannula was completely removed, R3 was not getting any oxygen or assisted breathing support. When V24 replaced the cannula, R3 was noted to be without a pulse. V24 said this assessment took about 30 seconds. V24 said there were no nurses on the unit at the time, as both nurses were on break. V24 said it took about two minutes to leave the room, called code blue (medical emergency) to the overhead speaker and grab the emergency cart to bring into the room. V24 said when going back into the room, V24 attached the automated defibrillator pads, started compressions, and waited for help to arrive. V24 said there was one nurse who responded from the next unit over. V24 and the nurse (V30) performed cardiopulmonary resuscitation until the paramedics arrived. On 10/29/24 at 11:40am V10 Respiratory Therapist and Respiratory Manager said R3 was known to occasionally pull on the tracheostomy and ventilator tubing. V10 said when residents display this behavior, interventions to address this may include using a 1:1 sitter or a psych consult for agitation and adding medications to treat the agitation. V10 could not recall any of these interventions being placed for R3. R3 received care in the facility on the dialysis/ventilator unit. Interviews from nursing staff on duty at the time R3 was found unresponsive revealed that both nurses (V31 and V32) assigned to the unit had left the facility for break between 1am and 2am. According to the working schedule for night shift 10/1/24 11pm to 7am, seven nurses were on duty. Only one nurse (from long-term care) responded to the emergency and provided CPR (cardiopulmonary resuscitation) with V24 prior to paramedic arrival. When the paramedics arrived, the nurse assigned to R3 (V31) was outside of the facility on break and did not return until after paramedics transferred R3 out of the facility. Ventilator flow sheets document R3 pulling and disconnecting ventilator tubing on 9/27/24, 10/1/24 and 10/2/24. On 9/27/24 at 10:27pm V24 wrote patient disconnected couple of times, vitals stable. On 10/1/24 at 7:11pm R24' note included, (R3) frequently disconnected his ventilator circuit over 10 times the first hour. (R3) calmed down with (as needed) nursing meds and has desisted. On 10/2/24 at 1:08AM V24 wrote, (R3) had a major reduction of self-circuit disconnection. Just one incident tonight in the 7-12 interval where 15 incidents occurred in recent shifts from 7-12. (Respiratory Therapist) noted no new distress presentation. On 10/31/24 at 4:01pm V2 Director of Nursing said, V2 was unaware of R3 exhibiting behaviors that included removal of tracheostomy cannula or ventilator tubing and R3 did not have any care plans for these behaviors. V2 said for R3 and other residents that exhibit this behavior, the facility is able to initiate the use of soft restraints, medications and more frequent observation which is prompted by an increased frequency of ventilator alarms. V2 said if they had known that R3 had these behaviors, interventions would have been ordered and documented on the care plan. V2 was also unaware that the unit was left without nursing supervision at the time R3 was found unresponsive. Provider and Nursing progress notes were reviewed for R3 from September 2024 to October 2024, and did not include assessments by providers or nurses that addressed Respiratory Therapy's observations of R3 disconnecting tubing and removing the tracheostomy cannula. An interview was attempted on 11/4/24 at 2:34pm to V37 (R3's Primary Physician). V37 refused to answer questions related to R3 due to being out of the country. A care plan for R3 was initiated for ventilator dependence on 8/2/24. Interventions included (8/2/24): Prevent accidental extubating by taping tube securely, checking every 2 hours and restraining/sedating as needed. Care Plan was also initiated 8/2/24 for trach (tracheostomy): at risk for complications (related to) tracheostomy placement secondary to respiratory failure. Interventions included replace trach immediately if removed. Physician Order sheet reviewed during R3's admission did not include any interventions for preventing accidental decannulation or extubation. 2.) R3 was admitted to the facility 4/22/24 with diagnoses that included but are not limited to cerebral infarction, type II diabetes mellitus, chronic obstructive pulmonary disease, tracheostomy, and dependence on ventilator. On admission and according to the MDS (Minimum Data Assessment) R3 had severe cognitive impairment, was non-verbal and unable to follow commands. According to the physician's order sheet and care plan, R3 was considered full code which indicates all life saving measures should be performed in the event of cardiac arrest. Fire Department run sheet dated 10/23/24 notes the facility called the fire department at 1:13am. Fire department crew reported to the bedside for assessment of R3 at 1:18am and noted R3 lying in bed on a ventilator, and unresponsive. Crew's assessment as stated in the report said R3 was deceased on arrival as evidenced by cold to touch, no palpable pulse, rigor mortis setting in, and asystole (no heart rhythm) on cardiac monitor. The Crew obtained report from the nurse as documented: 'Nurse stated that while doing rounds R3 was noticed to have low blood sugar. The nurse gave glucagon twice, but the blood sugar kept dropping to the 30's. Per the fire department run sheet, no resuscitation measures were performed by the facility staff or fire department crew, and fire department contacted the local hospital for orders. The hospital physician on-call pronounced R3's time of death at 1:30am. Facility Policy Hypoglycemia (6/2015, no revision) states in part; 1. Hypoglycemia is defined as a blood glucose of less than 70. If the resident has any symptoms of hypoglycemia including pallor, clammy skin, restless sleep, hunger fatigue, headache confusion, irritability or sweatiness notify the physician. (3.) If semi-conscious, uncooperative, unable to swallow or is NPO (nothing by mouth): a. Administer 50 milliliters of D50W (Dextrose 50% in Water) (1 amp) slow IV (intravenous) push and start IV D5W (Dextrose IV solution) at 100 milliliters/hour. B. If NO IV access: Glucagon 1 milligram Subcutaneously or IM then establish an IV access and start IV D5W at 100 milliliters/hour. C. Repeat glucose check and treatment every 15 minutes until greater than 70. D. Once greater than 70, repeat blood glucose check every one hour for 3 hours to monitor for recurrence. According to R3's electronic health record, R3 did not have intravenous access prior to the incident. Progress notes do not indicate the nurse on duty called a Registered Nurse for assistance to start intravenous access at any time during this incident. On 11/6/24 at 2:37pm V38 LPN (Licensed Practical Nurse) said they were about 15 minutes late reporting for the 11pm to 7am shift on 10/22/23. V38 said after getting report, V38 completed visual rounds on the unit and saw R3 in bed on the ventilator, noted rise and fall of the chest and R3 did not appear to be in distress. V38 did not perform any physical assessment during this initial round. V38 said they returned to R3's bedside at approximately 12:30am to give medications which included insulin. When V38 took R3's blood sugar, it was noted to be low. According to V38's progress note, R3's blood sugar was 52. V38 said they gave R3 a dose of glucagon injection to increase the blood sugar and took vital signs. Vital signs as written in the progress note: Blood Pressure: 145/75, Pulse: 78 (beats per minute), Respirations: 18 (breaths per minute) and Temperature 97.5F. V38 said R3 did not have an active order for glucagon at the time, however it was standard protocol that in the event of low blood sugar, the glucagon medication should be given and an order from the physician would be obtained after administration. V38 said R3's primary physician was called, but V38 did not receive an answer. V38 said they could have called the telemedicine service but didn't, because it often takes a long time for a provider to answer the call. V38 said after giving the glucagon injection, no additional interventions were initiated while waiting for R3's physician to respond. V38 also said they did not ask any staff for assistance and did not call any other providers for guidance. In the progress note, V38 wrote after about 15 minutes giving the glucagon injection, R3's blood sugar increased to 65, however, R3's pulse increased to 99 beats per minute, and R3 was noted to be diaphoretic (excessive sweating) and short of breath. During the interview, V38 said R3's physician didn't respond within the 15 minutes of reassessment, so V38 called 911. V38 did not stay at the bedside of R3 and was outside of the room with the paramedics arrived. V38 said when the paramedics arrived, they attached the heart monitor to R3. V38 was unaware R3 did not have a pulse until V38 was notified by the paramedics. 11/7/24 at 1:51pm, V2 Director of Nursing said, according to the progress notes, when V38 reassessed R3's condition had not improved after giving glucagon, 911 should have been called right away. According to the facility policy Hypoglycemia, glucagon should be given and then IV access should be established as to administer IV fluids to increase blood sugar. V2 said R3 did not have an IV access, and that considering R3 is a hard stick (difficult to establish IV access), 911 should have been notified immediately after giving glucagon. The facility's Medical Director (V26) was interviewed 11/7/24 at 5:42pm. V26 said when a nurse assesses the blood sugar of a patient to be significantly low (less than 70), it is expected that the nurses do their best to stabilize the patient by giving food, or intramuscular glucagon to immediately increase the blood sugar. V26 said at that time, the nurses should call 911 right away rather than wait because a continuous decrease in blood sugar could result in the resident going into a diabetic ketoacidosis, which could be potentially life threatening. 911 should be called immediately, because in the nursing facility, dextrose intravenous solution is not usually immediately on-hand. V26 was unsure if the nurses were experienced enough to provide this acute intervention. V26 said they had not been notified of this particular situation until this interview. V26 explained that in emergency cases such as this, if the primary physician was not available, V26 should be called as an alternate for immediate guidance, although V26 would prefer the nurses to use proper judgement in calling 911 during an emergency and then notifying the physician after.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a ventilator care unit had uninterrupted nursing supervision on [DATE]. Due to this failure, the unit was left in the care of unlicensed staff and (R3) experienced cardiac arrest while the two assigned nurses were on break outside of the facility. Findings include: R3 was admitted to the facility [DATE] with diagnoses that included but are not limited to cerebral infarction, type II diabetes mellitus, chronic obstructive pulmonary disease, tracheostomy, and dependence on ventilator. On admission and according to the MDS (Minimum Data Assessment) R3 had severe cognitive impairment, was non-verbal and unable to follow commands. Respiratory progress notes dated [DATE] at 2:04am said R3 was found decannulated and without pulse. On [DATE] at 11:24pm V24 Respiratory Therapist said they worked the night shift [DATE] from 7pm to 7am. On [DATE], V24 responded to an alarm at approximately 1:45am and found R3 with the tracheostomy cannula removed from R3's neck. V24 explained that the cannula is the tubing that is placed in the neck of an individual who is unable to breathe independently, and the ventilator mechanically assists with breathing. Since the cannula was completely removed, R3 was not getting any oxygen or assisted breathing support. When V24 replaced the cannula, R3 was noted to be without a pulse. V24 said this assessment took about 30 seconds. V24 said there were no nurses on the unit at the time, as both nurses were on break. V24 said it took about two minutes to leave the room, called code blue (medical emergency) to the overhead speaker and grab the emergency cart to bring into the room. V24 said when going back into the room, V24 attached the automated defibrillator pads, started compressions, and waited for help to arrive. V24 said there was one nurse who responded from the next unit over. V24 and the nurse (V30) performed cardiopulmonary resuscitation until the paramedics arrived. On [DATE] at 8:03am, V30 LPN (Licensed Practical Nurse) said on [DATE], V30 was charting at the nurse's station on the long term care unit, when an agency CNA (Certified Nursing Assistant) came to notify V30 of the active emergency regarding R3. V30 said that they had not heard a code blue called over the speaker prior to this notification. V30 said they announced the code overhead to get help to respond and called 911. V30 said the CNA only communicated the room number because they were from agency and did not know the name of the resident. V30 said after calling 911, V30 ran to the room which was right outside of the long term care unit and took over compressions with V24. V30 said there were two agency CNAs in the room and with V24, they took turns alternating the breathing bag and compressions. V30 said, they were getting tired from the exertion of compressions as they continued and no other staff from the building responded. V30 said the fire department paramedics arrived at the bedside, after letting themselves in the building. It wasn't until the paramedics took over that staff from other units reported to the room. On [DATE] at 11:56am V31 (agency nurse on duty) was asked about the emergency code blue for R3 and V31 said the RT (Respiratory Therapist) took care of it. V31 said they were outside taking a break in the car when a staff nurse came to inform V31 that R3 was coding in the building. V31 couldn't recall what time they left the building and did not know that they were required to tell any staff that they were leaving the unit or the building for break. V31 said they did not punch out or record any time leaving or re-entering the facility. V31 said they were aware the other nurse on the unit was on break at this time. During this interview, V31 repeatedly insisted they were unable to complete their break, due to being interrupted by staff because of the emergency with R3. When V31 said when they returned to the facility, the emergency had been cleared- meaning paramedics had already transported R3 to the hospital. V31 said, they couldn't recall when R3 was last assessed prior to going on break. On [DATE] at 2:10pm V32 LPN said, on [DATE], they notified the CNAs and V31 they would be leaving the building for break around 1am. V32 left their cell phone number to the CNAs and V31 because they were from agency and in case of emergencies. V32 said they did not punch out or record time leaving or re-entering the facility. V32 said once they arrived at the restaurant, an agency CNA called to notify V32 that an active emergency was taking place on the unit. V32 drove back to the facility and found that paramedics had already arrived. V24, V30 and CNAs were continuing CPR and other nurses were outside of the room. The paramedics were asking, 'who is the nurse' and no one responded. V32 then asked the staff where is the nurse? to no one in particular. According to the fire department run sheet, 911 was notified at 1:51am. Paramedics responded to the bedside of R3 at 1:57am. When paramedics arrived, they found V24 providing bag ventilation to R3's tracheostomy and another staff member doing CPR. Automated Defibrillator pads had been placed and advised no shock. R3 was assessed and was not breathing and did not have a pulse. The staff in the room did not know how long R3 had been unresponsive when asked by paramedics. R3 regained a pulse with resuscitative efforts from the paramedics, however, on transport to the hospital, R3 went into cardiac arrest again. Assessments maintain that R3 did not exhibit any eye movement or motor response. R3 was resuscitated in the emergency department and admitted to the Intensive Care Unit. On [DATE] at 4:01pm V2 Director of Nursing said, V2 was unaware that the unit was left without nursing supervision at the time R3 was found unresponsive. V2 said that when nurses go on break, they should communicate with one another to ensure the unit always has a nurse available in any event, but particularly during emergencies. Facility employee handbook (no revision) states in part; You are not permitted to leave the facility grounds during personal breaks. If you leave facility grounds at any time, you must punch out. Your supervisor will assign meal and break times. Meal and break times will be staggered among employees in order to provide adequate staffing at all times to meet resident needs. During emergencies it may not be possible to allow personal break periods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor one high risk for skin breakdown resident (R1) with a history of pressure sores who was admitted to the facility with skin intact for blanchable redness to sacrum. This affected one of three resident (R1) reviewed for pressure sores. This failure led to R1 developing an unstageable wound measuring 4 x 3cm within 12 days of being admitted to the facility. Findings include: R1 was admitted to the facility on [DATE] with a diagnosis of severe protein calorie malnutrition, atrial fibrillation, pressure ulcer of sacral area stage three (dated 2/2/24), adult failure to thrive, vascular dementia and Parkinson's. R1's Braden score dated 2/10/24 documents a score of 12 which indicates high risk for skin breakdown. R1's progress note dated 2/11/24 documents: Head to toe assessment was completed by wound team. Resident noted with red dark but blanchable discoloration to sacrum. Barrier cream applied/initiated. Resident noted with healed scratches to left and right rear thigh. Resident noted with healed surgical scar to left hip. Otherwise, skin intact. Resident is incontinent of bowel and bladder, has foley catheter in place, able to assist with turning and repositioning, Resident may have heel boots, chair cushion, treatment orders in place for redness and will be turned and repositioned. Although interventions will be in place, resident may continue to be at risk for further breakdowns due to unidentified factors. Wound care will continue the plan of care. R1's progress note dated 2/12/24 documents: Reason for visit: The resident is being evaluated today for a comprehensive skin assessment. SKIN: warm and dry, intact, no open wound. Blanchable redness to sacrum. The patient is at an increased risk of skin breakdown. Recommend good hygiene and skin care to prevent skin breakdown. Recommend continuing with moderate assistance with ADLs as needed. Recommend application of emollients daily. No open wounds on today's skin assessment; please keep the patient's skin clean and dry, apply barrier cream as necessary to prevent skin breakdown, and avoid pressure on any bony prominence by adhering to turning protocols and floating heels as applicable. R1's skin assessment dated [DATE] in progress documents: Moisture Associated Skin Damage (MASD) to sacrum inhouse acquired new. No measurements documented. No other documentation of this area. R1's skin assessment dated [DATE] in progress documents: Moisture Associated Skin Damage (MASD) to sacrum inhouse acquired new. Measuring 6.4 length and 2.1 width cm. R1's February medication and treatment records do not document any weekly skin assessments. R1's medical record did not document any skin assessments from 2/12/24 until 2/22/24. R1's care plan dated 2/12/24 documents R1 is at risk for skin complications related to bowel/bladder incontinence, impaired bed mobility, impaired nutrition, impaired circulation, impaired cognition, depression. Interventions dated 2/12/24 include: skin assessment weekly. R1's progress note dated 2/26/24 documents: SKIN: warm and dry, wound/skin condition noted. See wound assessment below. Wound: 1 Location: coccyx Primary Etiology: Pressure Stage/Severity: Unstageable Wound Status: New Odor Post Cleansing: None. Size: 4 cm x 3 cm x 0 cm. Calculated area is 12 sq cm. Wound Base: 0% epithelial, 0% granulation , 100% slough , 0% eschar Wound Edges: Unattached Peri wound: Fragile, Erythema Exudate: None amount of None Wound Pain at Rest: 0 Surgical Wound Debridement Location: coccyx Pre-Debridement Measurement: 4 x 3 x 0 cm . Calculated area is: 12 sq cm. Post-Debridement Measurement: 4 x 3 x 0 Percent of Wound Debrided: 100 Indications: Removal of necrotic tissue. On 8/28/24 at 10:47AM, V14 (wound care) said R1 was admitted to the facility with skin intact but had a dark red blanchable area to her sacrum. Floor nurses will do a weekly skin assessment on all residents without wounds and document in the medication or treatment record to monitor the area. On 8/28/24 at 1:06PM, V2 (DON) said facility monitors residents skin for breakdown by having assigned floor staff conduct weekly skin checks that is documented in the medication or treatment record for residents without wounds. Facility policy Skin Care Prevention revised 9/2023 documents: Resident will receive appropriate care to decrease the risk of skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement new and effective fall interventions after a fall for one high fall risk resident (R11) with a diagnosis of dementia and history of falls. This affected one of three residents (R11) reviewed for fall and fall prevention. This failure resulted in R11 sustaining another unwitnessed fall a week later that required a hospital stay with 6 staples to the left side of the head. Findings include: R11 was diagnosis with Dementia, Alzheimer, and repeated falls. Minimal data set section C (cognitive patterns) dated 8/9/24 documents a score of six which indicates severe cognitive impairment. Fall risk evaluation dated 8/2/24 documents a score of twenty-six. Scoring a ten or higher makes resident high risk for falls. Mentation: Impaired memory or judgement. History of fall in the past one to six months. Interim baseline care plan dated 8/2/24 documents: Impaired cognition related to a decline in cognitive functioning. Use task segmentation to support short-term memory deficits. Fall Interventions: Call light within reach, provide clutter-free environment, encourage use of assistive device and provide proper, well maintained footwear. Care plan dated 8/3/24 documents: resident is at risk for falls. Anticipate and meet the resident's care and safety needs. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Care plan dated 8/7/24 documents be sure residents call light is within reach and encourage to use it for assistance as needed. Nursing note dated 8/7/24 documents: Patient (R11) was found on the floor on the side of her bed. Bed was in lowest position with the rails up; call light was within reach, and table was within reach. Assessment was completed, skin check was completed. Vitals were completed when patient was on the floor, when the CNA and I transferred her to the bed and when we transferred her to her wheelchair. Skin is intact. No complaints of pain, vitals within normal limits. Neuro checks in progress. Fall report dated 8/7/24 documents: Mental status: confused/forgetful, not oriented. Predisposing Physiological factors: noncompliant with safety guidance, impaired memory, recent illness and weakness/fainted. Predisposing situation factors: Ambulating without assist. Notes: resident had a change in plane. Resident was observed sitting next to bed on buttocks. Resident stated she was okay she was just trying to get up. Encourage resident to keep call light within reach and use it for assistance. On 8/27/24 at 3:29pm, V36 (nurse) said, she was not given report that R11 was a fall risk. R11 would not remember to use the call light related to her cognition/Dementia. R11 was alert to self. R11 did not have any fall intervention in place. The bed was not low it was approximately a foot off the ground. V36 said, she went to give R11 her medication, and R11 was reaching over trying to get out of bed. R11 was repositioned and place in bed. V36 said she left the room to find the aide to help transfer R11 to wheelchair to bring to common. Aide went to get another resident to help transfer resident and that's when R11's roommate put on the call light. V36 said, when she entered R11's room. R11 was on the floor. On 8/27/24 at 1:54Pm, V2(DON) said R11 is alert to self and has periods of confusion. Intervention implemented after first fall was to be sure residents call light is within reach and encourage to use it for assistance as needed. Call light in reach was also documented in baseline care plan as well so the new intervention should have said to reeducate R11 on call light use. Nursing note dated 8/14/24 documents: At 5:50 pm-6pm, I (V36) gave the resident (R11) her scheduled medications. Call light was within reach; however, the resident did not utilize it and was attempting to exit the bed without assistance. Redirection and reorientation to surroundings was provided. At 6:45pm the resident was observed on the floor by the CNA. I was notified. The resident was conscious and alert. Gauze was applied to the site. Writer interviewed patient's roommate re: this incident. According to the roommate, she heard a loud thud that sounds like a chair that fell off. Roommate is uncertain about what time it happened, but roommate said she pressed the call light right away. Roommate did not hear anything else aside from the loud thud. Staff is able to answer the call light promptly per roommate's report and roommate only found out that the patient has fallen when she saw the nurse coming in immediately, and after a while, she heard the nurse saying, Let's put her back to bed. Fall report dated 8/14/24 documents: Injury type: Laceration, Injury Location: Back of head. Mental status: Confused/forgetful not oriented. Predisposing Physiological factors: Confused, noncompliant with safety guidance, impaired memory, recent illness and weakness/fainted. Predisposing situation factors: Ambulating without assist. Notes: R11 was alert to self only. R11 is mod assist times one with activities of daily living and transfers. It was determined that the fall was unavoidable. Root cause: unassisted transfer. Floor mats given and to be used when resident is in bed. After care visit dated 8/14/24 documents: revisit for visit: fall/ head laceration. Diagnosis head injury, Dementia Facility reportable dated 8/15/24 documents: R11 admitted on [DATE]. R11 is alert to self only. R11 sent to hospital and returned to six staples to left side of her head. Fall prevention and management policy dated 5/2015 documents: The facility will identify and evaluate those residents at risk for fall, plan for preventive strategies and facilitate as safe an environment as possible. Care plan to be updated with a new intervention based on root cause analysis after each fall occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly assess a resident's change in condition after showing signs of respiratory distress, changes in oxygen saturation, and a low blood pressure. This affected one of three (R1) residents reviewed for quality of care and assessments. This failure resulted in R1 suffering a delay in being sent to the hospital, having a critically low blood pressure, and being tachycardic upon the paramedics' arrival. Findings Include: R1 is a [AGE] year old with the following diagnosis: hemiplegia affecting the right side following a cerebral infarction, type 2 diabetes, chronic respiratory failure with tracheostomy status, gastrostomy status, and dysphagia. A Nursing note dated 2/11/24 at 8:39AM documents upon arriving for the morning shift, R1 was very lethargic and weak. Vital were stable (no actual vital signs were charted at this time just that they were stable) but family was concerned R1 was not in a normal state. The physician was called and ordered to send R1 to the hospital. A Nursing note dated 2/11/24 at 9:36AM documents R1 had a change in condition per the family. R1 seems to be in distress with trying to breath and isn't talking to family. Oxygen saturations are at 93% on the trach. The physician was contacted again and ordered to send R1 to the hospital. There is no documentation a respiratory assessment or vital signs were completed at this time when a change of condition was noticed. There is also no documentation that respiratory therapists were not notified of R1's change in condition to assist. A Nursing note dated 2/11/24 at 7:27PM documents R1 was admitted to the intensive care unit for diabetic ketoacidosis. The Ambulance Run Sheet dated 2/11/24 documents the ambulance was called at 9:34AM for a resident having a breathing problem. Upon assessment, R1 was on 5L of humidified oxygen and the crew placed a non-rebreather at 15L oxygen to the trach site. Family reported R1 was not acknowledging their presence at today visit when R1 is usually alert to them. R1's blood pressure was low at 70/46 (normal is 120/80), pulse was 140 (normal is 60-100), and respirations were 26 (normal is 12-20). The oxygen level was 90% while on the 15L of oxygen. The Hospital Record dated 2/11/24 documents R1 was brought to the hospital for hypotension and hypoxia after the family noticed a change in mental status. R1 is toxic appearing and tachypneic. R1 is on 15L via nonrebreather mask at the trach site and there is an increased work of breath. Upon arrival the blood pressure was very low at 50/22 (normal is 120/80) and the temperature was 94.7 degrees Fahrenheit indicating hypothermia. R1 had a white blood cell count of 41.5 indicating infection in the body. Possible infection source was listed as urine vs, lungs vs abdomen. R1 was given 3L of IV fluid in the emergency room to increase the blood pressure. R1's blood sugar was 1196 mg/dL (normal is 60-100 mg/dL). R1 was in diabetic ketoacidosis likely caused by the septic shock. R1 was placed on an insulin drip for the elevated blood sugar, placed on Iv antibiotics for the septic shock, and continued with aggressive IV fluid resuscitation. R1 was admitted to the intensive care unit. On 5/29/24 at 1:07PM, V3 (Nurse) stated R1's family was in R1's room after V3 received report just after 7AM. V3 reported the family was thinking R1 was acting different so V3 took a set of vital signs and went back to the nurse's station to look at R1's medical record. V3 stated R1's oxygen level was at 93% on the trach collar. V3 denied calling a respiratory therapist to come assess R1. V3 reported the family then reported R1 had a difficult time breathing but V3 disagreed with the family and thought R1 was fine. V3 reported calling 911 based on what the family requested. V3 was not able to recall what R1's vital signs were when R1 was transported to the hospital. On 5/30/24 at 2:50PM, V13 (Agency CNA) stated V13 only peeked into R1's room that morning to check in R1. V13 reported the family was concerned and got the nurse. V13 stated R1 got sent out to the hospital for shortness of breath. On 5/31/24 at 11:48AM, V21 (Respiratory Therapist) stated residents get assessed twice a shift at 9PM and 3AM. V21 reported at the 9PM assessment R1 reported shortness of breath but the oxygen level was noted to be still above 90%. V21 stated if a resident is having shortness of breath, then the nurse should call the respiratory therapist into the room to assist. V21 reported rounding on R1 during the night but none of those assessments are documented to check in with R1 after R1 reported begin short of breath. On 5/31/24 at 12:43PM, V23 (Nurse) stated V23 has no recollection of R1 having any issues breathing the night before going out to the hospital. V23 reported R1 had no issues over night and was last seen around 5:30AM for the morning blood glucose check. On 5/31/24 at 12:57PM, V24 (CNA) stated during the second shift (3-11PM), V24 took R1's vital signs and R1's blood pressure was low and R1 felt cool to touch. V24 was unable to remember what the temperature or blood pressure were but remembers then being low. V24 reported R1 was also moaning. V24 noted this was different because R1 could normally talk even with a trach. V24 stated V24 told the V23 what was happening with R1 and V23 told V24 that R1 would be assessed. V24 reported V24 was pulled to a different unit so V24 could not check on R1 the remainder of the night. V23 was interviewed again at 1:11PM to confirm V23's previous interview and to ask questions regarding V24's interview. V23 did not deviated from the original statement of R1 being fine. V23 stated if something was wrong with R1 then V23 would have sent R1 out via 911. On 6/12/24 at 11:37AM, V59 (Nurse Practitioner) stated if a resident is having a change of condition, then staff should notify the physician or nurse practitioner immediately so new orders can be given. V59 reported when someone is septic, they tend to have a low blood pressure, a fever, and have tachycardic. V59 also noted there could also be some respiratory issues involved if that is the system that is infected. V59 stated if staff notice it changing condition with the resident or a family is saying that there has been a change then V59 would expect the nurse to get a set of accurate vital signs and assess the resident so V59 can know more of what is going on with the resident. V59 reported hypothermia would be a later stage of sepsis. V59 said, I can't really say exactly when it occurs, but I can say that blood pressure and fever along with tachycardia usually present first and then overtime the body will develop hypothermia in order to compensate for whatever infection. V59 reported telling the nurses to notify V59 immediately if something's going on and make sure they chart it so we can be getting a basis or a trend going and what's happening. V59 stated if an accurate set of vitals aren't obtained then staff can't accurately let anyone know what's going on. V59 reported, The patient might look OK on the outside, but if they're vital signs are showing something different than they need to be sent out immediately. V59 reported if a resident isn't sent out immediately when it changes are noticed then the sepsis is likely to get worse. V59 stated any indication of a resident being septic V59 would order at minimum a chest x-ray and urine with possible labs. V59 reported if the resident is in anyway unstable then call 911. On 6/12/24 at 1:43PM, V2 (DON) stated a resident needs to be assessed and the vitals should be done if there is a change in condition. V2 reported the next step is to call to notify the doctor and administer oxygen if needed. V2 stated if the resident is in the vent unit, then respiratory therapy is called for additional support. V2 reported if a resident is having respiratory issues, then 911 should be called immediately. The Ventilator Flowsheet dated 2/10/24 documents R1 was noted using accessory muscles with inspiratory breaths. R1 was suctioned with noted improvement. The oxygen level increased to 96% after suctioning. R1's breath sounds were diminished on both sides. There is no documentation what the oxygen level was before being suctioned. There is no documentation from the respiratory therapist that R1 was assessed again after experiencing labored breathing during the first assessment. The vital signs were reviewed for 02/2024. Vital signs (blood pressure and heart rate only) are charted for 2/11/24 at 11:10AM after R1 had left the facility. There is no documented respiratory rate or oxygen saturation level the morning of 2/11/24. The Care Plan that is not dated documents R1 has a potential for difficulty breathing related to COPD and acute respiratory failure. Interventions include: assess respiratory status to include rate, depth, pattern, and skin color; monitor vital signs and lung sounds; and observe for changes in breathing pattern. The policy titled, Emergency Management, dated 09/2017 documents, General: Emergency guidelines refer to actions given to residents with urgent and critical needs. When emergency situation arises, emergency procedures are initiated, which includes sending the resident to the closest emergency room. Policy: 1. The object of the emergency management of a resident is to administer necessary care until the paramedics arrive . 5. Monitor and treat as much as possible the following areas: f. Take vital signs and provide reassurance to the resident. Vital signs should be taken every 10-15 minutes based on resident need until the resident is stable or transferred . Guidelines for specific medical emergencies: 1. Acute respiratory distress . c. Take record, vital signs, including pulse oximetry . g. Document events in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcer development for residents assessed at risk for alteration in skin integrity upon admission and failed to provide ongoing skin assessments for residents who are dependent on staff for care. This failure affected three (R1, R9 and R14) of four residents reviewed for pressure ulcers and resulted in R14 developing a facility-acquired stage 4 pressure ulcer to the right ear; R9's wound progressing to stage 4 on the sacrum, which required hospitalization for sepsis and an unstageable pressure ulcer to left hip; and R1 developing a stage 2 sacral pressure ulcer. Findings include: 1. R14 is a [AGE] year-old female admitted to the facility on [DATE] with past medical history of hemiplegia and hemiparesis following cerebrovascular disease affecting left non dominant side, dysphagia, difficulty walking, generalized weakness, essential primary hypertension, etc. Braden score assessment dated [DATE] scored R14 as a 9, MDS assessment dated [DATE] section G (functional) coded R14 as total dependence with two staff physical assist for bed mobility and transfers, and total dependence with one to two staff physical assist for all other ADLs. Section H of the same assessment coded R14 as always incontinent for bowel and bladder, review of physician orders shows an order for oxygen 2 liters via nasal canula, and weekly skin screen ordered 6/6/2023. ADL care plan initiated 6/19/2023 states that R14 requires assistance with daily care needs, interventions include but not limited to assist to turn and reposition every 2 hours, keep clean and dry after each incontinence episode, monitor skin integrity during routine care and report abnormal findings etc. 08/09/2023 10:41AM, R14 was observed in her room, awake but could not respond to interview questions. Floor mats were on each side of R14's bed. R14 was lying on her bed on her right side and was receiving oxygen via nasal canula. R14 had a bandage on her right ear. There was not an ear cushion between the oxygen tubing and R14's skin. V19 (Registered Nurse) stated R14 has a wound on her right ear. 08/14/2023 11:25 AM observed R14 lying in her bed on her right side. The assigned nurse was asked to remove the bandage on R14's ear. A large area of abrasion to R14's right ear was noted. R14 had oxygen via nasal canula. Oxygen tubing observed rubbing the skin, no ear cushion was in use. Wound assessment dated [DATE] documented a stage 4 pressure ulcer to the right ear measuring 2.2 x2.5 x 0.3cm, light serosanguineous exudate, less than 5 days, and an unstageable DTI to the left ear measuring 1.7 x 1.4 and unmeasurable depth. 08/14/2023 at 3:00PM, V39 (Wound Care Nurse/LPN) stated R14's pressure wound to her right ear was first reported to her 06/29/2023 and R14's wound is healing. Ear cushions were placed on R14 on 06/29/2023. R14 typically leans her head to the right side and is supposed to be repositioned from right to left to relieve some pressure off her ear. V39 stated if R14 was turned and repositioned every 2 hours it is possible the pressure wound on her ear could have been prevented. V39 stated R14 cannot move on her own and must be repositioned to a different side. Interventions in place for R14's pressure wound to her ear are ear cushions, daily treatment, and turning and repositioning. 08/21/2023 1:26 PM, V2 (Director of Nursing) stated residents who require repositioning every two hours are supposed to be repositioned from left to right or to back. V2 stated R14 has a stage 4 pressure wound on her right ear so she should be repositioned to her back to relieve pressure on her ears. V2 stated R14 should be gotten out of bed on Mon, Wed, and Fri by restorative staff. R14 is normally located in the dining room when she is gotten out of bed. 8/21/2023 at 2:53PM, V2 (DON) said R14 favors her right side but she should have foam behind her ears to prevent the oxygen tubing from rubbing on the skin. V2 stated they just in-serviced all staff and made sure everyone has the foam cushion available for R14's ear. 2. R1 is a [AGE] year-old male who was admitted to the facility 4/27/2023, with past medical history of fatigue, other symptoms and signs concerning food and fluid intake, dysphagia pharyngoesophageal phase, unsteadiness on feet, other abnormalities of gait and mobility, need for assistance with personal care, dementia, etc. R1 was not at the facility during the investigation and could not be observed or interviewed. Per record review, R1 was sent to the hospital on 5/27/2023 per family request. Facility Braden scale assessment dated [DATE] scored R1 as 15 at risk for skin breakdown. Minimum data set assessment (MDS) section G (Functional) documented R1 requires extensive assistance with two staff physical assist for bed mobility and transfers, requires extensive assistance with one or two staff physical assists for all other activities of daily living (ADLS). Wound care admission assessment dated [DATE] documented a DTI to right heel. Wound care note dated 5/10/2023, documented a healed skin condition to the sacrum, scar tissue noted to the area. Wound care note on 5/16/2023, documented healed scar tissue to sacrum opened. Interim/baseline care plan dated 4/27/2023 documented alteration in skin integrity goal: resident will show sign of healing through next review. Interventions include inspect skin daily, keep skin clean and dry, peri care after each incontinence episode, etc. Review of facility wound assessment dated [DATE] documented a stage 2 pressure ulcer to the sacrum measuring an area of 0.69cm squared, length 1.84cm and width 0.58cm, new-minutes old, acquired in-house. Wound evaluation on 5/23/2023 documented stage 2 pressure ulcer to the sacrum measuring 1.05 cm squared, length 1.61cm and width of 0.87cm. R1 was not placed on an air loss mattress until 5/16/2023, after the scar tissue in his sacrum opened. Review of physician orders for R1 show an order for weekly skin screen every day shift on Tuesdays and resident to be turned and repositioned every two hours or as tolerated every shift (order date 5/26/2023). Hospital record dated 5/27/2023 for R1 documented a pressure injury of left heel and a sacral -coccyx stage 3 pressure ulcer present upon admission. 8/14/2023 at 3:15PM, V39 (LPN/Wound care) said R1 acquired a stage 2 pressure ulcer to his sacrum but was admitted with a DTI to his left heel. Surveyor pointed out that there are several documentations of deep tissue injury (DTI) to right heel and questioned if resident had 2 facility acquired pressure ulcers. V39 said, I am sorry, he (R1) only had issue with the left heel, there was nothing on the right heel. We documented the wrong heel. V39 stated R1's pressure ulcer to the sacrum was a stage 2 before he left the facility. V39 stated, if interventions are put in place nut they are not implemented, then they are of no use. 3. R9 is an 81year-old female originally admitted to the facility on [DATE] with past medical history of adult failure to thrive, hemiplegia and hemiparesis, dysphagia oropharyngeal phase, weakness, pressure induced deep tissue damage of right heel, aftercare following joint replacement surgery, essential primary hypertension, etc. On 8/7/2023 during the complaint investigation R9 was sent to the hospital for complaints of chest pain, was admitted to the hospital and was found to have sepsis related to sacral wound vs UTI as documented in hospital record dated 8/7/2023. R9 was readmitted to the facility on [DATE]. R9 was observed in her room on 8/16/2023 around 10:30AM with V39 (wound care nurse), awake and alert. R9 stated she is doing okay but just wanted to be left alone. Braden scale dated 6/6/2023 scored R9 as a 9, indicating a very high risk for skin breakdown. MDS dated [DATE] section G (functional coded R9 as requiring extensive and 2-person physical assist for bed mobility, total dependence with persons physical assist for transfer and total to extensive assist with one to person assist for all other ADLs. Section H (bowel and bladder) of the same assessment documented R9 is frequently incontinent of bowel and bladder. R9 has an order for weekly skin screen dated 6/25/2023, ADL care plan initiated 6/27/2023 stated R9 requires assist with daily care needs. Interventions include to encourage and assist with turning and repositioning, keep lean and dry after each incontinent episode, etc. Per record review, R9 was admitted to the facility originally on 5/15/2023 with a DTI to left heel and healed pink scar tissue on the left/right buttocks and sacrum as documented in new admission head to toe assessment dated [DATE]. Wound care note dated 5/23/2023 shows, the scar tissue at the sacrum was documented to have an opening. R9 was discharged home on 6/5/2023 with a facility acquired stage 2 pressure ulcer to the sacrum. Wound care instruction and supplies given to the family. R9 was re-admitted to the facility on [DATE], DTI to left heel resolved, wound to sacrum remained. On 7/5/2023, facility identified an unstageable pressure ulcer to R9's left hip as documented in wound care notes. Resident currently has an unstageable pressure ulcer to left hip and stage 4 pressure ulcer to the sacrum per wound report dated 8/1/2023. 8/14/2023 at 3:15PM, V39 (LPN/Wound care) said R9's unstageable pressure ulcer to the left hip was identified on 7/5/2023. The dressing was being changed daily with Dakin's, then it was changed to three times a week. V39 said R9 is completely dependent on staff and R9 requires mechanical lift to be turned and repositioned. 8/16/2023 at 12:45PM, V33 (Wound Doctor) said he is not sure when R9 got the air loss mattress. The facility has their own preventative measures and V33 cannot tell them how to implement them. V33 stated he is just in the facility to follow-up after the wound is identified. V33 stated if an intervention is not being implemented it will not be beneficial. Skin care prevention policy presented by V1 (Administrator) with a revision date of 1/2023 states that all residents will receive appropriate care to decrease the risk of skin breakdown. Under guidelines, item 2 states in part that all dependent residents will be assessed during care for any changes in skin condition including redness (non-blanching erythema) and this will be reported to the nurse. The nurse is responsible for alerting health care provider. 5. All residents unable to reposition themselves will be repositioned as needed based on person-centered approach (minimum of 2 hours). Pressure injury policy revised 9/2017 states in part under guidelines to implement preventive protocol according to resident needs. Moisture: avoid prolonged periods of wetness, apply moisture barrier with each incontinent episode, etc. Activity: turn at least every two hours, provide appropriate pressure distributing devices, teach resident to weight shift if appropriate, ensure proper body alignment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to lock and secure a resident's personal belongings after being sent to the hospital. This affects one (R7) of three residents reviewed for misappropriation of property. This failure resulted in R7 having his wallet and credit cards stolen. R7 expressed feelings of being violated, angry, and frustrated. Findings include: R7 was admitted on [DATE] with diagnosis listed in part to: End stage renal disease, Acute respiratory failure, Pressure ulcer of sacral region. R7 is alert and oriented x 3, able to verbalize needs to staff. Care plan indicated that R7 is at risk for abuse and neglect related to his medical diagnosis/condition. On 5/31/23 at 10:11am, observed R7 lying in bed. R7 is alert and oriented x 3, able to verbalize needs to staff. R7 said his wallet was stolen while he was in the hospital and fraudulent activities occurred in his credit cards. R7 said his former roommate took his wallet and distribute it to other residents and used it for their personal needs. R7 wanted to file a case against them, but the police and facility discouraged him. They said that these residents are old, indigent and they don't have anywhere to go. They said that R7 has poor chances of winning the case and advised R7 to go after the bank to refund his money and dispute the charges. R7 said he felt violated, angry, and frustrated. R7 said that he does not have lock drawer that he can keep his valuables. On 5/31/23 at 1:26pm, review of R7's incident report of misappropriation of property with V1 Administrator dated 5/1/23 indicated: Upon R7's returning to the facility from the hospital this afternoon, R7 stated that he is missing his wallet containing credit cards and insurance cards and a black cellphone. Facility searched R7's room and did not locate the items. Facility assisted resident with contacting credit card companies to lock cards and alert for fraudulent activities. Facility initiated investigated. Local police department called and reported incident to Officer. No police report was generated. Reported to IDPH and Ombudsman. It was discovered fraudulent charges were incurred while R7 was at the hospital. R7 is not sure if there is a connection between his wallet and phone missing because he believed the phone may have been misplaced while he was being provided incontinent care. Follow up investigation: Alleged Perpetrator: 1. R11 - R11 stated that R11 got the wallet (R7's) because he thought the resident (R7) was not returning from the hospital. R11 then gave the cards to 3 other residents (R8, R9 and R10) to purchase items for him. R11 stated that other residents used the cards for their own items, and he did not tell them to do that. When he heard that R7 returned from the hospital, he asked the other residents for the cards back and informed SW of the wallet's location. R11 apologized and stated the situation got out of hand. 2. R8 - R8 stated R8 was asked by R11 to go to the store on 4/30/23 using the cards that R8 thought was given to R11 by R11's family. R8 ran the errands and purchased the items for R11 and gave R11 back the cards. R8 stated that on 5/1/23 people in the facility were talking about missing cards and R8 realized he used credit cards that did not belong to R11' R8 asked R11 why R11 would give R8 cards that weren't his (R11) or his (R11) family's. R8 apologized and stated he wouldn't have used the cards if R11 told him it didn't belong to R11's family. 3. R9 - R9 stated R9 was given credits cards by R11, and R11 asked R9 to run errands for R11. R9 stated R11 gave R9 the cards again to order items from Amazon for R10. R9 stated R11 asked R9 to use the cards again to order pizza. R9 stated R9 had no idea where the cards came from until 5/2/23 when R9 heard the facility is looking for missing credit cards. R9 was apologetic and wanted to make a personal apology to R7 for using his cards. 4. R10 - R10 stated that R9 came to the room and got the cards. R10 stated R10 ordered a shirt for R10 but cancelled the order. R10 stated R9 tried to give R10 the cards but R10 refused since R10 did not know how to use the cards. Staff on the units were interviewed and stated they did not hear or witness anyone who may have taken the items from the resident's room while R7 was in the hospital. On 6/7/23 at 9:58am, review of R7's Police Report with V1 Administrator indicated: Police report dated 5/1/23. Nature: Citizen assist. Theft. Called by V1 Administrator. Wallet and cell phone missing. Spoke with subject (R7) who explained that his wallet and black cellphone were stolen between 4/21/23 to 5/1/23. His wallet contained 3 credit cards, Illinois driver's license and a link card. There was no cash inside the wallet, His credit one credit card had 4 fraudulent charges in the sum of approximately $1000.00. He (R7) contacted all 3 credit cards companies and cancelled all his accounts. No complaint wants to be signed. He (R7) just wants his incident documented for now. V1 has launched an internal investigation regarding this matter. Nothing further. A couple days after this incident the facility contacted me and advised me that they located the subjects missing items with another resident. The items have been returned to the subject. 5/10/23, The subject (R7) contacted me and left me a voice message explaining he wanted to sign complaints against the resident that had his items. 5/11/23, I called the subject back and advised him (R7) that since his items have returned and the credit card companies will eventually reimburse him for the fraudulent charges, charges should not be filed at the time. Advised subject to call me back if a problem occurs with the credit card companies. On 6/2/23 at 12:08pm, V3 DON said the nursing staff pack the belongings of resident when he/she is admitted to the hospital and will keep it in storage for safe keeping. On 6/8/23 at 10:15am V1 said that R7's personal belongings were not packed when R7 went to the hospital. They were kept in R7's room until R7 returned from the hospital. V1 said, nursing staff should have packed R7's belongings when R7 was discharged from the facility. The facility has storage to keep the belonging of the discharged residents. On 6/8/23 at 10:30am, V1 Administrator and this surveyor went to R7's room, observed bedside drawer with key inserted in the drawer. V1 opened the drawer and observed electric razor inside. Cell phone was located on top of the bedside table. R7's wallet and laptop were inside the unlocked drawer on the other side of R7's bed. Facility's policy on Abuse Prevention Program indicates: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: *Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment. *Identifying occurrences and patterns of potential mistreatment *Immediately protecting residents involved in involved in identified reports of possible abuse, neglect, exploitation, mistreatment and misappropriation of property. Definition: Misappropriation of resident property: means deliberately misplacement, exploitation or wrongful temporary or permanent use of resident belonging's or money without the resident's consent. Facility's policy on Personal Belongings-inventory indicates: Procedure: 6. Upon discharge to the hospital, the resident's belongings are packed and sent to the storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide safety by not utilizing two-person assistance while providing resident care during bed bath. This affected 1 of 3 residents (R20) reviewed for safety. This failure resulted in R20 falling from the bed while under staff direct care sustaining a subarachnoid hemorrhage, and right-sided frontal scalp hematoma. Finding include: R20 is an [AGE] year-old female admitted on [DATE]. Care plan review dated 3/13/2023 documents R20 as high risk for falls related to impaired cognition due to diagnosis of encephalopathy. Minimum Data Set (MDS) section G with ARD/Target Date of 5/25/2023 documents: A. Bed mobility - Two plus persons physical assist. B. Transfer - Two plus persons physical assist. On 6/8/2023 at 09:30 am, R20 was observed lying on her bed with bruises on her face and forehead. R20 said that she fell. R20 recalled standing at the edge of the bed for a second when she fell and hit her face on the dresser. R20 said there was one staff assisting her to stand up. R20 said usually its only one person assisting her. On 6/8/2023 at 09:40 am, R21 (R20's roommate) said she witnessed R20 fall. R21 said a CNA (V33) was giving R20 a bed bath. The CNA (V33) turned R20 to her right side when R20 started to fall and the CNA (V33) pulled the sheet underneath to try to prevent R20 from falling but R20 fell and hit her face on the air conditioner. On 6/7/2023 at 11:04 AM, V32 (Registered Nurse - RN) said she was charting on the computer when V33 (CNA) started yelling out for help from R20's room. V32 said when she got to R20's room, she saw R20 on the floor. R20 said she hit her head on the floor and was in pain. V32 called 911. V32 said she knows R20 is a two-person assist for transfer but is not sure if R20 requires 2 persons assist for turning. V32 said she didn't check if R20 is a 2 person assist for turning because she assumed that V33 knows her since she works with R20 often. On 6/7/2023 at 2:00 PM, V33 said after giving R21 (R20's roommate) a bed bath, V33 checked R20's incontinent brief which was soiled and her skin was flaky so V33 decided to give R20 a bed bath. V33 said she gathered supplies for R20's bed bath and noticed there were no other CNA's on the unit. V33 said she told R20 she will proceed to give R20 a bed bath without any other CNA's assistance, and R20 said OK. V33 said as she turned R20 to her side, R20 started leaning to reach out to the window. V33 said she started pulling R20 back but R20 fell with face forward. V33 said she yelled out for help for a while before the nurse came in and the other 3 CNA's working on the unit returned. V33 said she has been working with R20 since the last 2 months. V33 said that R20 needs 2 persons assist with mobility/transfer, but V33 proceeded to give R20 a bed bath without the 2nd assist. V33 said she thought R20's bed was locked, but it was not. On 6/8/2023 at 2:00 PM, V3 (Director of Nurses - DON) said R20 was receiving a bed bath from CNA (V33) when R20 started to fall from the bed. V33 CNA tried to try to pull R20 back with the sheet but couldn't and R20 continued to fall. R20 fell to the floor and stated she hit her head on the floor. R20 was sent to the hospital for evaluation and diagnosed with subdural hemorrhage. V3 said R20 is 2 persons assist and should have two people providing the bed bath. Facility Fall Prevention Management Review Date 9/2022 General: This facility is committed to maximizing each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible. All resident's falls shall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to inform a physician of the onset of a resident's change of condition (R227), failed to monitor a resident's vitals as ordered (R227), failed to monitor blood sugars levels for residents with diabetes (R220 and R227). This failure affected 2 of 52 sampled residents. As a result, R227 was unable to be aroused by staff for over 5 hours (6:38AM-12:26PM) and experienced decreased oxygen levels before nursing/medical interventions were given. Findings include. 1. According to a face sheet, R227 is an [AGE] year-old male with diagnoses of history of Diabetes Mellitus, Myocardial Infarction, Dementia with Behavioral Disturbance, Atrial Fibrillation, Peripheral Vascular Disease, and chronic kidney disease, who was originally admitted to the facility 10/27/2022. R227's physician progress note dated 10/31/2022 12:37PM documents: pulmonary follow-up: he was sitting in a recliner chair at the nursing station, Full Code status, patient recovering after heart attack related to partial blood vessel blockage and has underlying blood flow restriction related cardiomyopathy (heart muscle disease), diabetes and hyperlipidemia. Does not offer new symptoms today, Vital signs remained stable, Oxygen saturation is good. Examined to be awake and confused. R227's current physician order sheet documents he is full code and documents an active order effective 10/27/2022 for vital signs (blood pressure, temperature, pulse, respirations, and oxygen saturation) to be measured every shift daily. R227's current care plan included the following: Transfer to hospital and/or intensive care unit if indicated; R227 is at risk for signs/symptoms including Hypoglycemia, Hyperglycemia, or Uncontrolled diabetic status related to diagnosis of Diabetes Mellitus with interventions including blood sugar measurements as ordered. Administer medication as ordered. Monitor vital signs during routine care and notify physician of abnormal findings; R227 has potential risk for altered cardiac function related to diagnosis of Atrial Fibrillation, Coronary Artery Disease, Hyperlipidemia, and Ischemic Cardiomyopathy with interventions including. Give meds for hypertension and document response to medication. Monitor blood pressure. Notify physician of any abnormal readings; R227 is at risk for complications including fluid volume overload related to diagnosis of Stage 3 Chronic Kidney Disease with interventions including: Monitor changes in mental status - Lethargy; Somnolence; Fatigue. Monitor for signs and symptoms of fluid overload or fluid loss. Monitor vital signs as ordered. Monitor/document/report to physician the following signs and symptoms: difficulty breathing (Dyspnea); increased heart rate (Tachycardia); elevated blood pressure (Hypertension); skin temperature; peripheral pulses; level of consciousness. On 11/01/22 from 11:21 AM - 11:45 AM the surveyor observed V22 (Agency Certified Nursing Assistant - CNA) enter R227's room to provide care. R227 was noted to be non-responsive to several attempts from V22 to stimulate him by calling his name, touching his arms, legs, and repositioning him for incontinence care. R227 did not open his eyes during these activities and move his arms very little when firmly touched. V22 stated R227 did not rouse when she took his vitals earlier in the morning. V22 repositioned R227 and provide incontinence without rousing him. V22 stated she doesn't even think R227 ate breakfast because he could not be roused. V22 stated she's not sure how R227 even received medication in his current condition. V22 stated R227 had been unresponsive since she started working at 6:38AM and didn't even rouse when she took his blood pressure earlier in the morning. On 11/01/22 at 12:26 PM V25 (Registered Nurse) entered R227 room. V25 reported she gave R227 medication this morning and he opened his eyes for her. V25 stated she called his name multiple times, but he won't rouse. At the time of the observation, V25 reported R227's oxygen levels were at 64 and fluctuating and he needed oxygen. V25 left R227's and return to the room with an oxygen tank. V26 (Nurse Manager) came into R227's room to measure his oxygen levels with the fingertip oxygen measuring device. On 11/01/22 at 12:34 PM while in R227's room, V25 (Registered Nurse) and V26 (Nurse Manager) administer oxygen to R227. V25 stated R227's oxygen levels are going back up. V25 stated R227 was lethargic this morning. V25 stated she was trying to get ahold of the physician. V25 stated V26 called the doctor for instructions, we'll wait five minutes for her to call back and if she doesn't respond in that time frame, we'll call 911. V25 stated she was informed by V22 (Certified Nursing Assistant - CNA) this morning R227 was not able to be roused. Observed R227 to remain unresponsive to stimuli while receiving oxygen. On 11/01/22 at 12:52 PM the surveyor observed R227 to remain unresponsive to stimuli while being taken by paramedics to the hospital. V25 (Registered Nurse) reported R227's oxygen saturation was fluctuating between 50-64% when she initially assessed him at 12:26PM. On 11/01/22 at 01:02 PM V22 (Agency Certified Nursing Assistant) stated at 10:51 this morning (15-20 minutes before encountering the surveyor) she informed V25 (Registered Nurse) that R227 could not be roused when she took his blood pressure earlier in the morning. On 11/01/22 at 01:13 PM V25 (Registered Nurse) stated R227's initial oxygen levels were at 94 and his respirations at 17 when she assessed him in the morning while giving him medication between 8:30 AM - 9:00 AM. V25 stated she was alarmed by that oxygen level because she prefers it to be at least 95 and over so she wrote down all R227's other oxygen levels. V25 stated V22 informed her twice that R227 was lethargic and didn't want to get up. V25 stated because of what was reported to her by V22, she checked in on R227 multiple times, entered his room at least twice and rubbed the center of his chest firmly to rouse him and he would open his eyes. V25 stated when giving R227 medications in the morning he opened his eyes and turned his head although he didn't say much. V25 stated when V22 informed her the 2nd time about not being able to rouse R227, she then went in his room to check on him. V25 stated she did not inform the physician about the difficulty arousing R227 and wishes she would have. V25 stated she didn't notify the physician because R227's blood pressure and heart rate were normal. V25 stated she assumed R227 was not responding to her attempts to rouse him by calling his name because he was hard of hearing. V25 stated it's not normal to have to firmly rub an individual's chest to rouse them regardless of whether they are hard of hearing or not. R227's vital measurement reports from 10/28/2022 - 11/01/2022 document the following: -no oxygen saturation, respirations, or temperature measurements for 10/29/22 and 10/31/22, one oxygen saturation, respiration, temperature measurement 10/28/22 and 10/30/22, no pulse measurement 10/29/2022, one pulse, and one blood pressure measurement 10/28/22, 10/30/22, and 10/31/22. -from 10/28/22 - 10/30/22 low - normal blood pressure levels, and on 10/31/22 elevated blood pressure level of 132/67. -on 11/01/22 at 07:45AM a 94% oxygen saturation level with room air, pulse rate of 98 beats per minute (noted as not applicable), blood pressure rate of 139/77; at 12:27PM a 64% oxygen saturation level with room air, pulse rate of 88 beats per minute (noted as unable to determine), and blood pressure level of 164/79. R227's progress note dated 11/1/2022 12:25PM (created at 5:08PM) documents: Writer observed resident unresponsive, color ashen, lips bluish tinged, oxygen saturation 64% room air. Manager notified. Oxygen via nonrebreather applied at 6L, oxygen saturation increased to 99% within 2-3 mins. Physician notified per manager. Received order to send resident out via emergency medical services. R227's progress note dated 11/1/2022 12:32 (created at 6:06PM) documents: order received by physician to transfer him to hospital emergency room via 911 emergency medical transportation. R227's progress note dated 11/1/2022 12:45 (created at 5:11PM) documents: Paramedics here, resident sent to hospital emergency room with appropriate paperwork. R227's progress note dated 11/2/2022 12:56AM documents: patient admitted to the hospital with diagnose of Urinary Tract Infection (note not provided by facility). On 11/03/22 at 03:51 PM V35 (Medical Director) stated when a resident who is alert and oriented has a change in condition the nurse should notify either the Director of Nursing, Assistant Director of Nursing, or their physician. V35 stated if a resident was alert and interactive and becomes unresponsive to a sternal rub then there is a change of condition and their vital measurements such as pulse, oxygen saturation, and blood sugar should be assessed. V35 stated in a change of condition such as this there are many ways to determine the possible causes of their change in condition. On 11/04/2022 from 2:46PM - 3:25PM V2 (Director of Nursing) stated R227's vitals should be taken every shift and include blood pressure, respirations, pulse, temperature, and oxygen saturation. V2 stated R227's blood pressure on 10/30/22 was elevated compared to previous days. V2 stated R22's 7:45 AM and 12:27PM blood pressure levels on 11/01/22 was elevated compared to his previous ones. V2 stated R227's blood oxygen saturation 11/01/22 at 12:27PM was abnormal at 64%. V2 stated there is an issue with not following orders to monitor changes in R227's vital signs by not ensuring his vitals were measured each shift daily. V2 stated since R227 was still not responding to stimuli when his oxygen levels increased while receiving oxygen, there should have been an emergency transfer. V2 stated responsiveness would include eyes opening and responding appropriately to stimuli such as responding to his name being called or to touch. V2 stated emergency transfers would include calling 911 while performing interventions which is part of the facility's emergency management policy. V2 stated as soon as V22 (Agency Certified Nursing Assistant) notified V25 (Registered Nurse) of R227's change in condition of non-responsiveness he should have been immediately assessed by the nurse which would have included taking all his vital signs and checking his responsiveness to his name being called and being touched. V2 stated it is not normal to have to firmly rub a resident's chest to rouse them. 2. R220 is an [AGE] year-old male with a diagnosis of Diabetes Mellitus with Diabetic Neuropathy, Metabolic Encephalopathy, Acquired Absence of Left Leg Above Knee, Gangrene, and Sepsis with Septic Shock who was originally admitted to the facility 10/27/2022. R220's current care plan does not include diabetic care. On 10/31/22 at 11:25 AM V27 (Family Member) reported R220 is supposed to receive morning insulin. V27 stated R220s's blood sugar levels during breakfast were measured by a student nurse to be at 272. V27 stated at around 8:30AM R220 ate a muffin, oatmeal and drank apple juice for breakfast and hasn't received insulin. R220's current physician order sheet documents an active order effective 10/27/2022 for injection of 34 units insulin under skin daily at bedtime for diabetes mellitus, an active order effective 10/30/2022 for insulin injection underneath skin before meals and at bedtime per sliding scale blood sugar measurements for diabetes mellitus due to underlying condition with diabetic neuropathy; no blood sugar measurements included in orders. R220's October 2022 Medication Administration Record documents he did not receive ordered 34 units insulin injection at bedtime on 10/28/22 as ordered; did not receive ordered insulin injection administration per sliding scale blood sugar measurement in the late afternoon/evening and at bedtime on 10/28/22 as ordered; in the late afternoon/evening on 10/30/22, and in the morning and afternoon on 10/31/2022. R220's blood sugar measurements from 10/28/22 - 10/31/2022 documents multiple measurements of 200's to 300; no blood sugar measurements in the late afternoon/evening or at bedtime 10/28/2022; blood sugar levels of 358 on 10/28/2022 at 11:31AM, 271 on 10/30/2022 at 5:19PM, 172 on 10/31/2022 at 9:40AM, 322 on 10/31/2022 at 11:14AM. On 11/03/22 at 11:34 AM V2 (Director of Nursing) reported that there were two missed blood sugar reading documentations for R220 on 10/28/2022. Next, according to the face sheet R227 is an [AGE] year-old male with a diagnosis of a history of Diabetes Mellitus., R227 was originally admitted to the facility 10/27/2022. R227's current physician order sheet documents had an active order effective 10/27/22 for injecting 16 units of insulin every 12 hours for diabetes - notify physician if blood sugar levels are below 60 and over 300; an active order effective 10/29/22 for injecting 16 units of insulin before meals and at bedtime for diabetes - notify physician if blood sugar levels are below 80 or over 200. No orders were included for blood sugar measurements. R227's progress note dated 10/29/2022 5:30PM documents: Physician in facility today with new orders for blood sugar measurements 4 times per day. Orders carried out. R227's blood sugar measurements from 10/28/22 - 10/31/22 documents one blood sugar measurement from 10/29/22 - 10/31/22, blood sugar levels of 272 on 10/28/2022 at 8:39AM, 222 on 10/28/2022 at 11:35PM, 286 on 10/30/2022 at 5:45AM, 239 on 10/31/2022 at 6:25PM. On 11/04/2022 from 2:46PM - 3:25PM V2 (Director of Nursing) was interviewed. The information included but not limited to the following: V2 reported, she did not see an order for R220's for blood sugar measurements and does not see one for R227. V2 stated they R220 and R227 should have orders for blood sugar measurements, however they should have blood sugar checked each time they receive their insulin. V2 stated if blood sugars are not measured as ordered for residents there is no way to appropriately assess changes in levels so the physician can be notified to address the changes. V2 stated, R220 not receiving insulin as ordered could result in altered blood sugar levels which could contribute to high blood sugar levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R377 was a [AGE] year old female admitted to the facility [DATE] with diagnoses that included Dementia, Hypertension, Cerebral Infarction and Dysarthria and Anarthria. According to Minimum Data Set (dated [DATE]), R377 had mild cognitive impairment with a BIMS score of 10. R377 had a functional assessment requiring extensive 2 person physical assistance with transferring and toileting; required extensive 1 person assist with bed mobility and was incontinent of bowel and bladder function. Timeline according to progress notes and physician order sheets: [DATE]: R377 developed Moisture Associated Skin Dermatitis (MASD) to sacral area. Order placed for Zinc Oxide barrier cream to the sacrum three times daily and as needed. This order was later discontinued [DATE] [DATE]: V36 Wound care coordinator noted shearing MASD to Sacrum. New order placed to clean sacrum with normal saline, pat dry and apply zinc oxide barrier cream and applu foam dressing three times weekly and as needed. [DATE]: NP ordered Augmentin suspension for 7 days due to elevated [NAME] Blood Count of 12.04 and multiple blisters presenting over axilla and breast. [DATE]: Nurse charted no new skin concerns during bathing [DATE] Assessed by V36 Wound Care coordinator with MASD with intact blister to sacrum. No new orders placed with continued use of Zinc barrier cream. [DATE]: Nurse noted blister to sacrum ruptured and notified wound care team. [DATE]: V36 wound care coordinator assessed sacrum with ruptured blister, slough tissue, and granulation tissue with odor. Placed orders for air loss mattress and wound care consult. Treatment orders placed to cleanse with normal saline, apply honey and cover with foam dressing three times weekly and as needed. [DATE]: Seen by Wound care MD; assessed sacrum wound as unstageable. Debridement and culture taken at the bedside. Augmentin antibiotic ordered by Infectious Disease Nurse Practitioner for multiple blisters. Does not address sacral wound within progress notes. Nursing staff note that resident accepts antibiotic and supplement despite refusing other meds per baseline behavior. V36 Wound care coordinator revised order to cleanse with Dakin's Solution, rinse with normal saline and apply honey with foam dressing three times weekly and as needed. [DATE]: No treatments administered to the sacrum according to Treatment Administration Record. No further wound care notes or observations identified in resident chart [DATE]: Seen by V38 Nurse Practitioner who ordered CBC and CMP to be collected in the AM. V37 Wound coordinator ordered Dakin's solution soak to sacral wound with dry dressing daily. 11:41AM Nurse received orders to send Resident to the hospital for sacral wound infection debridement. 1:15PM Resident transferred via ambulance to hospital. Did not return to the facility. Expired on [DATE] at hospital with primary diagnoses of sacral osteomyelitis. On [DATE] at 12 30PM V2 Director of Nursing said, R377 was at risk of developing pressure wounds but did not have a history of any pressure related wounds prior to this one. There are no skin assessments available that depict the worsening of the sacral wound. There are no measurements documented after the wound was identified and I would have expected the nursing staff to communicate with the nurse practitioner or the primary doctor any progression of the wound. There was a time where the facility did not have a Wound Care Coordinator, Nurse or provider due to staffing issues. On [DATE] at 1:45PM V36 said, I was alerted by the nursing staff that the rash on R377's sacrum was progressing after the blister ruptured. I was not following her prior to this because she didn't have any wounds. I usually expect for MASD to be resolved with barrier ointment, but for residents who are incontinent, it may take longer to heal because they are always sitting or lying in bed. I placed an order for honey and did the treatment and expected to round with the wound care doctor the following day. The next day, the wound care doctor identified the wound as unstageable because it contained some necrotic tissue with some slough and drainage. We debrided the wound to obtain a culture, and I placed orders for low air loss mattress and updated the treatment order. R377 did not have an air mattress in place at the time. We suspected that the wound may be infected based on how it presented. I abruptly ended my employment shortly after that and was not able to complete an investigation as to how the wound progressed. On [DATE] at 12:56PM V37 Wound Care nurse said, I began working at the facility [DATE] and there was no wound care team in place. I came in and found that dressings and assessments were not being done and some residents didn't have wound orders or they weren't updated. The first time I was able to assess R377, she was in a lot of pain associated with the wound while I was providing care. I placed orders but decided that she needed to go to the hospital because the wound was beyond the level of care that we could provide in the facility. I asked the primary nurse at the time to contact Infectious Disease Nurse Practitioner and I told them that this wound was beyond our care. I felt that R377 needed quick antibiotics intravenously and a debridement because it was so bad. The wound care doctor wasn't expected to come for another week, and I didn't think we could wait that long. The wound was red, draining and necrotic. On [DATE] at 1:56PM V38 Nurse Practitioner (NP) said, I am the house NP and am in the facility 3 days a week. The nurses did not inform me of the sacral wound, and I did not review the progress notes from nursing or wound care that were in the chart. I did not discuss the sacral wound with the Infectious Disease Nurse either. R377's primary physician was not available to interview during this survey. V35 Medical Director interviewed on [DATE] at 3:35PM. V35 said, osteomyelitis is an infection of the bone that can spread to the bloodstream. This can be caused by a wound or a pressure sore and requires extensive IV antibiotics usually at a minimum of 6 weeks. If a wound is infected and has some necrotic tissue it requires debridement to discover what is underneath. Osteomyelitis is hard to miss without an x-ray to determine the diagnosis. For a resident with a sacral wound, osteomyelitis can be caused when bacteria is introduced such as episodes of incontinence. Facility policy titled Skin Care Prevention states in part; Dependent residents will be assessed during care for any changes in skin condition including redness, and this will be reported to the nurse. The nurse is responsible for alerting the Health Care Provider. For residents who are bed or chair bound, provide a chair cushion and pressure reducing mattress. Facility policy titled Monitoring of wounds and documentation states in part; General Monitoring Guidelines: With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the Pressure Ulcer/Pressure Injury) should be documented. At minimum, documentation shoild include the date observed and : Location and staging; size; exudate; pain; wound bed; and description of wound edges and surrounding tissue. If a wound shows no signs of healing after three weeks, a reevaluation of the treatment plan including determining whether to continue or modify the current interventions is done. If the decision is made to retain the current regimen, documentation of the rationale of continuing the current plan will occur. R377's progress notes reviewed, and it was noted that no admitting diagnosis was documented. Hospital records requested which were not received during the survey conclusion. Death Certificate dated [DATE] lists primary cause of death as Sacral Osteomyelitis. Based on observation, interview and record review, the facility failed to implement interventions to prevent and treat pressure ulcer/pressure injury (PU/PI) development for residents who were at increased risk for PU/PI development, failed to provide ongoing skin assessments for the residents, failed to provide proper treatment to prevent worsening of pressure ulcers or infection and provide appropriate pain management. These failures affected four of four residents (R39, R228, R269 and R377) identified with issues concerning pressure ulcer or injury. As a result, R269 and R377 were admitted without pressure ulcers and developed infected pressure ulcers while at the facility. In addition, R377 death was linked to sacral osteomyelitis. Findings include: 1. R269 is a [AGE] year-old male who was admitted to the facility on [DATE] with past medical history including, but not limited to unspecified protein-calorie malnutrition, metabolic encephalopathy, nonchronic ulcer of unspecified part of unspecified lower leg with unspecified severity, urinary tract infection. [DATE] at 12:45PM, resident's son came to the dining room during lunch and stated that he would like to speak to someone regarding his father, R269. V4 (Family member) stated that he thinks his father is being neglected, he does not like the condition he found him in. Surveyor went to the room with V4 and V6 (nurses). Upon entering R269's room, the surveyor noted a strong smell of urine and feces. R269 had indwelling catheter draining via gravity and some dark yellowish colored urine. R269 was lying on a regular mattress and did not have any heel boot applied, contracture noted to R269's left hand that was placed on a pillow. V6 (nurse) said that the urine is more yellow in color than the last time she saw the resident, she will call the doctor and let him know. V5 (C.N.A/certified nurse aide) was called to the room and she said that she is the assigned C.N.A for the resident but she has not had the time to check him today. V6 was asked to pull the blanket on the resident and resident was noted with a big bowel movement stuck to his butt and on the bed cover. R269 not have any adult brief. R269 also noted to have wound dressing on the buttocks that was saturated with drainage and brown in color. [DATE] at 9:15AM, the surveyor observed dressing change for R269 with V7 (wound care nurse). V7 said that R269 has two pressure ulcers and both are facility acquired. She described them as an unstageable pressure ulcer to the left buttocks and a Deep Tissue Injury (DTI) to the right hip. V7 said that she became aware of the pressure ulcers on [DATE]. V7 removed the dressing on the left buttock and there was a large area of excoriation with greenish brown drainage that has a foul smell. V7 said that the wound care doctor has not seen the resident. V7 added that she will ask the nurse to call and get some antibiotics for the resident because the wound looks like it is infected. On the resident's right hip is a large area of breakdown that is brownish ping in color. V7 said that she will change the current treatment and use collagen with foam dressing, the current treatment is peeling off his skin. Surveyor asked V7 if they can just change the order without calling the doctor and she said that she is just using her judgement and she will call the doctor and inform him, when he makes rounds, he can change the treatment again if needed. V7 added that she ordered an air loss mattress and foam boots for resident. Resident was placed on oral antibiotics for wound infection as indicated in physician order dated [DATE] that shows an order for Augmentin Tablet 875-125 MG (Amoxicillin-Pot Clavulanate) give 1 tablet by mouth two times a day for wound for 7 Days. Braden scored assessment dated [DATE] coded R269 as a 13, moderate risk for pressure sores. Nursing admission assessment dated [DATE] documented pain to the right lower leg and toe, and pain to the left lower leg and toe. Skin condition was documented as normal, with old scabs and dryness to the lower extremities. Physician order dated [DATE] shows the following weekly skin screen (Complete skin screen form if new alteration is present) every day shift every Tue, Thu, Sat. Activities of Daily Living (ADL) care plan dated [DATE] reads: Resident requires assist with daily care needs r/t dx/hx of AMS, HTN, CKD, Glaucoma, HTN, benign prostatic hyperplasia with lower UTI. Resident is a total assist of two staff members for bed mobility, toileting and transfers Interventions include: Assist resident with ADLs, encourage/ assist with turning and repositioning every two hours and as needed, Hoyer lift with two assists for transfers. Review of records did not show any care plan or interventions in place for alteration in skin integrity for the resident. R269 Minimum Data Set (MDS) dated [DATE] coded R269 as 4/3 indicating total dependence with 2 persons physical assist for bed mobility and transfer, 3/3 (Extensive assist with one- person physical assist for dressing, toilet use and personal hygiene and 2-person physical assist for bathing. Section H of the same assessment coded resident as always incontinent of bowel. [DATE] at 3:34PM, V35 (Medical Director) said that that he is not aware of the increased number of facilities acquired pressure ulcers. V35 stated the staff should be doing skin assessment on residents as ordered by the physician and the attending physicians should be rounding on the residents. V35 was asked how often the attending physicians are expected to see residents and he said that it varies and depends on cases. He added that the resident's nutritional status should also be monitored as that can also affect wound healing. V35 said that preventive measure like turning and repositioning, daily skin assessment during showers/baths and air loss mattress could help to avoid development of pressure ulcer. V35 stated he will discuss with the DON to see how to deal with the issue. Facility skin care prevention policy with a review date of 1/2022 presented by V2 (DON) stated in part that all residents will receive appropriate care to decrease the risk of skin breakdown. Under guideline the same document states that the nursing department will review all new admissions/readmissions to put a plan in place for prevention based on resident's activity level, comorbidities, mental status, risk assessment and other pertinent information. For residents who are bed or chair bound, provide a chair cushion and pressure reducing mattress. Another document presented by V2 (DON) titled skin management, monitoring of wounds and documentation dated 01/2022 states: it is important that the facility have a system in place to assure that the protocols for daily monitoring and for periodic documentation of measurements, terminology, frequency of assessment, and documentation are implemented consistently throughout the facility. 3. R39 is a [AGE] year-old male with a diagnoses history of Moderate Protein Calorie Malnutrition, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hemiplegia and Hemiparesis (Partial Paralysis) due to Cerebral Infarction (Stroke), Need for Assistance with Personal Care, and Peripheral Vascular Disease who was readmitted to the facility [DATE]. On [DATE] at 12:31 Observed R39 in his bed sleeping in a gown with his lunch meal at bedside. On [DATE] at 11:21 AM V22 (Agency Certified Nursing Assistant - CNA) reported R39 stated his but hurt when she informed him she was going to get him up out of bed. V22 stated she was going to give R39 a shower, but staff advised her not to because of his wound. V22 stated she was told by the nurses and CNA's not to get the residents dressed and out of bed. V22 stated a staff reported to her she had never seen R39 in clothes and never seen him up. V22 stated R39's bottom was raw and red. V22 stated multiple residents beds are worn out and sunken in and that's why they have wounds. Observed R39's mattress was tattered and sunken in the middle. Observed R39's mattress was not a pressure relieving mattress. V22 stated when she began providing care to R39 she observed him to be in a gown with a large amount of dried feces which means he was likely in that condition for a long time. Observed R39's removed gown with a large amount of dried feces on it. On [DATE] at 11:58 AM Observed R39 sitting in his wheel chair in his room. R39 stated he has wounds on his butt and legs and they hurt. No offloading booties observed on feet. On [DATE] at 1:36 PM R39 lying in his bed. R39 wearing socks on both feet with no off-loading items on him or in his bed. During this time, V23 remove (Wound Nurse) R39's socks to reveal a dime sized wound on his left heel. V23 (Wound Nurse) was presented at the time. V23 reported R39 has a foam dressing for his left heel wound. V23 also reported, R39's left heel wound is from pressure, and he should have heel protectors. R39's heel wound is open, draining and reaches past the first skin layer. V23 stated R39's heel is treated three times per week. Surveyor observed V23 applied barrier cream to R39's buttock wound without cleaning the area. V7 (Wound Nurse/Licensed Practical Nurse) stated R39's left heel wound is a vascular wound. V7 reported the following: R39's wound was noted in his medical records as a diabetic wound and possibly he has diabetes. V7 stated a pressure wound would be open. She would label R39's heel wound as unstageable due to not being able to fully observe the depth of the wound and having slough on the surface. V7 stated R39's heel wound should be treated with med honey and she will update his treatments and have the physician update the stage of his wound. V7 stated the wound physician was aware of his heel wound and he is on a list to be seen tomorrow. R39 has had a stage 3 wound to his left and right buttocks which he has had for a couple of weeks. V7 believes those wounds have resolved and the treatments for that area should be changed to a barrier cream. V7 stated R39 does not have a pressure relieving mattress. She believes R39 has developed a fungal rash around his buttock area due to moisture and it requires barrier cream. Observed R39's buttock area to with red, scaly, irritated skin. V7 stated R39's buttock wound was not as red when she last observed it during treatment. V7 stated R39's sunken mattress wound hinder his wound from healing because the cushion is compromised and no longer providing protection for his skin. V7 stated R39 needs a new mattress or a pressure relieving mattress. V7 stated she began working for the facility [DATE], went on vacation [DATE] and returned from vacation on [DATE] during which time she began working as the wound coordinator. V7 stated she oriented with the previous wound coordinator for a few days before going on vacation then when she returned began providing wound care on her own. R39's current care plan documents he has MASD (Moisture Associated Skin Damage) to sacral area; diabetic left heel wound. R39 has potential for further skin impairment related to Disease processes of Immobility and history of pressure injuries with interventions including: Anticipate and meet the resident's, care and safety needs. Be sure the resident's, call light is within reach and encourage to use it for assistance as needed. R39 has, an ADL (Activities of Daily Living) Self Care Performance Deficit related to diagnoses history of Anxiety, Type 2 diabetes mellitus, Glaucoma, cerebral infarction and requires an extensive assist of one staff member for bed mobility, toileting and transfers. R39's current physician order sheet documents an active order effective [DATE] for a pressure reduction mattress, reposition every 2 hours, offload heels. R39's wound care progress notes dated [DATE] documents: R39 is noted as [AGE] year old male admitted with a diagnoses history of Type 2 Diabetes Mellitus, Congestive Heart Failure, and Nonrheumatic Aortic Stenosis; patient noted with skin warm, dry with stage 3 wound to Left Buttock and Right Buttock, skin tear to Left Posterior Thigh and diabetic ulcer to Left Heel with slough tissue present; patient noted with risk for further skin integrity conditions due to sensory deficit, limited mobility and decreased cognition; preventative skin integrity measures initiated upon admission, air loss mattress ordered at this time. R39's initial wound evaluation report dated [DATE] documents he was examined with newly developed one day old stage 3 pressure wounds of the left and right buttocks with interventions including: house barrier cream every shift for 30 days, off load wound, Low air loss mattress, Turn side to side and front to back in bed every 1-2 hours if able; newly developed one day old diabetic left heel wound with interventions including: medicated honey apply three times per week for 30 days, Gauze dressing applied three times per week for 30 days, Float heels in bed; Off-load wound; Sponge boot. R39's wound care progress note dated [DATE] 3:24PM documents resident was assessed by wound team. Wounds to left and right buttock noted resolved no open area noted, but buttocks noted with bright red redness with white patches (Fungal) orders updated. Resident may have an air loss mattress, Heel boots worn while in bed. 4. R228 is a [AGE] year-old male with a diagnoses history of Unstageable Pressure Wound of Sacral Region, Difficulty in Walking, and Weakness who was originally admitted to the facility [DATE]. On [DATE] at 12:50 PM Observed R228 in a gown in his bed receiving feeding assistance by V28 (Certified Nursing Assistant). On [DATE] at 11:21 AM V22 (Agency Certified Nursing Assistant - CNA) reported that she observed R229's adult brief to be heavily soiled while providing incontinence care to him earlier and she couldn't place a new brief on him because of the condition of his wound. V22 stated R228's wound was in such poor condition that the wound nurse expressed frustration with the condition of his wound. On [DATE] from 1:11 PM - 1:30 PM V7 (Wound Nurse/Licensed Practical Nurse) stated R228 receives wound care on Tuesdays, Thursdays, and Saturdays. R228 has an unstageable sacral (between his lower back and tailbone area) wound. V7 stated R228's sacral wound has 50% dead tissue slough which is a result of pressure. The frequency of the med honey treatment helps to eat away the dead tissue. V7 stated R228's wound bandaging was last changed yesterday. V7 stated R228's wound is treated with med honey and foam during scheduled treatments and as needed. V7 stated R228's back condition appears to be a rash. V7 stated R228's back should be treated with barrier cream and moisturizer during daily care. V23 (Wound Nurse) stated R228 appears to have moisture associated yeast around his groin area and if left untreated the skin will break down. At the time of the interviews, the surveyor observed R228's sacral area to be raw and show deep skin injury and a large area of reddened skin on his back. During the wound treatment, R228 yelled loudly in pain when being repositioned for skin assessment and when treatment was applied by V23 to his sacral wound. V23 applied cream to R228's groin area without cleaning the area. V23 stated R228's current care plan documents he requires assist with daily care needs related to chronic kidney disease, Pressure ulcer of sacral region unstageable hypertension, afibrillation, Obstructive sleep apnea, pulmonary fibrosis, retention of urine, low back pain. Resident is a total assist of two staff members for transfers and toileting. Resident is an extensive assist of two staff members for bed mobility; with interventions including: Encourage/ Assist with turning and repositioning every two hours and as needed. R228's current physician order sheet documents an active order effective [DATE] for Reposition every two hours. R228's point of care bed mobility reports from [DATE] to [DATE] document he was provided extensive assistance once on multiple days and twice on multiple days; once on [DATE] and once in the morning and night shift on [DATE] and [DATE]. R228's point of care bed bowel incontinence reports from [DATE] to [DATE] document he was checked for bowel incontinence once during the afternoon on [DATE] at 2:59PM and once [DATE] at 6:41AM and once during the night at 9:45PM. On [DATE] from 3:25PM - 3:40PM V2 (Director of Nursing) stated it is not documented in the medical records if residents are repositioned. V2 stated resident's incontinence status should be checked and changed every 2 hours and as needed and incontinence checks and changes are documented in the residents medical records. V2 stated the only way to confirm that a resident is being repositioned every 2 hours would be for it to be observed and monitored by the Certified Nursing Assistants and the Nurses. V2 stated the only way for administrative staff to monitor if residents are being repositioned every 2 hours would be to observe them repositioned. V2 stated she is not conducting rounds every 2 hours to monitor whether residents are being repositioned every 2 hours. V2 stated if R228's wound has worsened since it was developed, and the wound nurse indicated pressure as a contributing factor to the wounds current condition, it could potentially be due to not being turned and repositioned every 2 hours. V2 stated wound areas should be cleaned prior to applying barrier cream and if this is not being done there is a risk of holding moisture or irritation to the skin. V2 stated if R39 had an order for foam boots and pressure relieving mattress it should have been provided for him. V2 stated not having these interventions in place could cause R39's heel wound to worsen and his sacral wound to redevelop.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to prevent further decline of a contracture on bilateral hands for one (R78) of one resident reviewed for restorative program. This deficiency resulted in R78's range of motion on left wrist deteriorated from normal to moderate loss/50% of norm and on the right hand from normal to mild loss/75% of norm. Findings include: R78 is a [AGE] year old female, admitted in the facility on 02/12/22 with diagnoses of Primary Generalized (Osteo) Arthritis; Muscle Weakness, Generalized and Weakness. On 10/31/22 at 11:30 AM, R78 was observed in bed, alert and verbal. Her hands are both contracted, fist like position, fingers were curled inward and tight. R78 stated she cannot move her hands. There was no splint, or any devices applied on both hands. On 10/31/22 at 2:59 PM, V21 (Family Member) was visiting R78. V21 verbalized that he is concerned about R78's hands. He (V21) further stated that she (R78) used to wear a splint on both hands, but it was not applied anymore. On 11/01/22 at 12:47 PM, R78 was observed asleep on bed. No splints observed on both hands. On 11/01/22 at 12:50 PM, V15 (Restorative Nurse) was asked regarding R78s splint. V15 stated, She is on restorative nursing. She wears splint during the day and into the night. V16 (Restorative Aide) was also asked on 11/01/22 at 12:53 PM if R78 needs to wear a splint on both hands. V16 replied, She has a splint that she wears every day to prevent hands from contracting further. Facility's Nursing Rehab Standard Task documentation dated 05/18/22 for R78 documented: Standard Task: Nursing Rehab - Assistance with splint or brace Description: Assistance with bilateral splints. Should be applied during the day into the night. V15 was asked on when was the last time R78's splint was applied. V15 stated, She is on the program for a splint, it is in the rehab plan of care but it was not scheduled. That is why it is not in the system. She was not wearing it probably because the Aide (V16) did not see it in POC (point of care). V16 is a new Aide, been here for two and a half months. The treatment for wearing the splint did not pop up in the POC task. She does not have any logs to be signed when splint is applied. When I put it in POC, I did not put the shift that is why it did not populate. There were no documentation or logs on R78's medical records regarding application of bilateral splints. There was no care plan for restorative related to R78's bilateral splints application prior to 11/01/22. V15 was asked on 11/02/22 at 1:16 PM regarding R78's care plan for splint. V15 stated, I formulated the care plan for splint only yesterday, but OT referral is for her to wear splints. I guess, I oversight it. I did not do a care plan for the bilateral splints. A care plan for R78, dated 11/01/22 documented: Splint: Requires the use of bilateral splints to her hands related to contractures. (R78) doesn't like to wear her splints that often due to her stating they cause her pain. Interventions: Encourage resident (R78) to assist with applying and removing brace. encourage resident to demonstrate ability to apply the brace and praise participation with program and improvements. Observe skin for complications related to brace usage every shift and each time it is removed. Provide proper cleaning of brace on residents (R78) specific shower days and PRN (when necessary) when soiled. Provide verbal cues as to proper placement of brace when applying. Splint to be on during the AM (morning) and off at PM (evening) up to eight hours as tolerated. On 11/02/22 at 10:54 AM, V14 (Director of Rehab, Long-Term Care) was asked regarding R78. V14 replied, She was evaluated for OT on 08/02/22 for three times a week for four weeks. The goal is for her to wear her splint bilaterally for two hours every day. Her hands are both contracted, in fist position, tight and painful for her when fingers are straightened out. During therapy, she improved from not wearing the splint to wearing it for two hours as tolerated. She was discharged from OT on 08/29/22, she met his goals for wearing the splint and able to perform other set goal tasks. She was referred to Restorative Nursing to continue wearing the splint. R78's OT DC summary 08/29/22: Summary since eval (evaluation)/SOC (start of care): Patient response - patient has reached maximum potential with skilled services; Discharge status and recommendations: Restorative Nursing Program On 11/03/22 at 1:15 PM, V2 (Director of Nursing) was interviewed regarding R78 and splint application. V2 stated, Splints should be applied according to doctor's orders. For R78, there should be an order obtained for her splint at the time that splint was recommended. I am not sure what happened. Restorative Department is the one responsible for the orders and the application of splints or braces. R78's OT evaluation dated 11/03/22 documented in part: Range of Motion (ROM) Goniometric Measurements: Joints - Shoulder = impaired; Elbow/Forearm = impaired; Wrist = impaired; Shoulder = impaired; Elbow/Forearm = impaired; Wrist = impaired R78's Range of Joint Motion Screen dated 09/28/22 documented: A. Evaluation 6. Left wrist and fingers (flexion and extension) 1. Within normal limits 7. Right wrist and fingers (flexion and extension) 1. Within normal limits R78's Range of Joint Motion Screen dated 11/02/22 documented: A. Evaluation 6. Left wrist and fingers (flexion and extension) 3. Moderate loss/50% of norm. 7. Right wrist and fingers (flexion and extension) 2. Mild loss/75% of norm. On 11/03/22 at 1:54 PM, V34 (Physician) was interviewed regarding R78 and use of splint. V34 stated, She is a long-term patient. Been taking care of her for five to six months now. She had history of stroke before, has contracture on both hands due to inability to move them. Use of splints can help in preventing further decline in contractures. Facility's policy titled, Splints review date 10/2021 stated in part but not limited to the following: Guideline: 1. Residents will be evaluated for the use of a splint based on their assessed deformity or contracture. 2. A physician's order will be obtained for any needed splint.