**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review the facility failed to follow policy procedures, failed to implement care plan interventions, failed to obtain physician orders for blood glucose monitoring/sliding scale insulin, failed to receive blood glucose parameters for physician notification, failed to follow physician orders, failed to ensure that medication was administered/documented within regulatory requirements, and/or failed to ensure that (critical) blood glucose levels were addressed by a physician/nurse practitioner for two of four residents reviewed for change in condition. These failures resulted in R1 sustaining critical blood glucose levels ranging from 413-500 (without intervention) for a total of 8 days within 1 month. These failures also resulted in R2 sustaining a critical blood glucose level of 400 (without prescribed sliding scale insulin) for 11 hours.Findings include:On 8/21/25, IDPH (Illinois Department of Public Health) received neglect allegations due to facility staff refusing to contact a doctor when resident blood sugars were elevated.R1 was admitted to the facility on [DATE] with diagnoses which include but not limited to morbid obesity due to excess calories and type II diabetes mellitus. R1 was discharged on 7/2/24 (prior to this survey).R1's (6/5/24) care plan includes potential for complications of metabolic functioning as evidenced by hyper/hypoglycemia, interventions: monitor blood sugars as ordered and cover as ordered per sliding scale. Report abnormal blood sugars to Medical Doctor. R1's (6/1/24) POS (Physician Order Sheets) include check blood glucose before each meal and at bedtime [parameters for physician notification are excluded]. Glargine (insulin) inject 85 units every morning and at bedtime. Humalog (Insulin) inject 50 units before meals. [Sliding scale insulin is excluded].On 9/3/25 at 1:19pm, surveyor inquired if any residents were recently sent out to the hospital due to blood sugar concerns V2 (DON/Director of Nursing) stated We haven't had anybody go out for hyperglycemia or hypoglycemia recently, not that I'm aware of. Surveyor inquired if any residents or family members recently reported concerns regarding blood sugars V2 responded No. Surveyor inquired when R1 was discharged from the facility V2 replied He (R1) has been gone a while, he discharged I wanna say back in 2024. He (R1) was short term stay; I (V2) don't believe he was sent out for blood sugar. I (V2) do remember him (R1) having issues with his blood sugar because the wife (V3) was bringing in all the wrong foods. She (V3/Wife) brought him (R1) whatever he wanted, and we (staff) had to have a meeting with her (V3) about it. She was educated on his diet. We (staff) also found out that she (V3) was giving insulin to him when she was here, and we have that care planned. R1's progress notes state (6/2/24) 9:22am, upon entering resident room, writer noted resident wife with a filled syringe in her hand about to administer it to resident but stopped when I entered the room. Writer made appropriate parties aware [R1's 6/2/24 blood glucose was 330 at 7:30am and 339 at 11am per MAR/Medication Administration Record]. (6/5/24) 3:47pm, Staff reports resident's wife was observed with a vial of insulin to administer to the resident [R1's 6/5/24 blood glucose was 202 at 4pm per MAR]. R1's (June 2024) MAR also affirms that blood glucose levels were (critical) high on the following dates: 6/1: 413. 6/7: 432. 6/15: 500. 6/18: 419. 6/20: 469. 6/23: 450. 6/24: 430. 6/27: 419 however R1's (June 2024) Nurses Notes exclude critical high blood glucose levels and physician notification of resident change in condition. On 9/4/25 at 1:01pm, surveyor inquired about resident blood glucose monitoring V6 (Medical Director) stated, If someone's uncontrolled we (staff) would probably be checking that with meals. Surveyor inquired what parameters should be inclusive for hyperglycemia V6 responded We have about 3 different options; it would be 350 or 400. Surveyor inquired about staff requirements if a resident's blood glucose is 400 or above V6 replied It should be whatever the order is [R1's Physician orders exclude sliding scale insulin] and affirmed the physician should be contacted. Surveyor inquired about potential harm to a resident with a blood glucose level that's 400 or above V6 stated Medical comorbid conditions associated with hyperglycemia which could be infection, DKA (Diabetic Ketoacidosis), or hyperosmolarity.On 9/4/25 at 2:20pm, surveyor inquired if there was any documentation in R1's EMR (Electronic Medical Records) regarding notification for R1's (6/15/24) critical blood glucose level of 500 - per MAR V2 (DON/Director of Nursing) reviewed R1's EMR and stated No, there's no documentation that she (Nurse) called the Physician or Nurse Practitioner for the 15th. Surveyor inquired if there was any documentation that R1's Physician was notified for any of R1's (June 2024) critical blood glucose levels V2 reviewed the EMR to no avail and responded They (staff) were giving the insulin that was ordered but nobody thought about a sliding scale. He (R1) had no sliding scale the entire time he was here, everybody missed it [R1 resided at the facility for over 1 month]. __R2's diagnoses include diabetes mellitus with hyperglycemia however the (9/3/25) facility glucose monitoring log - excludes R2's name. R2's POS includes (8/27/25) Lispro (Insulin) 25 units before meals. Glargine (Insulin) 50 units two times daily. (8/29/25) Lispro inject per sliding scale 150-199 = 2 units, 200-249 = 4 units, 250-299 = 6 units 300-349 =8 units, 350-399 = 10 units at bedtime. [Blood Glucose Monitoring is excluded].R2's (11/7/18) care plan states resident has hyperglycemia related to disease process, interventions: monitor for signs/symptoms of hyperglycemia, report to Nurse and Physician as needed. R2's (7/31/25) BIMS (Brief Interview Mental Status) determined a score of 10 (moderate impairment).On 9/3/25 at 4:09pm, surveyor inquired if R2 has any facility concerns that she would like to discuss R2 responded No, I've always been with the Santa Clause therefore not appropriate for interview. R2's (9/2/25) MAR affirms the following: blood glucose level was 486 (at 5:00pm) and 9 (see nurse note) was documented. R2's blood glucose level was 400 (at 9:00pm) and 9 was documented. [R2's blood sugar was not rechecked until 8am the following day - 11 hours later]. On 9/4/25 at 9:19am, surveyor inquired what 9 indicates on the MAR V2 (DON) stated If they (staff) didn't give it for whatever reason they'll put in a 9 and put in a nurses note. Surveyor presented R2's (September 2025) MAR and inquired if R2 received insulin on 9/2 when the blood glucose was 400 and above V2 responded Let me (V2) see, I'll have to see if the Nurses made any note and did anything with that. The sliding scale only goes up to 399 so she (V5/Registered Nurse) should have called the doctor. They (staff) should know you follow the sliding scale, if the blood sugar is higher than what it is, you reach out to the physician and find out if they (Physician) want to give insulin. R2's (9/2/25) Medication Administration Note states (10:33pm) medicated with 25 units Lispro insulin for blood sugar of 486 per Nurse Practitioner (V7). (10:40pm) Medicated with 10 units Lispro insulin per (V7) however R2 was prescribed sliding scale insulin at 5pm and 9pm - therefore not administered within regulatory requirements (1 hour before or after the scheduled time). On 9/4/25 at 2:16pm, surveyor inquired why V5 (Registered Nurse) documented on 9/2/25 that R2 received Lispro (25 units) at 10:33pm and Lispro (10 units) at 10:40pm (7 minutes later) per electronic Medication Administration Note V2 (DON) responded She (V5) should have put it was given at 5pm or whenever it was given. On 9/4/25 at 3:23pm, surveyor inquired if the Physician was notified of R2's critical blood glucose levels on 9/2/25 V5 (Registered Nurse) stated The Nurse Practitioner (V7) gave the orders to the ADON (Assistant Director of Nursing/V8) she (V7) said to give the 25 units when she (R2) was 486 and then I (V5) gave the 25 units. She (V7) said recheck in 30 minutes, call her (V7) back and it was 400. She (V7) said follow the sliding scale and affirmed that R2 received Lispro 10 units at that time [R2's sliding scale only covers a blood glucose level up to 399 - therefore the sliding scale was not followed]. Surveyor inquired what time R2 received the 25 units and 10 units of Lispro on 9/2/25 V5 responded It was about 5pm but I didn't sit down to chart it then. Surveyor inquired if insulin was administered to R2 on 9/2/25 (at 9pm) as prescribed V5 replied She (R2) gets Lantus at night, so I gave her the Lantus [Sliding scale Lispro - scheduled for 9pm administration was excluded]. Surveyor inquired if V7 was notified of R2's (9/2/25) critical blood glucose level (at 9pm) V5 replied I called her (V7) twice (at 5pm and a half hour later) and during the 9pm, I didn't call her because she (R2) was within the limits to give her a sliding scale. At 9pm, I covered her with the sliding scale because she was under 400. For the 9pm, I just give her the insulin I didn't make a note [R2's blood sugar at 9pm was 400 - therefore not within sliding scale parameters and 9 was documented on the MAR which affirms Lispro was NOT administered as ordered]. Surveyor inquired (again) which insulin was administered to R2 on 9/2/25 at 9pm (due to inconsistent statements) V5 responded I gave her Lantus. The (undated) blood glucose monitoring policy states blood sugars found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. Notify physician if blood glucose is outside resident's parameters for blood glucose as ordered by their physician. Nursing interventions for treatment of hyperglycemia: follow the sliding scale parameters for fast acting insulin and any additional orders received from the physician. Immediately notify the physician and the resident's representative any time the resident's blood sugar is outside the ordered parameter range as well as any interventions taken to address a hypoglycemic or hyperglycemic event. Complete all appropriate documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to a resident who is at high risk for skin impairment. The facility failed to formulate wound/pressure care plan and implement LAL (Low air loss) mattress manufacturer's recommendation in prevention and management of wound care. These failures resulted R54 to develop DTI (Deep tissue injury) on right heel. This deficiency affects all five residents (R28, R36, R45, R54 and R59) in the sample of 17 reviewed for Wound/Pressure ulcer prevention and treatment management. Findings include: On 3/4/25 at 8:07AM, Observed R28 sleeping in a LAL (low air loss) mattress bed with V10 Family member at bedside. V10 said that R28 is totally dependent with ADLs (Activity of Daily Living). V10 said that last week Friday (2/28/25), R28 re-opened her sacral pressure ulcer. V10 said she noticed it when she assisted the CNA (Certified Nurse Assistant) in performing incontinence care and they applied wound dressing. V10 said she notified the ADON (Assistant Director of Nursing), and V5 Wound Care Coordinator (WCC) came to see R28, both were aware of R28's re-opened sacral pressure ulcer. Observed R28 has fitted sheet covered the LAL mattress and a cloth pad over the mattress. R28 wears disposable brief. On 3/4/25 at 8:11AM, Observed R59 lying in LAL mattress bed with flat sheet folded in half and cloth pad over the mattress. R59 wears disposable adult brief. V11 CNA said that R59 should only have flat sheet over the LAL mattress. The night shift CNA is the one who did apply the multi layers of linen over the mattress. On 3/4/25 at 8:20AM, Observed R36 lying in LAL mattress bed with V11 CNA. Observed R36 has flat sheet and cloth pad over the mattress. R36 wears disposable brief. On 3/4/25 at 8:25AM, Observed R54 lying in LAL mattress bed with V5 WCC. Observed flat sheet and cloth pad over the mattress. R54 wears disposable brief. V5 said that R54 should only have flat sheet over the mattress. No multi-layer of linens as manufacturer's recommendation. On 3/4/25 at 8:30AM, Observed R45 lying in LAL mattress bed with V5 WCC. Observed flat sheet and cloth pad over the mattress. R45 wears disposable brief. V5 said that R45 should only have flat sheet over the mattress. No multi-layer of linens. Informed V5 of above observation made to R28, R36 and R59 with multi layers of linen over the LAL mattress. V5 said that residents on LAL mattress should only be on flat sheet so it will not affect the purpose of LAL mattress. On 3/4/25 at 10:04AM, V5 WCC said that she is responsible for wound assessment and treatment for resident with pressure ulcers and other skin conditions. She said, resident who is admitted with skin impairment or open wound should have skin assessment with measurement done by the floor nurse or herself. The physician will be notified to obtain appropriate treatment and care plan will be updated. V5 presented list of residents with skin impairment/pressure ulcers in the facility. The list did not indicate R28 and R54. On 3/4/25 at 10:21AM, Informed V5 WCC of V10 Family member reported that R28 has re-opened her sacral pressure ulcer last Friday (2/28/25). V5 said that she is not aware, and this is her first time hearing this report. V10 Family member denied statement of V5 and reminded her that she came to see R28 on 2/28/25 after she reported to ADON about R28's re-opened sacral wound. V10 added that V5 did not see the wound because the floor nurse applied wound dressing, but she reported to her. V5 said, she probably forgot about it. V5 then started preparing to perform wound assessment and treatment. She wears only gloves, she opened R28's disposable brief then she repositioned R28 to her left side and removed her brief. The brief is clean, but the wound dressing is contaminated with black fecal matters. Observed R28 has fitted sheet and cloth pad over the LAL mattress. R28 has sign posted at her door indicated Enhanced Barrier Precaution. V5 cleansed open sacral wound with normal saline solution (NSS). V5 said, R28 has stage 2 pressure ulcer. Observed clean pinkish tissue and whitish color (maceration) at peri wound. V5 measured sacral wound and obtained 0.5cm x 0.4cm x0.1cm. V5 said that she will call R28's physician to obtain treatment order. On 3/4/25 at 10:41AM, Observed R54 lying in LAL mattress bed. He has tracheostomy tube connected to ventilator. He has gastrostomy tube connected to feeding bag. He is awake and non-verbal. V5 assisted with V8 Restorative Nurse to remove R54's bilateral heel protectors. Observed R54 dressing on the following: Left dorsal foot, left lateral ankle, right inner/medial lower leg, and right heel. Wound dressing dated 3/2/25. V5 said that she was not aware of this wound dressing because there is no order in his chart. V5 removed all wound dressing and cleansed with NSS then did measurement. Left dorsal foot has 1.5cm x1.5cm dry necrotic scab. Left lateral ankle pressure ulcer measures 2.5cm x 1.3cm with 50% pinkish tissue and 50% necrotic dry scab. Right inner/medial lower leg measures 1.5cm x 0.5cm. Observed bleeding granulating, reddish tissue, full thickness. Right heel DTI measures 4.5cm x 6cm, 35% necrotic tissue, 10% red tissue exposure, 65% maroon discoloration. V5 painted betadine to all wounds and covered with bordered dressing. V5 said that she calls the physician to obtain treatment orders to all new identified skin impairments for R54. On 3/4/25 at 11:19AM, Observed R45 lying in LAL mattress bed. He is alert, responsive but with episodes of confusion. V5 WCC assisted with V18 CNA preparing R45 for wound care. V18 open his disposable brief. He as morbid obese abdomen. Surveyor requested to check for underneath his abdominal folds. R45 screams for pain as V18 lifted his abdomen. Observed MASD (Moisture associated skin disorder) underneath the abdominal folds with fluids. Both V5 and V18 said that the fluid from his urine (due to anatomical position of his genital/penis). R45 continues to scream for pain as V18 and V5 cleansed the abdominal folds. Surveyor asked V5 if R45 has scheduled pain medication. Both said that R45 always complains of pain even just touching him. V5 said that she is not aware of this MASD, and this is new for her. V5 applied barrier cream. Then V18 positioned R45 to his left side. V5 said that R45 has Stage 4 sacral pressure ulcer. She applied collagen sheet and covered with foam dressing. V5 said that she will call R45's physician about MASD on abdominal folds. On 3/6/25 at 10:03AM, Reviewed R28, R54, R45, R36 and R59 medical records with V5 WCC. R28 is re-admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus, Dementia, Contractures on right and left ankle, left and right hand, Gastrostomy, Chronic Kidney disease. Active physician order sheet indicates: Weekly skin checks for wound prevention. Moisture barrier ointment apply to buttocks and peri area topically every shift for skin protection secondary to incontinence. No wound treatment addressing to re-opened sacral wound on 2/28/25. Comprehensive care plan indicated she has as alteration in skin integrity and is at risk for additional and or worsening of skin integrity issues related to impaired cognition related to dementia, impaired mobility, and other medically related diagnosis. Intervention: Skin will be checked during routine care daily and during weekly bath/shower schedules. Any skin integrity issues /concerns will be conveyed to the charge nurse for further evaluation and or treatment changes/new interventions and the physician will be called as needed. Pressure reducing/relieving mattress. Informed V5 that Physician was not notified of re-opened sacral wound, did not obtain appropriate treatment intervention, care plan was not implemented and updated not until the surveyor addressed the concerns during survey. Informed V5 that wound assessment done with surveyor on 3/4/25 was dated 3/3/25, it was signed on 3/5/25. R54 is admitted on [DATE] with diagnosis listed in part but not limited to Encephalopathy, Respiratory failure, Emphysema, Chronic obstructive pulmonary disease, paralytic syndrome following cerebral infarction bilateral, Tracheostomy status, Gastrostomy status, Muscle wasting and atrophy. Braden scale/skin assessment upon admission [DATE]) and most recent (3/2/25) indicated that He is at very high risk for developing pressure sore. No admission wound assessment and measurement was done. admission notes dated 2/11/25 indicated open areas multiple, scrotum under red, right outer leg open, back open area, multiple scabs back, back upper open area, back middle open area, toenails thick, top right great toe bruise, left hand callus, right ball foot scab, heel right red area, right inner lower leg red open area, left leg multiple scars, right lower leg scars. Active physician order indicated No treatment orders addressing the identified skin impairment upon admission. V5 did not complete skin assessment after admission. Wound care physician initial wound assessment dated [DATE] indicated: 1) Diaper dermatitis on perineal and buttocks. Treatment recommended- moisture barrier or zinc oxide, 2) Venous stasis on left big toe. Treatment - betadine paint. 3) Open blister on left mid back. Treatment- zinc oxide or Vit A& D. Treatment ordered were written in physician order sheet and not carried out not until the surveyor addressed the concerns. V5 write the treatment recommended by wound care physician on 2/17/25 not until 3/4/25 during survey. R54 physician order sheet and Treatment administration record indicated that treatment orders recommended by wound care physician was only documented on 3/4/25. Informed V5 WCC that they failed to implement its policy and procedure on prevention and treatment management of pressure and non-pressure wounds. They failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to resident who is at high risk for skin impairment. R54 developed DTI on right heel, open wound on lateral ankle and open wound on right medial lower leg. It was not identified, documented, and did not obtain appropriate treatment from the physician not until the surveyor identified it during survey. No comprehensive care plan was developed upon admission to address the skin impairment and prevention of developing pressure ulcer. V5 said that the previous MDS/Care plan coordinator was the one responsible for developing wound/pressure ulcer care plan. V5 submitted all new identified wounds with assessment and measurement done with surveyor on 3/4/25, signed and dated on 3/6/25. R45 is re-admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus, Senile degeneration of brain, Chronic obstructive pulmonary disease, Hemiplegia, and hemiparesis following cerebral infarction affecting left non dominant side, Vascular dementia, Muscle wasting and atrophy. Most recent Braden scale/skin assessment (1/24/25) indicated that he is at high risk for skin impairment. Active physician order indicated Sacrum: cleanse with NSS, apply collagen sheet or puracol, zinc oxide around then cover with foam silicone dressing daily and as needed. Weekly skin assessment. Moisture barrier ointment apply to buttocks and peri area topically every shift for skin protectant secondary to incontinence. No treatment order for MASD abdominal folds that was identified on 3/4/25 with surveyor. Comprehensive care plan indicated that he has an alteration in skin integrity and is at risk for additional and or worsening of skin integrity issues. Interventions: Skin will be checked during routine care on daily basis and during weekly bath /shower. Any skin integrity issues/concerns will be conveyed to the charge nurse for further evaluation and or treatment changes new interventions and the physician will be called as needed. Pressure reducing/relieving mattress (low air loss mattress). Informed V5 WCC that they failed to implement its policy and procedure on prevention and treatment management of pressure and non-pressure wounds and implement care plan interventions. They failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to resident who is at high risk for skin impairment. R36 is re-admitted on [DATE] with diagnosis listed in part but not limited to Parkinson, Dementia, Muscle wasting and atrophy, Stage 3 sacral region pressure ulcer. Active physician order sheet indicates: Low air loss mattress. Treatment sacrum: Apply protective dressing as needed for skin protective dressing. Comprehensive care plan indicated she is at risk for alteration in skin integrity. Most recent Braden scale assessment dated [DATE] indicated at risk for developing pressure ulcer sore. Informed V5 WCC of multilayers of linens over the mattress on 3/4/25. R59 is re-admitted on [DATE] with diagnosis listed in part but not limited to Sequelae of cerebral infarction, Senile degeneration of brain, Metabolic encephalopathy, Subarachnoid hemorrhage, Vascular dementia. Comprehensive care plan indicated she is at risk for alteration in skin integrity related to impaired cognition, incontinence of bladder and bowel and impaired mobility. Intervention: Pressure relieving/reducing mattress. Informed V5 WCC of multilayers of linens over the mattress on 3/4/25. On 3/6/25 at 12:51PM, Informed V24 Medical Director of above concerns identified that the facility failed to ensure ongoing assessment is done to identify new skin impairment, document and notify physician for appropriate treatment in a timely manner to residents who are at high risk for skin impairment. The facility failed to develop wound/pressure care plan and implement LAL (Low air loss) mattress manufacturer's recommendation in prevention and management of wound care. V24 said that they should follow and implement the facility's policy and procedures in prevention, treatment and management of wound/pressure ulcers. Facility's policy on Wound Assessment indicates: It is the policy of this facility to complete a systematic, ongoing assessment of all wounds that will provide a consistent means of wound evaluation to determine the response to treatment modalities and to facilitate continuity of care and communication among staff and healthcare providers on an ongoing basis. Procedure: I. The presence of wounds, injuries and or other skin abnormalities will be identified upon admission/readmission or identification of a new wound, pressure injury, or other skin abnormality. A. The staff will complete a complete skin and wound assessment upon admission/readmission, identify any wounds, pressure injuries or other skin abnormality and document it in the medical records. B. The wound team will complete a skin and wound assessment and document the presence of any wound assessment in the medical record. C. Any wound, pressure injury or other skin abnormality identified during the resident's stay will be documented in the same manner as when identified upon admission/re/admission. II. Wounds are measured weekly by the wound team or designee A. The status of the wound is documented in the medical record B. Wound status is also monitored with each dressing change C. Any changes in the wound are documented at the time identified and the physician and family are notified. Facility's policy and procedures on Treatment/services to prevent /heal pressure and non-pressure wounds revised 11/2/23 indicated: Policy: It is the policy of the facility to ensure it identifies and provides needed care and services that are resident centered in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental and psychosocial needs. Procedure: 1. The facility will ensure that based on the comprehensive assessment of a resident: 1a. A resident receives care, consistent with professional standards of practice to prevent pressure and non-wounds and does not develop pressure or non-pressure wounds unless the individual's clinical condition demonstrates that they were unavoidable as documented by the wound care specialist. 1b. A resident with pressure ulcers or non-pressure wounds received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing. 2. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. 3. Interventions will be implemented by the nurse in the resident's plan of care to prevent pressure sore development when the resident has no areas of concern. 4. When the resident is admitted with a pressure or non-pressure wounds the admitting nurse or wound care nurse will document the size, location, odor, drainage, and current treatment ordered. 5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure and non-pressure wound. 6. The admitting nurse will notify the attending physician as well as the resident and or resident's representative of the condition of the wounds that were observed on admission. 7. The pressure and non-pressure wounds will be evaluated weekly by the wound care nurse and or the wound care specialist. 8. If the wound care specialist changes any treatment or indicates other interventions the wound care nurse will put these orders in the resident's electronic medical record. 9. The nurse will notify the resident and or the resident's representative of any changes related to the improvement, deterioration and or treatment changes on an ongoing basis. Facility's policy Guidelines for Low Air Loss Mattress use dated 7/18/23 indicated: Purpose: To provide the features of a support system for the resident that provides a flow of air in managing the heat and humidity (microclimate) of the skin. Procedure: 8). A single non fitted sheet may need to be utilized on the mattress for assistance in positioning and repositioning the resident. Fitted sheets are not recommended. Quilted reusable pads and incontinent briefs tend to block the airflow and trap moisture against the skin. Disposable, air permeable incontinence pads designed for low air loss mattresses should be used instead.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to treat one resident with respect and dignity by placing him in the hallway tied to a wheelchair and having pictures taken.This failure affected one of one resident (R5) reviewed for dignity. Using the reasonable person concept it is reasonable to conclude that R5 felt cold, uncomfortable, and dehumanized when he was sitting in a wheelchair, in the hallway, with a sheet, no shoes, no socks. The findings include: On 8/29/23 an image of identified resident R5 obtained. Image is of a male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, in the hallway, leaning forward, back exposed, no hospital gown is seen in the picture. R5 appears to be covering his face or head with a white sheet. Image matches with the identified hallway of the facility hallway, outside of the elevator to the left, in front of the dining room door, below sprinkler device. R5 sitting across from nurses' station desk with the back of the computer monitor. The floor pattern and wallpaper match to the facility décor. No face for the resident is visible and his feet are exposed, no shoes or socks. Additionally, the picture shows R5 tied with a white sheet to the wheelchair and two knots in the back. A gait belt is visible around the back of the wheelchair. A blue scrub pant is visible in the lower corner of the image. A camera is observed in the vicinity directly in the line of sight where the resident in the picture is sitting. R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 9/10/24 at 9:46AM V24, CNA, said V19 told her was going to take pictures of the situation with R5. V24 said I didn't report it because I wasn't in the facility. On 9/10/24 at 10:40AM V18, Scheduler said she heard V19 talking about R5 on the phone and say I'm going to take pictures and send them. V19 said staff taking pictures of resident is a HIPPA violation. On 8/30/24 at 12:29PM V5, DON, said she had seen V19 on his phone while on duty and told him to get off the phone. V5 said another staff heard V19 talking on the phone about R5. V19 said talking about the patient to someone else is a HIPPA violation. On 9/3/24 at 3:20PM V5, DON, said V18 called me and told me V19 was on the phone talking to someone about R5 and about how bad he is and something about pictures. V5 said, V18 and V24 should have reported V19. On 9/10/24 at 12:07PM V25, Administrator, said V19 probably should not have completed the shift on 7/26/24. V25 said if I had been there, V19 would not have been allowed to return to the floor after walking out. V25 said I did not know anything occurred with R5 until V5 spoke with me after she spoke with the surveyor. On 9/12/24 at 11:50AM V26, Infection Preventionist, said when a resident comes out of the room, to a common area they should have clothing on, no gown, be clean, face washed, and have their walker or wheelchair. V26 said for footwear we use non skid socks if they don't have shoes or slippers. V26 said we can use donated clothing from laundry that they can wear, or we can double gown to cover their front and back. V26 said we would double gown to give them some privacy. V26 said if they are out in a common area not dressed or with a their back exposed they could most definitely feel uncomfortable and maybe a little cold. The facility abuse prevention dated 1/2019 states during orientation of new employees the facility will cover the following topics sensitivity of resident rights and resident needs, staff obligations to prevent and report abuse, neglect, exploitation, mistreatment, any kind of crime against the resident, theft and how to distinguish theft from lost items and willful abuse from insensitive staff actions. Dementia management and resident abuse prevention. What constitutes abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This prohibitions against taking, using, keeping, distributing photographs, recording of residents. The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident sensitive and resident secure environment. Staff taking or using a photograph or recording of a resident in a manner that demeans or humiliate a resident, regardless of the residents cognitive status, is strictly prohibited and will be handled as an allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to follow their abuse policy to prevent unauthorized photos of a resident restrained to a wheel chair in the hallway. This affected one of three residents R5 reviewed for mental abuse. This failure resulted in R5 having unauthorized photos taken of him restrained to a wheelchair which is demeaning, and humiliating. Findings include: On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 I saw R5 had a gait belt around him. V19 said I was assigned to be R5's one to one, monitoring him. V19 said I talked to V11, LPN, and V5, DON, and the scheduler. V19 said I told V5 about the gait belt around R5 before she left like at 4:30PM. V19 said they said if you don't want to watch the patient, then go home. V19 said I left the floor and then I came back up to the floor around 6:00PM or 7:00PM and R5 had the sheet around him. V19 said I got fired because of this. V19 said I saw R5 with the sheet tied with two knots around his stomach and he was sitting on a regular wheelchair, he also had the gait belt on. V19 said I documented it, V19 provided pictures to IDPH from his personal phone. On 8/29/23 an image of identified resident R5 obtained. Image is of a male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, leaning forward, back exposed, no hospital gown is seen in the picture. Image matches with the identified hallway of the facility hallway, outside of the elevator to the left, in front of the dining room door, below sprinkler device. R5 sitting across from nurses' station desk with the back of the computer monitor. The floor pattern and wallpaper match to the facility décor. No face for the resident is visible and his feet are exposed, no shoes or socks. A blue scrub pant is visible in the lower corner of the image. A camera is observed in the vicinity directly in the line of sight where the resident in the picture is sitting. R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disorder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 9/10/24 at 9:46AM V24, CNA, said on 7/26/24 around 5:00PM - 5:30PM I was at home when V19 called me, he said they stuck him with a one to one monitor. V24 said V19 said they were restraining the resident. V24 said V19 was going to document by taking pictures. V24 said I don't think V19 took pictures of R5's face, just the restraint. V24 said I didn't report to anyone because I felt V19 had it under control and I didn't see it because I wasn't in the facility. On 9/10/24 at 10:40AM V18, Scheduler, said I heard V19 on the phone when I was walking in the hallway, after dinner between 5:15-5:30. V18 said I heard V19 telling someone, this resident he doesn't sit down, he is getting on my nerves. V18 said I don't know who V19 was talking to. V18 said I asked V19 if he was taking pictures and he said no he was not. V18 said I told V5 I heard V19 say I'm going to take pictures and send them. V19 said V24 mentioned V19 told her he was going to send the pictures. V18 said I told V19 you can't take pictures. V18 said I didn't see V19 take pictures. The surveyor asked V18 do you have to see abuse happen to report it? V18 said no. V18 said I felt I needed to call V5 to see if V19 needed to be sent home, because he was on the phone. V18 said V19 stayed with R5 until the end of his shift. V18 said staff are not allowed to take pictures of the residents because it is a HIPPA (Health Insurance Portability and Accountability Act) violation. V18 said staff are not supposed to be on the phone while on duty with a resident. V18 said staff are not to be on the phone while assigned one to one monitoring with residents. On 8/30/24 at 12:29PM V5, Director of Nursing, said V19 was terminated for being on his cell phone, twice. V5 said on 7/26/24 I told him to get off the phone when I saw him. V5 said another staff observed V19 on the cell phone and heard V19 talking about R5 and how bad R5 was and R5 did not need to be here. V5 said that same night V19 was mad and said he was leaving, he was upset about having to do the one to one. V5 said when I spoke to V18 by phone, it may have been 9:00PM or 10:00PM. V5 said V19 did not finish his shift, we got someone else to monitor R5. V5 said taking resident pictures is a HIPPA violation. V5 said I told V18 to take V19 off the schedule until I speak with him on Monday. On 9/3/24 at 3:20PM V5, said V18, Scheduler, called me while I was at home and said when she walked in R5's room and saw V19 on the phone. V5 said V18 reported V19 was on the phone talking to someone about how bad R5 is and something about pictures. V5 said V18 said she asked V19 if he was taking pictures. V5 said V19 was the only CNA assigned to R5. V5 said after the surveyor spoke with me (on 8/30/24) I spoke with my staff and V24 said V19 called me and said he was going to take pictures of the resident. V5 said V24 said she didn't report it because it didn't involve me and she didn't want to get involved. V5 said V18 and V24 should have both reported V19 on 7/26/24. On 9/10/24 at 12:07PM V25, Administrator, said V19 probably should not have completed the shift on 7/26/24. V25 said V19 talking about R5 on the phone violates policy. V25 said if I had been there, V19 would not have been allowed to return to the floor after walking out. V25 said I did not know anything occurred with R5 until V5 spoke with me after she spoke with the surveyor. V19 employee file notes his hire date is 7/10/24. Review of V19's employee file conducted. V19's HIPPA Quiz dated 7/10/24 has no responses for the questions. On 7/10/24 V19 signed I acknowledge that I have received and read the facilities abuse prevention program policy and procedure. I have received and read the social media policy. I understand the requirements of the social media policy represents the standards and policies of the facility. The facility provided two Personnel Change Forms for V19, both dated 7/29/24. One notes termination is voluntary Employee left on his own accord. Last day worked 7/29/24. The second form notes termination is Involuntary violation of facility policy. No last day worked is noted. IDPH received three pictures of R5 on 8/29/24 at 11:49AM. The last time V19 worked with R5 was on 7/26/24. R5 retained the pictures in his phone for 34 days. The facility abuse prevention program policy and procedure dated 1/2019 states during orientation of new employees the facility will cover at least the following topics prohibitions against taking, using, keeping, or distributing photographs, recordings of residents or a resident's personal space, as described in section below. The facility defined mental abuse includes taking or using photographs or recordings in any manner that would demean or humiliate the resident. This includes taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (cameras, smart phones, and other electronic ) devices and/or keeping or distributing them through multimedia messages or on social media networks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure one resident was not physically restrained by being tied into a wheelchair with a gait belt and a bed sheet. This failure affects one of three residents (R5) reviewed for restraint use. This failure resulted in R5 having his freedom of movement inhibited and ongoing agitation, aggression, and anxiety. It is reasonable to conclude that R5 felt embarrassed and dehumanized. The findings include: On 8/29/24 at 11:21AM V19, Certified Nursing Assistant (CNA), said on 7/26/24 R5 was on one to one monitoring, he was a lunatic. V19 said R5 was trying to throw himself on the floor. V19 said I saw R5 had a gait belt around him and I told them, I don't feel comfortable with the belt on him. V19 said I talked to V11, LPN, and V5, DON, and the scheduler. V19 said I told V5 about the gait belt around R5, before she left like at 4:30PM. V19 said I didn't say anything about the sheet. V19 said they said if you don't want to watch the patient, then go home. V19 said I left the floor and then I came back up to the floor around 6:00PM or 7:00PM and R5 had the sheet around him. V19 said I got fired because of this. V19 said I saw R5 with the sheet tied with two knots around his stomach and he was sitting on a regular wheelchair, he also had the gait belt on. V19 said I documented it, V19 provided documentation to IDPH. R5 is [AGE] years old with diagnosis including, but not limited to Convulsions, Alcohol Abuse with Alcohol Induced Anxiety Disroder, Depressive Episodes, Schizoaffective Disorder, Dementia, Acute Cystitis, and Bacterial Pneumonia. R5 was admitted to the facility on [DATE] around 2:00PM - 2:30PM (per DON). At 6:02PM R5 was ordered a psychiatric transfer, and transferred to the hospital on 7/27/24 at 12:25AM. R5 was admitted to the hospital. On 8/29/24 at 1:18PM V10, Registered Nurse (RN), said I did the admission for R5. V10 said R5 was a little aggressive and he was not verbal. V10 said when I spoke with R5 he understands a little and was alert times 1-2. V10 said R5 was not mobile, he was not steady, he liked to grab at people. V10 said R5 was a complete assist, he needs staff assistance for everything. V10 said R5 was a fall risk. V10 said I had to call for someone to sit with him. V10 said R5 was constantly trying to get up and he was aggressive. V10 said R5 sat in a regular wheelchair. V10 said we got a sitter for him in the evening. V10 gave a description of R5, she said he was an African American male, about 110 pounds, 5'3 - 5'2, thin, and he had a gastric tube when he first came to us. V10 described R5's hair as not well kept and he had a thin beard. V10 was shown a picture of a male, sitting in a chair, in a room and V10 said that is him identifying R5. On 8/29/24 1:33PM V11, Licensed Practical Nurse (LPN), said we needed a one to one for R5. V11 said R5 had behaviors. V11 said R5 would throw things at staff, use verbal profanity, and he would not stay seated for 2 seconds. V11 said the assigned monitors reported R5 was hitting them and he would urinate wherever he was. V11 said R5 sat in a wheelchair. On 8/29/24 at 2:25PM V14, CNA, said I used to take R5 outside to try and calm him down, in a wheelchair. V14 said I know V19, CNA, was assigned as one to one monitor for R5 on 7/26/24. V14 said I saw V19 standing outside of R5's room, and not in the room like he should have been. V14 said at one point, R5 was brought out to the nurses station, he was in a gown, in a wheelchair. V14 said R5 was always trying to stand up. V14 said I had seen R5 leave urine on the floor. On 8/30/24 at 10:09AM V16, CNA, said on 7/26/24 V19 got pulled to monitor R5. V16 said R5 was really anxious, he tried to get up, and his legs go weak. V16 said we kept coming back to check on V19 because R5 was anxious, he was in the wheelchair rolling everywhere. V16 said at first V19 was nervous with R5, I had to pull him out the room and talk to V19 about how to address R5's behavior. V16 said R5 and V19 were in the hallway and in the room. V16 said I think V19 had blue scrubs on that day. V16 said V19 said R5 was throwing feces. V16 said R5 was in a wheelchair. V16 said V19 was having a panic attack after R5 was throwing feces and urinating. V16 said V19 came to the nurses' station, and he said this is too much, I can't deal with this and R5 was in the room. V16 said I told V19 you need relief for a one to one. V16 said V19 was belligerent, he was not listening and having a panic attack, and V19 went down the stairwell. V16 said V19 ended up coming back to the floor, he was gone like 10 minutes. V16 said V19 was doing this around 5:30PM, mealtime. V16 said R5 had tried to throw himself out of the chair or lean forward. V16 said V18, Scheduler, tried to do education with V19 about how to care for R5. V16 said the shift ends at 11:00PM, and V19 sat with R5 until 11:00PM. On 8/30/24 11:10AM V5, Director of Nursing (DON), said we issue gait belts to the CNAs and we expect them to use them for transfers. V5 said they have the gait belts on them, they are expected to carry them while at work. V5 said R5 was all over the place he kept getting up from his wheelchair. V5 said we assigned a one to one monitor because we were afraid R5 was going to fall. V5 said R5 was standing, difficult to redirect, pulling at his gastric-tube, reaching and grabbing for the CNAs. V5 said we got a wheelchair for R5 and sat him at the nurses' station because he kept trying to stand. V5 said V19 was pulled to monitor R5. V5 said R5 was at risk for falls, not redirectable, not listening, and not interested in anything. At 12:29 V5 said V19 was terminated for being on his cell phone twice on 7/26/24 while he was assigned the one to one with R5. V5 said a CNA observed V19 on the cell phone, and heard him talking about R5 and how bad he was and he did not need to be here. V19 said that same shift V19 said he was mad and he was leaving. V5 said V19 was upset about having to do the one to one. V5 said a physical restraint would be to tie a resident down in bed or a chair using a gait belt or a sheet. V5 said a restraint would be anything used to keep a resident from getting up. The surveyor asked V5 does a restraint inhibit freedom of movement, can it cause anxiety, agitation, and aggression? V5 responded yes to all. V5 said the use of physical restraint is considered abuse. 9/10/24 9:46AM V24, CNA, said I was at home when V19 called me on 7/26/24. V24 said V19 said they stuck him with a one to one. V24 said V19 said they were restraining R5. V24 said V19 said that R5 was restrained to a chair. V24 said it was around 5:00-5:30PM when V19 called me. 9/10/24 10:40AM V18, Scheduler, said as I walking in the hallway, I heard V19 telling someone on the phone this resident he doesn't sit down, he is getting on my nerves. V18 said I don't know who V19 was talking to. V19 said when I went in R5's room V19 was standing behind R5 holding him down. V18 said I told V19 it could be intimating to be behind him. On 9/3/24 at 3:20PM V5 said V19 was assigned to R5 and from the start he was mad and upset because he did not have the option to refuse. V5 said one of the CNAs I spoke to said V19 called me and said he felt uncomfortable taking care of this patient because the resident was restrained. V5 said V18 called me on 7/26/24, after I had gone home, and said when she walked in R5's room V19 had R5 in a choke hold in the wheelchair, trying to hold him down, and talking on the phone. V5 said, V18 said V19 was on the phone talking to someone about how bad R5 is. On 9/10/24 at 11:51am V15, Assistant Director of Nursing, said there are no restraint use assesmsents because we are a restraint free facility. On 9/10/24 at 12:07PM V25, Administrator, said during orientation I say no restraints, unless notified otherwise, and then we would assess the resident on an as needed bases. V25 said I spoke with V19 yesterday (9/9/24) and all he could tell me is that when he got to the floor R5 had a gait belt on the chair. V25 said I asked if the ambulance had left him like that, V19 said he didn't know. The surveyor asked V25 if the ambulance transfers residents to them in wheelchairs, V25 said typically they don't come in with a wheelchair. V25 said the camera only shows the hallway. V25 said the camera looks down towards the dining room. V25 said there is only one camera, it can see the nurses' station, elevator, towards the dining room, and the entrace to the dining room. V25 said it is very blurry I can't make out a whole lot. On 8/29/24 an image of identified resident R5 obtained. Image is of African American, dark-skinned male, with disheveled, long, black hair, and long facial hair. R5 sitting in a room, in a wheelchair, no socks or shoes, in a hospital issued gown, with a face mask on, below his chin. A second image of a male, dark skinned, sitting in a wheelchair, leaning forward, back exposed. Image matches with the identified hallway of the facility hallway, outside of the elevator to the left, in front of the dining room door, below sprinkler device. R5 sitting across from nurses' station desk with the back of the computer monitor. The floor pattern and wallpaper match to the facility décor. A white with beige, red, and blue striped gait belt is visible with a long tail portion off the lower back of the wheelchair. A white linen, possibly bed sheet, is visible tied around the resident, left and right side of wheelchair have the same linen and 2 knots with a visible loop is present on the back of the wheelchair. No face for the resident is visible, but he is in a hospital gown and feet exposed, no shoes or socks. A blue scrub pant is visible in the lower corner of the image. A camera is observed in the vicinity directly in the line of sight where the resident in the picture is sitting. On 8/30/24 at 12:15PM V20, Human Resources, said V19 worked 7/26/24 3:00PM-11:00PM with a 30 minute lunch from 9:01PM- 9:30PM. V20 provided V19's time card. On 8/30/24 at 12:57PM V5 provided two samples of gait belts given to CNAs for use in the facility. One sample is beige with three stripes, blue, red, blue and metal clip. This belt is similar to the one seen in the picture used on R5. Review of R5's careplan and assessments. No risk of abuse assessment is in R5's chart. No restraint use assessment is in R5's chart. Facility provided Restraint Policy and Procedure dated 1/15/21 states physical restraint is any manual method, or physical, or mechanical device, material, or equipment attached or adjacent to the individual's body that the individual cannot remove easily, which restricts freedom of movement or access to his or her body. Any resident that has restraint will have it removed during activities, meals, one to one and activities of daily living (ADLs) when and if staff can safely monitor the resident. Any resident requiring a physical restraint will be assessed prior to application to determine the least restrictive restraint used. A verbal consent at minimum will be obtained prior to the physical restraint application. A plan of care will be developed for all residents with chemical and physical restraints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent an incident of physical abuse during a resident to resident verbal altercation for one resident (R4) of five reviewed for abuse in a total sample of 11. This failure resulted in R4 being physically attacked by R5 suffering from a bruised face and bleeding from the mouth after being hit in the face by R5. Findings Include: R4 is a [AGE] year old with the following diagnosis: schizoaffective disorder, psychosis, post traumatic stress disorder, and subdural hematoma. R5 is a [AGE] year old with the following diagnosis: Alzheimer's disease. A Nursing note dated 1/13/23 documents around 2 AM the nursing staff responded to a call from R4. Upon arrival to the room, R5 was observed assaulting R4. A general assessment on R4 was remarkable for left lower eye bruising/swelling and minimal buccal bleeding. On 3/1/24 at 12:26PM, R4 denied remembering getting into a fight with any other residents in the facility. R4 denied any having any problems with any other residents in the facility. This surveyor assessed cognition and R4 was only able to state name and a location of Chicago. R4 was not able to state the date, president, or what kind of place R4 was living in. On 3/1/24 at 12:39PM, R5 denied getting into a fight with anyone at the facility. R5 was unable to recall if R5 was called a racial slur by anyone at the facility. R5 was unable to respond to questions with answers that made sense due to cognition. This surveyor assessed cognition and R5 was only able to state R5's name. When asked other questions, R5 would respond with an answer that was unrelated to the question asked. On 3/1/24 at 6:31PM, V6 (CNA) stated staff heard R4 screaming and when they entered the room, R5 was punching and slapping R4 in the face. V6 reported R4 was lying in bed and R5 was standing over R4 and hitting R4. V6 stated R5 was using open and closed fists when hitting R4. V6 denied hearing R4 using any racial slurs before hearing R4 call for help. V6 reported R4 had bruising on the face and R4's lip was bleeding. V6 stated this would be considered physical abuse. On 3/5/24 at 11:09AM, V9 (Nurse) stated staff notified V9 of the altercation between R4 and R5 and both residents were separated by the time V9 came into the room. V9 reported R4 had bruising and possibly some bleeding but V9 able to recall where. V9 stated this would be physical abuse. V9 reported R4 is not able to walk and could only lie in bed and defend R4's self. On 3/5/24 at 11:34AM, V1 (Administrator) stated while investigating this altercation, it was believed that R4 called R5 a racial slur and R5 proceeded to hit R4 after being called the N-word. V1 stated both residents are confused and did not remember the altercation but R5 did report being called the N-word by R4. The Hospital Transfer Form dated 1/13/24 documents R4 was being sent to the hospital for left lower eye swelling and bruising. The Hospital Transfer Form dated 1/13/24 documents R5 was sent to the hospital for an evaluation after a physical altercation. The Police Report dated 1/13/24 documents the police were dispatched to the facility for an assault occurring between residents. When the police arrived, V9 told police two mentally deficient residents were involved in a physical altercation. V9 told the police that R5 physically assaulted R4 by hitting R4 in the face. The Hospital Records dated 1/13/24 documents R4 was brought to the emergency department after an altercation with another resident. R4 was punched in the face by another resident, and was struck around the eye. Upon assessment, R4 has minimal bruising noted around the left orbit and scattered abrasions over the left lower leg. R4 had a discharge diagnosis of facial trauma. The Hospital Records dated 1/13/24 documents R5 was brought to the emergency room for aggressive behavior toward another resident. R5 was confused with disorganized thoughts. The Facility Incident Report Form dated 1/13/24 documents the nurse heard R4 yelling and entered the room. R5 was observed hitting R4 in the face. R4 was noted to have swelling to the left lower eye and scant amount of bleeding to R4's mouth. R4 is noted to call R5 racist names. R5 does not remember the incident. When asked about the incident, R4 just said, Oh, that n*gger. The Care Plan dated 4/17/20 documents R4 demonstrates behavioral distress as manifested by verbally abusive behavior, use of profanity, verbal threats, and yelling, racial slurs. R4 also exhibits physically, abusive behavior when agitated by attempting to push, shove, scratch, or harm another person. R4 was involved in altercations on 4/16/20, 8/10/20, 9/5/21, 1/29/22, and 1/13/23. The Care Plan dated 12/14/20 documents R4 has a history that reveals a previous suspected abuse and/or neglect or factors that may increase susceptibility to abuse/neglect. R4 demonstrates behavioral symptoms and difficulty in adjustment with mood. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as eight (moderate cognitive impairment). Section E of the MDS documents R4 has not had any physical or verbal behavioral symptoms directed towards others since the last assessment. The Care Plan dated 1/13/24 documents R5 displays conflictual, difficult behavior as manifested by complaints about roommate and unprovoked expressions of anger towards staff and peers. R5 was the aggressor in an altercation with a roommate. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as six (severe cognitive impairment). The policy titled, Abuse Prevention Program, dated 01/2019 documents, It is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility . This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals . For the purpose of this policy and to assist staff members in recognizing abuse, the following definition shall pertain: 1. Abuse: The willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .4. Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform dressing changes as ordered by the wound physician for one resident (R6) of three reviewed for wound care in a total sample of 11. This failure resulted in R6's wound(s) declining by increasing in size on two separate occasions. Findings Include: R6 is a [AGE] year old with the following diagnosis: paraplegia, osteomyelitis, pressure ulcer of the sacral region stage four, pressure ulcer of the right buttocks stage four, and pressure ulcer of the right hip stage 4. On 3/5/24 at 3:13PM, R6 stated, there is one full time wound nurse (V13) and one part time wound nurse (V12). R6 stated V13 left the country for over a month and the only time R6's dressings would be changed was when V12 was in the facility. R6 reported telling V2 (DON) the dressing changes weren't being changed and V2 reported having a conversation with the nurses about doing the dressing changes. R6 admitted the nurses continued to not change the dressing for about two weeks until R6 went to the hospital. R6 stated when R6 got back from the hospital V13 had returned to work and the dressing changes now take place as ordered. R6 reported nurses told R6 they refused to do the dressing changes because they were not certified for that care. R6 was unaware how many dressing changes were missed and was not aware if the wounds declined or not. On 3/7/24 at 10:21AM, V12 (Wound Care Nurse) stated staff nurses are responsible for completing the ordered wound treatment when V12 or V13 (Wound Care Coordinator) are not in the building. V12 reported if a wound has a decline then the wound could get larger in size, have more necrotic tissue, or develop foul odor. V12 stated all wound treatments should be completed as ordered and there is no reason the treatments should not be completed. V12 stated R6 has mentioned to V12 that the staff nurses have not been completing the wound treatments but V12 was unsure of how many. V12 denied checking the Treatment Administrator Record to see if the wound treatments were being completed on R6 and denied notifying the physician or management about the missed wound treatments. V12 reported residents who have wound treatments are round on by the wound doctor weekly. V12 stated a staff nurse should round with the wound physician if V12 or V13 are not in the building so residents can still receive the weekly wound assessment. On 3/7/24 at 11:04AM, V13 stated, V13 was out of the country from 01/01/24 through the second week of 02/2024. V13 reported V12 and V13 normally take care of the dressing cares but in their absence staff nurse need to complete the wound treatments. V13 stated the orders for what treatments to provide are in the TAR and that can be accessed by the nurses. V13 stated residents are rounded on by the wound physician weekly. V13 was unaware that the wound physician was not able to assess resident wounds in the facility on one or two occasions and reported a staff nurse should have rounded with the physician so the wounds could have been assessed. V13 stated the importance of the wound physician seeing residents each week is to observe and document any changes to the wound and changes treatment as necessary. V13 reported if dressing changes are not completed then a wound could have a decline. V13 defined a decline in a wound as the wound growing in size or developing a smell. V13 stated all wound treatments in the TAR should be documented as completed and if they are not documented then it is considered not done. On 3/7/24 at 11:35AM, V2 (DON) denied R6 reporting wound treatments were not being completed when V13 was out of town. V2 stated R6 has a habit of refusing wound treatments but the refusal should be documented in a progress note if R6 refuses. V2 reported staff nurses are responsible for completing the wound treatments when V12 and V13 are not in the building. V2 denied there being a reason an ordered treatment should not be completed. V2 reported the nurses might have completed the treatments on the days that the TAR are empty but understands if the treatment is not charted then it is considered not completed. V2 stated the wound physician sees residents with wounds on a weekly basis to assess the wounds to see if there are any changes in the wounds. V2 recalled maybe two occasions when the wound physician had to cancel weekly visits because no one was able to round with the physician. On 3/7/24 at 1:08PM, V14 (Wound Physician) stated V14 visits the facility weekly to round on the residents. V14 reported on two occasions staff was not available to round with V14 so those weeks the rounds were not completed. V14 stated the residents were not seen until the following week due to V14 going to other facilities. V14 reported having no staff to round with to V2. V14 stated per the wound company's regulations V14 has to have a staff member round with V14. V14 reported V14 assesses the wounds weekly because it is part of the residents wound care plan. V14 denied being made aware by staff that R6's wound treatments were not being completed as ordered. V14 stated that unless clinically contradicted then the wound treatments should be completed as ordered. V14 did not recall R6 refusing any wound treatments. V14 reported wounds can possibly get worse if the dressing changes aren't done. V14 defined getting worse as increasing in size or developing an infection/more necrosis. On 3/7/24 at 4:12PM, V16 (Nurse) stated if a resident refuses a wound treatment then it is documented on the TAR as refused. V16 reported if the TAR is empty a nurse could have forgotten to chart the treatment was completed, but stated if it is not charted then there is no way to prove the treatment was completed. V16 reported R6 did report to V16 that nurses were not doing the wound treatment but V16 did not follow up with R6's statement by notifying V2 or V14. V16 stated if the wound treatments are not completed then the wound can get worse by getting bigger or becoming infected. The Treatment Administration Record (TAR) dated 01/2024 has orders for a treatment to the sacrum, right hip, and right ischium that are ordered to be completed every day shift. R6 missed a total of six treatments for each wound from 01/19/24 through 1/31/24. The TAR dated 02/2024 has an order for a treatment to the sacrum, right hip, and right ischium that are ordered to be completed every dayshift. R6 missed a total of one treatment for each of these wounds on 2/9/24. There is no documentation that R6 refused wound care treatments on any of the days the treatments were not completed. The Wound Physician note dated 1/9/24 documents R6 has a stage four sacrum measures 3.3 cm 3.5 cm x 1 cm. The stage 4 wound to the right ischium that measure 6 cm x 6 cm x 1.5 cm. The stage four to the right hip measures 5.5 cm x 6 cm x 1.5 cm. The Wound Physician note dated 1/16/23 documents the stage four to the sacrum measures 3.1 cm 3.2 cm x 1 cm. Wound is documented as improved as evidence by decreased service area. The stage four wound to the right ischium measures 6.4 cm x 7.5 cm x 1.5 cm. This wound is documented as not at goal. The stage four to the right hip measures 5 cm x 5.5 cm x 1 cm and is documented as improved as evidence by decreased surface area. The Physician Wound note dated 1/23/24 documents R6's visit has been rescheduled due to facility staffing for rounds. There is no documentation of any assessments of the wounds for this day. The Wound Physician note dated 1/30/24 documents the stage four wound to the sacrum measures 3.1 cm x 3.3 cm x 1 cm. The wound is documented as not goal. The stage four to the right ischium measures 6.5 cm x 6.5 cm x 1.5 cm. This is documented as improved as evidenced by decreased surface area. The stage four to the right hip measures 6 cm x 5.7 cm x 1 cm. This wound is documented as not at goal. This wound increased in size from 1/16/24 to 1/30/24. Weekly wound evaluations are completed in 01/2024 on 1/09/24, 1/16/24, and 1/30/24 (the measurements of the wounds and other documentation coincide with the wound physician notes). There is no weekly wound evaluation for the week of 1/21/24 through 1/27/24. R6 left the faciity on 1/31/24 and returned from the hospital on 2/8/24. The physician did not see R6 on the day R6 was readmitted , but a weekly wound evaluation completed for R6. The Weekly Wound Evaluation dated 2/8/24 documents R6 has a right hip wound that is a stage four that measures 5 cm x 5 cm x 0.5 cm. The right ischium stage four measure 5.8 cm x 6.8 cm x 1.5 cm. The stage four to the sacrum measures 3.2 cm 3.2 cm 1.0 cm. No weekly wound evaluation was completed the week of 2/11/24 through 2/17/24. The next weekly wound evaluation was completed on 2/20/24 when the wound physician rounded at the facility. There are no wound physician notes in 02/2024 until 2/20/24. The following measurements are for 2/20/24. The stage four to the sacrum measures 3 cm x 3.5 cm x 1 cm and is documented not at goal. The stage four to the right ischium measures 6.9 cm x 7.3 cm x 1 cm and is documented as not at goal. The stage four to the right hip measures 6 cm x 6.2 cm x 1.3 cm and is documented not at goal. All three of these wounds suffered a decline by increasing in size from the last time they were measured and assessed on 2/8/24. There are no documented measurements of the wounds from 2/8/24 through 2/20/24. The Care Plan dated 8/19/22 documents R6 has an alteration and skin integrity and is it risk for additional and/or worsening of skin integrity issues related to comorbidities. Interventions include: Administer wound care treatments per physician orders. See the TAR for current orders. The Braden Scale for Predicting Pressure Sores dated 3/1/24 documents score of 12 indicating R6 is a high risk for developing pressure ulcers. The policy titled, Skin Integrity - Care and Prevention Policy, dated 8/27/18 documents, Purpose: To ensure that based on the comprehensive assessment of a resident, a resident that enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary services to promote healing, prevent infection, and prevent new sores from developing. Procedure: .Monitor and evaluate the impact of the interventions and revise as appropriate .c. Wound care nurses will assess and measure wounds weekly and document. d. Wound care nurses will track pressure ulcer/wound progression on weekly wound log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow their practice to confirm and follow physician orders to monitor blood glucose and administer insulin per sliding scale as prescribed for a resident diagnosed with type 2 diabetes with hyperglycemia. This affected one of three (R8) residents reviewed for physician orders. This failure resulted in 13 missed opportunities for blood sugar checks and 13 opportunities for insulin administration, R8 was sent to hospital, evaluated and treated for diabetic ketoacidosis, R8's blood glucose 658mg/dl. Findings include: R8's face sheet shows diagnosis of type 2 diabetes mellitus with hyperglycemia. On 12/8/23 at 10:23 pm, V19 (R8 family) said when she visited R8 on 11/16/23 around 11:30am-11:45am, R8 was observed in the dining room slumped over in his wheelchair, V19 said she called out to R8 and R8 replied help me V19 said she informed the nurse of R8's condition. V19 said the Nurse checked R8's blood sugar and she informed her that it was reading high. V19 said the facility gave R8, 8 units of insulin a couple of times but the reading remained high. V19 said while in the hospital R8's blood sugar was over 600 mg/dl. V19 said when R8 recovered days later R8 told her he was not getting his insulin like he should have been. On 12/8/23 at 12:20 pm V20 (LPN) said she was informed that R8 was in the dining room and R8 was experiencing a change in condition. V20 said she checked R8's blood glucose at that time and it was reading high. V20 said she had not check R8's blood sugar prior to the change in condition, she did not administrator insulin prior to the change in condition. V20 said she did not check R8's blood sugar that morning before breakfast, she did not administrator insulin to R8 before breakfast. V20 said she does not know if R8 is a type 2 diabetic or type 1 diabetic. V20 said she just follows the orders on the M.A.R- (medication administration record). V20 said if there was not an order for blood glucose monitoring then she did not check R8's blood sugar. Follow up interview with V20, V20 said she administered R8 insulin on 11/16/23 from an insulin pen that R8 had from a previous insulin order. On 12/8/23 at 11:27 am, V9 (Director of Nursing) said R8's Humalog insulin had not arrived at the facility by 11/16/23. V9 said the order was pending in the electronic system. V9 explained that the pharmacy has authority to change a medication as appropriate, V9 said that's a therapeutic interchange. V9 said the original medication will be discontinued and the new medication would be started, pharmacy will enter the order. V9 said the nurses are supposed to check for pending orders and confirm orders so that the pharmacy can send the medication. V9 said she was made aware on 11/16/23 that R8 was having a change in condition and so she checked R8's orders. V9 said she noticed that R8 had a pending order for Humalog insulin. V9 said she confirmed the order on 11/16/23 as R8 was being transferred to the hospital for the change in condition. V9 said R8's Humalog had not arrived before he was sent to the hospital. V9 said she checked the electronic records and there are no blood glucose results for R8 outside of 11/10/23 date. V9 said the nurse should check the blood glucose level before administering insulin. V9 said the blood glucose results are attached to the insulin orders. V9 said the nurse should follow the physician orders for monitoring the blood glucose levels. V9 was asked how the facility ensures that the resident with diabetes mellitus continue to receive blood glucose monitoring when the insulin order is in a pending status. V9 said the policy for blood glucose must be reviewed, V9 said she can't answer that. V9 said assessing the blood glucose is basic nursing practice, the nurse should know to check the blood glucose before administering insulin. V9 was asked if R8 received blood glucose monitoring before being given insulin at nighttime. V9 restated that she cannot find any blood glucose results outside of the 11/10/23 date. V9 presents glucometer used by facility, V9 said the glucometers will give blood glucose up to 600 mg/dl (milligrams/decaliters). V9 said any blood glucose results after 600mg/dl will read hi on the glucometer. V9 said the nurses have been in-serviced on checking the electronic records for pending orders. V9 omitted if staff was in-serviced /trained on monitoring the blood glucose for diabetic residents when the blood glucose order are in pending status with the insulin orders. V9 continued to say assessing blood glucose is basic nursing practice. V9 explained that the letters BS noted on the MAR refers to blood glucose results, V9 said to administer insulin sliding scale the nurse must check the blood glucose. V9 explained that the blood glucose results should be documented to the MAR and signed off by the nurse that checked the blood glucose and administered the insulin. V9 said the pending order is an active order. On 12/12/23 at 2:12 pm, V22 (Medical Doctor) said he was not aware that R8 missed 13 opportunities for accu-checks and 13 opportunities for insulin administration. V22 said he was not aware that R8's blood glucose was reading was over 600mg/dl. V22 said the facility informed him today (12/12/23) of the situation. V22 said he does have a Nurse Practitioner that sees his residents and that the NP sent R8 out to hospital on [DATE], but she should have informed him. V22 said R8 is diabetic and should have his blood glucose monitored before meals, and R8 should be administered insulin per sliding scale. V22 said the blood glucose monitoring order and insulin order should not be attached together, V22 said there should be 2 orders. V22 said there should be 2 orders to ensure that the blood glucose is continued to be monitored. V22 said the facility needs to correct this. V22 said R8 did not need blood glucose monitoring for the 9:00 pm insulin but R8 did need to have his blood sugar monitored before meals. V22 said the nurse should have notice that R8 was not receiving accu-checks before 11/11/23- 11/16/23. On 12/12/23 at 2:46 PM, V24 (Pharmacy Rep) said R8's insulin was delivered to the facility on [DATE] at 12:30 according to his report. On 12/12/23 at 3:04 PM during observation tour of medication room on second floor with V23 (LPN), there was 2 insulin pens to be returned to pharmacy labeled with R8's name, dated 11/10/23, one pen was labeled Humalog, and the other pen was labeled Novolin. V23 said those medications were removed from the medication cart and will be returned to pharmacy. V9 (DON- Director of Nursing) arrived at the unit to observe insulin pens for R8 that remained in facility on 12/12/23. V9 said she can see that R8 has insulin pens, and they are to be returned to pharmacy. V9 reviewed the label on the pens and verified date of 11/10/23, V9 verified there was medication inside both insulin pens, V9 said she does not know how much medication is inside the Humalog insulin pen. V9 said the Novolin insulin pen had 250 units of insulin inside. R8's progress notes dated 11-16-23 completed by nurse practitioner, denotes lethargic, change in mental status, HPI: R8 is a [AGE] year-old male seen today at the request of nursing due to change in condition, including lethargy, hyperglycemia. Resident seen lying in bed. Nursing reports that he slumped over in the dining room. He was found to have blood glucose reporting high on the glucometer and taken to his room. His wife had come to have lunch with him and was at his bedside. Nurse had administered 8 units of lispro before lunch. Resident did not eat lunch, ordered 8 more units of lispro. BP 99/59, HR 56, T 96.6F, SpO2 95% RA. BGM (blood glucose monitoring) 15 minutes later was still high on glucometer. Ordered administration of an additional 8 units lispro. Resident was alert and oriented x2. Reporting abdominal pain, discomfort, asking for help, stating his sugar was high. Resident not answering questions, anxious facial expression. Resident had facial symmetry, however, left side flaccid. About 10 minutes, resident raised hand to his wife, previous flaccidity may have been attributed to not following instructions, still ambulance was made aware of possible stroke alert. Per wife, resident had a TIA during his last episode of severe hyperglycemia. Writer and nursing management with resident until EMTs arrived. Resident was transported to the ED. R8's physician order sheet dated 11/11/23 denotes orders for Humalog Kwik pen 100 units/ML (milliliters) solution pen injector, inject as per sliding scale: if 120-150=3 units, 151-200=6 units, 201-250= 9 units, 251-350=12units, subcutaneously before meals related to type 2 diabetes mellitus with hyperglycemia. Novolin N subcutaneous suspension 100 unit/ ML (insulin NPH (human) (isopheal) inject 12 units subcutaneously at bedtime for diabetes. Review of R8's (MAR- medication administration record) dated 11/11/23 at 4:00 pm, there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/12/23 at 7:30am, 11:00am, and 4:00pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/13/23 at 7:30am, 11:00am, and 4:00pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/14/23 at 730am, 11:00am, and 400pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/15/23 at 7:30am, 11:00am, and 4:00pm there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. 11/16/23 at 7:30am, and 11:00am there is no blood sugar results or initials by staff denoting blood glucose was completed or insulin was administrated. The facility missed 13 opportunities out of 13 opportunities to monitor R8 blood sugar and administrator insulin as prescribed between the dates 11/11/23 through 11/16/23. R8's emergency room records dated 11/16/23 denotes in-part R8, [AGE] year-old male past medical history on dialysis, CVA, DM, L tibia fracture, presents to ED via EMS from nursing home for altered mental status. Wife found patient at noon with altered mental status, ambulance was not called by, and mark for over an hour, reason unknown. Per EMS he was very hyperglycemic with readings high s/p (status post) 10 units prior to arrival and remains hypotensive s/p 500 bolus in transit. He was not given insulin today prior to incident. Comprehensive metabolic panel denotes in-part glucose results 658mg/dl, reference range is 70-99 mg/dl. Active problem list denotes in-part diabetic ketoacidosis. Facility physician order policy, no date noted denotes in-part it is the policy of the facility to follow orders of the physician. At the time of admission, the facility must have physician orders for the resident's immediate care. The facility will have orders to provide essential care to the resident, consistent with the residents mental and physical admission. Facility policy titled Blood Glucose Monitoring no dated noted, denotes in part it is the facility policy to ensure that residents who require blood sugar monitoring due to hyperglycemia or hypoglycemia secondary to diabetes or for any reason deemed necessary by the physician receives this monitoring. All glucose monitoring will be ordered at the direction of the resident's physician except in emergency situations. High and low parameters will be determined by the physician to maintain residents blood sugar within normal limits. Blood sugar found to be below 70 or above 400 will be reported immediately to the physician and the resident's representative. Any orders received from the physician will be implemented. Explain procedures to resident, clean finger, perform finger stick, place blood on accu-check strip and obtain a reading, record accu-check reading on the facility blood glucose monitoring tool, administer insulin to include sliding scale insulin per physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have an effective policy for contraband material to ensure that contraband is not brought into the facility. This affected two of two residents (R5 and R15), this failure resulted in R5 found unresponsive sent to hospital, tested positive for opioids on 9/6/23 and 10/31/23, R15 sent to hospital for chest pain and diagnosis with marijuana use. Findings include: 1. On 12/6/23 at 11:35 am, R5 observed alert to person, place, time and situation. R5 said on 9/6/23 he got heroin from someone in the facility, then R5 said he received heroin from someone that delivered the drugs to him. R5 said he was outside the front of the facility and someone in a car pulled up and dropped it off to him. R5 said he took too much heroin that day he overdosed. R5 would not say if he received deliveries of street drugs on any other day. V9 (Administrator) made aware of R5 alleged he got heroin from someone in the facility, then stating he got heroin from someone outside the facility. On 12/14/23 at 12:12 pm, V25 (Assistant Director of Nursing) said on 9/6/23 R5 was found on the first floor unresponsive, R5 was given Narcan and responded to the Narcan, 911 was called, escorted R5 to hospital and R5 returned with diagnosis of drug overdose. V25 said she does not know where R5 retrieved the drugs from. V25 said R5 was readmitted back to the facility the same night. On 12/14/23 at 12:19 pm, V11 (social services) said on 9/6/23 he saw R5 prior to R5 being found unresponsive outside visiting with someone in a black vehicle. V11 said about an hour later there was a code blue announcement for R5. V11 said he did not see anything in R5 hand when R5 return to the facility. V11 omitted to searching R5 upon return to the facility. V11 said R5 will not tell him or staff in the facility where he retrieved the drugs from. V11 said the resident's food and packages are opened in front of the staff. R5's hospital records dated 9/6/23 denotes in-part R5 is a [AGE] year-old male who presents today for concerns for a drug overdose. Urine drug screen positive for amphetamine, and opiates. R5 progress notes dated 10/31/23 denotes in-part contacted hospital to inquire on residents' status, resident admitted to room xx with opioid overdose accidental or intentional. 2. On 12/13/23 at 11:58 am, R15 observed alert to person, place, time and situation. R15 said he had a seizure on 10/18/23, he doesn't know about using marijuana. R15's progress notes dated 10/18/23 denotes resident went out via ambulance x4 assist to hospital. Resident stable and alert. Resident complains of chest pain and n/v (nausea/ vomiting). Vitals b/p=110/76 O2=98 pulse=69 temp=98.1. Resident reports pain level of 4. Writer spoke with MD (medical doctor). MD ordered to send resident out to hospital. Orders carried out. Writer spoke with sister. Sister satisfied transfer. DON (director of nursing) made aware. ADON (Assistant Director of nursing) made aware. No s/s of distress noted. Bed hold policy in place. Resident returned from hospital via stretcher per ambulance service. Accompanied x 2 attendants. Alert and oriented x 2-3. DX (diagnosis) marijuana use, Vomiting. No C/O chest pain. T 98.6 p76 R 18 b/p 130/78 pulse ox 98% to room air. Family made aware DON (Director of Nursing) made aware. On 12/13/23 at 11:07am V9 (Director of Nursing) said R15 did not have an independent pass privilege on 10/18/23, V9 said she does not know where R15 retrieved the marijuana from. On 12/14/23 at 12:19 pm, V11 (social services) said he does not know where R15 retrieved marijuana from, V11 said R15 won't tell him when asked. Review of R15 physician order sheet, there is no orders noted for use of marijuana. Facility policy titled contraband material, no date noted, denotes the facility reserves the right to check individuals and conduct room inspections if there is reason to believe resident or visitors are harboring contraband materials. Contraband material includes, but not limited to alcohol, illicit or street drugs, weapons including any sharp objects, smoking material (if a resident is a safety risk). Rooms may also be searched for lost or stolen property. These processes will only occur when the administrator, director of nursing or mental health practitioner suspects a resident or residents are harboring contraband materials. The search of an individual or rooms will be conducted with privacy and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R74 is a [AGE] year-old male who is a long-term resident of the facility, with past medical history including, but not limited to schizophrenia, bipolar disorder, cognitive communication deficit, hyperlipidemia, major depressive disorder, weakness, etc. 03/14/23 9:15AM, observed wound care for resident with V3 (wound care nurse) and noted a large area of excoriation at the resident's sacrum with a big hole in the middle packed with dressing that is saturated and brownish in color. Per wound care doctor, area is measuring 3.4 x 3.8 x 0.9, and still a stage 4. Per V3, (wound care nurse) resident was admitted with no skin issues, not sure if he was on air loss mattress, resident usually do not get an air loss mattress unless they have stage 3 or 4. Per record review, admission assessment dated [DATE] documented no skin abnormalities under skin and foot observation. Braden score assessment dated [DATE] coded resident with a score of 9, placing him at a high risk for skin alteration. A focused wound exam dated 6/14/2022 documented a stage 3 pressure wound to the sacrum measuring 3.0 x 9.0 x 0.1cm, duration >than 1 day. Weekly wound evaluation dated 6/28/2022 documented a stage 4 pressure ulcer, in house acquired, to the sacrum measuring 3.0 x 3.3 x 0.2 identified on 6/14/2022 with moderate serous exudate described as thin watery. Wound evaluation dated 3/14/2023 documented a stage 4 pressure ulcer to the sacrum measuring 3.4 x 3.9 x 0.9 cm with moderate serous exudate. No previous skin assessments provided to confirm that resident skin was being monitored to prevent skin breakdown prior to new wound being identified. Care plan initiated 3/24/2021 stated that resident has a self-care deficit and requires assistance with ADLs to maintain the highest possible level of functioning, resident is total dependence x2 person assist for toileting, total assist x1 for eating, total assist x2 person for bed mobility, total assist x1 staff for locomotion on and off unit, total assist x 2 with mechanical lift for transfers. Incontinent care plan initiated 1/31/2022 stated that resident is incontinent of bowel and bladder due to diagnosis of hemiplegia and hemiparesis. Interventions include to toilet resident at regular intervals throughout the day, check and change at minimum of every 2-3 hours. Report any new skin integrity issue to nursing. Facility Minimum Data Set (MDS) assessment dated [DATE] coded resident in section H (Bowel and Bladder) as always incontinent. Review of physician order summary showed an order for air loss mattress dated 10/18/2022. On 3/15/2023 at 11:37AM, V6 (wound care nurse) said that resident's pressure ulcer was first identified as a stage 3 and then it progressed to a stage 4, the wound deteriorated at one point but is improving now, resident is incontinent of bladder and bowel and is dependent on staff for all ADL care. V6 added that the certified nurse assistants (CNAs) are trained to report any skin alterations or discoloration to the nurse, who in turn will notify the doctor to get an order and notify the family. Residents that are at risk for alteration in skin integrity are supposed to be turned and repositioned frequently, other risks for pressure ulcer development will include proper nutrition and making sure resident are not sitting on soiled incontinent briefs for a long time. Based on observation, interview and record review, the facility failed to conduct daily skin assessment, follow physician's treatment orders and implement interventions in preventing the development and reopening of a pressure ulcer for two (R14 and R74) of four residents reviewed for pressure ulcers. This failure resulted in R14's healed pressure ulcer on the sacral area reopening and being classified as a facility acquired unstageable deep tissue injury and R74's intact skin developed a facility acquired Stage 3 pressure ulcer on the sacrum. Findings include: 1. R14 is an 89-year- old, female, originally admitted in the facility on 06/24/22 with diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. According to Wound Evaluation and Management Summary dated 03/14/23, R14 has a Stage 4 pressure ulcer on the sacrum. R14's current POS (Physician Order Sheet) dated 03/07/23 documented: Calcium Alginate - Apply to sacrum topically as needed for soiled dressing change. Cleanse wound with saline solution, apply calcium alginate and cover with gauze island dressing. And apply to sacrum topically everyday shift for wound care. On 03/14/23 10:09 AM, wound care was observed on R14. It was observed that there was no covered dressing noted on her sacral area. V6 (Wound Care Director) was asked regarding R14's wound dressing. V6 stated, During incontinence care, if the wound dressing is soiled, the nurse has to replace it with a new dressing if wound care team is not here. Never leave the wound uncovered. V6 was also asked regarding her (R14) sacral pressure ulcer. V6 verbalized, When she came here she had a healed open area on the sacrum, then it reopened and healed, then it opened again. R14's Wound Evaluation and Management Summary documented the following: 07/26/22: Stage 3 pressure ulcer, sacrum - resolved 12/20/22: Unstageable DTI (deep tissue injury) sacrum, measurement: 3.0 cm (centimeters) x 2.0 cm x not measurable cm 12/27/22: Stage 3 pressure ulcer sacrum R14's progress notes recorded the following: 12/06/22 - R14 was admitted in the hospital due to COVID (Coronavirus Disease) positive. 12/16/22 - received resident (R14) via stretcher via ambulance, accompanied by two attendants. Resident (R14) is alert and verbally responsive. Resident (R14) requires assistance with all ADLs (activities of daily living), old scars that are heal from previous wound on buttocks, also noted old scar of left eyebrow. 12/20/22 - Skin/Wound note: sacral wound noted to have re-open during regular routine rounds with the wound doctor. This site was noted healed in the recent time; resident has history of wound on same site as observed during the assessment at the time of original admission to the facility. It was recorded as closed scar upon admission, now re-opened. On 03/15/23 at 11:24 AM, V6 was interviewed regarding R14's sacral pressure ulcer. V6 stated, Prior to 12/20/22, I don't see any documentation pertaining to any skin alterations. On 12/20/22, it was seen as Unstageable DTI sacrum. Basically, the site was still fragile, so there is a possibility that it may open up again. It had become a facility acquired pressure ulcer. The only reason for reopening was the site was still fragile. Immobility, poor nutrition and incontinence could also be some of the predisposing factors. We maintain the use of low air loss mattress, foam pad on the sacrum, staff does the weekly skin checks and should report it to me if there is a skin issue. According to R14's Bath and Skin Report from November to December 2022, there were no skin concerns documented. On 12/18/22 report, there was a check mark indicating normal/redness but no wound assessment was completed. There was also no documentation that nurse or wound care team was notified of any skin concerns even prior to 12/20/22 when the sacral wound reopened. V13 (Wound Doctor) was asked during wound care regarding R14. V13 replied, Any pressure ulcer resolved makes it risky for resident to have pressure ulcers again. She (R14) has Dementia, has chronic disease, likely bowel and bladder incontinent, immobility. In preventing the occurrence of pressure ulcers, interventions should be implemented based on the facility's policy and regulations. On 03/15/23 at 1:21 PM, V2 (Director of Nursing) was asked regarding pressure ulcer management and prevention. V2 stated, Repositioning every two hours, use of low air loss mattress; notifying the doctor for any skin changes; making sure residents are provided with meals; document any change in condition; staff needs to do skin checks during shower days and notify doctor and wound care team for any skin changes and document. R14's Care plan dated 07/05/2022 regarding Alteration in skin integrity and is at risk for additional and/or worsening of skin issues documented: Interventions: Skin will be checked during routine care on a daily basis and during the weekly/biweekly bath or shower schedule Precautions for prevention of pressure ulcers will be completed: Good pericare and drying of the skin, Apply protective barrier cream, Reposition resident (R14) frequently when in bed/chair/reclining chair and/or wheelchair, offload heels PRN (when needed), CNA (Certified Nurse Assistant) showers/skin observations to be reported to nurse for any unusual findings/changes in residents skin integrity Administer Wound Care (Treatments) per MD (medical doctor) orders. Facility's policy titled Wound Management Program dated 05-19-17 stated in part but not limited to the following: Risk and Skin Assessment Policy: Intact skin is the body's first line of defense. It is the policy of this facility to assess all residents for factors that place them at risk for developing pressure injuries. It is also the policy of this facility to monitor the skin integrity of our residents for the development of wounds or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in our facility. Procedure II. All residents will have a visual inspection of their skin B. Skin checks are completed weekly by the nurse. C. Skin check is completed on each shower day by nursing assistant staff 1. Shower sheet may be used to document the skin check. 2. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. 3. Appropriate measures will be instituted. D. The nursing assistant visually inspects the skin daily and with care. 1. If an area is identified, the nurse is notified and the Stop and Watch tool may be used to communicate this information. 2. Appropriate measures will be instituted. Pressure Injury Prevention Skin Care and Early Treatment Skin Assessment Complete Skin Assessment - The complete skin assessment is an integral part of the Pressure Injury Prevention Program. It is through these inspections that early skin problems can be identified and interventions implemented. Observations should continue daily for residents at risk for skin breakdown. Monitor skin condition for color, moisture, temperature, integrity, and turgor with close attention to the bony prominences. Also observe skin areas around medical devices such as oxygen cannulas, catheters, collars and braces. A weekly assessment should be completed on all residents. This can be completed by the nurse or the nursing assistant and should be documented in the medical record. Special attention should be given to bony prominences and skin folds. Wound Cleansing and Dressings Policy: It is the policy of this facility to perform wound dressing changes as ordered by the physician using clean technique on all chronic or contaminated wounds. A moist wound environment is most favorable for optimal wound healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to adequately assess residents for a fall risk, failed to have appropriate fall interventions in place, failed to ensure that staff are familiar with residents fall risk status and fall interventions and failed to provide appropriate and sufficient supervision for residents assessed as requiring staff assistance and supervision for Activities of Daily Living (ADLs). This failure affected two ( R15 and R62) of 14 residents reviewed for falls. This failure resulted in R62 falling in her room, being sent to the hospital where she was found to have a left hip fracture and required a surgical procedure; this failure also resulted in R15 falling, while walking outside, in the facility's smoking patio, without the use of assistive device, which resulted in a left foot fracture. Findings include: 1. R62 is a [AGE] year-old female who is a longtime resident with past medical history including, but not limited to acute respiratory failure with hypoxia, weakness, peripheral vascular disease, generalized muscle weakness, unspecified dementia unspecified severity without behavioral disturbance, essential primary hypertensin, etc. On 03/13/23 11:47 AM, during observation on the second floor, R62 was observed in her room, awake and alert with some confusion, resident was sitting in a wheelchair, no floor mats noted in the room. 03/15/23 10:30 AM, R62 was observed again in her room sleeping, bed not very low, no floor mats were noted on either side of the bed. Review of resident's progress note dated 1/24/23 showed the following: Around 2120 resident observed on floor in Lt side lying position near foot of bed. Resident stated, I was trying to go to the bathroom and my legs went down. Resident complained of pain 5/10 to LLE. LLE immobilized and immediately assessed head to toe for injury, then assisted back to bed for further assessment. No bruising or swelling noted. Neuro checks initiated, LOC within baseline limitations. Orders given for PRN pain medication. Medication tolerated well. Voicemail left for POA to call facility. DON, and MD notified of incident. Orders given to send resident hospital for further evaluation. Resident departed facility via 911 with RPFD with 2 attendees in route to hospital. On 1/25/2023, a nurse documented, Resident admitted at Hospital with dx- hip fracture. Nursing care plan dated 1/31/2023 stated that 27 staples to the left hip removed per PCP order. Site noted closed, no drainage or sign of dehiscence observed. Resident in stable condition, remains alert and oriented x3. Doctor's progress note dated 2/13/2023 documented the following: HISTORY OF PRESENT ILLNESS: Patient is a [AGE] year-old female, long-term resident of the facility, who was sent to the hospital because of fall when she fell to her left side sustained left hip pain. The patient was evaluated in the ER. She was found to have left hip fracture. She was evaluated by ortho service. She was found to have displaced intertrochanteric fracture of the left hip. The patient was evaluated by cardiology service, and she was cleared for surgery. She was taken to the OR and underwent open reduction internal fixation. Postoperatively, the patient was admitted to the ortho floor. She was started on physical therapy and occupational therapy and transferred back to the facility. She is currently in rehabilitation. Hospital record dated 1/28/2023 stated in part, Resident is a [AGE] year-old female with past medical history .transferred from an outside hospital for surgical management of a left sided intertrochanter femur fracture after a mechanical fall. Patient had a left sided head trauma as well and lost consciousness for an undetermined amount of time. Fall risk assessment dated [DATE] scored resident as 14, indicating a high risk for falls, another fall risk assessment dated [DATE] was incomplete and documented as to be determined, resident did not have any other fall assessment from 1/1/2022 till the fall on 1/24/2023. ADL care plan initiated 2/11/2018 stated in part that resident has an ADL self-care deficit, requires assistance with ADLs to maintain .following limitations and potential contributing diagnosis of respiratory failure, CHF, muscle weakness and lack of coordination, bed mobility - extensive x1, toileting extensive x1, transferring extensive x1, dressing and personal hygiene extensive x1. Fall risk care plan initiated 3/15/2021stated that resident is at risk for falls characterized by history of falls/injury, multiple risk factors due to impaired balance, unstable health condition, unsteady gait, etc. Interventions includes staff to make frequent rounds when resident is in a room alone, assist her up from bed when she is not feeling tired and keep her in common areas in easy view of staff when up. Minimum data set assessment (MDS) section G coded a resident as requiring extensive assistance with one-person physical assist for all ADL care, section H (bowel and bladder) coded resident as frequently incontinent. 3/14/2023 at 4:10 PM, V2 (DON) said that she completed resident's fall incident, resident self-propels, needs assistance with transfer, is considered a fall risk but she is not sure of any interventions at the top of her head. V2 added that fall assessment is done on residents upon admission and quarterly and when there is any incident. 3/15/2023 at 3:03 PM, V20 (C.N.A) said that she works on the second floor and is familiar with resident, prior to the fall, resident is independent, uses wheelchair, goes to the bathroom by herself but sometimes require staff assistance. V20 said that she is not sure if resident is a fall risk, she does not have any fall interventions that she can recall, she is not sure of the exact time of the fall, she was covering for the assigned C.N.A who was on break. V20 said that she saw resident on the floor, she went and got the nurse, she was not sure how long resident was on the floor, she continued with her assignment after she notified the nurse. 3/16/2023 at 11:52 AM, V37 (MDS) said that fall risk assessment is done upon admission, change in condition, quarterly and after a fall. V37 added that she did not find any fall risk assessment for resident from 1/1/2022 until the fall on 1/24/2023. At 1:05 PM, V38 (LPN) said that she is familiar with the resident and was assigned to her the day she had a fall. The C.N.A found resident on the floor around 9PM on her left side on her buttocks. Resident stated that she was trying to go to the bathroom, resident was assessed, she was complained of pain to her left leg, neuro check was initiated, doctor was called, and order received to sent resident to the hospital for further evaluation. V38 said that prior to the fall resident mostly required supervision and requires limited assistance with ADLs, resident goes in and out, is not a fall risk and V38 said that she does not recall if resident had any fall interventions. She added that residents who are fall risk sometimes have sign on the door and they are also listed on the fall binder located at the nursing station. The fall binder contains the fall interventions for those residents, she does not recall R62 being on that binder or having any listed fall interventions. CT lower extremity w/o contrast stated that there is a nondisplaced fracture extending obliquely from the greater trochanter superiorly the medial of the base femoral neck/intertrochanteric region no lytic or destructive lesion. Facility falls prevention policy undated presented by V2 (DON), stated that the facility is committed to safety and maximizing each resident's physical, mental, and psychosocial well-being. The document further states in part that the purpose of the fall prevention and management program is to provide residents with an interdisciplinary approach to assess risks for falls, provide appropriate interventions, etc. 2. R15 is a [AGE] year old male with a diagnoses history including Stroke, Partial Paralysis, Unspecified Convulsions, Lack of Coordination, Generalized Muscle Weakness, Unspecified Abnormalities of Gait and Mobility effective 2/13/2015, Epilepsy effective 4/7/2015, Foot Drop Left Foot effective 8/1/2018, Other Abnormalities of Gait and Mobility effective 9/21/2018, Weakness effective 12/20/2020 who was admitted to the facility 02/13/2015. The facility's Fall log from 10/01/22 - 03/13/23 documents R15 had falls on 11/30/22, 12/18/22, 12/28/22, Per the facility's Matrix Reviewed 03/13/23 R15 had a fall with a major injury. On 03/14/23 at 11:46 AM Observed R15's with a brace on his left lower leg. R15 stated he fractured his foot during his most recent fall at the facility. R15 stated he fell outside during smoke break while walking to the garbage can to dispose of his cigarette butt. R15's Incident report dated 11/30/22 documents prior to the incident he was returning from smoking. Staff was called to the room per staff, and he was noted on his back. Resident was assisted to feet by three staff. Resident stated he was returning from smoking and was going to sit on his bed and missed the bed because it was dark in his room. R15's Incident report dated 12/18/22 documents prior to the incident R15 was outside smoking. Staff informed the writer that R15 fell outside. R15 stated he was coming back from smoking and tripped over a bottle cap. R15's Incident report dated 12/28/22 documents writer was notified by staff that R15 was observed losing his balance and falling to ground while outside on patio during smoke break. Residents stated that he lost his balance and fell. Final Incident Investigation Report dated 01/03/2023 documents on 12/28/22 R15 was observed with a sudden loss of balance where staff attempted to intervene and was unable to reach him which resulted in him falling to the ground on his buttocks. R15 stated he was walking back to return from smoking when he lost his balance and fell to the ground. R15 is non-compliant with the use of his cane. It was determined that he was ambulated at a faster pace than usual when he lost his balance suddenly and fell to the ground. R15 complained of mild pain to left ankle. X-ray revealed closed fracture of left ankle. 03/14/23 04:13 PM V2 (Director of Nursing) stated fall risk assessments are completed on admission, after a fall and quarterly. V2 stated the admitting nurse completes an initial fall risk assessment then restorative completes a follow up assessment. V2 stated R15 is a fall risk. V2 she will have to follow up with information on R15's initial fall risk and any current fall risks. R15's Current Care plan documents he is high risk for falls related to stroke with left side partial paralysis, Seizure diagnoses and a history of falls; non-compliance with use of cane (4/30/20) - [Date Initiated: 01/08/2019, and Created on: 02/26/2015] with interventions including: Physical therapy to screen and treat, Re-educate the importance of utilizing cane while Ambulating, [Date Initiated: 12/19/2022]; was encouraged to use his cane while ambulating.(2/26/19) [Date Initiated: 02/26/2019]; Encourage to comply with using cane. Therapy to screen resident for ambulation and safety. (4/30/2020); Staff to assist with sitting, and cue R15 to sit in high back chair in dining room (2/3/2020); Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes as possible. Educate resident/family/caregivers/interdisciplinary team as to causes. [Date Initiated: 01/08/2019]; Be sure R15's call light is within reach and encourage him to use it for assistance as needed. [Date Initiated: 01/08/2019]. R15's progress note dated 11/9/2022 documents Resident received sitting on side of the bed, alert and oriented to person, place, and situation; Resident is ambulatory, gait is unstable due to left-sided weakness. Resident continues to refuse to use his cane. Continue to educate on the purpose of the cane. Resident continues to refuse. Will continue to monitor. R15's Progress note dated 11/24/2022 documents resident returned back to the facility from family visit, sister called and said resident fell at her house, on his buttock, nursing assessment was performed, denies any pain or discomfort, no apparent injury or bruises noted. R15's Progress note dated 11/30/2022 documents The Change In Condition/s reported on this Evaluation are/were: Falls Nursing observations, evaluation, and recommendations are: Resident had a fall in the room no apparent injuries were noted, and the room was dark. Bedside light was turned on so resident will be able to see in the room; Prior to the incident, the resident was coming back from smoking. Staff was called to the room per staff, and the resident was noted on back. Resident stated he was coming back from smoking he was going to sit on his bed and missed the bed because it was dark in the room. R15's Progress note dated 12/18/2022 documents The Change In Condition/s reported on this Evaluation are/were: Falls Nursing observations, evaluation, and recommendations are: Prior to the incident, the resident was outside smoking. Staff informed the writer that the resident fell outside; Prior to the incident, the resident was outside smoking. Staff informed the writer that the resident fell outside. R15's Progress note dated 12/19/2022 documents well being check. Staff reported that he fell. Writer met with resident to check on his wellbeing. Writer discussed why he doesn't use the cane despite counsel. Resident reported that he doesn't like. Writer encouraged him to use it. R15's Progress note dated 12/28/2022 documents The Change In Condition/s reported on this Evaluation are/were: Falls; While resident was outside on patio during smoke break staff observed resident losing his balance and falling to the ground landing on his buttocks. Staff was unable to catch resident before the fall. Writer and certified nursing assistant assisted resident into wheelchair and resident bought back to unit due to safety reasons via wheelchair. Upon further assessment writer observed minimal swelling to left ankle. Resident complained of pain to area when applying pressure. Resident reminded that he should use his cane while ambulating. Resident is being seen by Physical Therapy. R15's Quarterly Fall risk review dated 7/2/2021 documents a High Risk for Fall score of 10 with risk factors including medications, needing assistance with ambulation, Gait Imbalances including requiring use of assistive device, and status of 3 or more health conditions. No Fall Risk review was located in R15's medical records from 07/02/2021 - 11/30/22. R15's Fall risk review dated 11/30/22 documents a High Risk for Fall score of 10 with risk factors including falls within the last 3 months; medications, and status of 3 or more health conditions; ambulation noted as independent, noted as having normal gait/balance. R15's Fall risk review dated 12/18/22 documents a High Risk for Fall score of 11 with risk factors including falls within the last 3 months; medications, balance problem with standing and walking, and status of 3 or more health conditions; ambulation noted as independent. R15's Fall risk review dated 12/28/22 documents a High Risk for Fall score of 13 with risk factors including falls within the last 3 months; medications, balance problem with standing and walking, and status of 1-2 health conditions; ambulation noted as independent. On 03/15/23 at 01:35 PM V2 (Director of Nursing) stated a fall risk review is completed depending on the reason and circumstances of a fall. V2 stated a fall risk review should have been conducted when his family member reported he had a fall while out of the facility on 11/24/22. V2 stated that incident could have indicated an increase in his fall risk. V2 stated R15 uses a cane that he is not compliant with. V2 stated R15 can walk independently with a cane, but without cane can his balance is not stable when walking. V2 stated the way that the fall risk assessment is completed affects the fall risk score. V2 stated the higher the fall risk score the higher risk for falls. V2 stated if fall risk reviews are not completed accurately it can potentially contribute to their risk of falls. V2 stated she cannot explain why R15's fall risk assessments did not indicate he had more than 3 conditions that contribute to fall risk and why the information regarding his gait and balance did not reflect his gait imbalance. V2 stated a root cause analysis of falls is conducted and interventions are updated based on the interdisciplinary teams findings. V2 stated based on R15's non-compliance with the use of his cane he would benefit from increased monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures for providing dental care for residents by not identifying dental care needs and not ensuring dental services were provided for residents. This failure applies to four (R19, R27, R36, R55) of four residents reviewed for dental care and resulted in (R55) being hospitalized due to a dental infection and facial cellulitis. Findings include: 1. R55 is a [AGE] year old male who originally admitted to the facility on [DATE] and still resides in the facility. R55 has multiple diagnoses including but not limited to the following: COPD, Type II DM, ESRD, moderate protein calorie malnutrition, HTN, anemia, dependence on renal dialysis, aphasia, abnormalities of gait and mobility. Facility progress note dated 3/7/23 states in part but not limited to the following: Upon rounds this morning, observed resident face swollen on both sides. Received orders to send to emergency room. Hospital records dated 3/8/23 state in part but not limited to the following: Patient presented to emergency department from nursing facility secondary to external facial swelling, likely secondary to poor dental hygiene. Patient admits to mouth pain but information limited due to patient's baseline mentation. Multiple significant dental carries with missing maxillary incisors. Multiple periapical lucencies are seen at the maxillary and mandibular teeth. Thrush noted. Preorbital soft tissue edema extending to the nasal bridge. Dental consultation is recommended. Facility progress note date 3/10/23 states in part but not limited to the following: Resident re-admitted to the facility from hospital with facial swelling, tooth pain, and infection. On 3/14/23 at 10:53AM, V14 (Social Service Director) was interviewed regarding the dentist and dental hygienist visits. V14 says the dentist or dental hygienist comes once a month. They rotate their schedule. They provide cleanings, exams, and mouth care. We provide them with a list of residents to see while in the facility. The list includes new admissions and any resident that wants or requests to have dental services at that time. R55 has not been seen by the dentist or dental hygienist since he admitted on [DATE]. This surveyor asked if the CNA's (certified nursing assistants) are required to be providing daily maintenance such as brushing their teeth and identifying any concerns in which V14 said yes. On 3/15/23 at 12:20PM, V2 (Director of Nursing) was interviewed regarding dental services. V2 said all residents should be seen on a monthly basis by the dentist or the dental hygienist and CNA's should be providing residents with daily dental hygiene as needed. On 3/16/23 at 11:10AM, V2 was interviewed again. V2 says it is my expectation that the CNA's assist the residents with dental hygiene and report any concerns to their nurse. The nurses should be assessing the resident's oral hygiene every time they do an assessment. If the nurse's recognize a concern, they should be notifying the doctor. R55's admitting diagnosis was swelling of the face and he came back on an antibiotic due to an infection. Per facility care plan dated 11/3/22 states in part but not limited to the following: Focus: I have a self-care deficit and I require assistance with ADL's to maintain the highest possible level of functioning. Desired Outcome: I will maintain my current level of ADL functioning without significant decline unless the disease process causes unavoidable deterioration. Interventions: Personal hygiene and oral care: I require total assistance and one staff for personal hygiene and oral care. (Total dependent on staff). Physician order sheet shows the following orders: dental consult as needed with order date of 3/11/2023; clindamycin HCl capsule 300 mg- Give 1 capsule by mouth one time a day every Tuesday, Thursday, Saturday for tooth infection until 3/21/2023; Metronidazole tablet 500 mg- Give 1 tablet by mouth three times a day for oral infection until 3/20/2023. It is to be noted that a dental consultation has not been scheduled or conducted at this time. Per facility policy titled Oral Hygiene and Denture Care states in part but not limited to the following: It is the policy of the facility to assist the residents as much as necessary to see that they have good oral hygiene. 2. On 03/14/23 at 1:16 PM, V28 stated she believes R19 may have an infection in his mouth. V28 stated the facility is not providing any oral hygiene for him or and he is taking care of himself and no one at the facility is managing that. V28 stated R19 had a mouth full of rotten teeth since he's been at the facility and now they're gone. On 03/14/23 at 4:31 PM, Observed R19 with no visible teeth in his mouth. R19's Current care plan does not include dental care. R19's Current Physician Orders document an active order effective 12/20/22 for Dental Consult As Needed. 3. On 03/14/23 at 12:26 PM, R27 stated she needs to see a dentist and hasn't seen one in quite a while. R27 stated she believes you have to be put on a list to be seen. R27 stated she forgets after she informs staff she would like to be seen because she doesn't receive any follow up. Observed R27 missing teeth in front of her mouth. R27's Current care plan does not include dental care. 4. On 03/14/23 at 12:07 PM, Observed R36 with crooked teeth, missing teeth, and dark build up on bottom row of teeth. R36 stated he needs dentures. R36 stated it's been a long time since he has seen the dentist. R36's Current care plan does not include dental care. The facility's Dental Reports indicating residents that were seen for dental services from September 2022 - February 2023 does not document that R36 was seen for dental services. The facility's Dental Reports indicating residents that were seen for dental services from September 2022 - February 2023 does not document that R19, R27, or R36 were seen for dental services. On 03/16/23 at 11:00 AM, V2 (Director of Nursing) stated nursing staff would identify the need for dental services and social services would assist with being seen by the dentist. V2 stated the nurse should assess residents for dental service needs each time they see the resident. On 03/16/23 1:05 PM, V37 (MDS/Care Plan/Restorative LPN) stated dietary is responsible for developing dental care plans and did not identify any dental care planning needs for R27 or R36. The facility's Dental Services Policy reviewed 03/16/23 states: It is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services. A licensed nurse will conduct a comprehensive, accurate, standardized assessment of each resident's functional capacity to include dental status. These assessments will be conducted initially upon admission, quarterly, annually and when there is a significant change in the resident's condition that affects the oral cavity. The assessing nurse will ask the resident if they are experiencing any difficulties with chewing. The assessing nurse will physically inspect the resident's mouth (oral cavity) for any abnormalities. The assessing nurse will monitor for: broken or loose fitting full or partial dentures; chipped, cracked, unable to be cleaned, or loose fitting dentures/partial(s); no natural teeth-or only tooth fragments; darkness on a tooth (likely decay) or broken natural teeth.

Based on interview and record review, the facility failed to develop an effective plan that includes supervision, and intervention to reduce or prevent the risk of falling for 1 of 3 residents (R3) reviewed for fall prevention, This failure resulted in R3 having four falls within 8 days which resulted in a Right Acute Subarachnoid Hemorrhage and Right Subdural Hematoma, bruising to the face and a Left Subdural Hematoma. Findings include: R3 had the diagnosis of Hemiplegia and Hemiparesis following Cerebral Infraction affecting the left dominant side, Convulsion, reduce mobility, history of falling, lack of coordination, weakness and Syphilis. Brief interview for mental status dated 12/3/22 documents a score of twelve which indicates moderate impairment. Section G (functional status) documents: R3 needs extensive assistance with one person physical assist with bed mobility, transfers walking in room/corridor, locomotion on/off unit and toilet use. Balance during transitions and walking: R3 was not steady, only able to stabilize with staff assistance (moving from seated to standing position, walking, turning around and surface to surface transfers) Functional limitation in range of motion: R3 had upper/lower extremity impairment on one side. Fall review dated 1/25/23 documents a score of 14 which indicated as a high risk for falls. Care plan initiated 11/5/21 documents: R3 was a risk for fall related to history of falls, left hemiparesis and alcohol abuse. (2/1/23 fall) On 2/15/23 at 1:00pm, R3 was observed not positioned upright in his broader chair. R3's buttock was observed in the middle of the chair seat, slid down from the back of the chair. On 2/15/23 at 1:05pm, R3 who was assessed to be alert and oriented to person, place and time said, my first fall, I stood up to get a snack, I dropped that fell under my bed. I fell when I bent over and hit the right side of my eye brow on the floor. R3 pointed to his right eye brow. I was discharged to the hospital. On 2/15/23 at 1:38pm, V3 (asst. social service director) said, R3 is alert and oriented to person, place and time now. R3 is coming back to himself today. R3 was so confused when R3 was falling. On 2/15/23 at 2:13pm, V7 (restorative nurse/mds) said, R3 was found on the floor in his room in a sitting positon beside his bed. R3 reported trying to get some hot sauce from under the bed. R3 had an opening to the right eye brow. R3 was discharged to the hospital. We provided R3 a Reacher. On 2/16/23 at 12:38pm, V7 said, giving a R3 a Reacher when nothing was found on the floor was not an ineffective intervention. On 2/16/23 at 2:32pm, V9 (CNA) said, I was called in to reposition R3 in the chair. I had to pull R3 up in the chair. Nursing note dated 2/1/2023 documents: 5am-during routine rounding, observed R3 sitting on the floor on his buttocks near his bed. R3 was observed small open area noted to right brow. R3 stated, I was trying to pick my hot sauce from off the floor. R3 had on non-slip sock and lock wheelchair was beside the bed. 911 called. Incident dated 2/1/23 documents: R3 (A0X3) was found on the floor, beside the bed in a seated position with a small open area to the right brow. Predisposing physiological factors- gait imbalance. R3 stated, he was trying to pick up my hot sauce from the floor. There wasn't any food or hot sauce on the floor in R3's room. Upon further assessment wheelchair observed unlocked. Hospital paperwork dated 2/1/23 documents: R3 came in from a fall at the nursing home found to have a right acute subarachnoid hemorrhage and a right subdural hematoma. R3 overestimates/forget limitation. Final reportable dated 2/6/23 documents: R3 was transferred to the hospital, CT scan revealed subarachnoid hemorrhage. R3 stated that he was trying to pick up some hot sauce when he got out of bed without calling for assistance. It was determined that R3 was attempting to ambulate without assistance while bending down. Reacher provided to R3 with teaching on use with a safe and accurate return demonstration. (2/5/23 fall) On 2/15/23 at 1:05pm, R3 said, my second fall was due to me attempting to walk to my dresser to get a snack. On 2/16/23 at 12:43pm, V7 said, education and reminders to lock the wheelchair and sit down slowly are not effective interventions for R3 who was only orientated and alert to self. Nursing note dated 2/5/2023 documents: R3 was in the hallway like 50 feet from writer (V16 nurse). Writer (V16) observed R3 attempting to stand up out of his chair, writer (V16) tried running to catch R3 before fall with no success. R3 chair was unlocked. R3 fell on his buttock. R3 has an unstable gait. On 2/15/23 at 2:13pm - V7 (restorative nurse/mds) said, R3 had a fall on 2/5/23. R3 stood up from his wheel chair, to put his coat that R3 was sitting on, on the back of his wheelchair. When R3 attempted to sit back down, the wheelchair moved. R3 was educated and reminded to lock wheelchair and sit down slowly, physical therapy to evaluate for transfer and gait, to ensure wheelchair is clutter free. On 2/15/23 at 3:30pm, V12 (CNA) said, R3 has two falls on 2/5/23. R3 had a fall before, I started my shift. I was informed by V16 (nurse). Ten minutes into my shift, I heard a boom-flesh/skin hitting the floor. I entered R3's room. R3 keep stating, I have to use the bathroom. R3 had a urinal on the side of R3's wheelchair. R3 was confused. I guess R3 felt the need to stand up to void. I helped R3 to the bathroom. On 2/16/23 at 12:43 pm, V7 said, it is possible to educate a resident (R3) who was only alert to self. R3 was very confused. As team, we should of came up with something else for R3 and needed to review the full picture of R3 to determine interventions. Incident dated 2/5/23 documents: Mental status: R3 was alert to person. Predisposing physiological factor: gait imbalance. Predisposing situation factors: admitted with in the last 72 hours, ambulating without assist and recent room change. (2/6/23 fall) On 2/15/23 at 1:05pm. R3 said, I don't recall this fall. Nursing note dated 2/6/2023 documents: R3 was observed on floor mat near bedside in left side lying position. R3 was unable to give description of what happened. Floor mats in place. All safety precautions in place. Resident to be sent to hospital for CT scan. Incident dated 2/6/23 document: R3 was oriented to person. Injuries observed at the time is the incident: bruise to face. Care plan created on 2/6/23 documents: low bed, medication review, labs, and urinalysis. Hospital paperwork dated 2/6/23 documents: CT scan (2/7/23) documents: Right subdural hematoma has not changed significantly is approximately 8mm thick, mildly enlarged when compared to 2/1/23. Left subdural hematoma is also new since 2/1/23. (2/8/23 fall) On 2/15/23 at 1:05pm. R3 said, I don't recall this fall On 2/15/23 at 2:13pm, V7 (restorative nurse/mds) said, R3 had a fall in the dining room. R3 slid from wheelchair onto his buttock. Care planed intervention for R3 to take a nap after lunch was not an effective intervention. R3 should have cushion, if R3 was in the wheelchair. On 2/15/23 at 3:48pm, V14 (physical therapy) said, R3 was not at baseline, could not sit up or stand. R3 was a high fall risk who could maintain his balance. R3 was not considered for a lap buddy, seat belt or wedge cushion. R3 was given a broad-chair. On 2/16/23 at 1:00pm, V18 (activity aide) said, it was around 4:00pm in dining room. I was the only staff in the dining room. Activities had started at 1:00pm ended at 300pm. R3 was sleeping during the activity time and after the activity. R3 was in bigger chair like a geri-chair. R3 was sitting up in chair. One Resident yelled, he (R3) is moving. R3 was observed half way up out of the chair on the right side. I went to go get R3 but R3 was on the floor. I was about three tables away. R3 had raised his body up over the side and R3 hit the floor. I was collecting items from the residents at the tables prior to R3's fall. V18 said, she yelled for someone. R3 was just looking at me. R3 was alert but did not respond, not at his baseline. R3 unable to say what happened. R3 will sometimes sleep while in the dining room. Usually the fall risk residents need to be monitored in the dining room. When asked how long residents can sleep in the dining room, V18 said, fall risk resident have to be monitored and usually will not go back to the room. Nursing note dated 2/8/2023 documents: At approximately 4:30pm, writer (V17 nurse) was called to the dining room by staff. R3 was observed trying to get up from his chair. Staff attempted to intervene but was unable to catch R3. R3 was observed on the floor on his butt. R3 stated 'I slid from my chair. Incident dated 2/8/23 documents: R3 was oriented to person. Wheelchair bound. Witnessed statement documents: V18 (CNA) said, I was in the dining room during activities, R3 suddenly woke up from his sleep and began trying to get up. I immediately attempted to intervene but was unable to reach R3. R3 fell to the floor. It was determined R3 was observed on the floor lying on left side. R3 was unable to state what happen. Care plan intervention dated 2/8/23 documents: offer R3 to take a nap after lunch. Incident/Accident/Fall policy not dated did not apply.