Every finding on record at Accolade Healthcare of Savoy

Based on interview and record review the facility failed to ensure that a significant change in condition was adequately assessed, evaluated, and reassessed for one (R4) of three residents reviewed for death in the sample list of six.Findings Include:The facility's Acute Condition Changes - Clinical Protocol, revised on 01/26 documents that nurses and physicians must recognize an acute condition change and identify its nature, severity, and cause(s). This policy documents nursing staff shall assess, document/report baseline information, including vital signs, neurological status, current level of pain and recent changes in pain level, level of consciousness, cognitive and emotional status, onset, duration and severity of the change, recent laboratory results, active diagnoses, and current medications. The policy also documents nursing staff, before contacting the physician regarding someone with an acute change in condition, should make pertinent observations and collect appropriate information to report to the Physician. The policy also documents nursing staff shall contact the physician and nurse manager based on the urgency of the situation and required prompt physician response for emergency situations.The hospital after Visit Summary dated [DATE] documents, R4 was admitted to the facility on [DATE] following hospitalization for Acute Kidney Injury. The hospital's Electronic Medical Record documents R4's diagnoses including Acute Kidney Failure, Dependence on Renal Dialysis, Sepsis, Vascular Disorder of the Intestine, Thrombocytopenia, Type 2 Diabetes Mellitus with Hyperglycemia and Ketoacidosis, and Other Significant Medical Conditions.R4's Medication Administration Record dated [DATE] through [DATE] documents R4 was a Full Code. R4's Blood Pressure Summary documents a blood pressure reading of 186/83 mmHg (millimeters of mercury) on [DATE] at 4:10 PM and 182/95 mmHg on [DATE] at 11:36 PM. There is no documentation in the Nurse's Progress Notes of Physician notification of the elevated blood pressures.R4's nursing progress note documented that on [DATE] at approximately 3:05 a.m., R4 complained of right flank pain and difficulty falling asleep. The nurse notified the on-call physician and received orders for Acetaminophen (pain reliever) for pain, increased oxygen, and a one-time dose of Alprazolam (anti-anxiety).The physician call report note dated [DATE] at 3:08 a.m., documents the reason for the call was for a panic attack and low O2 (oxygen) sat (saturation). This note documents the Nursing Assessment information as R4 was a new admit having a panic attack, right hip pain, with oxygen saturation of 88% (percent), and hyperventilating. Vital signs were documented as blood pressure 185/95, heart rate 115, respirations 18, and temperature 97.5 (degrees)F(Fahrenheit). The nurse reported that oxygen had been applied at 2 L/min (liters/minute). The provider ordered oxygen to be increased to 4 L/min or more to maintain oxygen saturation above 90%, Alprazolam 0.25 mg (milligrams) one time, and Acetaminophen for pain.R4's Nurse's Progress Note dated [DATE] at 4:18 a.m. documents that at approximately 3:30 a.m., while staff were preparing to administer the medications, R4 was found unresponsive. CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called. EMS (Emergency Medical Services) arrived and continued CPR. R4 was pronounced deceased at approximately 4:10 a.m.On [DATE] at 10:58 a.m., V7, Registered Nurse, stated that upon entering R4's room on [DATE], V7 observed R4 hyperventilating. V7 stated that R4 was instructed to perform breathing exercises, which did not resolve the symptoms, and V7 then contacted the on-call physician. V7 stated orders were received for alprazolam 0.25 mg and acetaminophen 600 mg for pain. V7 stated that because R4 was a new admission and did not have medications available, a code was required to obtain the Alprazolam from the medication administration box, resulting in approximately a 30-minute delay before the medication was available. V7 stated that no physical assessment of R4 was documented at that time. V7 further confirmed that the on-call provider was not contacted when R4's blood pressure was 185/95 at 11:36 p.m.On [DATE] at 11:35 a.m., V9, Licensed Practical Nurse, stated that vital signs documented at approximately 4:00 p.m. on [DATE] included a blood pressure of 185/96. V9 confirmed that the physician was not notified and that no nursing assessment was completed in response to the elevated blood pressure.On [DATE] at 9:40 a.m., V12, Nurse Practitioner, stated that, even though R4 was a new admission, V12 expected to be notified of a systolic blood pressure greater than 160 mmHg. V12 further stated that changes in condition, particularly for new admissions, should be reported to the on-call physician. V12 stated that, had the provider been notified, medication could have been recommended and R4 could have been sent back to the hospital for further evaluation and treatment. V12 stated that R4 had multiple significant medical conditions and that the resident's prognosis and multiple contributing medical factors made it unclear whether earlier intervention would have prevented the death.

Based on observation, interview, and record review, the facility failed to provide all items noted on the daily menu and ensure availability of substitutions for residents of the facility. This has the potential to affect all 182 residents residing at the facility.Findings include:1. R4's Care Plan dated 3/4/2026 documents an admission date of 4/16/2026. The Care Plan documents R4's diagnoses including Generalized Anxiety, Osteoporosis, Barrett's Esophagus without dysplasia, Major Depressive Disorder, Mild Cognitive Disorder, Dysphagia, Communication Deficit, Unspecified Hearing Loss. The Care Plan further documents R4 has a potential fluid deficit related to cognition and may not recognize thirst with an intervention to encourage the resident to drink fluids of choice to help with hydration.R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact.On 5/2/2026 at 7:50 a.m., R4 was lying in bed eating breakfast. R4 stated food is not going well in the facility. R4 stated R4 loves to drink coffee, and R4 could not have it. R4 stated the facility is not serving hot water, not even for tea and they have served cold food for the last couple of days. R4 stated R4 doesn't care much about what they serve as long as R4 can have R4's coffee.2. R5's Care Plan dated 3/4/2026 documents an admission date of 4/2/2026. The Care Plan documents R5's diagnoses including Iron deficiency Anemia, End Stage Renal Disease, Type 2 Diabetes Mellitus, Dependence on Renal Dialysis, Gastro-Esophageal Reflux Disease, Benign Neoplasm of Colon, Disorder of Electrolyte and Fluid balance, Dysphagia and Aphasia. The Care Plan further documents R5 has a pressure injury to the right heel present upon admission with interventions in place to encourage good nutrition and hydration in order to promote healthier skin.R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact.On 5/3/2026 at 7:45 a.m., R5 was sitting in the common area with a meal tray in front of R5. R5 had two boiled eggs and a small cup of yogurt with a small cup of water. R5 stated R5 was not served drinks, the water was from the nurse when the nurse brought R5's medicines. R5 stated I did not want the banana because R5 doesn't eat bananas. R5 stated R5 will not eat boiled eggs or yogurt. R5 stated R5 asked a staff member for bread and peanut butter, and the staff told R5 they would check if they have it because the food is all coming from another place. R5 stated R5 cannot wait to go home so R5 can have coffee because the facility has not been serving coffee for days now because the kitchen was shut down.On 5/3/2026 at 8:20 a.m., R5 remained sitting in the common area and stated R5 was still waiting to see if there was bread and peanut butter.On 5/3/2026 at 8:44 a.m., R5 remained sitting in the common area and stated no one ever came back with bread. R5 observed eating biscuits and gravy, R5 stated R5's wife brought it for R5.On 5/3/2026 at 8:44 a.m., V12 R5's family member stated V12 brought R5 some food because R5 has not been eating, the facility has been serving boiled eggs, cottage cheese and yogurt for breakfast since the kitchen was closed down. V12 stated R5 does not like yogurt or cottage cheese, and occasionally R5 will eat boiled eggs. V12 stated the facility added bread and peanut butter for R5's diet for R5's extra protein but R5 has not been getting it.On 5/2/2026 at 5:20 a.m., V6 Dietary Manager stated the kitchen was closed since 4/30/2026 after failing the Local Health Department Inspection. The facility is not able to serve hot food and drinks. V6 stated they only serve cold items. V6 stated as a plan of correction, the facility arranged a contract with [NAME] Medical Center to supply the food for the facility but not until 5/4/2026. V6 stated since they closed down, the food has been catered from outside. V6 stated the facility cannot produce hot beverages also including coffee or hot water for tea and the options for drinks are water, milk and little cups of juice.On 5/2/2026 at 6:15 a.m., V7 Dietary Aide stated the facility is not serving hot food and drinks including coffee and can only serve cold items.On 5/3/2026 at 8:00 a.m., V10 Certified Nurse Assistance (CNA) stated V10 does not know what the other alternatives for food are. V10 stated everything has to come from the kitchen and all nursing staff can do is pass ice water.On 5/3/2026 at 8:05 a.m., V11 Licensed Practical Nurse (LPN) stated dietary staff takes the order for residents, V11 does not know what the alternatives are. V11 stated nursing are not to do anything in the kitchen and all the nursing staff can do is pass water and milk.Local Public Health Department Food Establishment Inspection Report dated 4/30/2026 documents At 11:15 AM on 4/30/2026. The food service was closed, and the health permit was suspended due to an inadequate food safety management system. All food handling, preparation, and service must cease as of this time. A Red Closed Placard was posted at a location determined by the health office. This placard is the property of the (Local Public Health Department) and shall not be removed, copied, or altered in anyway under penalty of law. Due to the R4 repeated violation, the health authority will pursue administrative and/or judicial remedies against the food establishment and/or permit holder. A request for reinspection was left with the PIC (Person in Charge).On 5/2/26 at 6:30 a.m., V2, Director of Nursing, provided a resident roster dated 5/2/26 that documented 182 residents were residing in the facility on that date. The facility's planned menus for dates 4/30/2026 through 5/4/2026 were not able to be followed due to the closure by the Local County health dept.

Based on observation, interviews and record review the facility failed to ensure meals were palatable, attractive, and appetizing for residents. This failure has the potential to affect all 182 residents residing at the facility. Findings include:1. R1's Care Plan dated 4/9/2026 documents an admission date of 3/27/2026. The Care Plan documents R1s diagnoses including Displaced Fracture of Left Humerus, Metabolic Encephalopathy, Mild Cognitive Impairment, Gastroesophageal Reflux, Disorder of Bone Density, Dysphagia, Cognitive Communication Impairment and Aphasia. The Care Plan documents R1 has nutritional problems and potential nutritional problems related to metabolic encephalopathy. R1's Care Plan also documents R1 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R1 has dehydration or potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment.R1's Nutrition/Dietary Note dated 5/4/2026 documents R1 has weight loss of five percent in one month. Weight loss could be a combination of fluid changes and decreased oral intake.On 5/2/2026 at 8:00 a.m., R1 was sitting in the room eating breakfast. R1's meal tray consists of two untouched boiled eggs served in a small disposable bowl; untouched cottage cheese served in a five-ounce plastic cup and yogurt (eaten) served in a nine-ounce plastic cup and a half pint carton of milk. R1 stated I cannot eat that (pointing to the cottage cheese), I don't even know what this is, it does not look good.2. R6's Care Plan dated 2/20/2026 documents an admission date of 8/25/2025. The Care Plan documents R6's diagnoses including Dysphagia following Cerebrovascular Disease, Chronic Kidney Disease Stage 3, Iron Deficiency Anemia, Alcohol Abuse, Dementia, Epilepsy, Psychotic Disturbances, Mood Disturbance, Alzheimer's Disease, Specified Disorder of Brain, Cerebral Infarction, Dysphagia and Cognitive Communication Deficit. The Care Plan further documents R6's dietary plan is mechanical soft related to Dysphagia. R6's Care Plan also documents R6 has an Activity of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R6 has dehydration or potential fluid deficit with intervention to encourage R1 to drink fluids of choice to maintain hydration.R6's Minimum Data Set (MDS) dated [DATE] documents R6 is moderately cognitively impaired.R6's Order Summary Report dated 3/20/2026 documents R6's diet was for No Added Salt mechanical soft texture.R6's Care Plan dated 8/13/2026 documents R1 has a communication problem related to dementia with interventions to anticipate and meet R6's needs.On 5/2/2026 at 7:35 a.m., R6 was in the smaller dining room on the second floor, eating breakfast. R6's meal plate consisted of two boiled eggs served in a small disposable bowl; cottage cheese served in a five-ounce plastic cup and yogurt served in a nine-ounce plastic cup. R6 was difficult to understand therefore unable to be interviewed.3. R4's Care Plan dated 3/4/2026 documents an admission date of 4/16/2026. The Care Plan documents R4's diagnoses including Generalized Anxiety, Osteoporosis, Barrett's Esophagus without dysplasia, Major Depressive Disorder, Mild Cognitive Disorder, Dysphagia and Communication Deficit. The Care Plan further documents R4 has a potential fluid deficit related to cognition and may not recognize thirst with an intervention to encourage the resident to drink fluids of choice to help with hydration.R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact.On 5/2/2026 at 7:50 a.m., R4 was lying in bed with R4's breakfast in front of R4. R4's meal plate consisted of two boiled eggs served in a small disposable bowl; cottage cheese served in a nine-ounce plastic cup and yogurt served in a five-ounce plastic cup. No drinks observed with R4's meal tray at that time. R4 stated this food does not look good at all. R4 stated food has not been well for a couple of days now.On 5/4/2026 at 10:21 a.m., V27 Assistant Dietary Manager stated the food should be presentable and appealing, not only will it encourage residents to eat but also for their dignity. V27 stated food should be served in dishes and not on disposable plates/bowls or in disposable cups.On 5/4/2026 at 10:39 a.m., V28, Dietary Aide stated food should be presentable and appealing to make the resident want it. V28 stated it should be served in dishes and not on disposable plates or in plastic cups. V29 stated we eat with our eyes, if the food is appealing, we tend to eat more.On 5/4/2026 at 10:56 a.m. V29, Dietary Aide stated food should be presentable and appealing to make the resident want to eat it. V29 stated it should be served in dishes and not on disposable plates or in plastic cups. V29 stated food served on disposable plates and in plastic cups was not appealing.On 5/3/2026 at 1:18 p.m., V6 Dietary Manager (DM) agreed that meals should be appealing and presentable. V6 stated for food to be appealing it should be served in dishes and not on disposable plates or in disposable plastic cups.On 5/4/2026 at 11:18 a.m., V30 Regional Dietician stated for the food to be appetizing, it should have variety of color and texture. V30 stated food served on disposable plates and in plastic cups was not appealing.On 5/2/26 at 6:30 a.m., V2, Director of Nursing, provided a resident roster dated 5/2/26 that documented 182 residents were residing in the facility on that date.

Based on observation, interview and record review, the facility failed to provide adequate beverages to residents. This failure has the potential to affect all 182 residents residing at the facility.Findings include:1. R1's Care Plan dated 4/9/2026 documents an admission date of 3/27/2026. The Care Plan documents R1s diagnoses including Displaced Fracture of left humerus, Metabolic Encephalopathy, Mild Cognitive Impairment, Gastroesophageal Reflux, Dysphagia, Cognitive Communication Impairment and Aphasia. The Care Plan documents R1 has nutritional problems, potential nutritional problems related to metabolic encephalopathy. R1's Care Plan also documents R1 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R1 has dehydration or a potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment.On 5/3/2026 at 1:00 p.m., R1 was sitting in the room eating lunch. R1's meal plate observed with ground chicken strips which appeared to be dry, no gravy or sauce observed on the side, a piece of garlic bread, a banana and french fries. R1 also has a cup of fruit but no drinks were observed on R1's meal tray. There was an empty disposable cup on R1's table and R1 stated the cup had been sitting there awhile and it was empty. R1 stated R1 does not have a drink and will have to ask for something. R1's staff are not very good at giving R1 something to drink, R1 has to ask most of the time.R1's Care Plan dated 3/27/2026 documents R1 has dehydration or a potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration.R1's Nutrition/Dietary Note dated 5/4/2026 documents R1 has weight loss of five percent in one month. Weight loss could be a combination of fluid changes and decreased oral intake.2. R3's Care Plan dated 5/4/2026 documents an admission date of 4/16/2026. The Care Plan documents R3s diagnoses including Cerebral Infarction due to Stenosis of small Artery, Weakness, Constipation, Dysphagia and Muscle Atrophy. The Care Plan also documents R3 has nutritional problems, and potential nutritional problems related to dysphagia, oropharyngeal phase. R1's Care Plan also documents R1 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R3 has dehydration or potential fluid deficit with intervention to encourage R3 to drink fluids of choice to maintain hydration.R3's Minimum Data Set (MDS) dated [DATE] documents R3 was cognitively intact.On 5/3/2026 at 1:03 p.m., R3 was sitting in R3's room eating lunch. R3's meal tray consists of ground chicken strips, which appeared to be dry and no moisture to it. R3 also had french fries and garlic bread. R1 stated R1's tray did not come with any drinks, R3 had to ask for the milk. At this time, there were no other drinks on the table except the half pint carton of milk.3. R6's Care Plan dated 2/20/2026 documents an admission date of 8/25/2025. The Care Plan documents R6's diagnoses including Dysphagia following cerebrovascular disease, Anxiety, Dementia, Alzheimer's Disease, Specified Disorder of Brain, Cerebral Infarction, Pain to right shoulder, Dysphagia, Lack of Coo0rdination and Cognitive Communication Deficit. The Care Plan further documents R6's dietary plan is mechanical soft related to Dysphagia. R6's Care Plan also documents R6 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R6 has dehydration or a potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration.R6's Minimum Data Set (MDS) dated [DATE] documents R6 is moderately cognitively impaired.On 5/2/2026 at 7:35 a.m., R6 was in the smaller dining room on second floor, eating breakfast. R6's meal plate consisted of two boiled eggs, cottage cheese and yogurt. R6 had one half pint carton of milk, and no other drinks observe given or offered throughout the meal from the intermittent observation. R6 was difficult to understand and was not interviewable. R6's Care Plan dated 8/13/2026 documents R1 has a communication problem related to dementia with interventions to anticipate and meet needs.R6's Care Plan dated 1/28/2026 documents R6 has a potential for dehydration or a potential fluid deficit related to cognition and may not recognize thirst. Interventions include encourage (R6) to drink fluids of choice to help maintain hydration.On 5/4/2026 at 8:01 a.m., V23 Certified Nurse Assistant stated residents should have at least two drinks during meals if they want milk. V23 stated they were not serving juice because of the kitchen being closed.On 5/4/2026 at 10:21 a.m., V27 Assistant Dietary Manager stated residents should always have at least two drinks with their meals. V27 stated residents should have ice water, milk or juice.On 5/4/2026 V28, Dietary Aide and V29, Dietary Aide both stated residents should receive at least two drinks, milk and ice water.On 5/3/2026 at 1:18 p.m., V6 Dietary Manager (DM) stated residents should always have milk for their calcium and extra calorie sources. V6 stated residents should have ice water or juice. V6 stated kitchen staff prepare the meal trays, and the CNAs serve the drinks. V6 stated residents may have refused the drinks served but there should not be any resident that does not have a drink at all.On 5/4/2026 at 11:18 a.m., V30 Regional Dietician stated V30 expects the residents to have six to 12 ounces of drinks per meal. V30 stated one glass was not enough for a resident to stay hydrated.On 5/2/26 at 6:30 a.m., V2, Director of Nursing, provided a resident roster dated 5/2/26 that documented 182 residents were residing in the facility on that date. The facilities Hydration and Prevention of Dehydration Policy dated January 2026 documents Nurse's Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.

Based on observation, interview and record review the facility failed to keep equipment functioning properly to ensure the kitchen was maintained in a manner to prevent food born illness. This failure has the potential to affect all 182 residents residing at the facility.Findings include:On 5/2/2026 at 5:20 a.m. V6 Dietary Manager (DM) stated the kitchen was closed since 4/30/2026 after failing the Local Health Department Inspection. The facility is not able to serve hot food and drinks. V6 stated they only serve cold items. V6 stated as a plan of correction, the facility arranged a contract with a local hospital to supply the food for the facility but not until 5/4/2026. V6 stated since they closed down, the food has been catered from outside. V6 stated the facility cannot produce hot beverages including coffee or hot water for tea.On 5/2/2026 at 6:10 a.m., kitchen staff did not cook or prepare in-house meals.On 5/2/2026 at 6:15 a.m., kitchen staff were scooping yogurt and cottage cheese in portions and putting it into nine ounces disposable plastic cups.On 5/2/2026 at 6:15 a.m., V7 Dietary Aide stated they are not able to cook or prepare in-house meals due to the kitchen being closed. V7 stated they can only prepare prepacked cold food such as prepacked boiled eggs, yogurt and cottage cheese for breakfast. V7 stated the food for lunch and dinner was being catered.On 5/2/2026 at 6:20 a.m., V6 DM stated the failure during the inspection with the Local Health Department on 4/30/2026 was due to the malfunction of one of the pieces of kitchen equipment. V6 confirmed the hot box was off and not being used. V6 stated V6 did not know the equipment was malfunctioning because the thermostat was at the bottom where they could not see it easily.On 5/2/2026 at 7:15 a.m., R1 stated the kitchen was shut down and they only been serving cold food.On 5/2/2026 at 7:18 a.m., R13 stated we haven't had any good food for a couple of days, they said the stove was broke and the kitchen staff were not cooking. My (spouse) has been bringing me food. Last night they served us pizza, but I did not eat it.On 5/2/2026 at 7:50 a.m., R4 stated that food has not been good. R4 stated the kitchen was closed and they could not serve coffee. R4 stated I don't understand why they cannot make coffee or even a hot water for tea.On 5/4/2026 at 10:21 a.m., V27 Assistant Dietary Manager stated V27 was told the hot box was broken and did not pass the inspection, so the kitchen was closed. V27 confirmed they have not been cooking food in the kitchen. V27 confirmed they have not been serving hot drinks or hot food.On 5/4/2026 at 10:39 a.m., V28 Dietary Aide stated the kitchen was closed and they have not been cooking and they are not serving hot drinks either.On 5/4/2026 at 10:56 a.m., V29 Dietary Aide stated V29 was told the kitchen will not be making hot food and not be serving hot drinks. V27 stated they can only serve cold food, ice water and milk.On 5/4/2026 at 11:18 a.m., V30 Regional Dietician stated V30 does not know what happened with the kitchen. V30 stated V30 came today and was told the kitchen was not cooking and food is being catered. V30 stated V30 was told the kitchen would only be serving cold food.On 5/4/2026 at 1:04 p.m., V32 Dietary Aide stated V32 came to work mid-shift on 4/30/2026 and was told they were closing the kitchen. V32 stated when V32 went back to work on 5/1/2026 V32 was told they were not cooking, and food will be catered.On 5/2/26 at 6:30 a.m., V2, Director of Nursing, provided a resident roster dated 5/2/26 that documented 182 residents were residing in the facility on that date. The (local) Public Health Department Food Establishment Inspection Reported dated 4/30/2026 documents At 11:15 AM on 4/30/2026. The food service was closed, and the health permit was suspended due to an inadequate food safety management system. All food handling, preparation, and service must cease as of this time. A Red Closed Placard was posted at a location determined by the health office. This placard is the property of (the local) Public Health Department and shall not be removed, copied, or altered in anyway under penalty of law. Due to the R4 repeated violation, the health authority will pursue administrative and/or judicial remedies against the food establishment and/or permit holder. A request for reinspection was left with the PIC (Person in Charge).

Based on observation, interview, and record review the facility failed to provide a clean and homelike environment for one of three (R2) residents reviewed for environment in a sample of six.Findings include:R2's Care Plan dated 4/27/2026 documents an admission date of 08/30/2024. The Care Plan documents R2's diagnoses Rhabdomyolysis, Hypertension, Cerebral Palsy, Muscle wasting and atrophy, Lack of coordination, Hypnosis, Unspecified protein-calorie malnutrition. The Care Plan further documents R2 need assistance during transfers.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. On 5/2/2026 at 8:57 a.m., R2 was in R2's room sitting in R2's bed eating breakfast. There were scattered deep scratches to the wall by R2's head of the bed measuring approximately 2.5 feet by 2 feet. The scratches were covered by white plaster. R2 stated someone knew about the scratches and someone applied the plaster about a month ago. R2 stated the wall does not look good, but it is what it is.On 5/3/2026 at 10:00 a.m., in the common area, there was a white patch on the wall by the entrance door of the facility located by the lobby measuring approximately 2.5 feet by 1 foot.On 5/3/2026 at 10:23 a.m., V13 Maintenance Director stated the patch by the front door was from dry wall mud applied about two weeks ago. V13 stated it needs to dry, usually for three to four days, then sand it and then apply the paint. V13 stated V13 only has two staff that work under V13 and with the amount of workload, they get behind with the work orders. V13 stated V13 usually prioritizes the repairs in the resident's room over common area.On 5/3/2026 at 10:30 a.m., while in R2's room, V13 stated the plaster was applied on the wall to cover the holes from being scratched by the bed when it goes up and down. V13 stated this kind of work order should be repaired the same day by applying a wall protection sheet. V13 stated V13 did not know about this plaster being applied and did not have a work order for it.On 5/4/2026 at 7:30 a.m., V9 Maintenance staff stated V9 applied the plaster in (R2's) room about a month ago and did not make a work order.On 5/4/2026 at 9:30 a.m., V1 stated that maintenance staff members have been making rounds and fixing what they see that need repairs as they go and did not need to complete a work order.The facility's Maintenance and Repair policy dated November 2025 documents that all maintenance and repair issues will be reported and addressed in a timely manner to maintain a safe, clean and operational facility.The facility's Safe, Clean, Comfortable, and Homelike Environment policy dated November 2025 documents the facility will maintain a safe, clean, comfortable, and homelike environment for all residents. The environment will support resident dignity, while ensuring safety, sanitation and regulatory compliance.

Based on observation, interview, and record review the facility failed to provide assistance with meals to one of three (R1) residents reviewed for activities of daily living in a sample of six.Findings include:R1's Care Plan dated 4/9/2026 documents an admission date of 3/27/2026. The Care Plan documents R1's diagnoses including Displaced Fracture of Left Humerus, Metabolic Encephalopathy, Mild Cognitive Impairment, Gastroesophageal Reflux, Disorder of Bone Density, Dysphagia, Cognitive Communication Impairment, Aphasia. The Care Plan further documents R1 has dehydration or potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration. The Care Plan also documents R1 has nutritional problems and potential nutritional problems related to metabolic encephalopathy. R1's Care Plan also documents R1 has an Activity of Daily Living (ADL) self-care performance deficit.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment.On 5/3/2026 at 1:00 p.m., R1 was sitting in the room eating lunch. R1's meal plate observed with ground chicken strips, garlic bread, a banana (unpeeled) and French fries. R1 also had a cup of fruit that was unopened, and R1's silverware was still wrapped. R1 observed with a condiment packet in R1's hand R1 was trying to open but was unable to open by R1's self. R1 stated R1 does not have the strength to open it. R1 stated I probably will not eat that banana either, I am not able to peel it. R1 stated R1 had a banana this morning, but I could not peel it either. R1 stated R1 will most likely not eat the cup of fruit either because R1 is not able to open it and it is hard to get someone to help R1 open it.On 5/3/2026 at 1:27 p.m., V17 Certified Nurse Assistant (CNA) stated it is expected for CNAs to provide assistance upon serving meal trays to the residents such things as unwrapping silverware, opening cups, and cutting up foods for the residents.On 5/3/2026 at 1:30 p.m., V3 Director of Nursing (DON) stated V3 expects the CNAs to provide assistance to residents before walking away after serving meal trays.The facilities Activities of Daily Living policy dated June 2025 documents all residents will have activities of daily living provided by nursing staff as needed in accordance with each individual's needs.

Based on observation, interview and record review the facility failed to provide the mechanical soft diet consistency per resident needs for three of three (R1, R3 and R6) residents reviewed for mechanical soft diet in a sample of six.Findings include:1. R1's Care Plan dated 4/9/2026 documents an admission date of 3/27/2026. The Care Plan documents R1's diagnoses including Displaced Fracture of Left Humerus, Metabolic Encephalopathy, Mild Cognitive Impairment, Gastroesophageal Reflux, Dysphagia, Cognitive Communication Impairment and Aphasia. The Care Plan documents R1 has nutritional problems and potential nutritional problems related to metabolic encephalopathy. R1's Care Plan also documents R1 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R1 has dehydration or potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment.R1's Nutrition/Dietary Note dated 5/4/2026 documents R1 has weight loss of five percent in one month. Weight loss could be a combination of fluid changes and decreased oral intake.R1's Order Summary Report dated 4/2/2026 documents R1's diet order for regular mechanical soft consistency.R1's meal ticket dated 5/3/2026 documents R1 was on a mechanical soft diet.On 5/3/2026 at 1:00 p.m., R1 was sitting in the room eating lunch. R1's meal plate contained ground chicken strips which appeared dry, no moisture and no gravy or sauce was on the side, a piece of garlic bread, french fries and an unpeeled banana. There was an empty disposable cup on R1's table and R1 stated that it was already there and it's empty. R1 stated R1 does not have a drink and will have to ask for something to drink. R1 stated R1 will not eat that thing (pointing at the ground chicken) it does not look good.2. R3's Care Plan dated 5/4/2026 documents an admission date of 4/16/2026. The Care Plan documents R3's diagnoses including Cerebral Infarction due to Stenosis of Small Artery, Cerebral Cysts, Occlusion and Stenosis of Right Carotid Artery, Dysphagia and Muscle Atrophy. The Care Plan also documents R3 has nutritional problems and potential nutritional problems related to dysphagia, oropharyngeal phase. R1's Care Plan also documents R1 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R3 has dehydration or a potential fluid deficit with an intervention to encourage R3 to drink fluids of choice to maintain hydration.R3's Minimum Data Set (MDS) dated [DATE] documents R3 was cognitively intact.R3's Order Summary Report dated 4/20/2026 documents R3's diet order of regular mechanical soft consistency.R3's Care Plan dated 4/16/2026 documents R3 was admitted to the facility related to cerebral infarction and may present with a swallow disorder.On 5/3/2026 at 1:05 p.m., R3 was sitting in R3's room eating lunch. R3's meal tray consisted of ground meat (chicken strips), appeared dry and not moist. R3 also had French fries and garlic bread. R1 stated R1 did not know what the ground meat was, it was not good but better than nothing. 3. R6's Care Plan dated 2/20/2026 documents an admission date of 8/25/2025. The Care Plan documents R6's diagnoses including Dysphagia following Cerebrovascular Disease, Chronic Kidney Disease Stage 3, Iron Deficiency Anemia, Anxiety, Dementia, Psychotic Disturbances, Mood Disturbance, Alzheimer's Disease, Specified Disorder of Brain, Cerebral Infarction, Dysphagia, Lack of Coordination and Cognitive Communication Deficit. The Care Plan further documents R6's dietary plan is mechanical soft related to Dysphagia. R6's Care Plan also documents R6 has an Activities of Daily Living (ADL) self-care performance deficit. The Care Plan further documents R6 has dehydration or a potential fluid deficit with an intervention to encourage R1 to drink fluids of choice to maintain hydration.R6's Minimum Data Set (MDS) dated [DATE] documents R6 is moderately cognitively impaired.R6's Order Summary Report dated 3/20/2026 documents R6's diet was for No Added Salt mechanical soft texture.On 5/3/2026 at 12:00 p.m. R6 was in the dining room eating lunch. R6 was served with ground chicken strips, no sauce or gravy and appeared dry and not moist. R6 was difficult to understand therefore was not interviewable.On 5/4/2026 at 10:21 a.m., V27 Assistant Dietary Manager stated V27 knows that on 5/3/2026 at lunch time, the chicken strips for mechanical soft diets were not mixed with gravy and did not have gravy on top like they would do if it was prepared in house. V27 stated the mechanical soft diet is expected to be moist.On 5/4/2026 V28, Dietary Aide and V29, Dietary Aide both stated that the mechanical soft diet is expected to be moist by mixing the mechanical food with gravy and then putting extra gravy on top and it should be easily scooped.On 5/3/2026 at 1:18 p.m., V6 Dietary Manager (DM) stated the lunch was chicken strips and was catered from a local restaurant. V6 stated if V6 would make the mechanical food in-house, V6 would make sure to mix gravy with the ground meat to make sure it's moist and would add more gravy on top. V6 stated the ground chicken for lunch was dry because it was not mixed with gravy and it should have been mixed with gravy to make it moister. On 5/4/2026 at 11:18 a.m., V30 Regional Dietician stated mechanical soft diet is expected to be moist. V30 stated all residents that are on mechanical soft diets should receive moistened mechanical soft food that is easily scooped.The facilities undated Mechanical Soft Diet Principles and Guidelines document mechanical food should be moist and fork tender. Meat should be ground and mixed with gravy, broth or another type of moistening agent.

Based on observations, interviews and record review the facility failed to ensure dependent residents were provided dignified care, this failure affected two (R1 and R8) of eight residents reviewed for hygiene/dignity on the sample list of nine residents.Findings include:1. R8's current Diagnoses List includes the following: Essential (Primary) Hypertension, Acute Respiratory Failure with Hypoxia, Pneumonitis due to Inhalation of Food and Vomit, Encounter for Surgical Aftercare Following Surgery of the Digestive System, Repeated Falls, Difficulty Walking, Not Elsewhere Classified, Other Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Age-Related Osteoporosis Without Current Pathological Fracture, and Other Specified Disorders of Cone Density and Structure, Site Unspecified.R8 Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status score as 11 out of a possible 15, which indicates moderate cognitive impairment. The same MDS documents R8 has had no episodes of rejecting care and required partial/moderate assistance or substantial/maximal assistance with activities of daily living, except eating. R8 required Setup or clean-up assistance.R8's current Care Plan documents the following: R8 has ADL (Activities of Daily Living), self-care performance deficit: Dressing: The resident requires one assistance of staff to dress. Personal Hygiene/Oral Care: The resident requires one assistance from staff. Toileting: The resident requires two staff assistance for toileting.R8's same care plan documents the following: R8 is at risk for falls, has Osteoporosis and Osteopenia which could contribute to falls/ severity of illness. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.On 4/1/26 at 2:40 pm, V33 (R8's) Family Member was in R8's room. R8 sat in a wheelchair at bedside. R8's pants had copious amounts of dried food on the upper legs/ lap of his pants and the abdomen area of his shirt. R8 stated This does not look good (points to his upper pant legs), I am supposed to have therapy. I am hoping I don't have to go like this. I asked the nurses to change my pants after finishing my breakfast (breakfast scheduled at 7:30 am). I am guessing, they are just busy. They are all very nice and I don't want to get anyone in trouble. I feed myself and my hands shake. I need to go to the bathroom. I better call someone to help me. R8 turns on R8's call light and V35 Certified Nursing Assistant (CNA) instantly entered R8's room and pushed R8's wheelchair into R8's bathroom. V33 (R8's) Family member stated I'm very happy with the room itself, it is the nursing care I am troubled with, and the (V1) Administrator knows this. I have been here, turned on the call light myself and waited fifteen minutes to get staff to R8's room for care. (R8) can't wait 15 minutes to use the bathroom. Yes, call lights are an issue. Approximately 20 minutes had passed since V35 CNA assisted R8 to the bathroom, as noted above. V3 voiced concerns that R8 was still in the bathroom with V35 CNA. This surveyor knocked on R8's bathroom door. R8 and V35 were no longer in the bathroom. R8's shared a bathroom with an adjoining empty room. V33 (R8's) Family Member stated Perhaps (V35) the CNA has taken (R8) to therapy. V33 (R8's) Family Member and this surveyor walked down the long facility entrance hallway, of which R8 would have traveled to get to the therapy room. R33 and this surveyor walked past several residents in the hall and visible in their room, past numerous staff, and visitors to get to the facilities therapy room. R8 was receiving therapy by an unidentified therapist. R8's pants and shirt remained soiled with copious amounts of dried food on R8's upper pants and lower shirt. As R8's therapy continued, V33 (R8's) family member stated the (V34) Home Care Provider does (R8's) laundry. There should be plenty of clothes for (R8) here.On 4/1/26 at 3:25 pm, V35 CNA confirmed V35 noticed all the food on R8's clothes when V35 took R8 to the bathroom, before therapy. V35 CNA stated I should have changed R8's clothes when I had R8 in the bathroom. I know R8 has clean clothes in R8's closet. I was going to come back later and change them. I never thought about it, until now, R8 probably was embarrassed when he went to therapy like that. I had to go help the woman (unidentified resident) across the hall, or I would have changed R8's clothes right away.2. R1's Minimum Data Set (MDS) dated [DATE] documents the following: R1's Brief Interview of Mental Status score of eight out of a possible 15, indicating moderate cognitive impairment. The same MDS documents R1s Primary Medical Condition is Progressive Neurological Condition. The same MDS documents: R1 required the following assistance with dressing, toileting, and to transfer from R1'swheelchair chair to bed: Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk limbs, but provides less than half the effort, during personal hygiene, On 4/07/26 at 8:05 am, breakfast trays were not delivered to residents in the rooms, yet. Therefore, R1 had not eaten. There was a kitchen tray cart parked at the end of the hall, filled with residents' meal trays. R1 was lying in bed with the bed sheet and blanket covering the lower half of R1's body. R1 did not have on night clothes. R1 was wearing a long sleeve, red shirt that was soiled with light colored food-like particles stuck to R1's chest area. R1 also had dried, long lines of liquid-like substance streaked down the front of R1's shirt. R1 stated R1 has not had breakfast this morning. R1 stated R1 was put to bed in R1's soiled day clothes, last night after supper. R1 stated I would prefer to sleep in clean pajamas. I would be more comfortable. R1 exercised R1's right to stay in bed, sleep and delay R1's morning care.On 4/7/25 at 10:25 am, R1 was awake lying in bed. V56 Certified Nursing Assistant (CNA) entered R1's room to complete morning care. V56 CNA confirmed R1 was in soiled day clothes and had to have slept in the soiled clothes overnight.The facility Policy Resident Privacy and Dignity dated January 2026 documents the following:PURPOSE:To provide all residents with a home-like environment that promotes dignity and respect to the residents of the facility.POLICY:To ensure that all residents are provided with dignity and privacy.RESPONSIBILITY:It is the responsibility of all staff to ensure that all residents have privacy and dignity.

Based on observations, interviews and record review, the facility repeatedly failed to maintain a safe environment for residents at risk of falls. These failures affected two residents (R2, R8) of six residents, which were reviewed for falls/environment, on the sample list of nine residents. With fall prevention interventions not being followed for R2 and R8. 1. R2's current Diagnoses List documents the following: Diabetes Mellitus Type II, With Hyperglycemia, Diabetes Mellitus Type II, With Polyneuropathy (damage nerves, causing numbness, tingling and weakness), Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Difficulty Walking, Not Elsewhere Classified.R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental status (BIMS) score as 12 out of a possible 15, indicating moderate cognitive impairment.The same MDS documents R2 has had one fall with no injury (during the lookback period of this assessment) and is dependent on staff for substantial maximum assistance, with all Activities of Daily Living, except eating.R2's current Care Plan documents the following: (R2) is at risk for falls r/t (related to) weakness, requires assistance with transfers, nonAmbulatory. Encourage the resident to use bell to call for assistance.R2's three progress notes below, each document recent unwitnessed falls without injury.R2's Fall/Incident Note (Unwitnessed) dated 3/24/26 at 10:20 am documents: R2 leaned over to pick up tennis shoes and fell out of R2's wheelchair.R2's Fall/Incident note dated 3/10/2026 at 8:31 pm documents: An unidentified Certified Nursing Assistant went in and found resident was lying on the floor on R2's back, against the wheelchair behind him, sitting in front of the toilet.R2's Fall/Incident note dated 3/6/2026 at 03:48 am documents: Resident was trying to reach for his bag and slipped off R2's bed.On 4/3/26 at 8:55 am, R2 was lying in an elevated bed. R2's bed was elevated with the mattress approximately three and a half feet off the floor bed. The head of R3's bed was positioned at approximately 45 degrees. R2's bed control device was behind the elevated head of the bed. R2's bed control device was attached to R2's headboard, behind the mattress, centered behind R2's head. R2 did not have R2's call light within reach. R2's call light cord was coiled on the floor under the head of R2's bed. R2 stated I have no way of asking staff for help, when my call light is not up on my bed. I cannot reach the bed control for my bed, and I sure don't like my bed off the floor, this far. I woke up like this when the dietary people brought my food. I am thinking, this probably is how the night shift left me when they changed me in the middle of the night.On 4/3/26 at 9:03 am, V40 Certified Nursing Assistant (CNA) entered R2's room and confirmed R2's bed was not at a safe height, call light was on the floor and R2's bed control was out of reach. V40 CNA lowered R2's bed to approximately two and a half feet off the floor and handed R2 the bed control and attached R2's call light to R2's clean bed linen within R2's reach.2. R8's current Diagnoses List includes the following: Essential (Primary) Hypertension, Repeated Falls, Difficulty Walking, Not Elsewhere Classified, Other Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Age-Related Osteoporosis Without Current Pathological Fracture, and Other Specified Disorders of Cone Density and Structure, Site Unspecified.R8's Minimum Data Set (MDS) dated [DATE] documents R8's Brief Interview of Mental Status (BIMS) score as 11 out of a possible 15, which indicates moderate cognitive impairment. The same MDS documents R8 has had two falls, without major injury while residing in the facility.R8's current Care Plan documents the following: (R8) is at risk for falls, has Osteoporosis and Osteopenia which could contribute to falls/ severity of illness. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.R8's (most recent fall) Nursing Note dated 3/25/2026 at 10:22 pm, documents the following: Note Text: 2030 (8:30 PM)- patient fell after standing up from recliner in room. CNA (Certified Nursing Assistant) entering room when patient fell. Right side of (R8's) head hit bedside table causing laceration. Large skin tear to right elbow. Bleeding controlled with pressure to both sites.On 4/3/26 at 8:10 am, R8 was seated in a wheelchair three feet from R8's bed. R8's call light cord was attached to R8's pillowcase on R8's bed. R8 stated I can't reach that call light (stretching his right arm out falling short approximately 18 inches from the call light). I can't call those girls if I need something.On 4/3/26 at 8:15 am, V37 Certified Occupational Therapy Assistant (COTA) confirmed R8's call light was out of R8's reach. V37 COTA stated to R8 Let me fix that. You should always have your call light within reach. I am sorry about that.

Based on observation, interview and record review the facility failed to provide incontinence care in a timely manner for one (R2) of eight residents reviewed for incontinence care/activities of daily living on the sample list of nine residents.Findings include:R2's current Diagnoses List documents the following: Diabetes Mellitus Type II, with Hyperglycemia, Diabetes Mellitus Type II, with Polyneuropathy (damage nerves, causing numbness, tingling and weakness), Diabetes Mellitus Type II, with Chronic Kidney Disease, Dependent on Renal Dialysis, Low Back Pain, Unspecified, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Difficulty Walking, Not Elsewhere Classified and Depression.R2's Current Physician Order Sheet documents the following diuretic (stimulates the kidneys to excrete excess fluid from the body) medication order: Spironolactone Oral tablet 50 milligrams, give one tablet by mouth in the morning, related to Essential Hypertension.R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview of Mental Status (BIMS) score as 12 out of a possible 15, indicating moderate cognitive impairment.The same MDS documents, R2 is dependent on staff for substantial/maximum assistance, with all Activities of Daily Living (ADL), except eating.The same MDS documents R2 is frequently incontinent of bladder and always incontinent of bowel.R2's current Care Plan documents the following: (R2) has an ADL self-care performance deficit r/t (related to) Fatigue and recentsurgery, Hemiplegia, weakness, SOB (Shortness of Breath) on exertiondue to CHF (Congestive Heart Failure). Transfers (R2) requires sit to stand lift. Encourage the resident to use bell to call for assistance.R2's same Care Plan documents: (R2) has MASD (Moisture Associated Skin Damage) to the scrotum/ bilateral buttocks. MASD to bilateral buttock/scrotum will show signs of healing within 5-7 (five to seven) days Date Initiated: 03/30/2026.Administer treatment as ordered.Educate resident/family/caregivers of causative factors and measures to prevent skin injury.Encourage good nutrition and hydration to promote healthier skin. Follow facility protocols for tx (treatment) of injury.Keep skin clean and dry. Use lotion on dry skin. Do not apply in open areas.Avoid scratching and keep hands/body parts from excessive moisture.Keep fingernails short.Observe/document location, size, and treatment of skin injury.Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration, etc. to MD (Medical Doctor).Weekly tx (treatment) documentation to include measurement of each area of skin breakdowns, width, length, depth, type of tissue and exudate, and any other notable changes/observations.Wound MD/wound nurse (V58 Wound Physician / V8 Wound Licensed Practical Nurse and V39 Wound Registered Nurse), round weekly as indicated by wound needs.R2's Wound Assessment -Detail Report dated 4/1/26 documents the following: Left Buttock, MASD due to incontinence, and present on admission 3/26/26.On 4/3/26 at 8:55 am, R2 was lying in bed. R2's bed was elevated with the mattress approximately three and a half feet above the floor. R2 had a strong feces odor permeating R2's room. R2's call light was out of reach, on the floor. R2 stated R2 has no way to call staff for assistance. R2 then stated R2 was thinking, A night shift Certified Nursing Assistants (CNA)(unidentified), probably left me with my bed elevated and my call light out of reach, when they changed me in the middle of the night. R2 also stated I am not sure if I am wet now. I know I had some wet gas overnight. I think I might have leaked then. I need to be checked. Could you let one of the nursing aides know?On 4/3/26 at 9:03 am, V40 Certified Nursing Assistant entered R2's room, adjusted R2's bed, provided call light and stated V40 CNA will tell R2's CNA (V16 CNA) that R2 needed incontinence care.On 4/3/26 at 9:10 am, V16 CNA stated I have not changed (R2) yet today. I came in at 6:00 am. Night shift told me in report they did (R2's) care around 5:00 am, on rounds. I was just going to check on him.On 4/3/26 at 9:30 am (approximately four hours and thirty minutes from last incontinence care, per V16 CNAs above interview), V39 Registered Nurse/Wound Nurse, V41 CNA and V16 CNA entered R2's room, after they put on Personal Protective Equipment (PPE). V16 and V42 CNAs completed R2's incontinence care. R2 was incontinent of feces that had dried on R2's bilateral buttocks. R2 had visible, bilateral buttocks Moisture Associated Skin Damage (MASD) with pencil eraser shearing in two areas on the left buttocks, and one area of R2's right buttock. V39 Wound Registered Nurse recleaned R2's bilateral buttocks with wound cleaner and applied Triad medicated wound paste, as the physician ordered. V39 Wound Registered Nurse confirmed R2's MASD was likely caused by delays in incontinence care.The facility policy Subject: TOILETING AND INCONTINENT CARE dated as revised January 2026 documents the following: PURPOSE:To provide guidelines to all nursing staff for providing proper assistance with toileting and incontinence care to clean skin so it remains clean, dry, free of irritation and odor.POLICY:All will receive assistance with toileting needs according to their plan of care guidelines. Incontinence care will be provided to keep skin clean, dry, free of irritation and odor. Incontinence care will be provided after each incontinent episode.RESPONSIBILITY:It is the responsibility of the C.N.A. to provide toileting assistance and incontinence care after each incontinent episode.It is the responsibility of the Charge Nurse to ensure that residents are provided toileting assistance and incontinent residents receive appropriate incontinence care.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 193 residents residing in the facility.Findings include:On 3/1/26 at 8:09am, V4 [NAME] stated V3 is the Dietary Manager.On 3/1/26 at 10:55am, V3 Dietary Manager was actively supervising dietary operations in the facility kitchen during resident meal preparations. V3 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Facility assessment dated [DATE] documents the facility's Staffing Plan includes a Certified Dietary Manager. The Facility Staff Roster (undated) documents V3 as the Dietary Manager.The facility Long-Term Care Facility Application for Medicare and Medicaid dated 3/1/26 documents 193 residents reside in the facility.

Failures at this level required more than one deficient practice statement. A. Based on interview and record review, the facility failed to develop a water management plan that included the required risk assessment, ranges for control measures, and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 193 residents in the facility. B. Based on observation, interview, and record review the facility failed to maintain appropriate handwashing during incontinent care for one of four residents (R92) reviewed for infection control in a sample of 62.Findings include: A. On 3/5/2026 at 11:40AM, the facility water management plan (February 2020) failed to document the required facility water system risk assessment where Legionella and other pathogens could grown and spread in the facility water system. The same record did not document the required consideration of the ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) standard or the (CDC) Centers for Disease Control and Prevention Water Management Program toolkit. The plan did not identify any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system. On 3/5/2026 at 11:45AM, V27 (Maintenance Director) reported the facility has not completed any water system survey or risk assessment and has not developed any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system. The facility Long-Term Care Facility Application for Medicare and Medicaid (3/1/2026) documents 193 residents reside in the facility. B. On 3/03/2026 at 11:05 AM, V15 Certified Nurse Aide (CNA) and V16 Licensed Practical Nurse (LPN) provided incontinent care to R92 who had been incontinent of a large amount of soft brown stool. V16 used disposable cleansing wipes and swiped R92's right buttock and her glove became soiled with fecal material. V16 removed soiled gloves and donned new gloves with no hand hygiene performed. V16 continued to cleanse feces from R92's left buttock and rectum and changed her soiled gloves without performing hand hygiene between glove changes. After all feces removed from R92's buttock and sacrum, V17 Registered Nurse (RN) entered R92's room wearing gloves and replaced a soiled dressing from R92's sacrum then left the room without performing hand hygiene. V15 turned R92 onto her left side and used a disposable cleansing wipe to swipe once between R92's legs and then proceeded to apply a new adult diaper and dressed R92 wearing the same soiled gloves without performing hand hygiene. On 3/4/2026 at 9:24 AM, V15 stated she is aware that she should have washed her hands between every glove change while performing incontinent care. On 3/4/2026 at 9:53 AM, V2 Director of Nursing stated she would expect staff to wash their hands when they enter or leave a room and when they change their gloves. On 3/5/2026 at 12:52 PM, V16 stated she is supposed to wash her hands after the third or fourth time of changing gloves with using sanitizer in between each change. V16 stated she didn't do that when she provided incontinence care to R92 on 3/3/26. The facility's policy, Hand Washing, revised 2/25 documents this facility considers hand hygiene the primary means to prevent the spread of infections. All staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed. Procedure: 5. (Employees must wash their hands for 15-20 seconds using antimicrobial or nonantimicrobial soap and water under the following conditions: A. Before and after direct contact with residents. B. When hands are visibly soiled with blood and other bodily fluids D. after removing gloves)

Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review the facility failed to maintain call lights accessible for resident use. This failure affects five of five residents (R1, R2, R11, R64, R97) reviewed for call lights on the sample list of 62.B. Based on observation, interview, and record review, the facility failed to ensure an electric bed remained consistently functional to maintain a resident's toileting independence. This failure affects one resident (R155) of ten reviewed for accommodation of needs in the sample list of 62. Findings Include: A. The facility's Call Lights policy dated January 2026 documents when a resident is in bed or in a chair, staff are to ensure the call light is within easy reach of the resident. On 3/1/26 between the hours of 11:00 AM and 12:00 PM R1, R2, R11, R64, and R97 were observed in their rooms without accessibility to their call light. Call lights were found on the floor or in areas not accessible to the residents. 1. On 3/1/26 at 11:42 AM R1 was in her room in her wheelchair. The room smelled of bowel movement and R1 stated she was soiled and needed to be changed. She had been waiting awhile for staff but did not have her call light. R1's call light was coiled up on the floor out of her reach. R1's Care Plan dated 1/28/26 documents R1 has a self care deficit related to Intellectual Disability, Impaired Mobility, Poor Safety Awareness, and Bowel and Bladder Incontinence. Staff are to encourage R1 to use the call light for assistance. R1 is also at risk for falls related to Deconditioning, Gait/Balance Problems, Syncope, Legally Blind in the Left Eye, Poor Safety Awareness and Impulsivity. Staff are to keep call light within R1's reach. 2. On 3/1/26 at 11:55 AM R2 was in her room in her wheelchair. R2 stated she needed some fresh ice water. R2 stated she would use her call light but couldn't reach it. R2's call light was hanging over a folded fall mat just out of her reach. R2's Care Plan dated 1/23/26 documents R2 is at risk for falls related to Impaired Cognition due to Dementia. Staff are to educate R2 to use her call light for assistance and keep call light within reach. 3. On 3/1/26 at 11:05 AM R11 was sitting on the side of her bed. R11's bed was soiled and the room smelled of urine. R11's call light was on the floor coiled by wall not within R11's reach. R11's Care Plan dated1/8/26 documents R11 is at risk for falls and requires staff assistance for Activities of Daily Living. 4. On 3/1/26 at 11:52 AM R64 was in her room sitting on her bed. R64 stated she needed help. R64 did not know where her call light was. R64's call light was on the floor under her bed and out of R64's reach. R64's Care Plan dated 2/26/26 documents R64 is at risk for falls related to Weakness and Deconditioning, Incontinence, and Vision and Hearing problems. Staff are to ensure R64's call light is within reach and encourage R64 to use it to call for assistance. Staff should respond promptly to all requests for assistance. 5. On 3/1/26 at 11:40 AM R97 was sitting on her bed asking for help. R97 stated she was cold and needed a blanket. R97 stated she did not know where her call light was. R97's call light was coiled up on the floor out of reach. R97's Care Plan dated 2/20/26 documents R97 is at risk for falls related to Left Hemiplegia and Confusion. R97 requires staff assistance for Activities of Daily Living. Staff are to keep R97's call light within reach. On 3/2/26 at 4:50 PM V1 Admin confirmed call lights should be kept within resident's reach at all times. B. R155's diagnosis list (3/4/2026) documents diagnoses including Paraplegia, Muscle Wasting and Atrophy, Abnormality of Gait and Mobility, and Lack of Coordination. R155's Resident Assessment (12/8/2025) documents R155 is occasionally incontinent of bladder and frequently incontinent of bowel. The same record documents R155 has impaired lower extremity range of motion, is unable to walk, and uses a wheelchair for mobility. On 3/2/2026 at 9:10 AM, R155 was laying in an electric bed with a commode located beside R155's bed. R155 reported independent use of the commode for bowel and bladder toileting. On 3/3/2026 at 12:21PM, R155 reported raising and lowering the electric bed via a bed remote control to facilitate transfers on and off of the commode. R155 reported the remote has been intermittently malfunctioning for months disallowing R155 to position the bed at the same height as the commode to facilitate independent transfer on and off of the commode. R155 reported the remote will quit working and then the bed will be stuck at a higher position than the commode creating difficulty in transferring back into the bed. R155 reported the commode will then slide on the floor when R155 is fighting so hard to transfer back into bed after using the commode. R155 reported informing facility staff numerous times about the malfunctioning bed remote and staff not addressing the problem in a timely manner. R155 reported having to manipulate the wires to successfully use the remote to position the bed appropriately prior to transferring to the commode. R155 reported R155 shouldn't have to do that. R155 then retrieved the bed remote to attempt to lower or raise the bed height but the remote buttons did not work when depressed. The facility maintenance log (2025-2026) documents wires hanging from R155's bed remote on 1/8/2026, the bed remote not working on 1/29/2026, and not working again on 3/2/2026. On 3/4/2026 at 10:53AM, V20 (Licensed Practical Nurse) reported having a history of providing care to R155 and and denied R155 makes false statements related to staff and nursing care.

Based on observation, interview, and record review the facility failed to provide adequate supervision and implement interventions to prevent accidents. These failures affect three of eight residents (R124, R133, R148) reviewed for accidents and supervision on the sample list of 62. Findings Include: 1. R133's Medical Diagnoses Sheet date March 2026 documents R133 is diagnosed with Dysphagia, Hemiplegia, and Vascular Dementia. R133's Physician Order Sheet dated March 2026 documents a regular mechanical soft diet order. R133's Minimum Data Set, dated [DATE] documents R133 is cognitively intact and coughs or chokes during meals or when swallowing medications and has complaints of difficulty or pain with swallowing. R133's Care Plan dated 2/27/26 documents R133 has a swallowing problem related to a diagnosis of Dysphagia. R133 is at risk for Choking and Aspiration. R133 should eat only with supervision. R133's Nurse Progress note dated 2/6/26 documents R133 reported she had a choking episode that day during the noon meal. R133 had a short instance of labored breathing. R133's diet order was downgraded and a request for Speech Therapy to evaluate R133 was entered. On 3/1/26 at 12:10 PM R133 was eating her lunch in her room in bed with no staff supervision. On 3/3/26 at 12:37 PM R133 was eating her lunch in her room in bed with no staff supervision. On 3/3/26 at 12:55 PM V9 Director of Therapy stated R133 was referred for a speech evaluation regarding a diet upgrade. There was no mention of a choking or coughing episode. V9 stated if a resident is referred to speech therapy for a choking episode or difficulty swallowing, the therapy staff need to be notified of that in the referral so they can see the resident right away. V9 confirmed that a nurse's note was documented in R133's chart on 2/6/26 stating R133 reported a choking episode to the nurse and R133's diet was downgraded to mechanical soft until an evaluation was completed. V9 confirmed staff should have notified speech therapy right away of the choking episode so R133 could have gotten evaluated quickly. V9 stated the last time R133 was in speech therapy was in May 2024. Upon discharge from therapy at that time, recommendations to address aspiration risk included set up assistance and supervised dining room. Strategies to facilitate safety include an upright posture and supervised dining among other things. On 3/3/26 at 3:56 PM V2 Director of Nurses (DON) confirmed R133 reported to staff she had a choking episode while eating. V2 confirmed that a resident that has a potential choking episode should be evaluated by speech therapy and should have increased monitoring and supervision while eating until deemed safe to dine unsupervised. V2 confirmed therapy should have already assessed R133 as almost a month had passed. 2. R148's Medical Diagnoses sheet dated 1/26/26 documents diagnoses including wedge compression fracture of the fourth lumbar vertebra (subsequent encounter with routine healing), pneumonia, and acute respiratory failure with hypoxia. The MDS dated [DATE] documents R148 is moderately impaired cognitively, dependent on staff for all activities of daily living, displays behaviors of inattention and disorganized thinking, and is incontinent of bowel and bladder. The facility's incident report dated 2/22/26 documents that R148 ingested an unknown amount of (Name Brand) Shampoo and Body Wash. According to the report, V24, CNA (Certified Nurse Assistant) entered the room and observed R148 holding the bottle with the lid off and asking if V24 would like a drink, as it tastes good. V24, CNA stated she did not know how much was in the bottle prior to ingestion. V24, CNA removed the bottle, discarded it away from the resident, and notified V25, LPN (Licensed Practical Nurse). The facility's incident report dated 2/22/26 documents upon V25 LPN's initial assessment, R148 showed no impairment to her airway and was behaving at baseline. After paging the provider, R148 began vomiting. Vital signs were retaken and showed an oxygen saturation of 85%. Lung assessment revealed diminished breath sounds with additional abnormal noises. The provider ordered R148 to be transferred to the emergency room (ER). EMS (Emergency Medical Service) was contacted, and V25, LPN sent the bottle of shampoo/body wash with EMS for physician review. On 3/4/26 at 9:35 AM, V24 stated the bottle should not have been there and believed the night shift had left it out. She further stated that R148's breathing and speech became odd, prompting reassessment and notification of the nurse. V24 reported the resident vomited 30–60 minutes after ingestion, developed diarrhea, and required oxygen while awaiting EMS. On 3/4/26 at 9:42AM V25, LPN confirmed that she responded immediately when notified, assessed R148, notified the physician, and initiated transfer after observing vomiting, abnormal lung sounds, and low oxygen saturation. The undated manufacturer's Safety Data Sheet for (Name Brand) Shampoo and Body Wash documents the product is for external use only and instructs users to consult a physician if ingested. On 3/4/26 at 2:30 PM, V2, DON (Director of Nurses) acknowledged awareness of the incident and stated that the shampoo/body wash should not have been left out where R148 could reach it and drink the contents. 3. R124's diagnosis list (1/7/2026) documents diagnoses including Dementia, Osteoporosis, and Osteoarthritis. R124's Resident Assessment (12/5/2025) documents R124 has severely impaired cognition and a history of falls. R124's fall risk assessment (2/1/2026) documents R124 is at high risk for falls. The facility fall investigation (2/6/2026) documents R124 resides on the memory care unit of the facility and had an unwitnessed fall on 2/6/2026. The investigation documents R124 was found by staff on the ground at the doorway to the central bathroom and staff were subsequently educated to keep the central bathroom door closed and locked at all times. On 3/4/2026 at 11:30AM, the above central bathroom doorway was observed closed and locked with a door handle keypad present on the door. V19 (Dementia Unit Director) was present and reported the door is supposed to remain shut and locked at all times and residents should only access the bathroom with staff supervision. V19 reported facility staff had propped the door open on 2/6/2026 when R124 accessed the bathroom independently and experienced a fall to the ground.

Based on observation, interview and record review the facility failed to administer medications according to physician's orders for three of 11 residents (R51, R116 and R187) reviewed for medication administration on the sample of 62 residents. The facility had three errors out of 27 opportunities resulting in a medication error rate of 10.71 percent. Findings include: 1.) R51's March 2026 Physician Order Sheet (POS) documents an order for Lidocaine External Patch 4 % (Lidocaine). Apply to left lower back topically one time a day for back pain ON for 12 hours and then remove/OFF for 12 hours and remove per schedule. On 3/2/26 at 5:33 AM V23, Registered Nurse (RN) prepared to apply R51's Lidocaine patch on R51's left lower back. At that time R51 had a lidocaine 4% patch on his back. V23 removed the old patch and placed a new patch on R51's left lower back area. V23 stated at 5:40 AM on 3/2/26 The nurse working must have forgotten to take the old patch off last night. 2.) R116's March 2026 POS documents an order for Calcium Carbonate-Vit D-Min Oral Tablet 600-400 MG-UNIT (Calcium Carbonate-Vitamin D w/ Minerals) Give 1 tablet by mouth in the morning for supplement. V28, RN stated on 3/2/26 at 7:20 am I am not able to give R116 all of her medications because her Calcium Carbonate is not here in the medication cart. 3.) R187's March POS documents an order for Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT 1 puff inhale orally two times a day related to PERSONAL HISTORY OF PULMONARY EMBOLISM. V22, LPN stated at 4:45 AM R187 is not receiving his Fluticasone-Salmeterol medication because I cannot find it in the medication cart. I will need to contact the physician to let them know the medication was not given. The facility's policy titled Administration of Medication with revision date of 1/2026 states: Residents shall receive their medications on a timely basis in accordance with state and federal guidelines, and within established facility polices. V2, DON (Director of Nurses) stated on 3/3/26 at 2:30 PM Yes, I know the nurses told me of the errors of the medications.

Based on observation, interview, and record review, the facility failed to ensure insulin pens were dated when opened and medications were discarded when discontinued. This failure affects four of four residents (R222, R47, R21, R89) reviewed for medication storage in the sample of 62.Findings include:On 3/4/26 at 11:45 AM the East Medication Cart on first floor contained a Lantus SoloStar Subcutaneous Solution Insulin Pen-injector 100 Unit/ML (Insulin Glargine) for R222 which was undated. V26, RN (Registered Nurse) stated at 11:50 AM on 3/4/26, I did not realize it was not dated. On 3/4/26 at 12:15 pm the Second Floor East Hall medication cart contained the following Insulin pens which were undated:R47's, Tresiba FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Degludec) was present in the medication cart, and the label did not document an opened date. R47's Medical Record documents this medication was discontinued on 2/23/26. R21's, Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) was present in the medication cart, and the label did not document a date when the pen was opened.R89's, Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) was present in the medication cart, and the label did not document a date when the pen was opened. On 3/4/26 at 12:17 PM V20 LPN (Licensed Practical Nurse) stated The pens will be removed and disposed of, I did not know they were not dated.The facility policy with revision date of 8/24 titled Labeling of Medications under the section titled Policy states The facility will ensure that medications are properly labeled in accordance with current state and federal requirements. V2, Director of Nurses stated on 3/4/26 at 2:00 PM The medications found without dates have been disposed of and replaced with new medications dated appropriately.

Based on observation, interview, and record review the facility failed to maintain and provide timely and dignified quality of care. This failure affects two of three residents (R1, R155) reviewed for dignity on the sample list of 62.Findings Include: The facility's Resident Rights for People in Long Term Care policy dated November 2018 documents residents in long term care facilities have the right to be treated with dignity and respect. The facility must provide services to keep each resident's physical and mental health at their highest practical levels. 1. On 3/1/26 at 11:42 AM R1 was in her room in her wheelchair. The room smelled of feces and R1 stated she was soiled and needed to be changed. R1 stated she had been waiting a long time for staff to come and change her. R1 appeared upset and kept repeating that she just needed help and wanted to be cleaned up. When asked how she felt, R1 replied, yucky. R1's Medical Diagnoses list dated March 2026 documents R1 is diagnosed with Legal Blindness, Moderate Intellectual Disabilities, Repeated Falls, Muscle Wasting and Atrophy, Gait and Mobility Abnormalities, and Lack of Coordination. R1's Minimum Data Set, dated [DATE] documents R1 is moderately cognitively impaired and is always incontinent of bowel and bladder and dependent on staff for toilet transfers and toileting hygiene. R1's Care Plan dated 1/28/26 documents R1 has a self-care deficit related to Intellectual Disability, Impaired Mobility, Poor Safety Awareness, and Bowel and Bladder Incontinence. Staff are to encourage R1 to use the call light for assistance. Staff are to keep call light within R1's reach. R1 has the potential for Impaired Skin Integrity related to Bowel and Bladder Incontinence, Obesity, and Impaired Mobility. Staff are to keep skin clean and dry. On 3/2/26 at 4:50 PM V1 Administrator confirmed staff should provide prompt care for residents to promote their quality of life and honor their right to be treated with dignity. 2. R155's diagnosis list (3/4/2026) documents diagnoses including Paraplegia, Muscle Wasting and Atrophy, Abnormality of Gait and Mobility, and Lack of Coordination. R155's Resident Assessment (12/8/2025) documents R155 is occasionally incontinent of bladder and frequently incontinent of bowel. The same record documents R155 has impaired lower extremity range of motion, is unable to walk, and uses a wheelchair for mobility. On 3/02/2026 at 9:10 AM, R155 was in bed with a commode located beside R155's bed. R155 reported independent use of the commode for bowel and bladder toileting. R155 reported facility staff take 20-40 minutes to empty the commode after use when R155 activates R155's call light. R155 reported the staff delay in responding to call lights occurs two to three times a week on second shift and is worse on the weekends. On 3/3/2026 at 11:58AM, R155 reported Certified Nurse Aides will frequently enter R155's room, shut the activated call light off, and then not return for 30 or more minutes to provide assistance to R155. On 3/4/2026 at 10:53AM, V20 (Licensed Practical Nurse) reported having a history of providing care to R155 and denied R155 makes false statements related to staff and nursing care. V20 reported sometimes only having one Certified Nurse Aide to take care of the residents on the East hall of the second floor, but they try to get to call lights as soon as possible. V20 reported R155 uses a bedside commode independently. Resident Council Meeting Minutes (January 2026) document resident complaints of call light response times of staff are getting lengthy. The facility Resident Privacy and Dignity policy (8/2/2017) documents all staff are responsible to ensure all residents have privacy and dignity.

Based on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS) assessment was completed upon discharge from the facility for one (R105) of four residents reviewed for resident assessments on the sample list of 62.Findings include:R105's Electronic Medical Record (EMR) documents R105 discharged from the facility to the hospital on [DATE] and did not return to the facility.R105's Census List documents and confirms R105 was discharged from the facility on 11/12/25.R105's MDS summary page (dated 3/3/26) documents R105's last MDS was completed on 10/11/25 and documents R105's Discharge ARD (Assessment Reference Date) of 11/12/25 and was 97 days overdue.On 3/3/26 at 1:09pm, V8 MDS Coordinator confirmed via email that R105 went to the hospital on [DATE] and did not return to the facility. This same email documents a discharge MDS was not completed (for R105) and therefore not done.

Based on observation, interview, and record review, the facility failed to update and revise a resident's care plan for suprapubic catheter care. This failure affects one (R27) of 35 residents reviewed for care plans on the sample list of 62.Findings include:The facility's Care Planning Policy (revised June 2024) documents the following: To utilize the results of the comprehensive assessment to develop, revise and review resident's care plan. To provide a method for all staff to have needed information in caring for the residents. Each resident will have a plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care. The resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate, and planned to meet the individual needs of the resident consonant with the physician's plan of care. The resident care plan must be kept current at all timesOn 3/1/26 R27 was observed with a suprapubic catheter in place.R27's Face Sheet dated 3/5/26 documents R27 was admitted to the facility on [DATE] with diagnoses including Obstructive and Reflux Uropathy, Hydronephrosis with Ureteropelvic Junction Obstruction, and Benign Prostatic Hyperplasia with lower urinary tract symptoms.R27's Physician Order Sheet (current) documents the following orders: 10/27/25 - change suprapubic catheter as needed; 18 french latex 10 milliliter balloon related to obstructive uropathy and 12/12/25-Suprapubic site: Cleanse site, pat dry, apply T-gauze daily and as needed. R27's Care Plan (current) documents the following: [R27] has an indwelling catheter due to obstructive uropathy secondary to BPH (Benign Prostatic Hyperplasia )/Hydronephrosis with Ureteropelvic Junction Obstruction. Suprapubic catheter 8/7/25 returned from hospital with foley catheter due to being unable to replace SP (suprapubic) catheter. This same record does not document any parameters for care or monitoring of R27's suprapubic catheter. On 3/3/26 at 2:22pm, V2 Director of Nursing stated different people are responsible for different parts of the resident's care plan. V2 stated R27 has had a suprapubic catheter since late fall 2025 and R27's care plan should have been updated to reflect that change from indwelling to suprapubic at that time.

Based on interview and record review the facility failed to timely report daily weight changes for congestive heart failure to the physician for one of three residents (R3) reviewed for changes in condition in the sample list of nine. This failure resulted in R3 admitting to the intensive care unit for acute on chronic respiratory and heart failure requiring intravenous diuresis related to fluid retention. Findings include:R3's Minimum Data Set, dated [DATE] documents R3 as cognitively intact. R3's active care plan revised 11/6/25, documents R3 has congestive heart failure (CHF) and includes an intervention for daily weight monitoring and to notify the physician with weight fluctuations as ordered. R3's November 2025 Medication Administration Record documents the following: R3 receives Torsemide (diuretic) 20 milligrams (mg) by mouth daily. No additional doses were given prior to a one time dose of 40 mg on 11/11/25. Obtain daily weight before breakfast and report gain of 3 pounds (lb) in 24 hours or 5 lbs in one week related to Congestive Heart Failure. R3 weighed 355 lbs on 11/1, 11/2, and 11/8. R3 weighed 394.6 lbs (39.6 lb gain) and 393.5 lbs. There is no documentation in R3's medical record that a provider was notified of R3's weight gain until 11/11/25 or that R3 was assessed/monitored for CHF symptoms such as edema after 11/9/25, besides routine vital signs and pulse oximetry (SPO2). R3's Situation Background Assessment and Recommendation (SBAR) Communication Form dated 11/11/25 at 3:36 PM documents R3 was lethargic (sluggish), pale, and sleeping on and off throughout the shift. R3 had edema (swelling) to both arms and left leg. R3 also had low Hemoglobin contributing to lethargy. These symptoms were reported to V15 Nurse Practitioner at 11:00 AM and new orders were given for an additional one time dose of Torsemide 40 mg for fluid retention. R3's Change in Condition note dated 11/11/25 at 3:26 PM documents V15 also gave orders to monitor vital signs every hour for the next four hours and apply R3's continuous positive airway pressure (CPAP) for oxygen therapy while resting in bed. R3's vitals were monitored and CPAP applied with no significant changes noted. R3's Nursing Note dated 11/11/25 at 5:38 PM documents V15 was updated on R3's change in condition and ordered for R3 to transfer to the hospital. R3's Intensive Care Unit (ICU) History & Physical Note dated 11/11/25 at 8:32 PM documents R3 presented to the emergency room for evaluation of progressive shortness of breath and over 35 lb weight gain over the past several days. R3 was found to be hypoxic with oxygen at 3 liters per nasal cannula and was placed on bilevel PAP. R3's chest x-ray showed pulmonary vascular congestion and R3 was given intravenous (IV) furosemide 40 mg in the emergency room and was admitted to the ICU for ongoing need for noninvasive ventilation and close monitoring and management of acute on chronic hypercapnic, hypoxemic respiratory failure. R3's assessment includes acute on chronic respiratory failure with diuresis treatment; and acute heart failure exacerbation with IV furosemide 40 mg three times daily, strict intake/output monitoring, and daily weights. On 11/21/25 at 9:27 AM R3 stated R3 just got back from the hospital and she was hospitalized due to retaining fluid. On 11/24/25 at 12:10 PM V3 Director of Nursing (DON) stated V3 thought the provider was notified of R3's weight gain before 11/11/25 since R3 had such a significant weight gain we obtained reweights to ensure the weight was accurate. V3 stated physician notification would be documented in a progress note. At 1:50 PM V3 provided a copy of a facsimile (fax) letter dated 11/10/25 notifying V15 of R3's weight gain. This letter did not document receipt of confirmation or that it was reviewed by V15, confirmed with V3. V3 stated this was the only documentation V3 could locate for R3's weight gain notification. V3 stated V3 also spoke with V15 who said that V15 never received the facsimile notification. At 3:15 PM V3 stated CHF symptom monitoring would be documented on the Medication/Treatment Administration Records and sp02 monitored, if spo2 was abnormal this would prompt for a full respiratory assessment documented in nursing note. V3 confirmed this does not include monitoring for edema. V3 stated the Nurse Practitioners gave the facility a list of things they want to be called about and a list of things to fax, and weight gain is not something they want to be called about. V3 stated the Nurse Practitioners have someone that reviews the faxes, but we don't always receive anything back to confirm they reviewed the information that was sent. On 11/24/25 at 1:00 PM V18 Registered Nurse stated V18 had compared R3's weight on 11/10/25 to the day prior and it was the same, so V18 did not notify the provider. V18 stated V3 DON had staff obtain R3's reweights and V18 was unsure if the provider was aware of R3's weight gain. V18 thought someone had sent a message to V15's office. On 11/24/25 at 1:41 PM V15 stated no one notified V15 of R3's weight gain until 11/11/25, staff should have been following the daily weight CHF protocol and should have notified V15 sooner. V15 stated V15 would have doubled R3's Torsemide dosage for a few days then had Basic Metabolic Panel drawn after the last dose was given. V15 stated on 11/11/25 R3 was lethargic, R3's left arm was swollen and abdomen was distended/stretched, and R3 was not wearing her CPAP. V15 gave orders for a one time dose of Torsemide 40 mg and to reweigh R3 because V15 suspected an error with the weight, but it was confirmed with V17 Assistant at 5:00 PM that R3's weight was accurate. V15 stated R3 was hospitalized for fluid retention and required intravenous diuretics. V15 stated R3's hospitalization could have been prevented if staff had reported R3's weight gain sooner. The facility's Acute Condition Changes Clinical Protocol dated October 2025 documents prior to notifying the physician of acute changes in condition, the nurse will make observations and gather information to report to the physician, and will utilize the SBAR assessment when appropriate. This protocol documents for emergencies staff will call or page the physician and request a prompt response and the physician/practitioner will respond in a timely manner to notifications of changes in condition. This protocol documents many acute changes in condition can be effectively managed at the facility with outcomes comparable to hospitalization.

Based on interview and record review the facility failed to monitor and report changes in condition, including monitoring and reporting blood pressures, daily weights, and urination for two of five residents (R1, R2) reviewed for changes in condition in the sample list of nine. These failures resulted in a delay in treatment for R1's changes in condition, R1 was hospitalized with congestive hyponatremia (low sodium), acute kidney injury (AKI), renal failure, urinary tract infection (UTI), and required dialysis. The facility's Physician Notification of Resident Change of Condition policy dated [DATE] documents the Director of Nursing (DON) is responsible for monitoring the 24-hour report to ensure physicians are notified of changes in condition. This policy documents when there is a change in resident condition, the nurse must assess the resident, document the change in the resident's medical record, notify the resident's physician, and place the resident on the 24-hour report to ensure close monitoring of the condition on each shift.1.) R1's hospital Discharge summary dated [DATE] documents R1 was hospitalized for cystitis with hematuria, AKI, Acute on chronic respiratory failure, Pneumonia, Myocardial Infarction, Severe Sepsis, Pulmonary Edema, elevated B-Type Natriuretic Peptide, UTI and Acute Heart Failure. R1's Blood Urea Nitrogen (BUN) was 47 and Creatinine (Cr) was 1.8 on [DATE]. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and required supervision/touch assistance from staff for toileting hygiene and partial/moderate staff assistance for toilet transfers. R1's Care Plan dated [DATE] documents R1 receives diuretic therapy, monitor for side effects and effectiveness, observe/document/report adverse reactions including postural hypotension, report lab results to the physician, especially Sodium and Potassium. R1's [DATE] Medication Administration Record (MAR) documents R1's daily weight (pounds) as 144.9 on [DATE], 145 on [DATE], 148.8 on [DATE], 150.2 on [DATE], 149 on [DATE] and 149.6 on [DATE]; and to notify of three-pound gain in 24 hours or five-pound gain in one week. This MAR documents R1 received the following medications: Amlodipine 10 milligrams (mg) one tablet by mouth (PO) daily 8/13-[DATE] when changed to half a tablet daily. Lasix 20 mg PO daily, Isosorbide Mononitrate Extended Release (ER) 120 mg PO daily, Lisinopril 20 mg PO daily and Metoprolol Succinate ER 50 mg twice daily [DATE]-[DATE]. R1's Physician Orders dated [DATE] document to notify if no urinary output for eight hours, and reporting parameters for systolic blood pressure less than 100.R1's Urinary Continence report dated [DATE]-[DATE] documents R1 as continent/incontinent once on [DATE], [DATE], [DATE], [DATE], and twice on [DATE], [DATE], and [DATE]. This report does not document the number of times R1 urinated or the amount. R1's blood pressure log documents R1's blood pressures as follows:[DATE] at 4:02 PM 90/43 [DATE] at 5:21 PM 90 / 42 [DATE] at 4:24 PM 79 / 29 [DATE] at 2:52 PM 95 / 47 [DATE] at 7:36 AM 89 / 34 [DATE] at 11:04 PM 91 / 35 [DATE] at 11:10 PM [DATE]/2025 at 8:34 PM 91 / 39 [DATE] at 1:25 AM 149 / 49 [DATE] at 7:31 PM 138 / 71R1's Progress Note dated [DATE], recorded by V21 Nurse Practitioner, documents to continue daily weight and will recheck Basic Metabolic Panel (BMP). There is no documentation that a BMP was collected prior to [DATE]. The Coverage On-Call Note dated [DATE] at 10:29 PM documents nurse contacted V20 Nurse Practitioner to report that R1 reports she had not urinated for two days, and R1 had been eating/drinking well with fluids encouraged. This note documents V21 ordered Urinalysis with culture and sensitivity this morning, but the nurse did not think this was completed. This note documents to straight catheterize to obtain urine sample and if greater than 300 cubic centimeter of urine return then leave the catheter inserted. R1's Progress Note dated [DATE], recorded by V21, documents R1 reported having minimal urine output for the last couple of days, R1's BUN was 76 and Cr was 6.2 on [DATE], will send R1 to the emergency room for further evaluation and treatment. R1's Nursing Notes document the following: -[DATE] at 7:36 AM R1 reported scanty urine overnight and was concerned she may be developing UTI. A request for straight catheterization and urinalysis was sent via electronic facsimile to V28 Physician. -[DATE] at 6:47 AM R1's urinalysis/culture and sensitivity order note, will collect on Sunday shift for lab to pick up Monday morning. [DATE] at 7:39 PM due to lab schedule, will collect tomorrow. [DATE] at 12:24 AM due to lab schedule, collect tomorrow.- [DATE] at 1:40 PM R1 urinated twice this shift and had removed the collection hat from the toilet, and the second time urine sample obtained by clean catch, but was contaminated with bowel movement. Urine sample to be collected and picked up on Monday. - [DATE] at 10:05 PM R1 voided in collection hat, but urine was contaminated with bowel movement. R1 also voided in the shower, but was unable to collect sample. R1 was unable to void again at this time. -[DATE] at 5:20 AM R1 had minimal urine in collection hat, missed hat. -[DATE] at 1:13 PM Unable to obtain R1's urine sample. -[DATE] at 10:17 PM R1's urine was collected via straight catheterization and placed in the fridge for lab pick up.-[DATE] at 1:21 PM V21 Nurse Practitioner reported R1 is being sent to the hospital due to critical lab results, acute kidney injury, low output, and increased confusion.R1's Care Plan Conference Note dated [DATE] document R1 and V23, R1's Family, voiced concerns regarding urine output and fluids; and V23 reported this to the floor nurse. R1's medical record does not document that R1's urine output and urine characteristics were routinely monitored every shift between [DATE] and [DATE], that R1's low blood pressures were reported prior to [DATE], or that R1's weight gain was reported to a provider. There is no documentation in R1's nursing notes that a provider was notified of unsuccessful attempts to obtain R1's clean catch urine sample or urinalysis and culture results prior to [DATE]. R1's urine culture dated [DATE] documents Candida Albicans (fungus) 70-99,000 colony forming units per milliliter (cfu/ml).R1's hospital emergency room note dated [DATE] documents R1 reports for the last couple days she has had diarrhea which started yesterday, increased back pain and concern for possible UTI with painful urination and frequency. This note documents R1 as alert and oriented to person, place and time, and R1 had coarse rhonchorous lung sounds. R1's laboratory results showed [NAME] Blood Cell 14.07 (normal 4-11), B-Type Natriuretic Peptide 1785 (normal 0-100), BUN 85 (normal 10-20), Chloride 87 (normal 98-107), Cr 6.51 (normal 0.55-1.02), and Sodium (NA) 115 (normal 136-145). R1's chest x-ray documents patchy bilateral infiltrates, which are stable and noted on prior x-ray, may be related to congestive heart failure. R1's urine culture dated [DATE] documents greater than 100,000 cfu/ml of Nakaseomyces glabrata and Candida Albicans (bacteria.) R1 was admitted to the intensive care unit (ICU) with diagnosis of hyponatremia (low sodium), acute kidney injury, hypoxia (low oxygenation), renal failure, and hypochloremia (low chloride). R1's ICU note dated [DATE] documents R1 received IV fluids, IV antibiotics, and had low urine output. R1 had AKI on CKD likely prerenal from diarrhea and volume contraction and likely the cause of hypovolemia and hyponatremia, R1's baseline Cr is around 2.25 and baseline NA is 133-139. R1's AKI on CKD is likely acute tubular necrosis (kidney damage leading to AKI or renal failure) and R1 has possible Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) (body produces too much ADH causing water retention and hyponatremia). Lasix was held due to signs of hyponatremia and may need continuous renal replacement therapy (dialysis) if diuresis remains inadequate. R1's ICU Note dated [DATE] documents R1 started dialysis and was intubated due to worsening oxygen requirement. R1's Death Summary documents R1 expired on [DATE] at the hospital after almost 10 days of intubation with worsening shortness of breath and continued dialysis through today, family opted for comfort measures. On [DATE] at 3:48 PM, V23 (R1's Family) stated R1 had pneumonia and UTI prior to readmitting to the facility, and the staff should have been monitoring R1's urination and labs. V23 stated R1 had reported back pain and lack of urination to her, which had been reported to unidentified nurses on day four, but R1 went seven days before anything was done. V23 stated by that time, R1 had developed low sodium levels and kidney problems, and was hospitalized . V23 stated R1 was placed on a ventilator and is actively dying.On [DATE] at 11:31 AM, V8 Licensed Practical Nurse (LPN) stated R1 initially admitted to the facility for about 16 hours and was sent to the hospital for a heart attack and sepsis. V8 stated R1 returned from the hospital and was sent out again due to lab work and concerns about kidney function. V8 stated it started out that we needed to get a urine sample on V8's shift and a collection hat was placed in R1's toilet. V8 stated we couldn't get the urine sample because it was contaminated with bowel movement and the second time R1's roommate had removed the hat. V8 stated R1 wanted to use the toilet rather than trying to straight catheterize her, so we let her. V8 stated R1's lab results came back before her urine results. V8 stated lab does not collect on the weekend, we have to have someone drop the sample off at the lab, and we would have straight catheterized R1 if we wouldn't have gotten the sample by Monday for the lab to pick up on Tuesday. On [DATE] at 3:08 PM, V7 Certified Nursing Assistant (CNA) stated V7 took care of R1 one time and R1 complained of back pain, which was reported to the nurse. V7 stated urine output measurements are recorded for catheters, otherwise it is charted once per shift if the resident was incontinent or continent. On [DATE] at 3:21 PM, V6 Registered Nurse stated V6 sent R1 to the hospital as ordered by V21 for critical labs and concern for kidney issues on [DATE]. V6 stated R1 urinated that day and twice on her shift on [DATE] but was unsure of the amount. V6 stated we were checking R1's urine because R1 thought she had a UTI, R1 toileted herself at times and we attempted to get a clean catch specimen in the hat, but it was contaminated with bowel movement. V6 was unsure if V6 notified the provider of unsuccessful attempts to obtain R1's urine sample. V6 stated provider notification would be documented in the nursing notes. On [DATE] at 10:09 AM, V16 Licensed Practical Nurse (LPN) stated staff tried to obtain R1's urine sample, but R1 kept having bowel movements in the collection hat. V16 stated R1's urine was being tested because R1 had complained of scanty urination, per the nursing notes. V16 stated on 8/16 or [DATE] V23 told V16 R1 had not urinated, but then V23 took R1 to the bathroom and R1 urinated, so V23 told V16 not to worry about it. V16 stated V16 encouraged R1 to drink cranberry juice and water, and refilled R1's water pitcher multiple times. V16 stated R1 drank the fluids at mealtimes too. V16 stated V16 was urinating but was unsure of the amount. V16 stated a urine sample can't' be collected too early which would cause lab to deny it on Monday's pick up. V16 confirmed V16 did not attempt to straight catheterize R1 prior to [DATE], when the sample was obtained and sent to lab. V16 stated only clean catch attempts were made since R1 was able to use the bathroom, and straight catheterization is used for residents who are incontinent. V16 confirmed R1 had low blood pressure and thought V16 reported this to the provider, which would be documented in a nursing note. On [DATE] at 11:25 AM, V2 Director of Nursing (DON) stated the providers specify if a straight catheterization or clean catch is needed, and clean catch is attempted if the resident is able to urinate on their own. V25 Assistant DON stated we have a standing order to straight catheterize if we are unable to obtain a clean catch sample within 24-48 hours. V2 stated lab only collects samples on the weekends if it is for STAT (immediate) orders, otherwise lab collects on Monday. V25 stated the nursing staff should call the on-call nurse manager to drop off a specimen on the weekends. V25 confirmed R1's urine culture was completed on [DATE]. V2 reviewed R1's daily weights and confirmed R1's weight gain noted between [DATE] and [DATE] and confirmed provider notification if greater than three pounds in one day or five pounds in a week. V2 stated strict intake, and output is only recorded if the resident has a catheter, otherwise it is documented in a progress note or as needed in the CNA tasks as incontinent/continent not the number of times or amount. V2 stated if it isn't recorded in the tasks, then that doesn't mean that the resident did not urinate. V25 provided R1's provider notes and communication notes and confirmed [DATE] was the only notification of R1's low blood pressures. At 11:58 AM, V2 confirmed there was no documentation that a provider was notified of R1's weight gain. On [DATE] at 8:45 AM, V21 stated R1's low blood pressures were reported to V21 on [DATE] and R1's Amlodipine was decreased to 5 mg and parameters given for blood pressure medications. V21 reviewed R1's recorded blood pressures and stated R1's blood pressures should have been reported sooner and V21 would have made adjustments in R1's medications sooner and added blood pressure parameters for blood pressure medications. V21 stated the facility contacted V20 Nurse Practitioner on [DATE] and confirmed the order to obtain urine via straight catheter and leave in catheter if greater than 300 ml of urine return. V21 stated V20 communicated this to V21. V21 stated V21 evaluated R1 on [DATE] and ordered BMP and CBC, which V21 scheduled for [DATE] since R1 had labs on [DATE]. V21 stated daily weights should be monitored and reported if gain of three pounds in one day or five pounds in a week. V21 reviewed R1's daily weights and confirmed R1's weight gain was not reported. V21 stated if this was reported, V21 would have ordered a one-time additional dose of Lasix based on R1's [DATE] BMP. V21 confirmed the staff should have been monitoring R1's urine output after R1's complaints on [DATE]. V21 stated staff should notify the provider if it has been eight hours without urination and staff should have straight catheterized R1 on [DATE]. V21 stated this delay in treatment could lead to complicated UTI, decreased urine output, and AKI. V21 stated if V21 was made aware of these changes in R1's condition sooner, V21 probably would have sent R1 out to the hospital sooner due to needing fluids and diuresis on top of having congestive heart failure and renal disease. V21 reviewed R1's [DATE] urine culture and stated V21 would have treated this as a UTI since R1 was symptomatic. sent her out to the hospital sooner due to needing fluids on top of having CHF. Reviewed R1's urine culture results from facility [DATE], stated she would have treated it as a UTI since she was symptomatic. V21 stated decreased blood pressure and decreased urine output along with days without reporting could have contributed to R1's [DATE] lab results, and R1 could have been sent out sooner and may not have required dialysis. V21 stated R1 was very sick and had a lot of things going on, so it is hard to say if these failures and delay in treatment caused R1's death, it may have only prolonged things if R1 had received hospital treatment sooner. On [DATE] at 10:27AM, V20 stated V20 verbally gave R1's orders listed on [DATE] to the facility nurse. V20 stated the facility does not have a nurse manager on the weekends to remove the orders from (electronic health record software) so the orders aren't followed up on until Monday. 2.) R2's Progress Note dated [DATE], recorded by V20, documents post hospital evaluation for R2 who was hospitalized 6/13-[DATE] for congestive heart failure exacerbation, sepsis, pneumonia, orthostatic hypotension; and hospitalized 7/16-[DATE] for worsening anemia. upper gastrointestinal bleed from duodenal ulcer, weakness, and shortness of breath. This note documents R1's weight is up 10-15 pounds, suspect fluid overload from hospital hydration and blood administration, if BMP is stable on [DATE] will consider increasing Lasix over several days if weight remains elevated, continue to monitor vitals and weight daily. R2's Progress Note dated [DATE], recorded by V30 Physician, documents the same findings as V20 noted above and to monitor weight and vital signs daily. R2's [DATE] Medication Administration Record (MAR) documents to obtain daily weights and report weight gain of three pounds in 24 hours or five pounds in one week, but there is no documentation this order was resumed after R2 readmitted from the hospital on [DATE]. This MAR documents to obtain vital signs every shift, but the last recorded vitals are on dayshift on [DATE].R2's weight log documents R2's readmission weight as 160.4 on [DATE] and 175.8 on [DATE]. There are no recorded weights after [DATE].R2's blood pressure log does not document R2's blood pressure was obtained after dayshift on [DATE] prior to R2's hospitalization on evening shift on [DATE]. On [DATE] at 10:00 AM, V25 Assistant Director of Nursing (ADON) confirmed R2 did not have daily weights resumed after [DATE] and no vital signs documented after dayshift on [DATE]. V25 stated V25 thought R2 was still in the hospital on [DATE] and therefor discontinued some of his orders. V25 stated we are pushing for the providers to enter their orders into the resident's electronic medical record (EMR) so that it requires the nurse to sign off and activate the orders. V2 and V25 confirmed physician and nurse practitioner progress notes are not consistently uploaded into the resident's EMR, these notes have to be pulled from (electronic health record software), which the floor nurses do not have access to. On [DATE] at 10:27 AM, V20 stated per facility policy, vital signs should be monitored at least twice daily, and staff should have been monitoring R2's vitals and daily weights. V2 stated R2 had a history of edema and shortness of breath with prior hospitalization. V20 stated the protocol for daily weight monitoring is to report a three-pound gain in one day or five-pound gain in one month.

Based on observation, interview and record review the facility failed to use foot pedals during wheelchair transportation for two of four residents (R3, R4) reviewed for accidents in the sample list of nine residents. This failure resulted in R3's right leg contacting the floor causing ankle fractures. The facility also failed to supervise a cognitively impaired resident (R7) at risk for elopement, which resulted in R7 leaving the facility's property unnoticed. R7 was one of three residents reviewed for elopement in a sample list of nine. 1.) On 8/27/25 at 9:30 AM, R3 was sitting in her wheelchair in her room. R3's right leg was in a splint and elevated on the wheelchair leg rest. R3 stated that V3 Physical Therapy Assistant was pushing R3 in a wheelchair down to the therapy gym, R3's feet were sticking out and the wheelchair did not have foot pedals. R3 stated R3 had difficulty holding her legs up, R3's right foot went underneath of R3 causing R3's ankle to roll or twist and R3 screamed out in pain. R3 stated R3 has two broken ankle bones because of that incident. R3 stated R3 had right knee replacement surgery on 7/23/25, V29 (Podiatrist) applied R3's leg splint yesterday and told R3 that she could either choose to have surgery or go four to six weeks non-weight bearing without surgery. R3 stated R3 has a follow up orthopedic appointment next week to determine if there was any damage to R3's right knee. R3 stated R3 has not had any other falls or incidents that could have caused the injury. R3 stated R3 admitted to the facility for rehab and planned to return home, but now R3's recovery will take longer. R3's Minimum Data Set, dated [DATE] documents R3 as cognitively intact and has impaired range of motion to one lower extremity. R3's Care Plan active care plan documents R3 admitted to the facility following right knee arthroplasty (knee replacement), R3 has decreased functional ability and fatigue, and requires wheelchair for long distance transportation. R3's Incident Report dated 8/22/25 at 9:30 AM documents the following: R3 was assisted in wheelchair by staff while R3 was holding leg up with immobilizer in place. As R3 went over the threshold, R3 dropped her leg causing her foot to drop to the ground and R3 complained of pain after therapy. R3 reported that R3 thought she could make it to the therapy gym without wheelchair foot pedals, but by the time R3 made it to the threshold of the gym, R3 was too weak to hold her leg up causing her leg to drop. R3's right ankle portable x-ray dated 8/22/25 documents acute nondisplaced medial malleolus fracture of right ankle. R3's emergency room right ankle x-ray dated 8/23/25 documents R3 has severe osteopenia (low bone mineral density), R3 had Subtle linear lucencies noted through the medial and lateral malleoli suspicious for acute nondisplaced fractures and soft tissue swelling. R3's emergency room Note dated 8/22/25 at 11:09 PM documents R3 presented for ankle pain after being pushed in a wheelchair to therapy while R3's right knee was in immobilizer and without wheelchair foot pedals. R3 reported R3 was unable to hold her right leg up, her leg dropped and her foot/ankle bent underneath the wheelchair causing significant pain, [NAME], and bruising. R3's Progress Note dated 8/26/25, recorded by V29 Podiatrist, documents R3 was evaluated for right nondisplaced medial and lateral malleoli fractures. Treatment options were discussed and included fracture fragments are in anatomical alignment, given R3's age and limited ambulatory status related to knee replacement, conservative therapy would be an option, which would consist of four to six weeks of non-weight bearing followed by 4 weeks of weight-bearing in a boot prior to transitioning to ankle brace. Risk associated with this include continued instability of the ankle joint requiring of surgical intervention in the future and with R3's osteopenia, healing may take longer. Surgical intervention option would include fixation of the fractures to the right lower extremity, with weight-bearing pivot status approximately two weeks post-surgery, and full weight-bearing with boot for 4 weeks to transition back into an ankle brace. Associated risks include infection, pain, and need for additional surgery. R3 wanted to think about the treatment options before making a decision at this time. On 8/27/25 at 10:14 AM, V3 stated V3 was pushing R3 in a wheelchair down to the therapy gym, R3's right leg dropped as they crossed the threshold causing R3's ankle to turn. R3's right leg was in an immobilizer and there were no foot pedals on the wheelchair. V3 stated there were foot pedals in R3's room, but V3 did not apply them prior to transporting R3 to the gym. V3 confirmed the use of foot pedals would have prevented R3's leg from dropping. V3 stated the facility did an in-service and now everyone should have footrests on when being transported in a wheelchair by staff, and if they don't have footrests on, we are to ask the resident to self-propel their wheelchair rather than transporting them. On 8/27/25 at 2:05 PM, V2 Director or Nursing stated osteopenia is an underlying contributing factor, and V3 pushing R3 in a wheelchair without foot pedals, causing R3 to hold her legs up, caused R3's ankle fractures. V2 stated the facility does not have a policy regarding wheelchair transportation or use of foot pedals. V2 stated V2 expects foot pedals to be used whenever staff are pushing residents in a wheelchair long distances, otherwise the staff should have the resident self-propel their wheelchair. On 9/3/25 at 8:45 AM, V21 Nurse Practitioner stated on 8/22/25 R3 had ice on her ankle when V21 evaluated R3. R3 told V21 that her foot got caught underneath the wheelchair while staff transported her to therapy. V21 stated R3 did not have any complaints of ankle pain prior and had admitted post right knee replacement. V21 stated an x-ray was ordered and confirmed R3's ankle fractures. V21 stated it depends on the angle R3's foot/ankle got caught on whether this incident caused R3's fractures. V21 stated R3's right leg is weak due to post knee replacement, and staff should have used the footrests, which could have prevented R3's injury. 2.) On 8/27/25 at 9:23 AM, V13 Certified Occupational Therapy Assistant transported R4 in a wheelchair without foot pedals, down the hallway, past the nurses' station and into R4's room which was near the end of the hall. R4's feet were approximately two inches off of the floor. On 8/27/25 at 9:27 AM V13 stated R4 broke her clavicle from a fall prior to admitting to the facility and R4 is receiving physical and occupational therapy. V13 confirmed there were no foot pedals on R4's wheelchair and there should be. V28 stated V28 is going to have to get R4 foot pedals, and foot pedals should be used when transporting a resident in a wheelchair. On 8/27/25 at 9:49 AM R4 was lying in bed with a sling to her right arm. R4 stated R4 had fallen prior to admitting to the facility due to low blood sugar and broke her collar bone. R4 stated R4 doesn't have foot pedals on her wheelchair and R4 has to hold her feet up during transportation. There were no foot pedals in R4's room or on R4's wheelchair at this time. 3.) The Facilities Missing residents Policy Revised on 1/23 is to provide facility staff with guidelines for ensuring the health, safety and welfare of all residents, and protocol to be followed when a resident is noted to be missing. Each Unit Charge Nurse, during their respective tour of duty will be aware and responsible for always knowing the location of their residents. Nursing must report and investigate all reports of missing residents. This policy also documents that should an employee discover that a resident is missing from the facility, he/she should: Determine if the resident is out on an authorized leave or pass, Announce a Code “green” three times consecutively. Make a thorough search of the building and premises. If the resident is not located within 15 minutes the charge nurse will report the incident to the shift supervisor who will direct additional staff to search the premises outside of the facility. The residents attending physician will be notified. This policy also documents that upon return of the resident the facility, should announce a code [NAME] is all clear, examine the resident for injuries, contact the attending physician and report what happened, take orders pertaining to the resident condition and follow through as indicated. Contact the resident's legal representative and inform him/her of the incident. Complete and file an incident report, make appropriate notations in the medical record, reflecting all facts induing specific times, time discover, time of notification, local police, administrator. On 9/2/25 at 11:08AM, R7 was wandering around the memory care unit walking up to the doors and windows and looking outside. On 9/2/2025 at 12:37PM, V10 Licensed Practical Nurse reenacted how R7 left the building through the door in the memory care unit. V10 stated that she had left to go to break around 8:55AM and when she returned around 9:08AM, V18 (R9's Family) had come into the facility and told V10 that V18 thought a resident was in the church parking lot. V10 stated V10 ran outside, R7 was in the church parking lot and V10 called V2 Director of Nursing to report the situation. V10 did not complete an assessment, notify the Medical Director or the Power Attorney and didn't follow the Facilities Missing Resident Policy regarding R7's elopement from the facility on 8/31/25. On 9/2/2025 at 1:10PM, V1 Administrator stated he was unaware of the situation that had occurred with R7 as it wasn't reported to V1 and V1 just initiated an investigation into the incident. Video surveillance was viewed with V1 at this time. On 8/31/25 at between 8:55 AM and 9:07 AM R7 left the facility through the southwest alarmed door of the memory care unit walking across the parking lot and grass lot, towards a church located next to the facility. R7 was found by V18 (R9's Family) at the church, which is located approximately a football distance away from the facility door. At 9:10 AM V10 Licensed Practical Nurse was alerted by V18 and was observed going to get R7 in the parking lot of the church. V1 stated that no notification to the medical director, power of attorney, and green code was completed, as V1 is still investigating the failure. R7's minimum data set documented on 7/1/25 documents R7 is cognitively impaired. There is no documentation in R7's medical record that R7's elopement risk was reassessed after this incident or that new interventions were developed and implemented to address R7's elopement and exit seeking behavior. The last recorded Elopement Risk Assessment in R7's medical record is dated 7/6/25 and documents R7 as low risk. R7's active care plan documents the problem area elopement/risk wandering related to Dementia was not revised after R7's elopement until 9/3/25. On 9/2/2024 at 2:35pm, V2 Director of Nursing stated she received a call around 9:15am on 8/31/25 from V10 stating R7 had got out of the building and was next door in the church parking lot. On 9/3/2025 at 9:10AM, V21 (Nurse Practitioner) stated that there was no communication provided to any of the Physician On Call encounters from the facility about R7's elopement. V21 stated R7 has a history of Asthma, has a shuffled gait, and is at high risk for falling. V21 stated if V21 had been notified, she would have put in an intervention for increased monitoring or one to one supervision.

Based on interview and record review, the facility failed to obtain weights per physician orders for two residents (R89, R96) and failed to adequately monitor an at risk resident for weight loss, failed to obtain weekly weights, failed to notify the resident's representative of weight loss, and failed to develop a plan of care to address severe weight loss for one resident (R154). These failures affected three of ten residents (R89, R96, R154) reviewed for nutrition on the sample list of 82. These failures resulted in continued severe weight loss for R154. Findings Include: The facility's Weight policy dated March 2023 documents weekly weights will be done with a significant change of condition, food intake declines for more than one week, or with a physician order. Any resident with an unexplained significant weight loss will be ordered a supplement until discussed during weekly RISK meeting. The family or Power of Attorney will be notified of significant weight changes and plan of care which will be documented in the resident's chart. The Director of Nurses (DON) or designee will forward dietary recommendations to the Physician or Nurse Practitioner for approval. 1. R154's Medical Diagnoses list dated December 2024 documents R154 is diagnosed with Dysphagia, Vascular Dementia with Psychotic Disturbance, Major Depressive Disorder, Alzheimer's Disease, and Anxiety Disorder. R154's Minimum Data Set, dated dated dated [DATE] documents R154 is severely cognitively impaired and requires supervision or touching assistance of one staff member for eating. R154 has had a significant weight loss and is not on a physician-prescribed weight loss regimen. R154's Weight documentation from June 2024 to December 2024 documents R154 had a -22.80% severe weight loss from June (210.5 pounds) to December (162.5 pounds) and a -5.52% severe weight loss from 11/13/24 (172.8 pounds) to 12/6/24 (162.5 pounds). R154's monthly weights are documented as 6/27/24- 210.5 pounds, 7/11/24- 200 pounds, 8/2/24- 193.4 pounds, 9/4/24- 188 pounds, 10/24/24- 188.3 pounds, 11/13/24- 172.8 pounds, 12/6/24- 162.5 pounds. R154's Physician Order Sheet (POS) dated December 2024 documents that R154 is on a regular diet with pureed texture and honey-thick consistency liquids with a bedtime snack. There is no order for any nutritional supplements or increased weekly weight monitoring for R154. On 12/6/24, after R154's severe weight loss was discussed with V2 Director of Nurses, V13 Regional Registered Nurse, and V7 Registered Dietician, orders were added to R154's POS for weekly weights, blood draw for Albumin, fortified foods with meals -nutritionally fortified cereal at breakfast- and pudding cups three times per day. R154's Nutrition/Dietary Note dated 11/13/2024 (V7 Registered Dietician) documents a November weight of 172.8 pounds, which is down 8% in two weeks, 10% in three months, and 18% in six months. R154's diet was recently changed to puree/honey-thick liquids, but intakes still need to be better-fair per food logs. Recommendations include high-protein ice cream twice per day for extra calories and protein and weekly weights for four weeks or until weight is stable. R154's current Care Plan does not address severe weight loss or provide any plan or interventions to address R154's continued weight loss. On 12/06/24 at 11:11 AM, V19, the Certified Dietary Manager, confirmed that although the order for the high-protein ice cream was not entered into R154's POS, it was on her dietary card and provided for R154 at breakfast and lunch. V19 stated he does not enter the orders; that would be the nursing's job. V19 stated there are standing orders from each resident's physician for any Dietician (V7) recommendations to be followed. On 12/06/24 at 11:18 AM, V23 Licensed Practical Nurse confirmed she works with R154 regularly. V23 confirmed that staff obtain monthly weights for residents unless there is an order for weekly or daily weights to be done. Certified Nurses Assistant CNAs complete the weights and give their sheets to the nurses. Nurses enter the weights into the electronic medical record. V23 stated she does not verbally notify anyone about weight loss, she believes the electronic medical record system flags residents for weight loss and notifies the dietary department. V23 confirmed there was no order in the electronic medical record system for R154 to be weighed weekly. On 12/06/24 at 11:19 AM V21 Certified Nurses Assistant confirmed she just obtained R154's December weight today at 162.5 pounds. V21 stated R154 is not on weekly weights. R154 requires assistance with meals and her intakes are variable. On 12/06/24 at 11:37 AM V13 Regional Registered Nurse confirmed the high protein ice cream and weekly weight recommendation from V7 Registered Dietician should have been entered on R154's chart as an order and weights should have been completed weekly. V13 confirmed further weight loss could have been identified sooner and potential changes could have taken place such as adding further interventions or changing the timing of supplements. V13 stated she believes R154 is having unavoidable weight loss due to her deteriorating medical condition. V13 confirmed unavoidable weight loss has not been determined or documented on until today (12/6/24). On 12/06/24 at 12:08 PM V13 Regional Registered Nurse confirmed the weekly weights should have been completed and if further weight loss continued then V7 Registered Dietician should have been notified and could have at least attempted to implement further interventions. V13 confirmed a resident's physician and representative should be notified with changes of condition such as severe weight loss. On 12/06/24 at 12:16 PM V7 Registered Dietician confirmed if she would have been notified of continued weight loss, she could have increased the high protein ice cream or added pudding for R154. V7 confirmed some weight loss is to be expected due to R154's progressive medical diagnoses however this should be addressed in her plan of care. R154's physician and family should all be involved and even if further weight loss continues it wouldn't hurt to exhaust all of the available options (interventions). On 12/06/24 at 12:58 PM V2 DON and V13 Regional RN confirmed weight loss should have been addressed in R154's Care Plan and it should be documented in R154's record when the physician and/or resident representatives are notified of a change of condition (R154's severe weight loss). 41002 2. R89's Facility Census dated 12/5/24 documents R89 has the following medical diagnoses: Acute on Chronic Systolic (Congestive) Heart Failure, Ischemic, Cardiomyopathy, Chronic Systolic (Congestive) Heart Failure and Pleural Effusion. R89's Care Plan dated 11/17/23 documents R89 has the potential for fluid volume overload relayed to Congestive Heart Failure. Interventions: Weigh each morning before breakfast. Contact provider if gain of more than 3 pounds in 24 hours or 5 pounds in 1 week. R89's Physician Order Sheet (POS) dated 9/20/24 documents daily weight-Notify Medical Doctor if weight gain of more than 3 pounds in 24 hours or 5 pounds in 1 week, in the morning related to Chronic Systolic (Congestive) Heart Failure. R89's Minimum Data Set (MDS) dated [DATE] documents R89 had a 5% or more weight loss in the last month or a 10% or more weight loss in last 6 months and a 5% or more weight gain in the last month or a 10% or more weight gain in last 6 months. R89's Weight Summary documents from 9/20/24 to 10/5/24 R89 missing 53 daily weights. 3. R96's Facilities Census dated 12/5/24 documents R96 has the following medical diagnoses: Dependence on Renal Dialysis, End Stage Renal Disease and Congestive Heart Failure. R96's Care plan dated 8/17/21 documents R96 is nutritionally at risk due to diagnosis of Diabetes Mellitus and Hypertension related to dialysis. R96 has potential for weight fluctuations due to dialysis. Interventions: R96 will be weighed as facility directed policy and notify dialysis of weight gain. R96's Physician Order Sheet (POS) dated 11/21/24 documents obtain daily weights, notify Medical Doctor if weight gain of more than 2 pounds per day or 5 pounds in one week, in the morning every Tuesday, Thursday, Saturday and Sunday for Congestive Heart Failure. R96's Minimum Data Set (MDS) dated [DATE] documents R96 had a 5% or more weight loss in the last month or a 10% or more weight loss in last 6 months and a 5% or more weight gain in the last month or a 10% or more weight gain in last 6 months. R96's Weight Summary documents from 11/21/24 to 12/5/24 R96 missing 9 weights. On 12/4/24 at 10:15am R96 stated that the facility doesn't weigh R96 daily, they do it every so often. On 12/5/24 at 10:30am V1 Administrator stated that the facility is not weighing the residents per physician orders as they should be. V1 said the facility is going to address this issue with staff. V1 acknowledged that R89 and R96's were not getting weighed per physicians orders.

Based on an interview and record review, the facility failed to communicate regularly with the dialysis center to coordinate care and failed to monitor a dialysis central venous catheter access site for one resident (R22). This failure resulted in R22's hospitalization with a central venous catheter infection. R22 is one of two residents reviewed for dialysis on the sample list of 82. Findings include: The facility Dialysis Protocol (revised 9/23) documents the following: It is the responsibility of nursing to provide care for the dialysis resident. Nursing will also monitor the access site for signs and symptoms of infection or bleeding at the site. Communication with dialysis center will be done by nursing, dietary, and/or social services with a change of status in the patient's care or treatment. Dialysis will also communicate to the facility any abnormal lab work or change of orders. The resident's care plan will reflect their dialysis needs. The facility Nursing Home Dialysis Transfer Agreement dated 9/13/23 documents the facility will provide for the interchange of information useful or necessary for the care of the designated resident. R22's Face Sheet (current) documents the following diagnoses: End Stage Renal Disease, Chronic Kidney Disease, Dependence on Renal Dialysis, and Cellulitis of Chest Wall. R22's Care Plan documents the following: 7/26/23- Check daily at the access site. Monitor/document/report PRN (as needed) any signs and/or symptoms of infection to the access site-redness, swelling, warmth, or drainage. R22's Physician Orders (current) document the following order: Dialysis: May go to dialysis on Mondays, Wednesdays, Thursdays, and Fridays at [outside] dialysis center. R22 did not have orders to monitor R22's dialysis site in August, September, and October of 2024. R22 only had orders to monitor R22's dialysis site in November 2024 when R22 returned from the hospital on 11/8/24. This order was discontinued on 11/25/24. R22's EMR documents R22 was out of the facility at the hospital from 11/25/24 through 11/29/24. R22 did not have orders to monitor R22's dialysis site from 11/29/24 to 12/5/24. R22's Electronic Medical Record (EMR) does not document routine pre and post dialysis communication with the dialysis center. R22's Progress Note dated 11/5/24 at 2:59pm documents R22's dialysis port dressing to left upper chest saturated with brown discharge and reddened edema noted under port site. This same note further documents R22 stated dialysis sent a culture of drainage on Monday [11/4/24] and R22 states that it [dialysis site] looks worse and itches. R22 sent to Emergency department. R22's 11/5/24 Emergency Department Report documents the following: [R22] presented to the emergency department with the concern of dialysis line (central venous catheter) infection. Patient [R22] states has had increased drainage and itching for the past week. [R22] states the drainage is brown. Physical Exam: Left chest port site with surrounding erythema (abnormal redness of the skin) and mild warm. Mild to purulent (containing pus) drainage noted from the port site. Suspected central line associated bloodstream infection. [R22] treated with Zosyn (antibiotic) and Vancomycin (antibiotic). [R22] admitting diagnoses: Complication associated with dialysis catheter and Cellulitis of the chest wall. On 12/3/24 at 2:00 pm, R22 stated a communication notebook used to go with R22 to and from dialysis. R22 stated R22 has not seen it in a while. R22 stated R22 was hospitalized with a dialysis port infection in November, and facility staff were not monitoring R22's dialysis site. On 12/5/24 at 2:46pm, V14 Licensed Practical Nurse stated R22 has a bag R22 takes to dialysis that contains a notebook for communication between the facility and the dialysis center. V14 stated R22 keeps that bag in R22's possession. V14 stated R22 has a central venous catheter (CVC) in R22's left chest for dialysis. V14 stated that the dialysis center handles everything related to CVC. V14 stated R22's CVC is covered with a clear occlusive dressing and nursing staff can see if there is any signs and/or symptoms of infection. V14 stated the monitoring of R22's CVC site is not documented. On 12/6/24 at 12:53 pm, V24's Nurse Practitioner stated that nurses should assess the CVC site for signs and/or symptoms of infection and document the status of the site and the dressing at least daily. V24 also stated that communication should occur between the facility and the dialysis center to inform the resident of any changes in condition, weights, and/or any other pertinent information.

Based on record review and interview the facility failed to provide pain management by not having the correct pain medication available for R1 upon admission to the facility. This failure resulted in R1 experiencing severe pain from R1's recent joint replacement surgery when pain medication was not available. R1 is one of three residents reviewed for pain management in a sample of three. This past compliance occurred from 9/26/24 to 9/27/24. Findings include: The facility policy titled Management of Pain revise date 7/23 documents Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Screen for pain every shift. Encourage residents to self-report pain. Preventing and minimizing anticipated pain when possible and using pain mediation judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. R1's Progress note dated 9/26/24 documents R1 was admitted to the facility on [DATE] at approximately 6:30 PM. The same Progress note dated 9/26/24 at 6:39 PM documents (R1) was admitted to his room, alert and oriented times 4 and able to make needs known. The Physician's Order Sheet (POS) dated September 2024 documents R1 was admitted with the following diagnoses: Aftercare following Joint Replacement Surgery and Chronic Lymphocytic Leukemia of B-Cell type not having achieved remission. R1's hospital transfer/discharge orders dated 9/26/24 document the medications R1 was prescribed to receive at the nursing home. Per doctor's orders, R1 was to receive the following the following medication for pain Oxycodone 5 milligram (mg) 1 tablet by mouth every 6 hours as needed for severe pain. R1 stated per phone interview on 10/09/2024 at 12:05 PM Yes, I was in pain the first couple of days I was at the nursing home. (V5, LPN (Licensed Practical Nurse) ) the nurse on duty that night came in and asked me if I had any pain and I told her not at that time because I received some pain medication at the hospital before I left to go to the nursing home. I told (V5,) I would need the pain medication when I go to bed so I would be able to sleep. At 9:00 PM I asked for my pain medication and (V5 ) told me they did not have my pain medication available and it was ordered from the pharmacy and it should be delivered around 4:30 to 5:00 AM, because this was the time they got their medication. I asked the night nurse (V6, RN (Registered Nurse)) if my pain mediation was available and (V6) stated 'no your pain medication did not come.' I was in bad pain and did not get any pain medication until later that day. On 10/9/24 at 2:27 PM (V5) stated, Yes I was the nurse working the night (R1) was admitted . All of his medication orders were faxed to the pharmacy by the admitting nurse. I went in to (R1's) room and explained to him we did not have his pain medication here at the facility. V5 stated the medication should have arrived around 5:00 AM. V5 stated R1 reported R1 would need pain medication around 9:00 PM. V5 stated No I did not call the Nurse Practitioner (V7) or V11 (R1's Doctor) to get an order for a substitute medication. V5 stated we did not have Oxycodone in our Emergency Box, we only had Oxycodone with Tylenol. On 10/9/24 at 2:35 PM per phone interview V7, Nurse Practitioner stated, I went to visit (R1) in his room from 8:00 AM to 10:00 AM on 9/27/24 to see how he was doing. I was shocked because (R1) was in excruciating pain you could see it in his face and his movements. (R1) looked really bad due to his pain. I asked him if he received his pain medication, he stated 'no the facility does not have my type of pain medication.' He stated the medication did not arrive with his other medications according to the night nurse (V6). V7 stated V7 went to the nurse (V3, ADON ) ( Assistant Director of Nursing ) and asked her why R1 did not receive his medication for pain and V3 stated the medication was not received from the pharmacy, and the emergency box only had Percocet available. V7 stated V7 immediately called the pharmacy with an emergency order for R1 to have Percocet two doses which is available in the Emergency Box. V7 stated I then had the nurse remove the medication from the Emergency Box and give it to (R1). Then called the pharmacy and sent the prescription that was needed for R1 to receive his Oxycodone 5 mg. V7 stated R1 should not have been in pain like that. V7 stated no one called V7 or the doctor when R1 was admitted for an order for a different type of pain medication. On 10/9/24 at 12:11 PM, V8 Pharmacist confirmed V7 called in an emergency order on 9/27/24 at 12:03 PM for R1, and the pharmacy received the prescription for R1's Oxycodone 5mg at on 9/27/24 at 3:49 PM. On 10/9/24 at 1:32 PM V3, ADON stated Yes V7 wrote new prescriptions for (R1) to receive his pain medication and I faxed to our pharmacy the new prescriptions for (R1) to receive his Oxycodone 5 mg. On 10/4/24 at 1:40 PM V1, Administrator stated We did not have the medication in the Emergency Box and the nurse did not pick up the phone and call the nurse practitioner or the doctor for an order to get the medication. The facility's policy titled Admission Orders and Process with the revised date of 7/23 documents under Procedure # 1 and 2 1. Physician orders for the resident immediate care will be obtained prior to or upon admission/readmission. 2. The Licensed Nursing staff shall obtain orders for the care of the resident from the resident's physician or his/her designee. If the resident's attending physician or his/her designee cannot be contacted, the DON (Director of Nursing) will be notified and the Medical Director will be contacted for immediate orders for care of the resident. Prior to the survey date of 10/10/24, the facility took the following actions to correct the noncompliance: 1. On 9/27/24 R1 was interviewed by V3 ADON and R1 was informed an alternative medication had been ordered while the pharmacy was processing his orders and pain medication was administered by V3 on 9/27/24 at 1:32 PM. 2. On 9/27/24 a plan was implemented to audit all newly admitted residents for narcotics orders and compare to the list of available medications in the emergency box. Completed by V3 ADON on 9/27/24. 3. On 9/27/24 all nursing staff were educated on the narcotic process and how to obtain a one time order for a narcotic that is available in the emergency supply. The emergency supply list will be placed in the Nurse Resource Binder for quick reference. The admissions nurse will screen orders for narcotics when received. Completed by ADON on 9/27/24 4. Audits are in place for each new admission to ensure alternative narcotics are available and ordered by the provider until original ordered narcotics arrived from pharmacy. This audit will be completed for each admission by the ADON. The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement. Completed on 9/27/24 and ongoing with each new admission by ADON.

Based on observation, interview and record review the facility failed to prevent the worsening of a resident's facility acquired pressure ulcers. The facility failed to implement pressure ulcer care plan interventions and prevent cross contamination during pressure ulcer wound care for a resident (R3). These failures affect one (R3) residents of three residents reviewed for pressure ulcers in a sample list of nine residents. These failures resulted in R3's Stage III pressure ulcer worsening and development of two additional necrotic pressure ulcers. Findings include: R3's undated Face Sheet documents R3 was admitted on [DATE] with medical diagnoses of Chronic Systolic Congestive Heart Failure, Moderate Protein-Calorie Malnutrition, Gastroesophageal Reflux Disease without Esophagitis, Atherosclerotic Heart Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, (COPD), Atrial Fibrillation and Anemia. R3 Minimum Data Set (MDS) dated [DATE] documents R3 as modified independent for daily decision making. This same MDS documents R3 as requiring extensive assistance of two people for bed mobility, transfers, toileting, extensive assistance of one person for dressing and personal hygiene. R3's Care Plan documents R3 is not able to make his own decisions. This same care plan documents an intervention dated 5/31/23 instructs staff to assist in turning and positioning R3 at least every two hours. This same care plan documents a pressure ulcer prevention intervention dated 7/3/23 for R3 to wear bilateral boots to offload pressure. R3's Wound Physician Progress Notes document the following: 9/12/23 documents R3's facility acquired Left Lateral Foot Stage 4 Pressure Ulcer as measuring 10.2 centimeters (cm) long by 2.5 cm wide by 0.3 cm deep. This same progress note documents an initial onset for this same wound of 5/26/23. 9/12/23 documents R3's facility acquired Right Lateral Ankle Stage 4 Pressure Ulcer as measuring 2.1 cm long by 2.3 cm wide by 0.1 cm deep. This same progress note documents an initial onset date for this same pressure ulcer of 7/3/23. 9/12/23 documents R3's facility acquired Right Lateral Lower Leg Stage 3 Pressure Ulcer as measuring 1.7 cm long by 0.6 cm wide by 0.1 cm deep. This same progress note documents an initial onset date for this same pressure ulcer of 7/3/23. 9/12/23 documents R3's facility acquired Left Anterior Ankle Unstageable Pressure Ulcer as measuring 0.9 cm long by 3.1 cm wide by unable to determine depth due to necrosis. This same progress note documents an initial onset date for this same pressure ulcer of 9/12/23. This same progress note documents this same pressure ulcer as being caused by a medical device with an initial onset date of 9/12/23. 9/12/23 documents R3's facility acquired Left Heel Unstageable Pressure Ulcer as measuring 3.8 cm long by 3.4 cm wide by unable to determine depth due to necrotic tissue. This same progress note documents this same pressure ulcer initial onset date of 9/12/23. R3's Facility Wound Assessment Details Report documents the following: 9/21/23 documents R3's facility acquired Left Lateral Foot Stage 4 Pressure Ulcer as measuring 9.0 cm long by 1.5 cm wide by unable to determine depth due to necrotic tissue. 9/21/23 documents R3's facility acquired Right Lateral Ankle Stage 4 Pressure Ulcer as measuring 6.3 cm long by 2.5 cm wide by 0.2 cm deep. 9/21/23 documents R3's facility acquired Right Lateral Lower Leg Stage 3 Pressure Ulcer as measuring 5.2 centimeters (cm) long by 2.0 cm wide by 0.25 cm deep. 9/21/23 documents R3's facility acquired Left Anterior Ankle Unstageable Pressure Ulcer as measuring 0.7 cm long by 3.5 cm wide by unable to determine depth due to necrotic tissue. 9/21/23 documents R3's facility acquired Left Heel Unstageable Pressure Ulcer as measuring 3.8 cm long by 2.4 cm twice by unable to determine depth due to necrotic tissue. On 9/21/23 continual observations were made from 8:51 AM-11:50 AM of R3 laying on R3's back in bed with legs crossed, knees out to each side and feet drawn up between thighs. R3's head of bed was elevated at 45 degrees. R3 was not wearing heel protectors. R3's bed did not have any pillows. R3's bilateral feet were pressing directly into R3's inner thighs and calves. No observations were made during this timeframe of staff assisting R3 with repositioning or offloading R3's facility acquired pressure ulcers. On 9/21/23 at 11:55 AM V8 Licensed Practical Nurse (LPN) and V9 Registered Nurse (RN)/Wound Nurse completed R3's dressing changes for R3's facility acquired pressure ulcers including Left Lateral Foot Stage 4 Pressure Ulcer, Right Lateral Ankle Stage 4 Pressure Ulcer, Right Lateral Lower Leg Stage 3 Pressure Ulcer, Left Anterior Ankle-Deep Tissue Pressure Injury (DTPI), Left Heel Unstageable Pressure Ulcer. R3's prior dressings to Right and Left lower legs/feet were not dated nor initialed. These same outer dressings were grossly contaminated with a dirt brown color and debris from unknown source. V9 RN removed all of the dressings at one time, then cleansed each wound and re-dressed each wound without changing gloves or using hand sanitizer. V9 RN did not perform R3's pressure ulcer wound care in order from less severe wound to most severe wound. V9 RN started wound care with R3's Right Lateral Lower Leg, then proceeded to R3's Right Lateral Ankle, then Left Lateral Foot, Left Anterior Ankle and lastly Left Heel pressure ulcer. V9 RN utilized the same paper measuring tape by pressing the paper measuring tape into every wound. R3's facility acquired Left Lateral Foot Stage 4 pressure ulcer observed to have red periwound and moderate amount of yellow/grey drainage. R3's facility acquired Right Lateral Ankle Stage 4 Pressure Ulcer area of cluster wounds as open and red with moderate amount of pink/clear drainage. R3's facility acquired Right Lateral Lower Leg Stage 3 pressure ulcer observed to be open, dark red tissue with moderate amount of yellow/pink drainage. Observed this same wound's prior undated dressing was firmly adhered to open wound. V9 Registered Nurse attempt to soak the prior dressing off for eight minutes. R3's facility acquired Left Anterior Ankle Unstageable Pressure Ulcer observed as firm brown necrotic tissue covering most of surface of pressure ulcer with minimal clear drainage. R3's facility acquired Left Heel Unstageable Pressure Ulcer observed as having a dry black surface with slightly reddened periwound and no visible drainage. On 9/21/23 at 1:25 PM V9 Registered Nurse (RN) stated R3 should always have his heel protectors on for pressure prevention. V9 stated I have just started in this position and have only worked at this facility for a couple of weeks. I only see one heel protector in (R3's) room. It is sitting on (R3's) bedside dresser completely out of his reach. I don't know why (R3) doesn't have those on. (R3) really needs them. (R3) crosses his legs (with legs crossed, knees out to each side and feet drawn up between thighs) which forces his feet to press on his thighs and calves. (R3) has multiple significant pressure ulcers on his lower legs and both feet. A few of the wounds did get larger but they all look better each time I see them. V9 RN stated not performing hand hygiene and the cross contamination of open wounds could lead to an infection in R3's pressure ulcer wounds. On 9/22/23 at 1:30 PM V27 Wound Physician stated I started at this facility approximately 10 weeks ago. I have been seeing (R3's) wounds since that time. (R3) has seven or eight total pressure ulcers in addition to a couple of Vascular ulcers. (R3's) wounds have been improving since I have taken over, but I am surprised (R3) has lived this long due to the condition of his wounds. Prior to me seeing (R3's) wounds they (wounds) had been deteriorating and with no one in charge of the wound program it was a recipe for disaster. I wouldn't say (R3's) pressure ulcers were unavoidable due to (R3) has shown healing properties in these wounds since I took over. I would be more inclined to say that the previous staff were not caring for (R3) as they should have been. There have been times I have seen (R3's) heel protectors not on and there have been times they have been on. I believe the Left Anterior Ankle-Deep Tissue Pressure Injury (DTPI) was caused the by staff applying the heel protector incorrectly which caused the strap to rub against the top of his Left Ankle. (R3's) bilateral hips and knees are very contracted. I believe (R3's) knees are measuring at 135 degrees flexion contraction. (R3) always needs those heel protectors on at all times. There is no excuse for (R3) going long periods without them. I can see that they might come off during showers or something like that but that would be the only reason. If they are soiled, then get them laundered and while (R3) is waiting apply another pair. This isn't critical thinking here. It is just basic care that was not being provided. The dressings should always be dated otherwise no one would know how long that previous dressing had been on. If (R3's) dressing to Right Lateral Lower Leg took that much work to soak it off of the pressure ulcer, then it has been on much longer than what I had ordered. The facility policy titled 'Wound Ulcer Treatment' revised 8/2023 documents put on gloves, loosen tape, and remove dressing. Dispose of dressing and gloves. Wash hands. Put on clean gloves. Date and initial tape before applying. Apply individual dressings and ointments as directed. The facility policy titled 'Wound Treatments dated 4/2023 documents mobility guidelines to turn resident every two hours and provide appropriate pressure reducing devices. When treating a resident with multiple pressure injuries, treat the most contaminated ulcer last.

Based on observation, interview, and record review the facility failed to supervise a resident (R1) with a known history of wandering, evaluate or assess residents' capacity or ability to consent to sexual activity, and identify resident to resident sexual activity as nonconsensual sexual abuse for three of five residents (R1, R2, R3) reviewed for abuse in the sample list of ten. This failure resulted in R1 sexually abusing R3, and R3 sexually abusing R1. The Immediate Jeopardy began on 6/13/23 when R1 wandered into R3's room resulting in R1 sexually abusing R3, and R3 sexually abusing R1. V1 Administrator was notified of the Immediate Jeopardy on 6/21/23 at 2:44 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/21/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's Initial Report dated 6/13/23 documents the facility reported physical contact between confused residents (R1, R2, R3). The section for sexual abuse allegation is not marked. This report documents R1 was seen in R2's room standing beside the bed touching R2's genitals, and it was unclear if this contact was direct or over top of the sheet. R1 was removed from R2's room and later that same day R1 was found in R3's room with R1's shirt pulled up and R3's mouth on R1's breast. R1 was removed from R3's room and was placed on one-to-one supervision. Immediate actions include contacting R1's family about a room change. The time the incidents occurred is unidentified. These incidents were reported to V1 Administrator on 6/13/23 at 6:32 PM. V7 Certified Nursing Assistant (CNA) statement documents: (V7) was walking down the hall and saw (R1) in (R2's) room with what appeared to be physical contact happening. Resident (R1) had their back to the door blocking a clear view. (V7) asked resident (R1) what they were doing and (R1) stated (R1) was washing (R2's) penis. (V7) approached the residents (R1, and R2) as (V7) could see (R1's) hand appeared to be by (R2's) privates, but by the time (V7) arrived at the bed (R1's) hand was moved. At that point (V7) escorted (R1) out of the room and back to (R1's) room to keep separated from other residents. V9 CNA written statement dated 6/20/23 documents: V9 walked past R3's room and saw R3 sitting in the recliner. R1 was leaning over R3, R1's dress was low, and R3's mouth was on R1's breast. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is usually understood and sometimes understands, wanders daily, and has severe impairment with daily decision making. R1 transfers and walks with setup assistance and supervision from staff. This MDS and R1's Brief Interview for Mental Status (BIMS) dated 6/15/23 documents R1 has short- and long-term memory loss. R1's Care Plan dated 9/6/21 documents R1 wanders aimlessly and without regards to needs or safety. R1's Care Plan revised 1/26/23 documents R1 is at risk for abuse/neglect related to diagnoses of dementia with behavioral disturbances and anxiety. R2's BIMS dated 6/2/23 documents a score of 6, indicating severe cognitive impairment. R3's BIMS dated 5/10/23 documents a score of 13, indicating R3 is cognitively intact. R1's Census documents R1 changed rooms on 6/14/23 at 3:44 PM (almost 24 hours after R1's/R2's and R1's/R3's incidents). On 6/15/23 at 9:28 AM and at 11:55 AM R1 was in bed in R1's room. There were no staff present in R1's room or stationed outside of R1's doorway. On 6/20/23 at 9:08 AM there were no staff present in R1's room. R1 walked out of R1's room down the hall towards the nurses' station. V37 CNA told R1 to go back to R1's room, and R1 walked back into R1's room independently. On 6/15/23 at 10:08 AM R3 stated: The other night R1 came into R3's room. R3 was sitting in the recliner. R1 pulled down the top of R1's gown and exposed R1's breasts. R3 touched R1's breast with R3's hand. R1 told R3 to stop, and R3 complied. R1 is confused and did not ask R3 to touch R1. R3 knows R3 probably should not have touched R1, but R3 did. There was a staff person who witnessed the incident from the doorway. The staff did not intervene, but R1 left R3's room. On 6/15/23 at 10:00 AM V9 CNA stated V9 passed by R3's room at approximately 4:30 PM- 4:45 PM on 6/13/23 and witnessed R1 bent forward towards R3 who was sitting in the recliner. R1 pulled R1's gown down exposing R1's breasts and R3's mouth was on R1's breast. V9 stated both residents were not upset by the incident and were actively engaged. V9 told R1 to get out of R3's room and R1 went into the hallway. V9 did not report the incident to anyone. V9 did not consider the incident to be abuse since R1 and R3 were both actively engaged in the sexual activity. On 6/15/23 at 9:34 AM V8 Registered Nurse stated: R2 yells out at times, is confused, and alert/oriented to person only. V8 stated R3 is alert/oriented to person, place, time, and situation. V8 stated R1 is confused and wanders into everyone's rooms. On 6/13/23 between 5:00 PM and 6:00 PM V7 CNA reported to V8 that R1 touched R2's genitals. V9 witnessed R1 enter R3's room. V9 went to R3's room and R1 exposed R1's breast and R3 was sucking on R1's breast. After the incident with R1/R2 we brought R1 to the nurse's station to keep a close eye on R1, but R1 just gets up and goes. After R1's/R3's incident R1 was placed on one-to-one supervision, but not continuous supervision. V8 stated staff checked on R1 frequently and observed R1 in the hallway. On 6/15/23 at 2:46 PM V7 CNA stated on 6/13/23 at approximately 4:30 PM V7 CNA witnessed R1 in R2's room standing over R2's bed. R1 told V7 that R1 was washing R2's penis. V7 did not witness R1 touch R2. V7 redirected R1 back to R1's room which was across the hall from R2's room and left R1 unattended. V7 stated prior to the incident the staff had to redirect R1 from R2's room multiple times. V7 stated there were no staff assigned to provide continuous supervision of R1 on 6/13/23, following the incident with R2. V7 was unsure what interventions were implemented to prevent sexual activity involving R1. On 6/15/23 at 11:55 AM V32 Licensed Practical Nurse stated R1 did not change rooms until after 2:00 PM on 6/14/23. On 6/15/23 at 10:48 AM V2 Regional Nurse stated V2 received a call from V1 Administrator on the evening of 6/13/23 informing V2 of the incidents involving R1, R2, and R3. V2 stated V2 instructed to implement one to one supervision after R1's/R3's incident. One to one means if R1 is sleeping staff are to sit outside R1's room and if R1 is outside R1's room then a staff person is assigned to be with R1. The staff had initially asked V2 about 15-minute checks for R1 and V2 told the staff that is not enough, because that would allow for periods of time for R1 to be unsupervised. At 3:45 PM V2 stated residents who exhibit a desire for intimate relationships with a BIMS score of 10 or greater have the ability/capacity to consent to sexual activity. V2 stated this type of behavior is not ok in these incidents (R1/R2 and R1/R3). V2 confirmed R1 does not have the ability/capacity to consent to sexual activity. V2 stated R1's one to one continuous supervision is still ongoing at this time. On 6/15/23 at 11:21 AM V1 stated V8 called V1 at approximately 6:30 PM to report R1's/R2's and R1's/R3's incidents. V1 did not report the incidents to the local police since R2 and R3 are able to consent to sexual activity. Resident's ability to consent to sexual activity is based on the BIMS score and is situational. V1 stated that there is no set BIMS score to identify when a resident is not able to consent. V1 confirmed the facility does not use any other assessment tool to determine residents' ability/capacity to consent to sexual activity. V1 was asked about R1's cognition and ability to consent to sexual activity. V1 stated That is a good point. V1 stated R1 implied consent because R1 initiated the sexual activity. V1 instructed staff that night to place R1 on one-to-one supervision and move R1's room. V1 stated V1 would have expected staff to notify V1 immediately after the incident with R1/R2 and implement one to one supervision at that time. On 6/20/23 at 11:02 AM V1 stated the facility does not have a policy for how they determine residents' ability to consent to sexual activity. On 6/20/23 at 8:58 AM V16 CNA stated following the incidents involving R1, R1 had a room change and we try to keep R1 in R1's room or involved in activities. V16 stated there are no staff assigned to do one to one supervision of R1. On 6/20/23 at 9:08 AM V37 CNA confirmed there were no staff assigned to provide one to one continuous supervision of R1. The facility's Abuse, Neglect, and Exploitation policy dated 2/28/2023 documents: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. The Immediate Jeopardy that began on 6/13/23 was removed on 6/21/23 when the facility took the following actions to remove the immediacy: 1. R1's, R2's, and R3's abuse risk assessments were completed on 6/21/23 and care plans were updated on 6/21/23. 2. The facility made an in-house behavioral health appointment on 6/19/23 for R1 with an appointment date of 6/28/23. Appointment verified by V15 Social Service Aide on 6/26/23. 3. The facility initiated continuous one to one monitoring of R1 on 6/20/23 per V40 Scheduler. Verified through review of Daily staffing sheets and interviews with V40 Scheduler and V2 Regional Clinical Nurse/Interim DON on 6/26/23. 4. The facility initiated continuous one to one monitoring of R3 on 6/21/23 per V40 Scheduler. Verified through review of Daily staffing sheets and interviews with V40 Scheduler and V2 Regional Clinical Nurse/Interim DON on 6/26/23. 5. R1's and R3's care plans were revised on 6/17/23 to include sexual behaviors and interventions to address these behaviors. 6. Abuse policies were reviewed and updated on 6/21/23 per V1 Administrator. V1 Administrator stated V2 reviewed the Abuse policies on 6/15/23 but it was not officially revised until 6/21/23. 7. All staff Abuse Inservice was completed 6/14/23. V2 Regional Clinical Nurse stated the in-service was initiated with all staff on 6/14/23 and is ongoing for any PRN staff that are yet to work. V2 stated all staff that are working have been in serviced and the in servicing is ongoing. We have a plan in place to continue to train staff through organized phone calls and in-service sheets at nurse's desks. No staff are allowed to work without having had been through the in-service. 8. The facility Inservice dated 6/21/23 documents staff were in serviced on 'documentation of behaviors'. V2 Regional Clinical Nurse stated this training was completed on 6/21/23. 9. Resident care plans were reviewed and updated on 6/20/23 and 6/21/23. V2 Regional Clinical Nurse and V40 Social Service Aide both verified that care plans have been updated. Care plan review has shown that all residents reviewed had care plans updated on 6/21/23. 10. The facility has assessed residents for a risk of sexual abuse. V2 Regional Clinical Nurse stated 100% of in-house residents were reviewed and assessed on 6/20/23 and 6/21/23 for being able to consent. Resident care plans were updated with interventions to help in managing behaviors. 11. The facility initiated a policy titled 'Policy on intimate resident behavior, privacy and relationships' dated 6/21/23 per V1 Administrator. 12. The facility implemented an assessment titled 'Screening assessment to determine the presentation of trauma factors including abuse and/or neglect' dated 6/21/23. V2 Regional Clinical Nurse stated the facility implemented a process for screening and assessing all residents for being at risk of sexual abuse. 13. The facility completed audits of resident clinical records who have been identified as having sexual behaviors on 6/20/23 and 6/21/23. V2 Regional Clinical nurse confirmed all audits have been completed on 6/20 and 6/21/23. 14. The facility audited a minimum of five staff members each week starting 6/21/23. Audits were dated 6/23/23 and 6/26/23 with at least five staff members listed on each audit. V2 Regional Clinical Nurse confirmed staff audits have been started and will be ongoing. 15. The facility reviewed all new allegations of abuse to ensure compliance is met. V2 Regional Clinical Nurse stated the facility has had one incident involving two residents on 6/22/23. V2 stated the Abuse policy was followed and the incident has been reviewed by the IDT (Interdisciplinary Team). V2 stated all future incidents will be reviewed ongoing. 16. V1 Administrator stated the facility will continue to follow up with ongoing review of all issues including abuse allegations and survey findings. V1 stated the facility will continue to train incoming staff as new hires on abuse and also V40 Scheduler will let any PRN (as necessary), or agency staff know to complete the abuse training when arriving and prior to caring for residents. V1 stated QAPI (Quality Assurance Performance Improvement) meetings are held monthly, and IDT meets daily and both teams review abuse audits of residents and staff.

Based on observation, interview and record review, the facility failed to update resident plans of care for pressure ulcers, failed to document measurements/assessments of pressure ulcers, and failed to document treatments to pressure ulcers were completed as ordered. The facility also failed to implement physician orders for a pressure ulcer wound treatment and notify the facility's wound nurse and/or wound physician of the development of a new pressure ulcer. These failures affect three of three residents (R4, R6 and R7) reviewed for pressure ulcers on the sample list of 10. The facility also failed to ensure identified pressure ulcer prevention interventions were implemented, causing R6's right buttocks wound to worsen. Findings include: 1. R6's Care Plans dated 2/9/23 document the following: staff will refer to my Physician as needed for skin impairment and issues; R6 has skin impairments including a Stage 3 pressure ulcer to the sacrum and right upper buttock. These Care Plans document interventions including the following: Assess/record/monitor wound healing measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed and healing progress. These Care Plans document to report improvements and declines to the physician, monitor/document/report as needed, any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. These care plans also document R6 requires pressure relieving/reducing device low loss air mattress on R6's bed with a date of 9/29/22. R6's Order Summary Report dated 6/22/23 documents the following: An order dated 2/8/23 documents R6 is to have a Low Air Loss (LAL) mattress and to check function and setting every shift. This Order Summary Report documents an order dated 5/16/23 to clean R6's Stage 2 pressure ulcer to the coccyx with wound cleaner and pat dry. This order documents to apply medical honey gel to the wound and cover with a bordered foam dressing. This report does not document orders for R6's pressure ulcer to the right buttock. There are no orders for a treatment for a Stage 3 pressure ulcer to the sacrum. R6's Wound Physician notes dated 4/25/23 document R6 had a right buttock skin tear that healed. There are no additional wounds documented for R6. These notes document R6 is at risk for reopening previous skin alterations due to: incontinence, limited mobility, poor intake and anemia and that R6 was being discharged from wound care. R6's Wound Physician notes dated 5/23/23 document R6 had an initial assessment for a Stage 4 right buttock pressure ulcer with full thickness/exposed underlying structure. These notes document R6's right buttock pressure ulcer measurements as 2.8cm (centimeters) length, 1.7cm width, 0.2cm depth with minimal exudate. These notes document orders including preventative wound recommendations including LAL air mattress. R6's Wound Physician notes dated 6/6/23 document R6's Stage 4 right buttock pressure ulcer with healing status of healing and measurements of 3.1cm length, 1.7cm width, 0.2cm depth with minimal exudate. These notes document Additional Notes/Orders including Wound Improving and LAL mattress. R6's Wound Physician notes dated 6/13/23 document R6 was not seen by the wound physician because R6 was not in R6's room. There is no additional documentation in R6's medical records as to where R6 was at that time. R6's Wound Physician notes dated 6/20/23 document R6's right buttock Stage 4 pressure ulcer healing status as declined with measurements of 3.4cm. Length x 4.1cm. Width x 0.1 cm. Depth. These notes document Related to wound status, R6 unable to adhere to offloading and that R6 had a prior stage 4 pressure ulcer to that area in the past. There is no documentation R6 had a pressure ulcer to R6's coccyx at this time. These notes document R6's TREATMENT ORDER: Every three times per weekday(s): Medical Honey Gel - Cleanse wound with normal saline or sterile water - Apply (medical honey gel) to Wound Bed - Cover with Dry Clean Dressing with Preventative Wound Recommendations: LAL Air mattress. This note does not document R6's open pressure ulcer to R6's coccyx. R6's Order Summary Report dated June 22, 2023, document an order dated 5/16/23 to clean R6's Stage 2 pressure ulcer to the coccyx with wound cleaner and pat dry. This order documents to apply medical honey gel to the wound and cover with a bordered foam dressing. This report does not document treatment orders for R6's pressure ulcer to the right buttock. On 6/21/23 at 2:05 PM, V32, Licensed Practical Nurse (LPN) completed R6's treatment to R6's right buttock pressure wound with V33, LPN assisting. Upon turning R6 to position R6 on R6's right side, R6's right buttock pressure ulcer was irregular in shape, with an open reddened wound bed. There was no dressing noted to R6's right buttock or coccyx pressure wounds. V32 stated staff cleaned R6 up when they assisted R6 to bed and the dressing was removed at that time. V32 cleaned V32's right buttock and coccyx pressure wounds with wound cleaner. V32 applied medical honey gel to the square bordered foam dressing and used a cotton tipped applicator to move the medical honey gel around on the foam dressing. V32 placed the dressing with the medical honey gel over the top of the right buttock wound. The adhesive portion of the dressing was positioned over the coccyx pressure wound, but not adhered to or covering the coccyx pressure ulcer. The coccyx pressure ulcer did not have any medical honey gel treatment or dressing completed as per R6's Physician's Orders. R6 was noted to be on a regular mattress with no alternating air capabilities. V32 confirmed R6's open pressure ulcer to the coccyx area at this time. There were no sacrum pressure ulcers observed at this time, but evidence of scarring over sacral area from previous sacrum pressure ulcers to which V32 confirmed. On 6/22/23 at 1:40 PM, V29, Wound Nurse stated V29 is the wound nurse for the facility. V29 stated V29 has only been able to come one day a week to round with V30, Wound Physician because V29 is attending school. V29 stated it is probably V29's fault for not making sure R6 was on an air mattress. V29 stated R6 was on an air mattress and had a room change and that R6's mattress must not have moved with R6. V29 stated R6's wounds had healed, but R6 was always on an air mattress. V29 stated V29 and V30 just saw R6 Tuesday 6/20/23, and R6's right buttock pressure ulcer is declining and not having R6 on an air loss mattress will contribute to/cause the decline. V29 stated they should be following the orders for the coccyx pressure ulcer, but V29 was unsure of when the coccyx pressure ulcer had re-opened as it was opened in the past. V29 stated the floor nurse should have entered the new orders for R6's pressure ulcer to the right buttock as ordered. V29 stated V29 would look at the orders and get them updated in R6's medical records so the treatment would be done to the buttock pressure ulcer and the coccyx pressure ulcer. V29 stated the gel is to be placed on/in wound bed and not on the dressing to ensure the entire wound bed has the medical honey gel applied. V29 also stated the facility documents resident treatments were completed on the Treatment Administration Records (TAR). V29 stated the treatments should be implemented as ordered and transcribed to the electronic medical records. V29 stated treatments are to be documented when they are completed on the TAR. 2. R7's Order Summary Report dated June 21, 2023, documents R7's Physician's Orders including to apply skin prep to bilateral heels every shift. R7's Care Plans document R7 is at risk for skin breakdown and that staff will refer to R7's physician for skin impairment and issues. These care plans do not document R7's left or right heel pressure ulcers. There is no documentation of an assessment by V30, Wound Physician or measurements by the facility for R7's right heel pressure ulcer. On 6/21/23 at 1:29 PM, V31, Licensed Practical Nurse cleaned R7's heels with wound cleanser and applied skin prep to R7's bilateral heels. V31 stated V31 is unsure of measurements of these wounds or who does them and that V29, Wound Nurse and V30, Wound Physician see R7 weekly and document. V31 stated R7 has had bilateral heel pressure ulcers for a while. V31 completed the treatment to R7's MASD (Moisture Associated Skin Damage) of the sacral area. At this time, R7 was noted to have a darkened circular non-blanchable pressure ulcer to the sacrum of which V31 stated was just smaller than a dime in size and that area had not been there previously. R7's June Treatment Administration Record (TAR) dated June 2023 does not document R7's skin prep to R7's bilateral heels was completed as ordered during the evening shift on 6/1/23, 6/6/23, 6/10/23, 6/20/23. There is no documentation in R7's medical record that V29 or V30 were notified of R7's new pressure ulcer to the sacrum. On 6/22/23 at 1:40 PM, V29, Wound Nurse stated staff should notify V29 and/or V30 for any new skin impairments/pressure ulcer development and document in the nurse's notes. V29 stated V29 was unaware of the dime sized circular pressure ulcer for R7. 3. R4's hospital Discharge Transfer Orders dated 5/12/23 document R4's Wound care orders including Pressure Injury - Coccyx/Ischial Instructions including to apply self-adherent bordered foam dressings to the coccyx and all bony prominences. These orders document to peel back and assess skin every shift and change dressings weekly and as needed for soiling, saturation, or slippage to prevent skin breakdown. R4's Order Summary Report dated June 15, 2023, does not document R4's orders for R4's pressure ulcer treatment to R4's coccyx as ordered on 5/12/23. R4's medical records do not document monitoring/treatment of R4's coccyx pressure ulcer. On 6/22/23 at 1:40 PM, V29, Wound Nurse stated the facility documents resident treatments were completed on the Treatment Administration Records (TAR). V29 stated the treatments should be implemented as ordered and transcribed to the electronic medical records. V29 stated treatments are to be documented when they are completed on the TAR. V29 stated V29 did not evaluate or know of R4's coccyx pressure wound.

Based on interview and record review the facility failed to implement increased supervision after a fall resulting in a second and third fall and subsequent injuries for one cognitively impaired resident (R1). This failure resulted in R1 being sent to the emergency room , diagnosed , and treated for multiple right side rib fractures, a Cervical-5 (C5) fracture, Lumbar-4 (L4) compression fracture, forehead laceration, and skin tears. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 is severely cognitively impaired and requires limited assistance of one staff person for transfers. R1's Fall Risk Evaluation dated 9/16/22 documents R1 is at high risk for falls related to intermittent confusion, 1-2 recent falls, ambulatory, balance problems while standing and walking, requires assistive device (walker), has medical diagnoses and takes medications that also put him at risk. R1's Incident Report dated 9/21/22 documents at 1:50 AM, R1 was heard yelling that he was falling and was found on the floor by his bed. R1 stated he was getting dressed to go home. At the time of the fall, R1 was orientated to person and had impaired memory, confusion, gait imbalance, recent illness, and had poor safety awareness related to Dementia. R1 was assessed for injuries and helped back to his bed. Neurological checks were started. The last neurological check was documented at 3:35 AM. R1's Incident Report dated 9/21/22 documents at 4:20 AM, R1 was yelling that he had fallen and was found in his room on the floor by his nightstand. R1 had a laceration to the right forehead and skin tears to his right arm and right knee. R1 was transported to the emergency room (ER). R1's Computed Tomography (CT) results dated 9/21/22 document R1 fell from a standing position and sustained a large laceration to his forehead, multiple acute right lower rib fractures, acute-subacute appearing L4 compression fracture, and an acute non-displaced fracture of the left C5 posterior transverse process. R1's Nurses Note dated 9/21/22 documents R1 returned from the ER with 11 staples to his forehead laceration and a cervical collar in place. R1's Incident Report dated 9/23/22 documents at 3:10 AM, R1 was walking in the hallway outside of his room with his walker and fell sideways to his right onto the floor. R1 reopened his forehead laceration from 9/21/22 and skin tears to his right arm. R1 was transported to the emergency room (ER). R1's Hospital History and Physical Note dated 9/23/22 documents R1 presented in the ER after recurrent falls. R1 was seen in the ER two days ago after a fall in which he suffered a left C5 fracture, right rib fractures, and lumbar fracture of indeterminate age. R1 also had a forehead laceration which was re-opened with this current fall. On 9/27/22 at 1:15 PM V16 Registered Nurse stated she was R1's assigned nurse during all three falls on 9/21/22 and 9/23/22. V16 stated R1 had been moved to first floor on 9/16/22 due to testing positive for Covid-19. He was on isolation in a room that was at the end of the hall furthest from the nurses' station. R1 was a high fall risk, had poor safety awareness, and was confused. On 9/21/22 at 1:50 AM, V16 found R1 on the floor in his room. V16 stated R1 didn't appear to have any injuries so they started neurological checks. R1 was last checked at 3:35 AM. He was in bed with no neurological changes noted. At 4:20 AM, V16 heard R1 call out and went down to his room. R1 had fallen again and hit his head on the bedside table. There was blood all over his head and the table. R1 was transported to the ER. On 9/23/22 V16 was again R1's nurse and at about 3:10 AM V16 noticed R1 walking in the hall with his walker. V16 stated she yelled for someone to get him, but they couldn't get to him before he fell over and hit his head on the floor and reopened his forehead laceration and skin tears. V16 stated there wasn't any new fall interventions put in place between the first fall, second fall, and third fall that she was aware of. V16 stated she was monitoring R1 more frequently during his neurological checks after his first fall on 9/21 but when the time frame moved to every hour, that is when he fell . V16 confirmed that visual monitoring should have been more frequent in order to prevent further falls. On 9/28/22 at 10:00 AM V4 Minimum Date Set Registered Nurse confirmed R1 was a confused resident with dementia, high fall risk, balance issues, and low safety awareness. He had previous falls and with his newly diagnosed Covid infection, he was even a higher fall risk than normal. He was also at higher risk because he was on isolation and at the end of the hall furthest away from the nurses' station. V4 confirmed R1 should have had more fall interventions in place and should have been supervised more closely, especially after his first fall on 9/21/22. These things could've potentially prevented the falls and subsequent injuries. On 9/28/22 at 1:52 PM V3 Medical Doctor confirmed R1 was a confused resident with Dementia, high fall risk, balance issues, and low safety awareness. He had previous falls and with his newly diagnosed Covid infection, he was even a higher fall risk than normal. R1 was on isolation and at the end of the hall furthest away from the nurses' station which would also make his fall risk higher. V3 confirmed R1's falls with injuries might have been prevented if staff had supervised him more frequently and had more fall prevention interventions in place. The facility's Fall Prevention Program dated January documents the fall prevention program will be implemented to ensure all residents' safety in the facility. Each resident's risk for falls will be assessed and appropriate interventions in order to provide the necessary supervision and assistive devices will be implemented.

Based on interview and record review the facility failed to administer ordered and available respiratory nebulizer treatments for a resident (R2) who requested treatment while experiencing a [CONDITION(S)] ([CONDITION(S)]) exacerbation. This failure resulted in R2 being transferred to the emergency room (ER) to receive treatment. R2 is one of three residents reviewed for a delay in care in the sample of three. Findings include: R2's Minimum Data Set, dated dated dated [DATE] documents R2 is cognitively intact. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 10:59 AM R2 stated on the early morning hours of 9/20/22, she was short of breath. She knew she was having a [CONDITION(S)] exacerbation. She asked for a nebulizer treatment at about 7:30 AM. She had one she could have as needed per the doctor orders. However, the nurse, V13 Licensed Practical Nurse/LPN wouldn't give her the nebulizer treatment. V13 stated she couldn't because it was against the facility's Covid policy. V13 told R2 to take her other medications and inhalers and rest and see if that helped. R2 told V13 it wouldn't help enough but V13 didn't listen. At 9:00 AM R2 went to the nurse's station and V13 was just sitting there. R2 told V13 if she didn't call the ambulance R2 was going to call them herself. R2 stated she was tired of waiting for V13 to do something to help her. Finally, V13 got on the phone and called Emergency Medical Services and they took R2 to the ER. R2 was given oxygen and nebulizer treatments and stated she felt better. R2 stated she felt helpless and the fact that V13 LPN, the nurse in charge of her care, wasn't willing to give R2 a nebulizer treatment made her feel very anxious and scared that V13 would just let R2 get worse and worse. R2 stated she felt neglected and like no one cared. R2's Nurses Note dated 9/20/22, written by V13 Licensed Practical Nurse documents R2 was complaining of shortness of breath and requesting a nebulizer treatment. V13 told R2 that due to Covid the facility doesn't administer nebulizer treatments. R2 requested to go to the emergency room . Emergency Medical Services were called and R2 was transported to the emergency room for evaluation. R2's Emergency Medicine Record dated 9/20/22 documents R2 arrived in the ER with shortness of breath. R2 has a history of [CONDITION(S)]. R2 stated facility V13 LPN would not give R2 her prescribed nebulizer treatment and R2 feels she was being neglected. ER pulmonary assessment showed expiratory wheezing and shortness of breath. On 9/27/22 at 2:58 PM V9 Infection Preventionist Registered Nurse confirmed R2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 did not follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 was terminated for this reason. V13's LPN Termination/Resignation record dated 9/21/22 documents V13 was terminated by the facility for a violation of policy. On 9/28/22 at 1:52 PM V3 Medical Doctor confirmed R2 had a PRN (as needed) nebulizer treatment ordered, and the nurse (V13 LPN) should have given it to R1 if she requested it due to respiratory symptoms from a [CONDITION(S)] exacerbation. The nurse should have not withheld the treatment.

Identified failures require more than one deficient practice statement. A.) Based on interview and record review the facility failed to ensure R52, R64, and R88 were not to subjected mental, verbal, and physical abuse by R46. This failure puts these residents at risk for severe, life threatening, and potentially fatal injuries. R46, R52, R64 and R88 are four of seven residents reviewed for abuse in the sample list of 99. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 9/7/22, the facility remains out of compliance at severity level 2. While the facility continues to develop and implement measures for each identified resident to address tendencies and triggers that could lead to physical aggression towards others. Findings include: The facility's Abuse Prevention Program policy with an effective date of 11/28/17 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention (77 Ill. Adm. Code 300.330). Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment (42 CFR 483.12 Interpretive Guidelines). Pre-Admission Screening of Potential Residents. The facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. For residents who are identified offenders, the facility shall incorporate the Identified Offender Report and Recommendation Report into the identified offender's plan of care including the security measures listed. Residents who allegedly abused another resident shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility. In addition, the facility shall take all steps necessary to ensure the safety of resident including, but not limited to, the separation of the residents. R46's Face Sheet dated 8/19/22 documents an admitted [DATE]. R46's Admission Minimum Data Set (MDS) dated [DATE] documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS documents a BIMS (Brief Interview for Mental Status) score of 9/15 indicating moderately impaired cognition. R46's Care Plan dated 6/20/22 documents R46 has a history of criminal behavior and documents a care plan updated 8/26/22 that since admission R46 has had some aggressive behaviors towards others with interventions to promote safety, intervene when inappropriate behavior is observed. This Care Plan documents R46 is a wanderer and (R46) goes in other resident's rooms and can be difficult to redirect with a revision date of 6/27/22. R46's Nurse's Notes in June 2022 documents R46 curses and yells at residents and staff and goes into other residents' rooms and gets agitated and does not want to leave easily. R46's Nurse's Notes in July 2022 documents R46 was physically and verbally abusive to staff. R46's Nurse's Notes in August 2022 continue to document verbal abuse and being combative with staff. R46's Nurse's Note dated 8/26/22 at 2:55 PM, documents R46 was sent to a Psychiatric hospital. R46's Nurse's Note dated 8/26/22 at 4:20 PM documents R46 was being issued a 30-day discharge notification due to recent incidents and behaviors which were affecting other residents. a.)1.) The facility's Preliminary Incident Investigation Report dated 8/19/22 at 12:20 PM, documents (R46) were ambulating in (R46's) wheelchair behind (R52) and (R64). (R46) said f*** you (expletive) and (R64) responded by saying the same to (R46). (R46) then propelled (R46's) wheelchair towards (R52) and (R64) and they fell to the ground. The residents were separated, and (R46) is being monitored 1:1 (one to one) pending orders received for (R46) to be sent out for evaluation. Following nurse assessments of the residents, no injuries were noted for any of the three residents. Residents will be monitored for signs and symptoms of distress. Physicians and POAs (Power of Attorneys) were notified. R46's Nurse's Note dated 8/19/22 at 12:20 PM, R46 became agitated with two other female residents (R52, R64). R46 was in a wheelchair on R46's way back from the dining room. (R52 and R64) were ambulating back from lunch. R46 was heard yelling F*** you to (R52 and R64). One of the female residents yelled F*** you back to R46. R46 sped up the wheelchair and hit (R52 and R64) directly knocking them to the ground. R46 stated that they deserved it, they shouldn't talk to R46 like that. R46 on 1:1 supervision from time of incident. On 9/1/22 at 9:42 AM, V14 LPN (Licensed Practical Nurse) stated V14 witnessed R46 run R46's wheelchair into R52 and R64 on 8/19/22 and knock them to the ground. V14 stated V14 heard bickering and cuss words being yelled and V14 saw R46 plow R46's wheelchair towards R52 and R64 and knock them to the ground. V14 stated when R52 and R64 were on the ground they were yelling cuss words at R46 and calling R46 a SOB (Son of a B****) (expletive). V14 stated V14 separated R46, R52 and R64. V14 stated V14 asked R46 why R46 knocked R52 and R64 down and R46 told V14 that they were making fun of R46 and R46 told V14 that R46 would do it again. V14 stated R46 stayed with V25 Social Services Director after the incident. R52's Order Summary Report dated 8/30/22 documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R52's Nurse's Note dated 8/19/22 at 12:20 PM, documents fall was witnessed and occurred in the hallway. R52 was ambulating back from the dining room and the reason for the fall was evident. Another resident knocked R52 over. R52 was ambulating down the hallway and a male resident (R46) yelled F*** you and R52 yelled it back. This prompted (R46) to speed toward R52 in R46's wheelchair knocking R52 to the ground. V14 LPN/writer witnessed the fall. No head trauma. Parties separated. Nursing Assessment completed. Vital signs recorded. No complaints of pain. Able to move all extremities. Assisted to standing with two assists. Able to ambulate back to room without difficulty. R52's BIMS Evaluation dated 8/19/22 documents a score of 9/15 indicating moderately impaired cognition. R64's Order Summary Report dated 8/30/22 documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R64's Nurse's Note dated 8/19/22 at 2:05 PM, documents at 12:20 PM R64 was ambulating back to room from dining room, talking with roommate. Another male resident (R46) became agitated, yelled F*** you at R64, R64 yelled it back. This prompted R46 to speed toward R64 in R46's wheelchair knocking R64 to the ground. V14/writer witnessed fall. No head trauma. Parties separated. Nursing assessment completed. Vital signs recorded. No complaints of pain. Able to move all extremities. Assisted to standing with two assists. Able to ambulate back to room without difficulty. Primary Care Provider notified. POA notified. R64's BIMS Evaluation dated 8/19/22 documents a score of 3/15 indicating severely impaired cognition. a.)2.) The facility's Preliminary Incident Investigation Report dated 8/30/22 documents the incident happened on an unknown date. (R88) stated another resident (R46) called me a f***ing b**** (expletives) and double fist hit my nose so bad around a month ago. R88's Order Summary Report dated 8/31/22 documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This Order Summary documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R88's Nurse's Note dated 8/30/22 at 2:50 PM, documents (R88) reported to Administrator (V1) that a month or so ago, another resident called me F---in b---- and double fist hit my nose so bad. (R88) reported that (R88) still felt pain on (R88's) nose bridge every now and then from the alleged incident. R88's BIMS Evaluation dated 7/14/22 documents a score of 10/15 indicating moderately impaired cognition. On 8/30/22 at 11:12 AM, during resident council meeting, R32 reported there was a physical altercation R32 witnessed that occurred between two residents in R32's room but asked to identify the residents and details in private. On 8/30/22 at 12:20 PM, (R32) requested the State Survey Agency come with R32 to R32's room after resident council meeting finished at this time. R32 stated R46 punched (R88) right in the face. R32 stated R32 witnessed this occur as it occurred right inside the doorway to R32's room. R32 stated R88 and R32 were in R32's room talking when R46 entered the doorway of R32's room. R32 stated R88 asked R46 to please move so R88 could leave R32's room and that is when R46 punched R88 with a closed fist. R32 stated R88's glasses went flying across the floor in R32's room and R88 started crying. R32 stated R46 got very hostile when this happened. On 8/30/22 at 1:25 PM, (R88) stated the picture the State Survey Agency showed R88 was R46. R88 stated R46 called R88 a fat f***ing b**** (expletives) a few different times. R88 stated around a month ago, R46 hit R88 so hard across the nose that R88 glasses fell off R88's face. R88 stated R88 hurt so bad and R88 was experiencing headaches and dizziness that R88 still gets from time to time since R46 hit R88. R88 stated R88 developed a little bruising to R88's nose. R88 stated R88 started crying and was afraid that R46 would come at R88 again. R88 stated, nothing would surprise (R88) with what (R46) could or would do to anyone in the facility. At this time R88 became tearful and began sobbing and crying again. R88 stated the facility would be stupid to ever let that f***ing a**hole (expletives) back in. R88 stated, (R88) just wants to feel safe. 8/30/22 at 1:41 PM, (R32) stated R32 is, very much so afraid of (R46) and that R46 has a bad temper. On 8/30/22 at 1:55 PM, (R88) began crying when discussing R46 hitting R88 across the nose. R88 stated R46 doubled up (R46) fist and hit R88 right across the nose. R88 stated, (R88) never hurt so bad as R88 did after R46 hit R88 with a closed fist. R88 stated it felt like R88's nose was split in half and R88's nose began bleeding after R46 hit R88. R88 stated R88 notified the staff nurses who R88 could not identify. R88 stated R88 nose still bleeds a little from time to time when R88 blows it. R88 stated staff had even taken stuff to clean R88's blood from R88's nose. R88 stated R88's nose still hurts. R88 agreed to go to the hospital for testing and/or radiology testing if the doctor says R88 needs to. On 8/30/22 the facility provided a list of interviewable residents on the second floor of the facility which also indicates all of the residents that could potentially be affected by R46's aggressive behavior. An Immediate Jeopardy situation was identified on 8/30/22. The Immediate Jeopardy was identified to have begun on 8/19/22 when the facility failed to ensure interventions were implemented related to R46's aggressive behaviors to prevent R46 from deliberately assaulting R52 and R64. On 9/2/22 at 11:23 AM, V1 Administrator was notified of the Immediate Jeopardy situation. On 9/6/22 at 1:05 PM, the surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1.) R52 and R64 were interviewed. An initial abuse allegation report was completed on 8/19/22 by V24 Corporate Administrator and the final abuse investigation was completed on 8/26/22 by V1 Administrator for the incident of 8/19/22. R52 and R64 were assessed and monitored. 2.) R88 was interviewed. An initial abuse allegation report was completed on 8/30/22 by V1 and a final abuse investigation was completed on 9/2/22 for an allegation reported on 8/30/22. 3.) R46 was involuntarily discharged to a Psychiatric hospital on 8/26/22 with paperwork completed by V3 Nurse Manager and a 30-day Discharge was issued to R46 on 8/26/22 completed by V1 Administrator. 4.) On 9/7/22, V25 Social Services Director and V34 Social Services Assistant completed a review of residents and identified residents who were predisposed to physical violence and the identified residents were assessed and evaluated for their ability to safely co-exist with other residents. 5.) All facility staff, including contracted agency staff, to complete training on abuse prevention policy and how to recognize triggers to prevent resident to resident abuse. This action was initiated on 9/2/22 and completed by V1 Administrator and V24 Corporate Administrator. B.) Based on interview and record review the facility failed to prevent a resident-to-resident altercation for two (R89, R95) of seven residents reviewed for abuse in the sample list of 99. Findings include: b.)1.) The facility's Abuse Prevention Program dated November 28, 2017, documents: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Final Incident Investigation Report dated 9/2/22 documents the following: On 8/28/22 staff observed R95 attempt to inappropriately touch another resident R89. V12 Certified Nursing Assistant (CNA) initially reported that V12 witnessed R95 touch R89 on R89's private (genital) area. V12 intervened and separated R95 from R89. V12 later clarified to local police that R95 was attempting to grab and unbutton R89's pants, and R89 was shaking and pushing R95 away with both of R89's hands. R95's hands were touching and grabbing towards R89's private (genital) area. R95's undated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R95's Minimum Data Set (MDS) dated [DATE] documents R95 has severe cognitive impairment, requires supervision of one staff person for locomotion on R95's unit. R95's Care Plan revised on 5/5/22 documents R95 has the potential to be physically aggressive towards other residents and has a history of a physical altercation with another resident. R95's Care Plan revised on 5/31/22 documents R95 has a behavior problem of exposing R95's self in R95's room and inappropriately touching female staff. This care plan includes an intervention Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. R95's Nursing Note dated 10/22/2021 at 11:51 PM documents R95 appeared in the common area wearing only an incontinence brief and shirt. R95 was asked what R95 was doing and replied that R95 wanted some. R95 was told that R95 was inappropriate and redirected back to R95's room. R95's Nursing Note dated 8/28/2022 at 2:24 PM documents R95 was touching a female resident (R89) and trying to unbutton her pants. R89's undated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R89's Nursing Note dated 8/28/2022 at 2:39 PM documents R89 was sent to the hospital for evaluation after R89 was touched in groin area by another male resident (R95). On 8/29/22 at 3:56 PM V22 Licensed Practical Nurse (LPN) stated: R95 has made sexual comments to staff and residents while passing them in the hallway. R95 would say things such as you can come sit on my lap, or I'll help you undo your pants. This has been an ongoing behavior. We try to keep a close eye on R95 and have R95 near the nurse's station. R95 does wander at times. On 8/30/22 at 9:38 AM V12 CNA stated: On 8/28/22 around 1:50 PM, R95 was in the television room facing the window, and R89 was facing the television. R95 had R89's hands on R89 trying to unbutton R89's pants. R89 is nonverbal. R89 used R89's hands to try and push R95's hands off of R89, while R95 continued to attempt to unbutton R89's pants. V12 immediately separated R95 from R89. R95 is confused, and during incontinence care has made sexual comments in regards to female staff's breasts. On 8/31/22 at 3:30 PM V39 LPN stated: About a month ago during shift change, V39 saw R89 and R95 in the television room. R95's back was facing V39, and R95's arm was near R89. V39 was not able to see R95's hands. V39 approached R95, and R95 acted startled and said I'm not doing anything. It (the situation) didn't sit well with me (V39). R95 and R89 were immediately separated. V39 reported the incident to V13 Previous Administrator, and V13 told V39 it sounds like two residents with Dementia. After that incident, whenever V39 worked V39 had the female residents sit in the hallway for monitoring. R95 required close supervision.

Based on interview and record review the facility failed to comprehensively assess a resident's aggressive behaviors upon admission for one of one resident (R46) reviewed for behaviors in the sample list of 99. This failure has the potential to affect 65 residents (R36, R42, R164, R365, R47, R88, R109, R17, R79, R92, R37, R18, R69, R3, R71, R22, R366, R76, R9, R64, R49, R63, R30, R67, R60, R72, R40, R57, R105, R113, R50, R85, R54, R44, R86, R48, R38, R23, R96, R16, R104, R12, R2, R53, R20, R78, R70, R33, R59, R5, R34, R6, R82, R32, R81, R13, R103, R110, R56, R29, R91, R77, R95, R55, R165) residing on the second floor of the facility. Staff allowed R46 unsupervised access to residents who are unable to protect themselves from R46's behaviors. Findings include: The facility's Behavior Monitoring policy dated 10/2015 documents, Problematic behaviors will be identified and managed appropriately. The facility staff and Attending Physician will identify individuals with a history of impaired cognition (e.g., dementia, mental [CONDITION(S)]), problematic behavior, or mental illness (e.g., [CONDITION(S)] or [CONDITION(S)]). R46's Face Sheet dated 8/19/22 documents an admitted [DATE]. R46's Admission Minimum Data Set (MDS) dated [DATE] documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS documents a BIMS (Brief Interview for Mental Status) score of 9/15 indicating moderately impaired cognition. R46's MDS dated [DATE] documents R46 had behaviors that put others at significant risk for physical injury, significantly intruded on the privacy of others, significantly disrupted care or living environment and wandering significantly intrudes on the privacy or activities of others. R46's Baseline Care Plan dated 6/20/22 documents the only behavioral concern was wandering. R46's Social Services Behavior Conditions Review dated 8/26/22 (after R46 was discharged to the Psychiatric hospital) documents R46's new or worsening behavior as aggressive behaviors towards staff and other residents. This Review documents R46 had exhibited physically aggressive behaviors towards residents. R46's Nurse's Progress Note dated 6/20/22 at 1:54 PM documented by V22 Licensed Practical Nurse (LPN) documents, (R46) having behaviors noted on this shift/ refusing medication. and (cussing) at nursing staff. NP (Nurse Practitioner) notified. Will continue to monitor. On 6/20/22 at 8:37 PM, V22 documents, (R46) noted having behaviors on this shift. (R46) was cursing/ yelling while (R46) was in (R46's) room. When staff tried to redirect (R46) continued to curse and yell. (R46) is now calm in bed call light within reach. Will continue to monitor. R46's Nurse's Progress Note dated 6/24/22 at 11:17 AM by V44 Licensed Practical Nurse (LPN) documents, (R46) has been trying to go to other (resident's) room with redirection. After being informed to not go into other (people's) (rooms) (R46) continued to do so. (R46) unplugged (R12's) air mattress and spilled water all over the floor. (R46) refused to come out by staff. (R46) was finally able to be redirected to (R46's) room. (R46) is now in (R46's) room in bed. Facility management notified. R12's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/8/22 at 4:25 PM, V4 LPN documents, (R46) Behavior: E) Hallucinations/Delusions/[CONDITION(S)] 1) Able to redirect and refocus 3) Medication given 2) Keep redirecting every shift. On 7/14/22 at 9:33 PM, V44 documents, (R46) having behaviors this evening. (R46) was being physically and verbally abusive to staff. (R46) stated I will punch you and give you two black eyes to the writer. (R46) was redirected and was unsuccessful. (R46) started to become a threat to staff, (residents), and self. (R46) started to push and shove furniture. MD (Medical Doctor) notified. (R46) is to be sent to (hospital) for altered mental status evaluation. When paramedics arrived (R46) became aggressive with EMT (Emergency Medical Technicians) by telling them Bet nobody touches me and screaming. Notified (POA) and facility (Administrator). Will continue to monitor. On 8/11/22 at 7:03 PM, V4 documents, (R46) Behavior: B) Combative/hitting/kicking staff/resists care C) Crying/restlessness/agitated E) Hallucinations/Delusions/[CONDITION(S)] 1) Able to redirect and refocus 3) Medication given 2) Keep redirecting every shift. On 8/19/22 at 1:53 PM, V14 LPN documents, (R46) became agitated with 2 other female residents (R52, R64). (R46) was in wheelchair on (R46's) way back from dining room. Female patients ambulating back from lunch in the 2 south dining room. Writer heard (R46) yell F*** you to (R52, R64). Writer began going toward the commotion. (R52, R64) yelled back F*** you. (R46) sped up his wheelchair and hit (R52, R64) directly knocking them to ground. Writer interviewed and separated all parties. (R46) stated they deserved it and they shouldn't talk to (R46) like that. PCP (Primary Care Provider) notified states to continue monitoring. emergency contact notified. (Administrator) and nurse managers notified. (R46) on 1-1 supervision at this time from time of incident. On 8/26/22 at 1:04 AM, V4 documents, (R46) Behavior: C) Crying/restlessness/agitated 1) Able to redirect and refocus 2) Keep redirecting. On 8/26/22 at 2:58 PM, V14 documents, (R46) left with transport for (Psychiatric) hospital in (the north) at (2:40 PM). Med list (medication list) and face sheet sent with. Writer reached out to (hospital) to give report, they stated they do not need a report just send (R46). R74's Order Summary Report dated 8/30/22 documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R74's Minimum Data Set (MDS) dated [DATE] documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R74's BIMS Evaluation dated 7/3/22 documents a score of 7/15 indicating moderately impaired cognition. The facility's Preliminary Incident Investigation Report dated 8/25/22 at 6:22 PM, documents Employee reported suspicion of unusual event on 8/25/22 approximately 6:22 PM. (R74) was in (R74's) room with door blocked open by a wheelchair belonging to (R46). (R74's) wheelchair was between R74 and the other wheelchair. (R74) was lying on the floor and reported that (R74) had fallen. (R74) was undressed from waist down and soiled depend lying on (R74's) bed. No injury noted by nurse assessing the resident. Both residents (R46 and R74) were sent out for evaluation. Physicians and POA/emergency contacts notified. Police notified. (V15 Police Officer) arrived at facility to interview staff and residents. R74's Nurse's Note dated 8/25/22 at 5:00 PM, documents CNA (Certified Nursing Assistant) notified nurse that (R74) was on the ground, undressed from the waist down and (R46) was wrapped in (R74's) bed sheet. CNA told second nurse. Nurse notified administrator; statement given. Doctor contacted gave order to send out for assessment. POA notified. (R74) assessed. (R74) Vital Signs WNL (Within Normal Limits). No c/o (complaints of) pain. Sent (R74) to hospital to be assessed. On 8/29/22 at 3:55 PM, V5 Certified Nursing Assistant (CNA) stated on 8/25/22 around dinner time, 5:00 PM-6:30 PM, V5 noticed R46 standing at the nurse's station with no wheelchair with R46. V5 stated that V5 went to look for R46's wheelchair. V5 looked in a couple of rooms but then came to R74's room and the door would only open a small way.V5 stated that there were wheelchairs blocking the door and R74 was on the floor on the other side of the wheelchairs. V5 stated R74 had no clothes on from the waist down and R74's used incontinent brief was laying on the bed away from R74. V5 stated V5 could not fit through the opening without pushing the wheelchairs into R74 so V5 got the nurse (V6 Licensed Practical Nurse/LPN) and V6 was able to fit through the opening and climbed over the bed to get to the other side of the wheelchairs and rearranged things so V5 could come in and assist. V5 stated they got R74 up off the floor and dressed and during this time R46 returned to the room with R74's personal bed sheet wrapped around R46. V5 stated R46 was screaming at them to get out of R46's house. V5 stated after they got R74 up and R74's pants back on V5 left R74 with V6. V5 stated that R46 is a resident with high behaviors. V5 also stated that R46 is a highly disturbed man that is abusive, mean and nasty. On 9/8/22 at 10:30 AM, V25 confirmed that there was no behavior assessment completed for R46 upon admission. V25 stated that R46's behavior assessment was not completed until 8/26/22. The facility's Resident Room Roster provided on 8/30/22 documents 65 residents (R36, R42, R164, R365, R47, R88, R109, R17, R79, R92, R37, R18, R69, R3, R71, R22, R366, R76, R9, R64, R49, R63, R30, R67, R60, R72, R40, R57, R105, R113, R50, R85, R54, R44, R86, R48, R38, R23, R96, R16, R104, R12, R2, R53, R20, R78, R70, R33, R59, R5, R34, R6, R82, R32, R81, R13, R103, R110, R56, R29, R91, R77, R95, R55, R165) reside on the second floor.

Based on observation, interview, and record review the facility failed to timely identify and address significant weight loss, complete thorough nutritional assessments, and implement physician ordered nutritional recommendations for four (R13, R70, R95, R63) of 12 residents reviewed for nutrition in the sample list of 99. These failures resulted in R13 sustaining a severe weight loss of 6.11 % in 15 days. Findings include: The facility's Nutritional Assessment policy dated as revised December 2011 documents: Nutritional assessments will be completed upon admission and with changes in condition that put the resident at risk for impaired nutrition. Nutritional assessments will be conducted by the interdisciplinary team and the dietitian will include an estimate of the resident's calorie, protein, nutrient, and fluid needs. The facility's Weight Assessment and Intervention policy dated as revised June 2012 documents: Nursing staff are responsible for obtaining resident weights. An unplanned weight loss of 5% in one month, 7.5 % in 3 months, and 10 % in 6 months is considered significant, and greater than 5% in 1 month, 7.5 % in 3 months, and 10 % in 6 months is considered severe. The dietitian will be notified of weight changes in writing, and the dietitian should respond within 24 hours of receiving the notification. Interventions for undesirable weight loss include consideration of the use of supplements and nutrition/hydration needs. 1.) R13's Minimum Data Set (MDS) dated [DATE] documents R13 has severe cognitive impairment, R13 is not on a prescribed weight loss regimen, and R13 has had a weight loss of 5% or more in one month or 10% or more in six months. R13's Care Plan dated 6/21/22 documents R13 has a potential nutritional problem secondary to wound healing and includes interventions to prescribe diet as ordered and Registered Dietitian to evaluate and make dietary changes as needed. This care plan has not been updated to include R13's significant weight loss. R13's undated weight log documents R13's weights and identified significant weight loss as follows: 118.6 lbs. (pounds) on 4/27/22, 118.7 lbs. on 5/3/22, 109.7 lbs. on 5/9/22 (7.58 % loss), 103.6 lbs. on 5/12/22 (5.56% loss in 4 days), 103 lbs. on 5/24/22 (6.11 % loss from 5/9/22), and 101 lbs. on 8/22/22 (a 10% loss since 4/27/22.) R13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's August 2022 Medication Administration Record (MAR) documents R13's ice cream is scheduled to be given at 12:00 PM. R13's Nutrition Note dated 4/28/22 at 12:48 PM recorded by V47 Registered Dietitian (RD) documents R13 was reviewed for recent admission, R13's BMI (Body Mass Index) was 21.6 and was adjusted for above knee amputation. This note documents, Will monitor for need to modify nutrition. R13's Nutrition Note dated 5/26/2022 at 9:50 recorded by V47 documents R13 was evaluated for wounds and weight loss noted. R13's weight is down 15 lbs. since R13 admitted in late April 2022. R13 has a low BMI of 18.8, adjusted for left above knee amputation. V47 requested to change multivitamin to multivitamin with minerals, offer double protein at breakfast, a frozen nutritional supplement once daily, whole milk at meals, and change diet from Low Concentrated Sweets to regular. R13's Dietary Note dated 7/21/2022 at 12:04 recorded by V47 documents V47 requested to add ice cream with lunch. There is no documentation that R13's significant weight loss first noted on 5/9/22 was identified and reported to V47 until 5/26/22, and that nutritional interventions were implemented after 4/28/22 and prior to 5/26/22. There is no documentation that the frozen nutritional supplement was implemented prior to R13's hospital discharge on 6/1/22. On 8/29/22 at 10:18 AM V38 (R13's Family) stated R13 has lost weight recently but was unsure how much weight R13 has lost. On 8/31/22 at 12:23 PM V38 stated V38 was not sure what the facility was doing to help with R13's weight loss. On 8/29/22 at 12:39 PM R13 at all of the noodles with tomato sauce, mixed vegetables, and garlic bread. R13's meal tray did not contain whole milk or ice cream. On 8/31/22 at 12:17 PM R13's meal tray was delivered and contained ice cream but did not include whole milk. R13's meal ticket documented ice cream. On 8/31/22 at 12:22 PM V38 entered R13's room and requested V40 Certified Nursing Assistant get R13 a carton of milk. V40 returned with a carton of 2 % milk. On 8/31/22 at 12:25 PM V40 was passing drinks to residents. V40 stated: V40 knows what drinks to serve each resident based on knowing the residents. V40 usually works night shift, and V40 asks other staff as well. On 9/06/22 at 10:43 AM V3 Infection Preventionist confirmed R13's frozen nutritional supplement was not added to R13's orders/MAR until 7/21/22. On 9/06/22 at 3:26 PM V3 stated V47 assessed R13 on 4/28/22 and not again until 5/26/22, and there were no nutritional interventions implemented prior to 5/26/22. On 9/06/22 at 12:31 PM V47 RD stated: Often times residents will drink better than they eat, so V47 recommends juice and milk with meals. The facility notifies me of weight loss when V47 is in the facility, or by telephone and electronic mail. V47 expects V47's recommendations to be implemented within 1-2 days, and V47 provides the recommendations to the facility on the same day V47 completes the evaluations. V47 assessed R13 on 5/26/22 for R13's significant weight loss. V47 cannot recall when V47 was notified of R13's significant weight loss. V47 would have given V47's recommendations sooner (than 5/26/22) if V47 was notified. V47 was in the facility on 5/5, 5/12, 5/23, and 5/26/22. V47 recommended Ice cream, whole milk, and the frozen nutritional supplement to promote weight gain. 2.) R70's MDS dated [DATE] documents R70 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5% or more in the last month or 10 % or more in the last six months. R70's Care Plan revised on 7/17/22 does not address nutrition/weight loss or interventions. R70's undated weight log documents R70's weights as follows: 121.3 lbs. on 4/11/22, 110.4 lbs. on 6/14/22 (8.99 % loss since 4/11/22), 103.2 lbs. on 7/31/22 (6.52 % loss since 6/14/22), and 107 lbs. on 8/31/22. R70's Nutrition Note dated 4/21/2022 at 1:19 PM by V47 RD documents R70 was reviewed for weight loss, R70 has history of fluid issues and receives a diuretic. This note documents a recommendation to add whole milk and juice with all meals. R70's Nutrition Note dated 8/11/2022 at 1:56 PM by V47 documents: R70 was reviewed for weight loss at 1, 3, and 6 months and R70 has a healing stage III wound. V47 recommended a frozen nutritional supplement once daily to provide an additional 290 kilocalories and 9 grams of protein. R70's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no identified time of when the frozen nutritional supplement is scheduled to be given or documentation that R70 receives the frozen nutritional supplement daily as ordered. On 8/29/22 at 12:14 PM R70's lunch tray included noodles with tomato sauce, mixed vegetables, garlic bread, mandarin oranges, and coffee. R70's meal ticket documents whole milk and juice with meals and does not document a frozen nutritional supplement. On 8/29/22 at 12:25 PM R70's meal tray did not include milk or juice. On 8/31/22 at 12:41 PM R70 ate 50 % of carrots, 75 % of mashed potatoes, all of the pears, and bites of roast beef. R70's meal tray did not include milk, juice, or a frozen nutritional supplement for the noon meals on 8/29 and 8/31/22. On 8/31/22 at 3:30 PM V39 Licensed Practical Nurse (LPN) stated: Frozen nutritional supplements and ice cream are delivered by dietary staff on the meal trays. The frozen nutritional supplement is documented on the MAR. R70 does not get a frozen nutritional supplement in the evening. On 9/06/22 at 12:31 PM V47 stated V47 recommended milk, juice, and a frozen nutritional supplement to promote weight gain for R70. 3.) R95's MDS dated [DATE] documents R95 has severe cognitive impairment, is not on a prescribed weight loss regimen, and has a weight loss of 5 % or more in 1 month or 10% or more in 6 months. R95's Care Plan dated as revised on 8/27/21 documents R95's diet is regular and R95 is at risk for altered nutrition due to new admission to the facility. This care plan includes interventions that R95 will be reviewed by the RD as needed, and this care plan has not been updated to reflect R95's significant weight loss and nutritional interventions to address weight loss. R95's undated weight log documents R95's weights as follows: 136.7 lbs. on 5/31/22 and 6/8/22, and 129.8 lbs. on 7/7/22 and 8/2/22 (5.05 % loss). R95's Nutrition Notes dated 7/21/22, 3/7/22, 2/26/22, and 9/9/21 and recorded by V47 RD, do not document an estimate of R95's calorie, protein, nutrient, and fluid needs . There are no documented thorough/complete nutritional assessments in R95's medical record since 7/24/21. R95's Nutrition Note dated 7/21/2022 at 11:35 AM documents R95 was reviewed for weight loss for the past month, and R95's BMI remains low at 21.6 with a goal of 23. R95's diet includes a nutritional shake 120 cc (cubic centimeters) four times daily. V47 suggested adding a frozen nutritional supplement for additional kilocalories. There is no documentation that R95 was evaluated by V47 after 3/7/22 until 7/21/22. R95's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R95's August 2022 MAR documents R95's nutritional shake is scheduled three times daily at 9:00 AM, 12:00 PM, and 5:00 PM. This MAR does not document the amount of the shake that R95 consumes or that R95 received the nutritional supplement on 5 times and refers to R95's Nursing Notes. R95's August 2022 Nursing Notes do not document R95 received the nutritional supplement as ordered 5 scheduled times during the month. On 8/29/22 at 12:33 PM R95 was eating in R95's room. R95's meal contained noodles with tomato sauce, mixed vegetables, garlic bread, mandarin oranges, and an orange drink. R95's meal ticket listed a nutritional shake for the noon meal. R95's meal did not contain a nutritional shake. On 9/6/22 at 9:15 AM V3 Infection Preventionist stated the facility was out of the (nutritional supplement) for a while and we replaced it with (nutritional shake). The nutritional shake is served by dietary staff on the meal trays. On 9/06/22 at 10:43 AM V3 provided R95's nutritional assessment dated [DATE] and stated that was the last full RD nutritional assessment V3 could locate for R95. On 9/06/22 at 12:31 PM V47 stated: R95's BMI was low. On 7/21/22 V47 recommended a frozen nutritional supplement. The nutritional supplement and shake are to promote weight gain and improve BMI. The goal is to have a BMI of at least 23 for age 65 and older. There was a shortage of the nutritional supplement, and we had switched to using the nutritional shake. V47 was off work during the first two weeks of July, and there was another RD who should have covered in V47's place. 4.) R63's Order Summary Report dated 9/8/22 documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This Order Summary documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/12/22 at 12:22 PM, V47 Dietician documented R63 was reviewed for weight loss at one and three months, BMI (Body Mass Index) 24.9, diet is regular/mechanical soft, and appetite has declined. Will request whole milk and juice at all meals and review as needed for need to further modify. R63's Weights and Vitals Summary report dated 9/8/22 documents R63's weight on 3/1/22 was 159.8 pounds and on 9/4/22 R63's weight was 135.8 pounds which was a 15.02% (percent) weight loss in six months. On 8/31/22 at 12:29 PM R63's meal tray only contained a 2% carton of milk. There was no whole milk on R63's tray as ordered. On 9/6/22 at 12:31 PM, V47 confirmed R63's recommendation for whole milk was for weight loss. V47 stated often times residents drink better than they eat, so V47 recommends milk and juice at meals.

Based on observation, interview and record review the facility failed to provide residents with pain control and pain assessments. The facility also failed to provide timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure affects two of three residents (R3, R214) reviewed for pain in the sample of three from a total sample list of 99. These failures resulted in R3 experiencing unrelieved pain and the ability to receive physical therapy post above knee amputation. Findings include: 1. R3's progress notes dated 8/5/22 document that R3 returned to the facility after sustaining a right above knee amputation due to [CONDITION(S)] and [CONDITION(S)] of the right leg. On 8/15/22 R3's Brief Interview Mental Status is documented as moderately impaired. R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The last comprehensive pain assessment was completed on 5/5/22. R3's care plan dated 8/7/22 documents to give analgesics as ordered by the physician and monitor and document for side effects and effectiveness. R3's medical record first documented dose of pain medication ([MEDICATION(S)] 5 milligrams) was on 8/6/22 at 3:40 PM. From 8/6/22 to 8/29/22, 29 of a possible 72 doses of [MEDICATION(S)] were given to R3 for pain. On 8/14/22, R3's progress notes document R3's indicator of pain was vocal complaints of the right thigh generalized as sharp, stabbing and aching. On 8/14/22 [MEDICATION(S)] 750 Milligrams was ordered every six hours as needed for muscle aches and muscle spasms. From 8/14/22 to 8/29/22, 14 of a possible 52 doses of [MEDICATION(S)] was given for muscle aches and spasms. R3's 8/25/22 progress notes document verbal complaints of pain. On 8/29/22 10:00AM R3 was observed laying in bed while grimacing and yelling, Help! and holding his right stump. On 8/29/22 at 10:30AM, R3 continued to yell, Help, I hurt! V12 Certified Nursing Assistant stated, He yells a lot. On 8/29/22 at 3:45 PM, R3 was yelling at R5 Certified Nursing Assistant, My leg hurts! My right leg! On 8/31/22 at 8:25 AM V10 Certified Nursing Assistant stated, He had been yelling for months, I have pain, I have pain. I need medication! On 8/29/22 at 4:05PM, V7 Licensed Practical Nurse stated, I called V11 Medical Doctor at 3:55PM for something for (R3's) pain. (R3) complains of pain a lot. Even before his amputation he yelled out in pain, but then he had [CONDITION(S)], so who knows. (R3) recently told me that even air hitting the stump made him hurt. He needs something for breakthrough pain. On 8/29/22 at 4:15PM, V7 Licensed Practical Nurse stated that V11 Medical Doctor had called with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] R3's August 29, 2022, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/31/22 at 10:29 AM, V17 Physical Therapist stated, (R3) was in such pain that I couldn't even touch him to work on him. I told the staff, but he just couldn't tolerate therapy. Physical therapy discharge notes dated 8/16/22 documents, Poor tolerance to stretching due to severe pain. On 8/31/22 at 10:47 AM, V19 Nurse Practitioner stated that the last time she saw R3 was on 8/24/22 and the staff didn't tell her that R3 was having increased pain. The facility pain policy dated 2/23/22 documents, The purposes of this procedure are to help the staff identify pain in the resident and to develop intervention that are consistent with the resident goals and needs and that address the underlying causes of pain. 1. The pain management program is to provide comfort to the resident. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain b. Effectively recognizing the presence of pain. c. Identifying the characteristics of pain. d. Addressing the underlying causes of the pain. e. Developing and implementing approaches to pain management. f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring to the effectiveness of interventions and h. modifying approaches as necessary. 2. R214's Brief Interview for Mental Status dated 8/11/22 documents R214 is cognitively intact. On 8/29/22 at 10:50 AM, R214 stated she is in a lot of pain, but her pain medications are effective most of the time. R214 stated one day she had to wait 3.5 hours to get her call light answered. R214 stated she was needing pain medication. R214 stated she called her daughter (V20) because she was in so much pain and no one was coming to her room. R214 stated she was in so much pain that she couldn't breathe. R214 stated the nurse finally came in and gave her some pain medication but that soon after the paramedics showed up to get her because V20 called 911 to get her help. R214 stated it turns out my call light wasn't working correctly so no one knew I needed pain medicine. On 8/31/22 at 8:51 AM, V20 stated R214 called her the evening of 8/26/22. R214 stated, She called me and told me she was in so much pain she couldn't stand it. She was crying and told me she had to wait too long to get a pain pill and that the pain pill wasn't touching her pain. I called the ambulance because no one at the facility would answer the phone and I was scared because she was in so much pain and told me she had a bump behind her knee. I was afraid she had a blood clot. I drove to the facility right after I called 911. When I got there, she was leaving by ambulance and was still in pain. R214's nurse's note dated 8/26/2022 at 7:13 PM documents, Medical team came in stating (R214) called 911 and complains of severe leg pain and wanted to go to hospital. She took [MEDICATION(S)] about 30 min (minutes) ago. Upon leaving the facility daughter came in and (R214) will go to (hospital). On 8/31/22 at 2:30 PM, V43 stated on 8/26/22 at 6:30 PM, I was working down the other side of the hall. A kitchen aide (unknown) told me R214 was having pain and that she was wanting pain medication. I gave her a [MEDICATION(S)] ([MEDICATION(S)] Acetaminophen 5-325 milligrams). Then I heard people coming in and it was the paramedics. I didn't know they were coming. They arrived thirty minutes after I gave her pain medication. V43 stated she was in severe pain, and I am not sure how long she waited. V43 stated when the paramedics came her pain wasn't relieved and she was still in a lot of pain, so she went to the hospital. V43 stated V43 didn't know her call light wasn't working that night. On 8/30/22 at 9:52 AM, V50 Maintenance Assistant stated he fixed R214's call light on 8/26/22. V50 stated when he pushed her call light, he discovered her light above the door didn't light up. He had to replace the light bulb. V50 stated he doesn't remember the time but it was late in the day.

Based on observation, interview, and record review the facility failed to ensure the emergency nurse call system had a functioning light for R214 and a properly functioning emergency nurse call device for R100. R214 and R100 are two of 24 residents reviewed for call lights on the sample list of 99. This failure resulted in R214 having excruciating pain for three hours and requiring R214 to be sent to the emergency room for evaluation. Findings include: 1.) R214's Brief Interview for Mental Status dated 8/11/22 documents R214 is cognitively intact. On 8/29/22 at 10:50 AM, R214 stated she is in a lot of pain, but her pain medications are effective most of the time. R214 stated one day she had to wait 3.5 hours to get her call light answered. R214 stated she was needing pain medication. R214 stated she called her daughter (V20) because she was in so much pain and no one was coming to her room. R214 stated she was in so much pain that she couldn't breathe. R214 stated the nurse finally came in and gave her some pain medication but that soon after the paramedics showed up to get her because V20 called 911 to get her help. R214 stated it turns out my call light wasn't working correctly so no one knew I needed pain medicine. On 8/31/22 at 8:51 AM, V20 stated R214 called her the evening of 8/26/22. R214 stated, she called me and told me she was in so much pain she couldn't stand it. She was crying and told me she had to wait too long to get a pain pill and that the pain pill wasn't touching her pain. I called the ambulance because no one at the facility would answer the phone and I was scared because she was in so much pain and told me she had a bump behind her knee. I was afraid she had a blood clot. I drove to the facility right after I called 911. When I got there, she was leaving by ambulance and was still in pain. R214's nurse's note dated 8/26/2022 at 7:13 PM documents, Medical team came in stating (R214) called 911, complains of severe leg pain and wanted to go to hospital. She took [MEDICATION(S)] about 30 min (minutes) ago. Upon leaving the facility daughter came in and (R214) will go to (hospital). On 8/31/22 at 2:30 PM, V43 stated on 8/26/22 at 6:30 PM, I was working down the other side of the hall. A kitchen aide (unknown) told me R214 was having pain and that she was wanting pain medication. I gave her a [MEDICATION(S)] ([MEDICATION(S)] Acetaminophen 5-325 milligrams). Then I heard people coming in and it was the paramedics. I didn't know they were coming. They arrived thirty minutes after I gave her pain medication. V43 stated she was in severe pain, and I am not sure how long she waited. V43 stated when the paramedics came her pain wasn't relieved and she was still in a lot of pain, so she went to the hospital. V43 stated V43 didn't know her call light wasn't working that night. On 8/30/22 at 9:52 AM, V50 Maintenance Assistant stated he fixed R214's call light on 8/26/22. V50 stated when he pushed her call light, he discovered her light above the door didn't light up. He had to replace the light bulb. V50 stated he doesn't remember the time, but it was late in the day. 2.) On 8/29/22 at 11:00 AM, R100 was lying in bed. R100's call light was attached to the mattress. V36 stated when she pushes it, it does not go off (activate the nurse call system). At that time, R100 attempted to activate call light device and it did not activate the call system. The call light device button, when pushed slowly, did not activate the nurse call system. The call light system did activate only when the button on the device was pushed fast and hard.

Based on observation, interview, and record review, the facility failed to sanitize scissors prior to a pressure ulcer dressing change, failed to document completion of pressure ulcer treatments, and failed to document weekly skin checks. These failures affect one resident (R1) on the sample of seven. Findings include: 1.) On 6/30/22 at 10:30 am, V5, Licensed Practical Nurse, conducted a pressure ulcer dressing change for R1. During this dressing change, V5 stated, I forgot my scissors, then requested for V18, Certified Nursing Assistant to go out to the treatment cart and retrieve the scissors. Upon receiving the scissors as requested from V18, V5 proceeded, without sanitizing the scissors, to cut a gauze roll which then was packed directly and firmly into the pressure ulcer on R1's sacrum. This pressure ulcer was approximately 5 centimeters (cm) long by 5 cm wide by 4 cm deep, had blackened areas of necrosis on the interior ulcer, devitalized slough tissue on the interior ulcer, and had a foul odor. At 10:40 am, V5 stated, Yes the scissors were here on top of the treatment cart. I am far from perfect. 2.) R1's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This same POS documents a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Treatment Administration Record (TAR) documents the sacrum ulcer did not receive a dressing change on 6/4/22, 6/9/22, 6/21/22, 6/25/22, and 6/29/22. This same TAR documents R1 did not receive the weekly skin check on Tuesday 6/21/22. On 6/30/22 at 3:47 pm, both V5, Licensed Practical Nurse/Wound Nurse, and V1, Administrator, stated they thought there needed to be some clarification and education among the nursing staff about the weekly skin check procedure because one nurse might only document a new open area, and one nurse might not document an open area if it is covered by a dressing, and some nurses don't necessarily disrobe a resident fully during the skin checks. V1 then stated, But in any event, they need to be documenting something rather than leave it blank.

Based on interview and record review the facility failed to prevent a fall with injury by ensuring a wheelchair was safely equipped for one (R1) of three residents reviewed for falls with injury (left parietal subgaleal hematoma and scalp laceration with 12 staples) on the total sample list of 15. Findings include: R1's incident report dated 5/28/22 documents that at approximately 9:55AM, R1 was sitting at the nurse's station and attempted to stand up from a wheelchair with pedals, stood up and attempted to walk, got her feet tangled up in the pedals and fell . R1 fell backward, hitting her head on the nurse's desk and was sent to the emergency department for evaluation and treatment. On 6/13/22 at 2:00PM, V11 Licensed Practical Nurse (LPN) stated, On 5/28/22) (R1) had been standing up all day and so we had her at the nurse's station to keep an eye on her. I ran to the nurse's station as soon as I heard her fall. I found her laying on the floor with her head next to the nurse's station, facing her wheelchair. The only way that could have happened was by getting her feet tangled up in the pedals. On 6/13/22 at 3:49PM, V12 LPN stated, (On 5/28/22 V11 LPN) and I were standing at the med (medication) cart. (R1) had been standing up and moving around all day, so (V11) LPN had her close to the nurse's station to keep an eye on her. I turned my back for one second and I heard her fall. She had to have gotten her feet tied up in the pedals to fall the way that we found her. On 6/14/22 at 9:55AM V5 Physical Therapy Assistant (PTA) stated that he knew R1 to use her legs in the wheelchair more than her arms. (R1) could move the wheelchair when she wanted to. On 6/13/22 at 1:45PM V10 Nurse Practitioner stated, I saw (R1) wheeling around in her room using her legs on 5/23/22. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as severely cognitively impaired. R1's fall assessments on 3/4/22, 5/18/22 and 5/28/22 all document R1 as a high fall risk. R1's care plan dated 3/4/22 documents R1 as a high fall risk. R1's May physician orders document [MEDICATION(S)] (anticoagulant) 20 milligrams every day by mouth. R1's care plan dated 5/11/22 documents, Resident is able to ambulate 10 feet, uses a four wheeled walker for walking and requires limited assistance by staff for locomotion in manual wheelchair. On 6/13/22 at 10:00AM V6 Physical Therapy Assistant stated, If a resident can move the wheelchair with their legs, they should not have pedals. At 10:30AM, V8 Therapy Director stated, If a person can propel their own wheelchair, they should not have pedals for safety. At 11:40AM, V7 Physical Therapist stated, If a person can stand or wheel themselves around, they should not have pedals on their wheelchair. It is a fall hazard. R1's emergency room notes dated 5/28/22 document resident fall with strike to head with a history of anticoagulant use resulted in a left parietal subgaleal hematoma and scalp laceration with 12 staples. On 6/14/22 at 10:56AM V7 Physical Therapist stated, Therapy did not recommend foot pedals, with or without straps. We would not have done that with (R1's) decreased cognition and ability to wheel herself around in the wheel chair. On 6/13/22 at 1:45PM V10 Nurse Practitioner stated, The laceration, staples and head bleed are a result of (R1) getting her feet caught in the pedals and falling.

Based on interview and record review the facility failed to notify the facility's Dietitian and/or modify nutritional interventions for a significant weight loss for one of three residents (R9) reviewed for weight loss on the total sample list of 15. Findings include: The facility's policy, with a revision date of September 2008, titled Weight Assessment and Intervention documents, Policy statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation: Weight assessment, 3- Any weight change of 5 percent or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. 4- The Dietitian will respond within 24 hours of receipt of written notification. 5- The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. R9's care plan documents: Problem: (R9) has potential for weight loss. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] & [CONDITION(S)], (initiated: 1/7/2021). Approaches (initiated 1/7/21): Administer medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Assess (R9's) food preferences. Avoid foods that (R9) complains about taste. Diet: Regular diet, Regular texture, Whole milk at meals. During periods of decreased appetite, monitor for constipation/intestinal obstruction/pain. Encourage oral intake of food and fluids. Monitor and record intake of food. Monitor need for changing diet consistency to increase ease of eating. Monitor/record weight per facility protocol. Notify Physician and family of significant weight change. Offer available substitutes if (R9) has problems with the food being served. Provide specify: setup help, cueing assistance for meals. R9's care plan documents: Problem: (R9's) dietary plan is as ordered per (Physician). (R9) is at risk for altered nutrition (revision date: 9/22/21). Approaches (initiated 4/21/21) 1- Explain and reinforce to the resident the importance of maintaining the diet ordered. 2- Encourage the resident to comply. 3- Explain consequences of refusal, obesity/malnutrition risk factors. 4- Provide and serve diet as ordered. 5- Registered Dietitian to evaluate and make diet change recommendations as needed. 6- Resident will be weighed as facility directed and policy. R9's medical record documents the following weight recordings: 2/17/2022: 141.0 Lbs (pounds). 3/1/2022 : 130.0 Lbs (-7.8 percent change, -11 Lbs, Comparison Weight 2/17/22). 4/5/2022: 131.0 Lbs (-7.1 percent change, -10 Lbs, Comparison Weight 2/17/22). 5/3/2022: 128.0 Lbs ( -9.2 percent change, - 13 Lbs, Comparison Weight 2/17/2022). 5/21/2022: 128.0 Lbs (-9.2 percent change, - 13 Lbs, Comparison Weight 2/17/2022). R9's medical record does not document V34 (Dietitian) was notified of R9's significant weight loss occurring on 3/1/22 through 5/21/22. R9's medical record does not document modifications were made to R9's plan of care for a significant weight change from 3/1/22 through 5/21/22. On 6/22/22 at 1:35 PM, V24 Interim Director of Nursing stated, I could not locate anything in (R9's) medical record that the dietitian was notified of (R9's) significant weight loss in February or after, there is no documentation that supports supplements were ordered or diet changes were made. (R9) was a monthly weight, when a weight is abnormal the staff should verify and see if the weight was accurate, if it is a weight loss, staff are to notify the dietitian for review.

Based on interview and record review the facility failed to ensure R1 was free from misappropriation of personal belongings and information including R1's billfold, personal checkbook, and debit card information. R1 is one of three residents (R1) reviewed for misappropriation of property in the sample list of nine. This failure resulted in R1 having $1,752.69 stolen from R1's bank account, R1 being upset and frustrated with not having use of R1's checkbook and debit card and having to close and reopen accounts. Findings include: The facility's Abuse Prevention Program policy dated November 2017 documents, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. R1's Order Summary Report dated 4/21/22 documents R1 was admitted to the facility on [DATE]. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's Preliminary Incident Investigation Report documents the date of the alleged incident as reported on 4/11/22, time reported was 8:15 PM. This report documents, SSD (V3 Social Services Director) found that (R1) had called (V3's) work telephone and left a message that (R1's) billfold and checks were missing. (V3) then reached out to (R1) and confirmed the concern of missing items. A room search was performed with no findings. (V1 Administrator) was called immediately, and an investigation was implemented immediately. (R1's) medical provider and responsible party were notified. The local police department was notified. On 4/21/22 at 8:14 AM, R1 appeared grouchy and was short with responses. R1 stated that R1's billfold and checkbook were missing from R1's bedroom. R1 stated that R1's billfold and checkbook were stored and last seen on R1's bed side table. R1 stated that the police have been to the facility to talk to R1 regarding the missing billfold and checkbook. R1 stated there were several charges on R1's debit card that R1 did not make. R1 stated that V6 (R1's Power of Attorney) has had to close R1's accounts and is trying to get a new checking account open for R1. On 4/21/22 at 2:40 PM, R1 stated that R1 has R1's debit card numbers written down on a piece of paper at the facility. R1 stated that this makes R1 angry and is very frustrating that someone would take R1's things and steal R1's money. On 4/21/22 at 11:35 AM, V3 Social Services stated that R1 called V3 on 4/11/22 and stated that R1's checkbook and billfold were missing. V3 stated that V3 reported it to V1 Administrator, and they went to R1's room to look for the items. V3 stated that V6 confirmed R1's debit card had been used and turned that information over to the police. V6 stated there was a lot of activity on the card for smaller amounts and that there was a larger purchase of over $1,000 for a vacation rental dated 2/23/22. V3 confirmed R1's debit card information has been gone longer than just last week. On 4/21/22 at 12:13 PM, V6 R1's Power of Attorney (POA) stated that R1 told V6 that R1 couldn't find R1's checkbook. V6 stated that there were 10 or so suspicious charges in February and then double that in March. V6 stated that shortly after R1 was admitted to the nursing home that V6 took R1's credit cards home. V6 stated that to V6's knowledge, R1 had R1's checkbook at the facility and has the debit card numbers written down at the facility. V6 stated that V6 and V3 just went over the bank statements with R1 on 4/20/22 to determine what charges were R1's and what charges were not R1's. V6 stated V6 then sent that information to the police officer. On 4/22/22 at 3:08 PM, V1 Administrator stated that they were not getting anywhere with the investigation but then reached out to V6 to check bank statements. V1 stated V6 brought statements into the facility and there were several charges on the statements that R1 did not make. V1 stated that V1 called the police and gave the information to them. V1 stated that V1 had been reviewing video footage from the time frame R1 reported the checkbook and billfold missing but was not aware that they had been missing for much longer than originally thought. On 4/21/22 at 11:35 AM, V3 provided R1's bank statements which documents one purchase on 2/14/22 for $24.99 that was not made by R1, one purchase on 2/23/22 for $1,185.85 for a vacation rental that was not made by R1, seven small charges from 3/1/22 through 3/7/22 for a total of $52.93 that R1 did not make and several more charges from 3/9/22 to 4/8/22 for a total of $488.92 that R1 did not make. On 4/21/22 at 2:30 PM, V4 Human Resource Director provided copies of two checks that R1 had written to the facility dated 12/25/21 and 1/4/22 for R1's portion of R1's stay and V4 confirmed R1 had R1's checkbook at that time. R1's Nurse's Progress Notes document R1 was sent to the hospital on 2/11/22 for an infection and did not return to R1's room at the facility until 2/23/22. On 4/22/22 at 8:50 PM, V1 confirmed R1 had money stolen on R1's debit card and stated V1 has not completed the investigation at this time.

Based on observation, interview and record review the facility failed to secure a wheelchair to the wheelchair anchors in the transport van which resulted in R5's wheelchair toppling over and R5 striking R5's head on the floor of the transport van. R5 sustained a bleeding head injury (abrasion/laceration) requiring first aid treatment. The facility also failed to identify a root cause for falls and failed to develop and implement post fall interventions for two of three residents (R3,R5) reviewed for falls in the sample list of nine. Findings include: The facility's Falls Prevention Program policy with a revised date of July 2021 documents, Fall prevention program will be implemented to assure that safety of all residents in the facility whenever possible. This program should include measure which determines the individual needs of each resident by assessing the risks for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. 1. As part of the initial assessment, identify individuals with a history of falls and risk factors for subsequent falling.4. Identify the root causes of the fall incident which could be related to resident's current or declining medical condition or worsening behavior. This policy also documents, Treatment/Management 1. Based on the preceding assessment, identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Monitoring and Follow-Up 4. If the individual continues to fall, re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. 1. R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact and R5's speech is unclear and is only sometimes understood. This MDS documents R5 is totally dependent on two staff for transfers, R5 does not walk and R5 has impairment in both upper and both lower extremities. This assessment reflects that with seat to stand and surface to surface movement R5 is unsteady and not able to stabilize without staff assistance. This MDS documents R5 has the diagnosis of [CONDITION(S)]. R5's current Physician Order Sheet and 4/21/21 Care Plan documents R5's diagnoses to include [CONDITION(S)], Spastic Quadriplegic [CONDITION(S)], Unspecified Lack of Coordination, Abnormal Posture, and Other Specified Disorders of Muscle. V7 facility van transport driver's statement dated 3/9/22 documents, Today at approximately 2:45 PM (V7) transportation driver for (the facility) with the assistance of (V8 student nurse) were taking (R5) to a medical appointment, about 3 minutes in to the trip we notice (R5) falling backwards with the chair, (V7) immediately stopped the van, (V8) and (V7) got (R5) up and (V7) realized that (V7) had forgot to fasten the front floor straps to the wheel chair, causing the chair to fall backwards. (V8) assessed the situation and we determined that since we were so close to our facility it would be best to get (R5) back so that a nurse could do a proper evaluation and determine the next step. (V7) all heartily hope that (R5) is ok, and (V7) I am terribly sorry for my gross negligence in what happen. signed by V7. The Occurrence Investigation 3/9/22 for R5 dated 3/10/22 documents, On 3/9/22 at approximately (2:00 PM) (R5's) wheelchair turn(ed) over resulting in a fall when being transported in the wheelchair van, from (R5's) wheelchair. (R5) hit (R5's) head on the floor of the van during the fall. The nurse assessed (R5) for any signs and symptoms of injury, pain, or changes in range of motion. Bleeding was noted on the posterior of (R5's) head. An abrasion was noted at the site of the bleeding. First aid was administered. (R5) was alert and could communicate by verbal gesture, and by turning (R5's) head side to side and up (and) down (normal for R5). (R5) denied any pain nor discomfort at this time. Vital signs were obtained. Neurochecks were initiated. (R5) was assisted upright into (R5's) wheelchair without event and returned to the facility. The Medical Provider and Responsible Party were notified. Upon completion of this investigation, it was identified that the root cause of this incident was related to the van strap. Education was provided. Immediate intervention was to initiate a checklist for van transports prior to transport. signed by V1 Administrator. The 3/9/22 Fall During Staff report for R5 documents under Injury Type as 'laceration.' On 4/21/22 at 2:10 PM, R5 was in R5's room in R5's wheelchair. When asked if R5 fell sideways in (R5's) wheelchair in the van, R5 motioned R5's head backwards over the back of the wheelchair indicating R5 fell backwards. On 4/22/22 at 3:08 PM, V1 Administrator stated that R5's wheelchair tipped over in the transport van because one of the straps was not secure. V1 stated that following the incident, they did training, and implemented a checklist that has to be completed prior to leaving with a resident in the van. On 4/22/22 at 6:35 PM, V7 confirmed V7's statement and V7 stated that R5 remained in the wheelchair when it tipped backwards because the rear wheelchair anchors and the lap and shoulder belt were fastened. V7 stated there was nothing broken regarding the wheelchair or the van itself, V7 stated V7 just forgot to fasten the front wheelchair anchors. 2. R3's MDS dated [DATE] documents R3 has moderately impaired cognition, inattention and disorganized thinking is present but fluctuates, R3 has other behavioral symptoms daily, R3 requires extensive assistance of one staff member for transfers and limited assistance of one staff member for toileting. This MDS documents R3's balance is not steady and only able to stabilize with staff assist. R3 is always incontinent of bowel and bladder. This MDS documents diagnoses including Alzheimer's Disease, non-Alzheimer's Dementia, Anxiety, Depression and Repeated Falls. R3's medical record documents falls on 3/27/22, 4/8/22 at 12:30 AM, 4/8/22 at 3:40 AM, 4/10/22 and 4/20/22. R3's Nurse's Progress Notes dated 3/27/22 documents R3 was found on the floor in R3's room and received a skin tear. R3's Fall Audit dated 4/4/22 documents, root cause related to (R3's) impulsive independent actions, impaired cognitive status, unsteady gait and poor balance. R3's Unwitnessed Injury Report dated 4/8/22 documents at 3:40 AM R3 was found on the floor in R3's room with a bump on R3's head over R3's eye and it was bleeding. The root cause was determined to be that R3 was attempting to get up and deals with impulsiveness. The intervention developed for this fall was to send R3 to the emergency room . R3's Nurse's Progress Notes dated 4/8/22 at 7:15 AM documents R3 was returning to the facility, all tests were negative, and they applied glue to a skin tear obtained in a previous fall. R3's Audit Report dated 4/12/22 documents on 4/10/22 at 8:20 PM, R3 was found on the floor by the nurse's station. R3 sustained a skin tear to R3's right forearm and right hand. The root cause determined for this fall was R3's Dementia, impaired cognition and impulsiveness. R3's Care Plan dated 4/10/22 documents an intervention implemented after the 4/10/22 fall to toilet R3 intermittently which will offer some diversion. On 4/22/22 at 3:57 PM, R3 was sitting in the television area across from the nurse's station in R3's wheelchair. On 4/22/22 at 5:00 PM, R3 was sitting in the same television area in R3's wheelchair. On 4/22/22 at 7:20 PM, R3 was sitting in the television area in R3's wheelchair rolling back and forth and crying that R3 was hurting. R3 was scooting R3's bottom around in the wheelchair and grabbing at R3's bottom and crotch area in the front. On 4/22/22 at 7:40 PM, V20 Certified Nursing Assistant wheeled R3 into R3's room and transferred R3 to the bed. R3 was whining that R3 hurt and grabbing at R3's bottom. When V20 pulled R3's slacks down there was stool everywhere in the incontinence brief from the front to the back. R3's slacks were wet out to the sides of the brief. R3's perineal area and bottom were fire red and had some open areas. V21 Licensed Practical Nurse applied some bandages to R3 and stated that R3 was obviously not repositioned or changed for quite some time like R3 is supposed to be. On 4/22/22 at 6:17 PM, V1 Administrator stated that they look at falls as a group and determine root cause and interventions. V1 confirmed there was no long-term intervention put into place for R3's fall on 4/8/22 at 3:40 AM. V1 confirmed that they determined the root cause for the above listed falls to be R3's impulsiveness and R3's cognitive status. V1 stated they could not determine any other root causes.

Based on observation, interview, and record review the facility failed to prevent the verbal and physical abuse of one (R1) of three residents reviewed for abuse on the sample list of eight. This failure resulted R1 having mental anguish during the abuse and continued mental anguish following the abuse. Findings include: The facility's Final Investigation Incident Report dated 11/19/21 documents on 11/16/21 at 5:50 AM, the facility received an allegation of physical and verbal abuse of R1 by a Certified Nursing Assistant (V5). This report documents R1 as alert and oriented. This report also documents that, (V5) will be separated from the company for unprofessional behavior. During interviews on 11/29/21 at 11:57 AM and 12/6/21 at 10:53 AM, R1 stated she had a problem with V5 Certified Nursing Assistant (CNA) a couple weeks ago (11/15/21). R1 stated she needed to get ready for therapy after lunch, so she put on her call light and V5 responded. R1 stated that V5 told her she would be right back. R1 stated she kept seeing V5 walk by her room and was talking to other people. R1 stated she saw V5 walk by again, so she hollered out that she needed to get ready. R1 stated. she came in and got face to face with me and screamed that she was not going to be yelled at and that she had been cleaning up (expletive for feces) all day. R1 put her hand about four inches from her face and stated with tears in her eyes that, she was this close and screaming curse words at me including (f-word) and was saying you aren't going to tell me what to do. R1 stated, I asked her to calm down and even told her that she was my favorite because she was losing it and wouldn't quit yelling. I was trying to smooth her over. Then, she grabbed my arm and yanked me over and it hurt my arm. I was scared of her. I was scared she was going to hit me. R1 stated V5 came in one more time that day and I was crying and then V5 asked why, and I told her she forgot to change my pad and gown. R1 stated V5 changed it without incident. R1 stated V6 CNA came on duty that evening and that the next morning V6 seen her crying. R1 stated V6 asked what was wrong so I reported the incident to V6. R1 stated R1 didn't see V5 after that. R1 stated during the incident she was very scared of V5. R1 stated tearfully that, I think about it every day and I am so worried that she might do this to someone else. R1's Witness statement dated 11/16/21 at 7:58 AM documents, About 12:15 PM I had my light on and (V5) came in and I asked her to change me, and she said she was about to feed (another resident) and she would change me after. A time passed and I seen her coming out of (another resident's room) and said (V5), I need to be changed, (they) want me to do therapy. She got really close in my face and was yelling at me. I've got all these people to take care of. I clean (expletive for feces) and I get no respect. She snatched my covers down and threw them to the floor and I said please don't yell at me. She snatched my arm to turn me over and I said wait (V5) my arm. She said I've been on this hall and they (2 other residents) are my witness that you are yelling at me to change you. She changed me and didn't change my bed pad or gown. She said you will probably call your (family member) and (V1, Administrator) but V1's in the hospital. I told her, I am going to report her, and she said if you don't then the b****h across the hall would. She (V5) gets mad sometimes, but she was bad this time and I was scared. On 11/29/21 at 12:34 PM, V6 stated around 5:00 AM on 11/16/21 R1 told me that she asked V5 to change her and that she left the room to help another resident. V6 stated R1 said 45 minutes had passed so she yelled at V5 to come in and change her. V6 stated R1 said V5 was screaming in her face not to be telling her what to do. V6 stated R1 said she was yelling and yanking her arm and her arm hurt. V6 stated R1 is reliable, she was upset and was crying. I reported it immediately. V6's Witness Statement dated 11/16/21 at 7:28 AM documents, I went in to check on (R1) and she asked if she could talk to me and if I would not say anything. I told her yes and she started crying. She said she asked (V5) to change her and (V5) said she would change her after she fed (another resident). V5 left. Therapy said they would work with her after she was cleaned up. About 45 minutes later she heard (V5) in the hall and called for her. V5 came in the room yelling and told her, I will change you when I get to you, don't tell me what to do. She (V5) was roughly grabbing her arm. (R1) said (V5) you're hurting my shoulder. (V5) snatched her blanket off of her and threw it. (V5) changed her but left her on a wet bed pad. (V5) said what are you going to do, call your (family member) and report me? V5's Witness Statement dated 11/16/21 at 7:30 AM documents, (R1) asked during the lunch meal to be changed. I stated I would change her after feeding (another resident) and picking up trays. (R1) said okay. I leave (another resident's room) and two lights are on. I answered (another resident's) light first. As I am in (that) room (R1) yells from her room, I need changed, you said you would, and therapy needs me. So, I leave (that) room and go to (R1's) room and said, Do not yell at me please, I said I would change you after (caring for the other resident) and I did not forget, and therapy did not tell me that you needed to get up so don't yell. (R1) started crying and I changed her. Twenty minutes later, I go back because (R1) had her light on. She states you changed me too quick, and my pad and gown are wet. I said okay I'm sorry and changed them. On 12/2/21 at 10:52 AM, V2 Director of Nursing stated when she interviewed R1, R1 was pretty upset. V2 stated R1 was scared, V2 stated R1 is high-strung but she was more upset than usual. V2 stated during the interviews R1 stated V5 yelled at her and V5 claimed she didn't. V2 stated she felt like their stories were similar enough. V2 stated, I didn't like that (R1) felt afraid so I told (V5) she could resign, or I would terminate her position, either way I didn't feel comfortable with her (V5) working in the facility. V2 stated R1 is alert and oriented and R1's account of the incident hasn't changed.

Based on interview and record review the facility failed to notify a physician of a resident's change in level of consciousness timely following an unwitnessed fall for a resident on an Anticoagulant (blood thinner), resulting in a delay in treatment for one of three residents (R7) reviewed for falls in the sample list of eight residents. This failure resulted in prolonged bleeding and a delay in R7 being hospitalized and treated for an acute intraventricular hemorrhage (brain bleed). Findings include: R7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Care Plan revised on 10/5/21 documents R7 receives an anticoagulant and includes interventions to monitor, document, and report as needed adverse reactions of anticoagulant use including lethargy and changes in mental status, review medications list for adverse interactions, and avoid use of aspirin or NSAIDS (Nonsteroidal Anti-[CONDITION(S)] Drugs). R7's Order Summary Report dated 11/15/21 documents R7's orders include [MEDICATION(S)] (anticoagulant) 5 mg (milligrams) twice daily, and [MEDICATION(S)] (NSAID) 7.5 mg daily. R7's November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Neurological Assessment Flow sheet for R7's fall on 11/8/21 documents post fall Neurological assessments are scheduled every 15 minutes x4, then every 30 minutes x2, then hourly x4, then every 4 hours x4, then every 8 hours x6. This form documents to assess vitals, pupil reaction, level of consciousness, hand grasps, and movement. V19 Licensed Practical Nurse (LPN) Witness Statement documents: R7 fell on [DATE] in the bathroom. V19 did not see R7 until R7 was brought to the nurse's station following the fall. V19 described R7 as having a flat affect and kind of lethargic. R7's right Sclera was red/bloody and R7's right cheek was bruised. R7's Progress Notes document: On 11/11/21 at 4:10 PM R7 had a witnessed fall in the hallway and sustained a 1.5 cm (centimeter) laceration to the right eyebrow. On 11/12/21 at 12:58 PM R7 was asleep, stayed in bed all morning, had 3 cups of water but no food intake for breakfast. On 11/13/21 at 1:02 PM R7 was asleep in bed most of the shift. Prior to 11/12/21 R7 is documented as ambulatory, wandering the unit, and self-transferring at times. On 11/13/21 at 7:00 PM R7 was found on the floor in R7's bathroom, and redness was noted to R7's Sclera. An initial Neurological assessment was completed. V18 Physician and R7's family were notified. R7's medical record only documents Neurological assessments were completed at the time of R7's fall and on 11/14/21 at 5:27 AM. On 11/14/21 at 6:06 PM V18 and R7's family were notified of periorbital redness. On 11/15/21 at 2:51 PM V15 Nurse Practitioner assessed R7 and gave orders to send R7 to the emergency room due to the fall, increased bleeding to the right eye, and R7 receiving [MEDICATION(S)] and [MEDICATION(S)]. There is no documentation in R7's medical record that R7 had increased lethargy following the fall on 11/13/21, and that R7's lethargy was reported to V18. R7's emergency room (ER) notes dated 11/15/21 at 3:14 PM document: R7 had fallen in R7's bathroom yesterday, and today bruising was noted to R7's right eye. Clinical Impression: Intracranial bleed. R7's Computed Tomography (CT) of the head or brain dated 11/15/21 at 4:33 PM documents: Acute intraventricular hemorrhage without [CONDITION(S)]. Non-hemorrhagic 0.5 cm (centimeter) right frontal subdural hygroma (collection of spinal fluid). Findings are new since the previous head CT (on 4/7/21) and most likely represents posttraumatic hemorrhage. R7 was transferred to another hospital. R7's Neurosurgery Consult Notes dated 11/15/21-11/17/21 document: R7 was given [MEDICATION(S)] (medication used to reverse anticoagulation) at prior hospital after CT showed right lateral ventricular hemorrhage and blood pooling in the left lateral ventricle. R7's CT [MEDICATION(S)] ruled out a vascular source of the brain bleed. On 12/1/21 at 11:00 AM V7 Registered Nurse (RN) stated: V7 was working when R7 fell on [DATE]. It was in the evening, and R7 was walking in the hall. Staff witnessed R7 walking and fall forward to the floor. R7 sustained a right eyebrow laceration. R7 fell again a few days later. Prior to the falls R7's gait was unsteady, R7 needed assistance of 1 staff person and other times R7 would walk by R7's self. On 12/1/12 at 1:07 PM V7 stated V7 worked dayshift on 11/14/21 and R7 did not get out of bed at all that shift. V7 stated I wouldn't say (R7) was (R7's) normal self that day. R7 took more time to respond, and V7 did not complete a Neurological assessment that shift. V7 did not notify anyone that day in regard to R7. On 12/1/21 at 11:56 AM V11 CNA stated: Before R7 fell , R7 would stumble while walking and staff would have to sit R7 down. R7 was able to ambulate independently. After R7's fall on 11/13/21, R7 stayed in bed more and R7 was not alert. It was difficult to wake R7 up at times. Sometimes R7 would wake up and feed R7's self. R7 stayed in bed all day on first shift on 11/14/21 and 11/15/21, and R7 was not up walking around like R7's usual self. That was new for R7. On 12/1/21 at 2:50 PM V10 CNA stated: The last few falls really did (R7) in. After that last fall (R7) wasn't (R7's self). R7 wasn't getting up out of bed as much. R7 was in the bed and not responding to V10 on the evenings of 11/13/21 and 11/14/21. We thought R7 hit R7's head hard and thought R7 had a brain bleed. V10 told the nurse (V9) that, and V2 Director of Nursing as well. I (V10) don't know why they didn't send (R7) out to the hospital sooner. By Sunday (11/14/21) R7's cheek bruise was larger and (R7's) right eye was blood shot. On 12/1/21 at 1:29 PM V9 RN stated: On 11/13/21 at approximately 7:00 PM, V9 found R7 lying on the floor of R7's bathroom. R7 had discoloration to R7's right cheek and right eye Sclera redness. V9 completed an initial Neurological assessment. V18 Physician and R7's family were notified of the fall and Sclera redness. The following day on 2nd shift, V9 noticed the redness to the Sclera had increased and spread to the periorbital area. V9 notified V18 Physician and R7's family. On 11/14/21 R7 was in bed for the entire 2nd shift. R7 did sit up on the side of the bed and fed R7's self-supper. On 11/15/21 V9 asked V15 Nurse Practitioner to assess R7. V15 gave orders to send R7 to the emergency room and R7 was admitted to the hospital. V9 forgot to complete the paper form for R7's post fall Neurological assessments. V9 confirmed V9 did not complete post fall Neurological assessments following R7's initial assessment after the fall on 11/13/21. On 12/2/21 at 10:24 AM V9 stated: V9 reported R7's fall and sent a picture of R7's reddened Sclera to V18 via text message on 11/13/21 around 7:00 PM. V18 returned a text message at 8:00 PM that said subconjunctival hemorrhage and no new orders. On the evening of 11/14/21 V9 sent another text message to V18 that said R8's Sclera redness had increased, and V18 replied ok. V9 did not mention R7's anticoagulant use to V18. V9 did not report R7's lethargy on 11/14/21 to V18, since R7 sat up and ate supper. On 12/2/21 at 1:15 PM V19 RN stated: V19 saw R7 shortly after R7's fall on 11/13/21. R7 usually wanders and is unsteady. That night R7 was sitting in a chair or wheelchair in the common area. R7's head was down and R7 wasn't really responsive and acting weird. V19 questioned what had happened and was told R7 fell . V19 noticed R7's Sclera was red. R7 would respond to R7's name by looking up, and then back down. V19 told V9 that V19 thought R7 may need to go to the hospital. V19 did not notify anyone since V19 was not R7's assigned nurse. On 12/1/21: At 1:13 PM V2 Director of Nursing stated: Neurological assessments are to be completed for unwitnessed falls or if the resident hits their head. Initial Neurological assessments are documented in the fall note, and then after that the assessments are documented on the paper Neurological flow sheet. V2 stated V2 did not have any Neurological assessments to provide following R7's fall on 11/13/21. The nurses told V2 the assessments weren't done. At 2:26 PM V2 stated: Prior to R7's fall on 11/13/21 R7 would ambulate independently about the unit. V2 would consider R7 spending an entire 1st or 2nd shift in bed a change in condition for R7 and expect to be reported to V18 and V2. V2 was not aware that R7 was lethargic and not getting out of bed prior to R7's hospitalization . V2 was not sure what the facility's policy was regarding unwitnessed falls for residents who are on anticoagulants, that was in place at the time of R7's fall. After R7's fall, the facility implemented a new policy that residents will be transferred out for evaluation if an unwitnessed fall or head injury occurs, and the resident is on anticoagulants. Attempts were made to contact V18 Physician but were unsuccessful. On 12/1/21 at 1:52 PM V15 Nurse Practitioner stated: R7 has had several falls. On 11/15/21 V9 reported R7's November falls to V15 and requested V15 assess R7. V9 told V15 that R7 had not been acting right since R7's fall on 11/13/21. V15 noted a change in R7's condition. R7 had bleeding/redness to R7's right eye and bruising to R7's right cheek. The bleeding of R7's eye was very concerning since R7 is on [MEDICATION(S)] and had fallen. R7 was admitted to the hospital with an intraventricular hemorrhage. If a resident is on anticoagulants and has an unwitnessed fall V15 likes to see them sent to the emergency room for evaluation, but V15 was not sure if that is the facility's policy. V15 would expect the nurses to complete post fall Neurological assessments for residents who had an unwitnessed fall and take an anticoagulant. On 12/2/21 at 11:17 AM V15 was asked what could happen as a result of prolonged bleeding and a delay in sending R7 to the emergency room . V15 stated: There could be permanent Neurological deficits similar to a stroke such as altered mental status, poor strength, and could absolutely lead to death if left untreated. The facility's undated Anticoagulation Therapy policy documents: The Nurse on Duty and/or Attending Physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (blood from the respiratory tract) or other evidence of bleeding, the Nurse on Duty will discuss the situation with the Attending Physician before giving the next scheduled dose of anticoagulant. The facility's Change in a Resident's Condition or Status policy revised November 2021 documents: The physician/practitioner will be notified of changes in the resident's mental/medical condition including a need to alter the resident's medical treatment, transfer the resident to the hospital, and changes in the resident's physical/emotional/mental condition. If the change in condition is emergent, contact 911 and transfer the resident to the hospital. Record assessment and observation information in the resident's medical record regarding changes in the resident's condition.

Based on observation, interview, and record review the facility failed to accurately complete fall risk assessments, complete post fall neurological assessments, implement post fall interventions and therapy recommendations, and thoroughly complete post fall investigations for two of three residents (R7, R8) reviewed for falls in the sample list of eight residents. This failure resulted in R7 falling and sustaining an acute [CONDITION(S)] (brain bleed) following an unwitnessed fall. Findings include: 1. R7's Diagnosis List dated 12/2/21 documents R7's diagnosis include [CONDITION(S)] with long term use of Anticoagulants (blood thinner), and Dementia. R7s Minimum Data Set (MDS) dated [DATE] documents R7 has short term and long-term memory impairment and is moderately impaired with decisions. R7 uses limited assistance of one staff person for transfers and walking in the room and corridor. R7 is not steady during transitions and walking and requires staff assistance to stabilize balance. R7 uses extensive assistance of one staff person for toileting and is frequently incontinent of bowel and bladder. R7's Care Plan revised on 10/5/21 documents R7 is at risk for falls and includes interventions to ensure that R7 is wearing appropriate footwear when ambulating or mobilizing in wheelchair, and R7 needs a safe environment including even floors free from spills and/or clutter. R7's Care Plan revised on 10/25/21 documents R7 had a fall and includes an intervention dated 10/25/21 to assist with lying down for rest periods as tolerated when noted to be tired, and an intervention dated 11/8/21 to encourage resident to wear nonskid socks instead of shoes when ambulating. R7's Order Summary Report dated 11/15/21 documents the following orders: [MEDICATION(S)] ([CONDITION(S)]) [MEDICATION(S)] take 100 mg (milligrams) daily. [MEDICATION(S)] (Antiseizure) take 250 mg twice daily and 500 mg daily at bedtime. [MEDICATION(S)] (Anticoagulant) take 5 mg twice daily. [MEDICATION(S)] (NSAID) take 7.5 mg daily. [MEDICATION(S)] (Antihypertensive) take 25 mg twice daily. [MEDICATION(S)] ([CONDITION(S)]) take 0.5 mg twice daily. [MEDICATION(S)] ([CONDITION(S)]) take 25 mg daily. R7's Physical Therapist Progress & Discharge Summary, recorded by V17 Physical Therapist, dated 10/15/21 documents: R7 is able to maintain standing balance without handheld support, may require occasional contact guard assist for less than 10 minutes. R7 requires supervision in gait due to impaired safety awareness. R7 will need a supervised walking restorative program set up to allow R7 to rest in order to prevent falls due to fatigue from overuse of prolonged weight bearing. Staff was provided education on the ambulation program. There is no documentation in R7's medical record that R7's supervised walking restorative program was implemented as recommended by V17. R7's Progress Notes document: On 10/23/21 at 9:15 PM R7 was wandering the hallways and was wobbly at times. R7 needed frequent reminders to sit in a chair or wheelchair. On 10/24/21 at 11:04 PM R7 had an unwitnessed fall. R7 was found in another resident room, lying on R7's back. R7 had a skin tear to the right elbow and R7's pupils were equally reactive to light. The only post fall Neurological assessment documented following this fall is on 10/25/21 at 3:35 PM. On 11/8/21 at 6:15 PM R7 was walking at a fast pace, leaned forward, lost balance and fell forward to the floor causing R7 to hit R7's forehead. R7 had a small, reddened area to R7's forehead and an initial Neurological assessment was completed. R7's nursing notes document Neurological assessments were not completed again until 9:53 PM on 11/9/21 and then not again until 11/10/21 at 4:10 PM. On 11/11/21 at 4:10 PM R7 had a witnessed fall in the hallway and sustained a 1.5 cm (centimeter) laceration to the right eyebrow. A Neurological assessment was completed at the time of R7's fall and on 11/12/21 at 5:18 AM. There are no other Neurological assessments documented following R7's fall on 11/11/21. On 11/13/21 at 7:00 PM R7 was found on the floor in R7's bathroom, and redness was noted to R7's sclera. An initial Neurological assessment was completed. R7's medical record only documents Neurological assessments were completed on 11/14/21 at 5:27 AM after this fall. R7's Neurological Flow Sheet for R7's 11/8/21 fall does not document Neurological assessments were completed as scheduled at 9:00 PM and 10:00 PM on 11/8/21, or after 6:00 AM on 11/9/21. This flow sheet documents post fall Neurological assessments are scheduled every 15 minutes x4, then every 30 minutes x2, then hourly x4, then every 4 hours x4, then every 8 hours x6. This form documents to assess vitals, pupil reaction, level of consciousness, hand grasps, and movement. R7's Fall Risk Evaluation dated 10/24/21 documents: A score of 10 or greater indicates the resident is at high risk for falls and prevention protocol should be initiated and documented on the care plan. For the medications section respond on the types of medications used including Antiseizure, Antihypertensive, and [CONDITION(S)] medications. R7's Fall Risk score is 8, indicating R7 is not at high risk for falls. This evaluation is not accurate and documents R7 takes 1-2 of the listed types of medications, R7's gait/balance is normal, and R7 is ambulatory and continent of bowel and bladder. R7's Fall Risk Evaluation dated 11/8/21 documents: R7's Fall Risk score is 7. This evaluation is not accurate and documents R7 is ambulatory/continent, and R7 takes 1-2 of the listed types of medications. R7's 10/24/21 fall investigation does not document interviews were conducted with staff. There is no documentation in R7's medical record or fall investigation of when R7 was last observed, or the last time R7 was assisted with toileting or to rest. R7's 11/8/21 fall investigation documents the root cause of R7's fall is believed to be that the rubber soles on (R7's) shoes may have caused (R7) to trip. R7's post fall intervention is to encourage R7 to wear non-skid socks instead of shoes when ambulating. R7's 11/11/21 fall investigation documents the root cause of R7's fall is believed to be that R7 fell due to fatigue. This investigation does not document when staff last assisted R7 to rest prior to the fall. The Final Investigation Report dated 11/22/21 documents: On 11/13/21 R7 was found on the floor in R7's restroom. R7 was barefoot and water was on the floor. R7 had redness noted to R7's Sclera (white part of the eye). During post fall assessments R7 was noted to have increased bleeding to the right eye, was assessed by the Nurse Practitioner (V15), and transferred to the local emergency room . R7's Computed Tomography (CT) scan of the head/brain showed acute Intraventricular Hemorrhage (brain bleed) and Non-Hemorrhagic 0.5 cm (centimeter) right Frontal Subdural Hygroma (collection of Cerebrospinal fluid.) The root cause of R7's fall was believed to be that R7 slipped in water on the bathroom floor. This investigation documents witness statements from V9 RN (Registered Nurse) and V19 LPN (Licensed Practical Nurse.) V9's statement documents: R7 fell on [DATE] in the bathroom. R7 was barefoot, R7's sink was leaking, and the floor was wet. R7 was last seen on the bed. V19's statement documents: V19 did not see R7 until R7 was brought to the nurse's station following the fall. V19 described R7 as having a flat affect and kind of lethargic. R7's right sclera was red/bloody and R7's right cheek was bruised. There are no other documented staff witness statements or interviews. There is no documentation of the time that R7 was last observed prior to the fall, when R7 was last toileted, and if R7 was wearing nonskid socks prior to R7's fall. R7's emergency room (ER) notes dated 11/15/21 at 3:14 PM document: R7 had fallen in R7's bathroom yesterday, and today bruising was noted to R7's right eye. Clinical Impression Intracranial bleed. R7's CT of head or brain dated 11/15/21 at 4:33 PM documents: Acute intraventricular hemorrhage without [CONDITION(S)]. Non-Hemorrhagic 0.5 cm right frontal subdural hygroma. Findings are new since the previous head CT (on 4/7/21) and most likely represent posttraumatic hemorrhage. R7 was transferred to another hospital. R7's Neurosurgery Consult Notes dated 11/15-11/17/21 document: R7 was given [MEDICATION(S)] (medication used to reverse Anticoagulation) at prior hospital after CT showed Right Lateral Ventricular Hemorrhage and blood pooling in the Left Lateral Ventricle. On 11/17/21 R7's CT [MEDICATION(S)] ruled out a Vascular source of the Brain bleed. On 12/1/21 at 11:00 AM V7 RN stated: V7 was working during one of R7's falls. It was in the evening, and R7 was walking in the halls. Staff witnessed R7 walking and fall forward to the floor. R7 sustained a right eyebrow laceration. Neurological assessments are done every 15 minutes following a fall and are documented in a progress note or on the Neurological flow sheet. V7 was unsure how long post fall Neurological assessments are to be completed following a fall. R7 fell again a few days later, and V7 was unsure what fall intervention was put into place after R7's fall on 11/11/21. Prior to the falls R7's gait was unsteady and needed assistance of 1 staff person, and other times R7 would walk by R7's self. On 12/1/21 at 11:23 AM V12 Certified Nursing Assistant (CNA) stated: When R7 first came to the facility, R7 ambulated independently. R7 had a fall and then staff started to supervise R7 with walking and used a gait belt if R7 was unsteady. R7 was incontinent and required staff to provide toileting/incontinence care every 2 hours. R7 would self-transfer out of bed at times. V12 was not sure what fall prevention interventions were used for R7. On 12/1/21 at 11:56 AM V11 CNA stated: Before R7 fell , R7 would stumble while walking and staff would have to sit R7 down. R7 was able to ambulate independently. R7's fall interventions included wearing shoes or nonskid socks and direct R7 to sit in the chair or wheelchair. On 12/1/21 at 1:29 PM V9 RN stated: On 11/13/21 at 7:00 PM, V9 found R7 lying on the floor of R7's bathroom. R7 was not wearing any clothing and was barefoot. The bathroom floor was wet, and the sink was leaking. R7 had discoloration to R7's right cheek and right eye sclera redness. V9 completed an initial Neurological assessment. The following day on 2nd shift on 11/14/21 V9 noticed the redness to the Sclera had increased and spread to the Periorbital area. V9 notified V18 Physician. On 11/15/21 V9 asked the V15 Nurse Practitioner to assess R7. V15 gave orders to send R7 to the emergency room and R7 was admitted to the hospital. V9 forgot to complete the paper form for R7's post fall Neurological assessments. V9 confirmed V9 did not complete post fall Neurological assessments after the initial assessment for the fall on 11/13/21. On 12/2/21 at 10:24 AM V9 stated: On 11/13/21 V9 saw R7 around the evening medication pass at an unknown time before R7's fall. R7 was lying in bed at that time, and V9 was unsure if V9 had on nonskid socks prior to R7's fall. Shoes or nonskid socks would have helped with traction and may have prevented R7's fall. On 12/1/21 at 2:50 PM V10 CNA stated: V10 worked 2nd shift on 11/13/21 and was assigned to R7's hallway. V10 was unable to recall details of R7 prior to R7's fall and was unsure of the last time R7 had been checked on or toileted prior to R7's fall. R7 is kind of wobbly in the evening after dinner and V10 would typically lie R7 down at that time. V10 stated V10 did not assist R7 into bed prior to R7's fall. R7 would locate R7's room and self-transfer into bed at times. On 12/2/21 at 1:15 PM V19 RN stated: V19 did not see R7 in R7's room at the time of the fall on 11/13/21, and V19 did not see R7 prior to the fall. On 12/2/21 at 9:56 AM V4 Certified Occupational Therapy Assistant/Rehab Director stated: R7 received Physical Therapy from 9/29/21 - 10/15/21. Upon discharge therapy recommended a supervised ambulation restorative program. Staff should be with R7 at all times when R7 is walking due to R7 being a fall risk and offer R7 frequent rest periods. On 12/2/21 at 10:38 AM V4 stated: V4 spoke with V17 Physical Therapist and prolonged weight bearing status meant R7 was constantly up walking. On 12/1/21: At 1:13 PM V2 Director of Nursing (DON) stated: Neurological assessments are to be completed for unwitnessed falls or if the resident hits their head. Initial Neurological assessments are documented in the fall note, and then after that the assessments are documented on the paper Neurological flow sheet. V2 stated V2 did not have any Neurological assessments to provide following R7's fall on 11/13/21. The nurses told V2 the assessments weren't done. At 2:26 PM V2 stated: Prior to R7's fall on 11/13/21 R7 would ambulate independently about the unit. R7's gait was shuffled at times and R7 was wearing tennis shoes with a lot of grip, so we had R7 start wearing nonskid socks instead of shoes. Fall risk assessment scores determine the resident's risk for falls. Residents who are high risk for falls have more narrowed specific fall prevention interventions on their care plan. On 12/1/21: At 3:50 PM V2 stated V2 was unable to provide any additional Neurological assessments for R7's falls on 10/24/21, 11/8/21, and 11/11/21. At 11:23 AM V2 stated R7 did not have any restorative programs implemented and confirmed R7's 10/24/21 and 11/8/21 Fall Risk Assessments were not completed accurately. At 11:58 AM V2 confirmed R7's 10/24/21 fall investigation did not document staff interviews/witness statements and did not document when R7 was observed or toileted before the fall. At 12:30 PM V2 stated the root cause of R7's fall on 11/13/21 was believed to be that R7 slipped in water on R7's bathroom floor. V2 would expect R7 to have on nonskid socks when ambulating. The 11/13/21 fall investigation only documented witness statements from V9 and V19. V2 confirmed there is no documentation in R7's medical record or fall investigation of when R7 was last observed or toileted, or if R7 had on nonskid socks prior to the fall. On 12/1/21 at 1:52 PM V15 Nurse Practitioner stated: R7 has had several falls. On 11/15/21 V9 reported R7's November falls to V15 and requested V15 assess R7. V9 told V15 that R7 had not been acting right since R7's fall on 11/13/21. R7 had bleeding/redness to R7's right eye and bruising to R7's right cheek. The bleeding of R7's eye was very concerning since R7 is on [MEDICATION(S)] and had fallen. R7 was admitted to the hospital with an intraventricular hemorrhage. If a resident is on anticoagulants and has an unwitnessed fall V15 likes to see them sent to the emergency room for evaluation, but V15 was not sure if that is the facility's policy. V15 would expect the nurses to complete post fall Neurological assessments for residents who have an unwitnessed fall and take an anticoagulant. On 12/2/21 at 11:17 AM V15 stated: V15 would expect R7's care plan intervention for nonskid gripper socks to be implemented. Gripper socks or shoes could have prevented R7's fall. 2. R8's Diagnosis List dated 12/8/21 documents R8 has diagnosis of Alzheimer's Disease. R8's MDS dated [DATE] documents: R8 has severe cognitive impairment, uses extensive assistance of two staff for transfers and extensive assistance of one staff for toileting. R8's Care Plan revised on 11/20/21 documents: R8 is at high risk for falls and was admitted to the facility after a fall that resulted in a Right [CONDITION(S)]. This Care Plan documents interventions dated 11/22/21 to offer more frequent toileting as R8 desires and to keep the bed in low position. R8's Order Recap Report dated 11/1/21-12/1/21 documents an order for [MEDICATION(S)] (anticoagulant) 40 mg/0.4 ml (milliliters) inject 0.4 ml subcutaneously once daily for 28 days beginning on 11/11/21. R8's Nursing Notes document: On 11/19/21 at 8:01 PM R8 was found on the floor beside R8's bed. R8 was incontinent of urine and was believed to be attempting to self-toilet. On 11/25/21 at 1:15 PM R8 was yelling out and staff found R8's head and back on the floor, and R8's legs were in the bed. R8 stated R8 hit R8's head and was holding the right side of R8's head. R8's nursing notes document Neurological assessments were completed on 11/25/21 at 1:26 PM, and on 11/26/21 at 1:39 AM and 10:44 AM, following R8's fall on 11/25/21. R8's medical record does not contain a Neurological Flow Sheet for R8's falls on 11/19/21 and 11/25/21. R8's Fall Investigation dated 11/25/21 documents the root cause of R8's fall was believed to be that R8 changed position and slid off of R8's bed, and R8 uses an air mattress. R8's post fall intervention was to place a draw sheet on R8's bed when R8 is lying in bed to prevent sliding. This investigation contained V8 LPN's witness statement that documents R8 had a small bump to R8's right side of scalp. R8 was assisted back into bed and R8's bed was positioned low to the floor. There is no documentation any other staff besides V8 were interviewed, when R8 was checked on or toileted prior to R8's fall, or that R8's air mattress setting was evaluated. On 12/1/21: At 9:35 AM R8 was lying in bed on an air mattress with R8's feet dangling over the side of the bed. R8's bed was not positioned low to the floor. At 10:55 AM, 12:02 PM, and 12:57 PM R8 was lying in bed and R8's bed was elevated, and not low to the floor. On 12/1/21 at 12:21 PM V8 LPN stated: (On 11/25/21) R8 was yelling out in R8's room. R8 was found with R8's back and head on the floor and R8's feet in the bed. R8's bed was not low to the floor at the time of R8's fall. That wasn't the first time R8 has fallen, and R8's bed should be low to the floor. I assessed R8 and R8 had a goose egg to R8's top right forehead. I checked R8's pupils, speech, hand grasps, level of consciousness, and vitals following R8's fall. Post fall Neurological assessments are to be completed every 15 minutes for 1 hour, then every 30 minutes for an hour, then every 4 hours for 24 hours. We use a paper form to document Neurological assessments that is passed on from shift to shift. On 12/2/21: At 11:10 AM V14 RN stated R8's 11/19/21 post fall intervention was for R8's bed to be in low position near the floor. At 11:31 AM V14 RN confirmed V8's witness statement was the only interview conducted for R8's 11/25/21 fall investigation. V14 confirmed the investigation does not document when R8 was last checked on or toileted, or that R8's air mattress setting was evaluated. On 12/1/21 at 3:50 PM V2 DON stated V2 was unable to provide additional documentation of post fall Neurological assessments for R8's 11/19/21 and 11/25/21 falls. The facility's Fall Prevention Program revised July 2021 documents: 3. Risk factors causing the fall should be identified such as: a. Lightheadedness or Dizziness, multiple medications, Musculoskeletal abnormalities, Peripheral [CONDITION(S)], Gait and Balance Disorders, Cognitive Impairment, weakness, environmental hazards, confusion, visual impairment, and illnesses affecting the central nervous system and blood pressure. 4. Identify the root causes of the fall incident which could be related to resident's current or declining medical condition or worsening behavior. Staff will attempt to determine possible root causes of falls. Collect and evaluate any information until either the cause of the falling is identified or can be speculated as to what was the resident trying to do causing the fall, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk. Follow up on any falls with associated injury until the resident is stable and complications such as fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. The facility's Neurological Evaluation policy revised March 2021 documents: The purpose of this procedure is to provide guidelines for a Neurological evaluation: 1. When following an unwitnessed fall; 2. Fall with injury to face and/or head; or 3. When indicated by resident condition. 1. When assessing Neurological status, always include frequent vital signs. 2. Any change in vital signs and/or Neurological status in a previously stable resident should be reported to the Attending Physician. Neurological assessment includes determining the resident's orientation to person, place and time, observing patterns of speech and clarity, monitoring temp, pulse, respirations, and blood pressure, checking bilateral pupil reaction, assessing bilateral strength and asking resident to squeeze fingers, assessing bilateral feet movement and determining if the resident has any numbness or tingling. Have the resident smile to determine if there is any facial drooping. Document findings in the resident's record.

Based on interview and record review the facility failed to notify the physician of abnormal lab results, obtain treatment orders, and failed to promptly obtain a urine sample for diagnostic testing per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1's urinary infection progressing and R1 becoming Septic. R1 was sent to the emergency room and admitted to the Intensive Care Unit for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: R1's Face Sheet dated October 2021 documents R1 is diagnosed with Cerebral Infarction, [CONDITION(S)], [CONDITION(S)] ([CONDITION(S)]), and Urinary Tract Infection ([CONDITION(S)]). R1's Physician Order Sheet (POS) dated 10/7/21 documents R1 had a Urinary Catheter which was to be cleaned and cared for every shift. The same POS documents staff were to notify physician of changes or irritation every shift. R1's Care Plan dated 8/30/21 documents R1 has a Urinary Catheter due to Urinary Retention related to [CONDITION(S)]. Interventions to prevent urinary catheter complications include: Call medical doctor for signs and symptoms of [CONDITION(S)], change urinary catheter and bag as needed for system failure, clean urinary catheter insertion site, monitor output, and obtain labs ordered by medical doctor. R1's Progress Note dated 9/18/21 written by V5 Licensed Practical Nurse documents R1 was complaining of burning urination and had a fever of 103.5 degrees Fahrenheit (F). A [CONDITION(S)] was suspected, and a urine specimen was taken. R1's Progress Note dated 9/20/21 written by V6 Registered Nurse documents R1's urinalysis results were received on 9/20/21 and V11 Medical Doctor was notified with no new orders. On 10/7/21 at 11:20 AM V5 LPN stated she worked the night shift on 9/17/21 and took care of R1. Early in the morning on 9/18/21, R1 spiked a fever of 103.5 F. R1 was complaining of burning and pain when urinating. R1 had a urinary catheter. V5 stated she called V11 MD and he ordered a urinalysis and culture and sensitivity (UA C&S). V5 stated she drew the urine and placed it in the refrigerator. V5 stated the urine didn't get picked up until that Monday (9/20/21) as 9/18/21 was a Saturday and the lab didn't come to collect specimen again until Monday. V5 stated she doesn't know what happened with the urine after that and she never saw the results. On 10/6/21 at 2:30 PM V6 RN stated she took care of R1 on 9/20/21 and received R1's urinalysis results. V6 stated she reported the results to V11 MD, and he did not order anything at that time because the culture and sensitivity results had not come back yet. V6 RN stated she is not sure when those results came in or who received them, but she did not. The Urinalysis Culture and Sensitivity results dated 9/22/21 from the urine received in the lab on 9/20/21 showed R1's urine was infected with [CONDITION(S)] Pneumoniae. On 10/7/21 at 11:45 AM V2 Director of Nurses (DON) confirmed V11 MD was not notified of R1's 9/20/21 culture and sensitivity results and that the results had shown a [CONDITION(S)] Pneumoniae urine infection. At 3:30 PM V2 DON confirmed R1 appeared to be having symptoms of infection (pain and burning related to his catheter) as well as spiked a fever (103.5 F) on 9/18/21 according to nursing documentation. V2 verified that if V11 MD had been notified of abnormal C&S of the urinary infection of [CONDITION(S)] on 9/22 he could have prescribed an antibiotic to treat the infection. V2 confirmed nursing should notify a physician with abnormal lab results and follow up for a response. R1's Progress Note dated 9/24/21 written by V8 Licensed Practical Nurse documents R1 had multiple complaints throughout the day of pain and burning sensation related to his urinary catheter. Pain medication given. Catheter checked for kinks and fluid encouraged with no relief. V10 Nurse Practitioner notified of R1's condition and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Note dated 9/24/21 written by V10 Nurse Practitioner (NP) documents R1 was assessed at the request of nursing staff. R1 was complaining of dysuria (painful urination) and R1's urine appeared bloody and cloudy with a strong odor. V10 ordered a urinalysis and culture and sensitivity to be completed. On 10/6/21 at 1:50 PM V8 LPN stated she took care of R1 on 9/24/21 and he was complaining of pain and burning around his urinary catheter. V8 stated R1's urine was bloody, cloudy, and odorous. V8 confirmed she notified V10 NP who saw R1 and ordered a UA and C&S. V8 stated however, that 9/24/21 was a Friday and she thought the lab service the facility uses had already came that day, so she put in the order for the UA C&S to be collected on the next day the lab was there which was Monday 9/27/21. V8 stated she is not sure if V10 NP was aware of the fact that the UA C&S would not be collected or sent to the lab for three days following V10's order. On 10/7/21 at 11:25 AM V10 Nurse Practitioner stated she expects that when she writes an order that it be completed right away and in a timely manner. R1's urine specimen should have been sent to the lab the day she ordered it (9/24/21) not three days later on 9/27/21. The Urinalysis Culture and Sensitivity results dated 9/28/21 from the urine received in the lab on 9/27/21 showed R1's urine was infected with [CONDITION(S)] Pneumoniae Extended Spectrum Beta-Lactamases (ESBL). R1's Progress Note dated 9/29/21 written by V6 Registered Nurse documents she received lab results of R1's 9/27/21 urine culture which showed Extended Spectrum Beta-Lactamases (ESBL). V6 spoke to V11 Medical Doctor and received order for [MEDICATION(S)] 500 milligrams (antibiotic) twice per day for seven days. On 10/6/21 at 2:30 PM V6 RN confirmed she notified V11 MD of R1's UA C&S results on 9/29/21 and the [MEDICATION(S)] antibiotic was started the next day on 9/30/21. R1's Progress Note dated 10/1/21 written by V7 Registered Nurse documents on the morning of 10/1/21 at approximately 9:00 AM R1 began experiencing shortness of breath, low oxygen saturation, fever of 104 degrees Fahrenheit, elevated blood pressure, and an erratic heart rate. R1 was sent to the emergency room and left by ambulance at 9:38 AM. R1's Infectious Diseases Consultation dated 10/4/21 documents R1 arrived at the emergency roiagnom on [DATE] with fever, altered mental status and tachypnea. R1 presented with a chronic infected appearing urinary catheter with hematuria noted. R1 had mottled skin and delayed capillary refill with a rectal temp of 103 degrees Fahrenheit on arrival. R1 was found to be in severe [CONDITION(S)]. According to R1, he had been experiencing dysuria for about 2 weeks. R1 was admitted to the Intensive Care Unit. On 10/7/21 at 11:25 AM V10 Nurse Practitioner stated if the 9/20/21 UA C&S results would've been reported to V11 Medical Doctor like they should have been then an antibiotic treatment regimen could have been started, and R1 would not have been left with an untreated infection with worsening symptoms of infection over the next two weeks and probably wouldn't have become septic. On 10/7/21 at 3:30 PM V2 Director of Nursing confirmed nursing should notify a physician with abnormal lab results and follow up for a response. V2 confirmed if a resident has symptoms of an infection, the diagnostic test should not be put off but should be competed when ordered so that the infection can be identified and treated appropriately in order to prevent further complications. The Lab and Diagnostic Test Results: Physician Role and Follow-up dated November 2015 documents residents will have appropriate lab and diagnostic testing, facility shall use a systematic process for obtaining and reviewing lab and diagnostic test results and reporting results to physicians, clinically significant test results will be reviewed and acted upon appropriately and in a timely manner, and Physicians shall address lab results appropriately and in a timely manner.

Based on observation, interview, and record review, the facility failed to implement pressure reducing interventions, keep skin free of moisture to prevent pressure ulcer development, assess for and implement additional nutritional interventions, monitor the pressure ulcer weekly, complete pressure ulcer treatment as ordered, and prevent cross contamination of the pressure ulcer for two of three residents (R5, R10) reviewed for pressure ulcers on the sample list of 12. This failure resulted in R10 developing an unstageable sacral pressure ulcer. Findings Include: 1.) R10's MDS (Minimum Data Set) dated 01/25/21 documents R10 has moderately impaired cognition, requires extensive assistance with bed mobility, transfers, and toileting, is always incontinent of bowel and bladder and is at risk for pressure ulcers. R10's Care Plan dated 01/15/21 documents R10 has the potential for skin alteration due to deficits in sensory, presence of moisture, decrease activity and mobility, deficits in nutritional intake, potential for friction and shear, due to resident's current medical condition with interventions of assisting with toileting and/or incontinence care and providing a pressure reducing mattress to the bed. R10's 03/18/21 Wound Evaluation and Management Summary dated 03/18/21 by V19 Wound Physician documents R10 has an unstageable pressure ulcer to the right sacrum, which R10 has had for more than one day that is 100% covered by thick adherent devitalized necrotic tissue measuring 1.8 cm (centimeters) by 2.5 cm by 0.2 cm. V19 debrided the pressure ulcer and post debridement, the pressure ulcer presents as a stage four. V19 recommendations are to turn R10 side to side, and front to back in bed, everyone two hours if able and apply a foam or gel cushion to R10's chair. R10's 03/31/21 Wound Evaluation and Management Summary dated 03/31/21 by V19 documents R10's sacral pressure ulcer as a stage four pressure ulcer of more than 14 days duration measuring 2 cm by 1.8 cm by 0.2 cm with 100% muscle showing. This Summary continues to recommend R10 be turned side to side and front to back in bed everyone two hours if able and apply a foam or gel cushion to R10's chair. R10's medical record does not contain any Wound Evaluation and Management Summaries or wound measurements or assessments after 03/31/21. R10's dietary assessment dated [DATE] by V16 RD (Registered Dietician) documents R10 has a low BMI (Body Mass Index) at 17.5, R10's weight has been stable for the past month. R10 eats the ordered magic cup well and would benefit from increasing it to three times daily. R10's recent wound has healed, will continue to monitor. There is no dietary assessment in R10's medical record since R10 developed the unstageable sacral pressure ulcer in March 2021. R10's April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/15/21 at 11:30 am, 12:02 pm, 12:30 pm and 1:09 pm, R10 was lying in a low bed, with a regular scoop mattress, on R10's back. There was a very strong odor of urine coming from R10. On 04/15/21 at 1:18 pm, V3 Scheduler/CNA (Certified Nursing Assistant) stated there wasn't any staff assigned to R10's hall due to their only being three CNA's on the floor today V3 stated V3 had not personally provided any care to R10 today. On 04/15/21 at 1:20 pm, V3 and V7 LPN (Licensed Practical Nurse) entered R10's room to provide R10's pressure ulcer treatment. R10's brief was saturated with dark yellow urine. V7 removed R10's soiled dressing, that was also saturated with urine, to reveal a sacral pressure ulcer that V7 measured as 1.5 cm by 2.5 cm not measurable due to the wound bed being covered in a white/yellow slough. V7 proceeded to cleanse the pressure ulcer with a gauze soaked in wound cleanser, then applied the ordered dressing, all without changing gloves or performing hand hygiene. On 04/15/21 at 1:38 pm, V14 CNA stated V14 was assigned to R10's floor but not the hall and V14 had not provided any cares to R10. On 04/15/21 at 1:39 pm, V15 CNA stated V15 was assigned to R10's floor and had been at work since 6:00 am, but that V15 had not provided any cares to R10. On 04/19/21 at 10:24 am, V10 NP (Nurse Practitioner) stated residents who are at risk for skin breakdown need to be on a routine turning/repositioning schedule with cushions in their chair and repositioning devices in the bed, be on a toileting/changing schedule. If they develop a wound, they need to be seen by the RD for recommendations. Even if the resident is on supplements, if the wound progresses to an unstageable wound, the RD would need to see again for additional recommendations. V10 stated extra protein like super foods, double proteins at meals, vitamin c, and [MEDICATION(S)], could be implemented but those recommendations would come from the RD. V10 stated in R10's case, there are multiple factors that could contribute to acquiring an unstageable wound but being wet for a long period of time could have contributed and it definitely won't improve the wound, R10 should also be on a specialty mattress, to prevent pressure. On 04/19/21 at 11:22 am, R10 was sitting up in a reclining wheeled chair in R10's room, without any pressure relieving devices under R10. On 04/19/21 at 12:10 pm, R10 remained up in the reclining wheeled chair being fed lunch by an unidentified nursing student. R10 had eaten 100% of the served pasta, potatoes, carrots, and fruit. On 04/19/21 at 1:00 pm, V16 RD confirmed the last note in R10's medical record was dated 02/14/21, that was when R10 was reviewed for weight loss and R10's wound had healed. V16 stated V16 would assume I {V16} would have made a note if I {V16} reviewed (R10) after that but can't say for sure if staff told V16 of R10's wound or not. V16 stated R10 had remained on R10's supplements even after R10's wound was resolved. V16 stated V16 does recommend fortified foods or double protein at times but with someone like R10 that doesn't eat well, the liquid supplements are the way to go. On 04/19/21 at 1:10 pm, V2 DON (Director of Nursing) stated V19 Wound Physician is at the facility weekly but that R10 has not been seen by V19 since 03/31/21. V2 stated there was some confusion and R10 got removed from V19's wound list. V2 confirmed R10's wounds have not been measured/assessed since 03/31/21 due to V22 Former Wound Nurse no longer working at the facility. V2 stated V2 was not aware that R10 even had a wound until this past weekend when V2 worked the floor. V2 stated V2 does not personally stage wounds, as V2 is not certified in that area. At this time, V1 Administrator stated, if you can't see the wound bed, it's an unstageable. V2 stated V19's recommendations of a chair cushion should have been implemented. 2.) R5's MDS (Minimum Data Set) dated 02/12/21 documents R5 requires extensive assistance with bed mobility and toileting, is totally dependent on staff for transfers, is frequently incontinent of bowel and bladder and at risk for pressure ulcers. R5's Progress Notes dated 04/12/21 by V11 RN (Registered Nurse) documents R5 has an open area on resident {R5's} sacrum approx.(approximately) measures 0.5 {cm} (Centimeters) x (by) 0.5 cm, barrier cream applied, NP (Nurse Practitioner) notified. R5's April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's April 2021 TAR (Treatment Administration Record) does not document the ordered [MEDICATION(S)] dressing was applied on 04/13/21. On 04/14/21 at 10:15 am, R5 was sitting up in R5's wheelchair and stated, R5 used to have a sore spot on my {R5's} butt, but nothing now. On 04/14/21 at 10:28 am, V4 CNA (Certified Nursing Assistant) and V5 CNA entered R5's room to provide cares. V4 and V5 removed R5's brief to reveal a 0.5 cm by 0.5 cm red, superficial open area to the left buttocks/sacral area, without a dressing. V4 and V5 confirmed there was no dressing. At this time, R5 stated, R5 has not had a dressing on the open area since it developed on 04/12/21. The facility Physician Orders-Medications and Treatments dated November 2017 documents each medication or treatment order shall be administered to the resident as ordered by the physician. The facility Prevention of Pressure Ulcers Policy dated December 2015 documents The purpose of this procedure is to provide information regarding identification of pressure ulcers risk factors and interventions for specific risk factors. For a person in bed, change position at least every two hours or more frequently if needed; if the resident has a wound on the sacral/buttocks area, determine if resident needs a special mattress. For a person in a chair, change position at least every two hours or more frequently if needed, and use foam, gel or air cushion as indicated to relieve pressure. Risk Factors for pressure ulcers include moisture, friction and shear, immobility, bowel/bladder incontinence, poor nutrition, and lowered mental awareness. Residents shall be checked and changed at least every two hours and PRN (as needed), use pillows or wedges to keep bony prominence's from touching each other, and the dietician shall assess nutrition and hydration and make recommendations based on the individual resident's assessment.

Failures at this level required more than one deficient practice statement. A.) Based on observation, interview, and record review, the facility failed to ensure a resident's safety while being transported in a facility van from a medical appointment. The resident (R2) slid from a wheelchair landing with buttocks on the footrests of the wheelchair which were on the floor of the van, with R2's legs extended and wheelchair tipped forward. This failure affects one of three residents (R2) reviewed for falls in the sample of three. R2 sustained excruciating pain to bilateral lower extremities, immediately after and with movement after the fall on the van, prior to being diagnosed with bilateral femur fractures identified to be consistent with a traumatic incident or fall. This failure also has the potential to affect 26 additional residents (R5, R8, R16-R39) who utilize the facility transport vehicle. This failure resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified on 3/17/2021 at 3:25pm. The Immediate Jeopardy was identified to have begun on 2/27/21 when R2 had a fall out of R2's wheelchair in the facility van during transport back to the facility following a [CONDITION(S)] appointment. R2 reported R2 was having pain to V6, Registered Nurse (RN) upon V6 coming on the facility van to assess R2 after R2's fall on 2/27/21. R2 reported R2 screamed out in pain immediately following this fall. R2 reported R2 remained in bed until 3/1/21 due to having a [CONDITION(S)] appointment. R2 tried not to move due to severe pain in R2's bilateral legs. R2 stated on 3/1/21, R2 had severe pain during transfer and movement which was reported to facility staff as well as V19, [CONDITION(S)] Administrative Assistant upon arrival to R2's appointment on 3/1/21. R2 was taken to the hospital emergency room and subsequently admitted for an elevated temperature. On 3/4/21, after continued complaints of pain and V18, R2's family reporting R2's fall in the facility van, the hospital performed X-rays of R2's left and right femur and knees which showed R2 had bilateral femur fractures. On 3/16/21 at 10:55am, V14, Radiologist stated V14 reviewed/read R2's imaging studies which showed bilateral distal femur fractures. V14, stated it is very uncommon/unlikely for acute bilateral femur fractures to occur spontaneously. V14 stated given (R2's) clinical history including a fall with the imaging studies, the fractures were most likely caused by trauma to bilateral lower extremities. On 3/17/21 at 3:25pm, V1, Administrator was notified of the Immediate Jeopardy situation. While the immediacy was removed on 3/12/21, onsite record review, and interview, verified that the facility is in the process of training staff including re-education on the facility transportation policy and protocol. The facility remains out of compliance at severity level two. Findings include: a.) R2's Physician Order Report dated February 2021 documents R2's diagnoses including End Stage [CONDITION(S)] (ESRD), Unstageable Pressure Ulcer of the Right Buttock, Gout, [CONDITION(S)], Renal [CONDITION(S)], [CONDITION(S)], Diabetes with Diabetic [CONDITION(S)], Obesity and Pressure Ulcer of the Sacral Region. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. R2's functional limitation in range of motion is documented as R2 having no impairment of the lower extremity's. This MDS also documents R2 occasionally had pain but the pain did not have an effect on R2's sleep or day to day activities. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. This MDS documents for R2's functional limitation in range of motion as R2 having impairment on both sides of the lower extremity's. This MDS also documents R2 has experienced pain Frequently and the pain has made it hard for R2 to sleep as well as has limited day to day activities because of the pain. The facility's investigation file for R2's fall on 2/27/21 documents R2 slid out of R2's wheel on to the footboard/foot pedals of the wheelchair with the wheelchair tipping forward with the foot pedals/board to the ground of the van while being transported by a facility van driver (V7) in the facility van. R2's Progress Note dated 2/27/21 documents R2 had slid out of R2's wheelchair on the way back to the facility from [CONDITION(S)]. This note documents when the van arrived to the facility, R2 was found in the transportation van, sitting on footboard that was laying across seat pedals. (R2) c/o (complained of) discomfort d/t (due to) the position in which (R2) was laying. This note documents R2 is to be securely placed in transport vehicle before leaving making sure seat belt and wheel locks are secured. On 3/15/2021 at 2:05pm, V7, Facility Transport Driver stated V7 and R2 were talking and as the van was coming up to the light and V7 noticed R2 was sliding slightly. R2 stated R2 was okay. V7 stated V7 kept driving but V7 noticed R2 was sliding forward more as V7 continued to drive. V7 stated V7 called the facility (R2 was still in R2's chair) and let them know help would be needed with R2 in the van when they arrived. V7 stated the seat belt was still on R2. Once back to the facility, V7 undid the seat belt and R2's seat remained tilted forward. V7 stated V6, Registered Nurse (RN) assessed R2. V7 stated R2 still had the lap belt over R2 while on the floor, but it had come up a little over R2's upper stomach not as low on R2 as when V7 first placed the lap belt. V7 stated V7 did not check to see if the straps were not tightened or loose or what may have caused R2's fall. There is no documentation V7 has been trained by the facility on operating or safely transporting residents in the facility transport van. There is no documentation the facility transport van was evaluated for function of safety restraints after R2's fall on 2/27/21 until the six month inspection on 3/9/21. There is no documentation the van was evaluated during the fall investigation by the facility. On 3/15/21 at 12:55pm, V6, RN stated, (V6) got a call R2 fell out of the wheelchair. They (R2 and V7) were coming back from [CONDITION(S)]. R2 had a foot board across foot pedals, she was sitting on that which was on the floor of the van due to wheelchair being tipped forward. (R2) complained of discomfort then, but there was not much space in relation to her position. When (V6) got out to the van, there were no straps around (R2) (seat belt). V6 stated V6 does not know if the straps/seatbelt was removed by staff prior to V6 arriving to the van. V6 stated V6 asked R2 what happened and R2 reported the belt popped when van came to a stop and R2 slid out of the wheelchair. V6 stated according to V7, V7 did not notice R2 had fallen out (of the wheelchair). R2 was saying help, help and then (V7) looked back to see R2's buttocks on the foot board to R2's wheelchair foot pedals. V6 stated V6 observed the straps to secure the bottom of the wheelchair were on the front wheels and the back wheels were in the air. R2's legs were extended out in front of R2, in the center of the van toward the front of the van. V6 stated R2 had complained of pain, but once (R2) was laid in bed R2 had no complaints. On 3/15/21 at 6:25pm, V1, Administrator stated the facility did not have documentation V7 had been trained in operating or safely transferring residents in the facility transport van. V1 stated V1 did not look at the van after R2's fall to check and see what may have caused R2's fall. On 3/16/21 at 12:15pm, V19, [CONDITION(S)] Administrative Assistant stated R2 arrived at [CONDITION(S)] on 3/1/21 and had a temperature so the ambulance was called to take R2 to the hospital. V19 stated R2 was complaining R2's legs hurt with movement. V19 stated R2 had not fallen at the [CONDITION(S)] center nor did R2 receive [CONDITION(S)] on 3/1/21. On 3/16/21 at 12:20pm, V20, [CONDITION(S)] Clinic Manager stated R2 had a history of chronic pain, but the chronic pain was more of a generalized pain and not severe. V20 stated when R2 arrived at the clinic on 3/1/21 from the facility via the facility transport van, R2 complained R2 could not straighten R2's legs. R2's Ambulance transport report dated 3/1/21 does not document R2 had any falls while being transported from the [CONDITION(S)] center to the hospital on 3/1/21. R2's Hospital Acute Care Surgery Progress Notes dated 3/4/21 at 8:32am document R2 is complaining of some bilateral knee pain and that R2 fell during transportation a few days ago. This note documents the hospital would follow up with x-rays of bilateral lower extremities. R2's x-rays of bilateral lower extremities were completed on 3/4/21 and document R2 was found to have Acute Comminuted Displaced Distal Femoral Metadiaphyseal Fracture with approximately 75% displacement of the dominant distal fracture segment of the right femur. There is apex posterolateral angulation with varus angulation of the lower leg. Impaction and angulation results in foreshortening of the femur. Osseous excrescence directed posterolaterally from the superior acetabulum may relate to prior trauma. Thickened appearance of the quadriceps tendon may relate to redundancy associated with the femoral fracture angulation. These reports document R2 had an Acute Comminuted Angulated Fracture of the Distal Femoral Metaphysis with apex dorsal angulation of the left femur. Angulation and mild impaction results in foreshortening of the femur. R2's Physician's Post-op (operation) Note dated 3/5/21 by V15, R2's Orthopedic Surgeon documents R2 had a fall during accident. This note documents after R2's admission to the hospital for other conditions R2 was found to have bilateral supracondylar femur fractures. This note documents V15's evaluation of R2's x-rays and CT scan demonstrated comminuted displaced extra-articular fractures of the bilateral supracondylar femurs. V15 documented V15 spoke with V18, R2's family to explain the injuries and expectations of outcome from them. This note documents primarily this is a palliative surgery to provide pain control. V15 also ensured V18 understood there is a very high risk of complications associated with this including infection fixation failure. This note documents, (V15) have been frank with (R2) and (V18) again that this is primarily palliative surgery. No guarantees were given. Again prognosis is extremely guarded at this point. On 3/15/2021 at 10:35am, V17, Registered Nurse (RN) stated V17 has been R2's nurse while at the hospital. V17 stated R2's bilateral femur fractures were concerning, especially since R2 had fallen on 2/27/21 with no follow up imaging completed until after R2 came to the hospital and screamed in pain any time R2 had any movement. V17 stated due to the continued complaints of pain to the bilateral lower extremities and V18, R2's Family report of the fall in the facility transport van, the hospital completed x-rays and computed tomography (CT) imaging studies where R2's bilateral femur fractures were identified. On 3/9/21, V18, R2's Family stated V18 saw R2 on 3/2/21. V18 stated R2 reported to V18 about R2's fall out of the wheelchair while R2 was a resident at the facility (on 2/27/21). V18 stated R2 was in excruciating pain to the point when staff attempted to lift the head of R2's bed, R2 was screaming in pain. V18 stated R2 has a history of chronic generalized pain, but the pain R2 was reporting was not R2's normal chronic pain. V18 stated the request was made to take x-rays of R2's bilateral lower extremities do to this extreme pain in addition to V18 reporting the fall to the facility and they found both (R2's) femurs, right above the knee were fractured. V18 reported it was found (R2) was not strapped in when the fall occurred. On 3/15/21 at 10:45am, R2 was laying in the hospital bed. R2 stated R2 was being transported back from [CONDITION(S)] around a couple weeks ago to the hospital (facility) when R2 fell out of the wheelchair in the facility transport van and hit both legs on something and started screaming in pain. R2 stated R2 calls the facility R2 resides in a hospital. R2 stated as soon as R2's legs hit something and immediately R2 had horrible, severe pain to both legs. R2 stated V7, Facility Transport Driver continued driving after R2 had began to slide and eventually fallen out of R2's wheelchair to the floor of the van until arriving at the facility. R2 stated R2's supposed to be strapped in but that R2's wheelchair did not feel like it had been secured because the chair was moving which had not happened during any prior transports. R2 repeated R2 had oh, a lot of pain with R2's eyebrows raised. R2 stated R2 reported the pain to V6, Registered Nurse (RN) immediately once V6 came on the van to assist R2 off the floor of the van. R2 stated the facility got R2 in bed and R2 just did not move until R2 had to because any movement caused pain in R2's bilateral knees/ legs right above R2's knees. R2 stated R2 was unable to bend (R2's) legs at the knees right. On 3/16/21 at 10:55am, V14, Radiologist stated V14 reviewed/read R2's imaging studies which showed bilateral distal femur fractures. V14, Radiologist stated it is very uncommon/unlikely for acute bilateral femur fractures to occur spontaneously. V14 stated given (R2's) clinical history including a fall with the imaging studies, the fractures were most likely caused by trauma to bilateral lower extremities. The facility's undated Van Transfer Policy and Procedure documents the facility will provide safe wheelchair transportation with properly securing the wheelchair shoulder and lap belts. This policy documents the facility will provide a safe resident environment as free of accident hazards as possible, with residents receiving adequate supervision and appropriate assistive devices to prevent accidents. All drivers will have a hands on return demonstration of the proper use of Safe-lock retractable combination belt with height adjustment and four point floor retractors . In the event of any type of emergency, the driver will be responsible to first ensure the safety of the residents. The administrator must be called as soon as possible and prior to leaving the incident . Any faulty equipment or problems during a transfer must be reported upon return to the facility. The facility's undated Vehicle Safety Policy and Procedure Manual documents the purpose of the procedure is to help ensure that people driving for facility do so in a safe manner. Seat belts, shoulder harnesses and wheelchair restraints (occupant restraint systems) shall be worn or used whenever the vehicle is in operation. Incident response and reporting I. In case of injury, call or have someone else call 911 immediately for emergency assistance. If you are involved in an incident and are not injured, do the following: 1. Protect the incident scene . Training I. Authorized Drivers shall be provided basic driver safety training including a review of the Vehicle Safety Policies and Procedures II. Additional training may be required for select employees based on incident involvement . Loading/Unloading - Balance the load; Plan ahead; Secure load from shifting properly securing residents in wheelchairs . The facility's undated list labeled Residents needing transport provided by the facility on 3/18/21 documents 26 residents (R5, R8, R16-R39) utilize the facility transport vehicle. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy: 1.) On 3/17/21 at 3:25pm V1, Administrator confirmed R2 remains hospitalized . 2.) On 3/25/21 at 9:00am, V1, Administrator confirmed facility transport staff had received education and training including how to latch wheelchairs, work the safety lock in the front/rear of the van and how to load a resident in the rear loading dock. The facility education and Training Attendance Sheet for this documents it was initiated and 100% completed on 3/12/2021 by V1, Administrator, V30, Supply Clerk, V10, Facility Van Driver and V31, Human Resources. 3.) On 3/25/21 at 9:00am, V1 provided documentation of return demonstration and competency for each van driver. The Agenda for Van Education and Training sheet dated 3/17/21 documents the training video's were utilized/referenced for training on the facility van. V31, Transport Driver stated the video was unable to be located until a different day after the education and training occurred but provided documentation it was viewed. 4.) On 3/25/21 at 9:00am V1, Administrator and V3, Assistant Director of Nursing (ADON) stated and provided documentation of Licensed Nursing personnel education regarding assessment and monitoring of residents post accidents/incidents documented on the facility's abatement plan with a completion date of 3/18/21 had not been completed as of 3/25/21 per V3, Assistant Director of Nursing as not all licensed nursing personnel had received the education yet, but it is ongoing. 5.) On 3/24/21, V1, Administrator confirmed the facility is monitoring incidents/accidents during van transport and there have been no additional incidents/falls during transport since 3/17/21 at 3:25pm. The facility abatement plan documents this action was initiated on 3/18/21 and is ongoing with V1, Administrator and Transportation staff members identified by V1 as V10, Facility Transport Driver and V30, Supply Clerk and Facility Transport driver. 6.) On 3/17/21, V1, Administrator provided documentation the facility van Vehicle Inspection Report for the every 6 month inspection was completed on 3/9/21. 7.) On 3/17/21, the facility provided sheets titled Transporting Resident in the Facility Van documenting random observation of van driver performance. These sheets document observations of transports on 3/18/21 with 3 transports and 3/23/21 with 4 transports. The facility updated the form for driving observations to include identity of transport driver observed on 3/25/21. B. Based on observation, interview, and record review the facility failed to complete post fall investigations to identify the root cause, complete post fall assessments, and develop and implement post fall interventions for three of four residents (R3, R5, R14) reviewed for accidents in the sample list of 40. Findings include: b.)1). R14's Face Sheet dated 3/23/21 documents R14 admitted to the facility on [DATE] and has diagnoses of Hypertension and has a Cardiac Pacemaker. R14's Admission Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact, uses limited assistance of one staff person for transfers and ambulation, and extensive assistance of one staff person for toileting. This MDS documents R14 had a fall with a fracture within the last six months. R14's Fall Risk assessment dated [DATE] documents R14 is at risk for falls and R14 overestimates or forgets R14's limitations. R14's Care Plan revised on 3/19/21 documents (R14) can potentially have a fall incident and may have an injury for being in a new environment, medications taken and current medical condition. This care plan documents R14 had multiple falls prior to admitting to the facility and documents interventions dated 1/29/21 to assist with transfers and Activities of Daily Living (ADL's) care needs. On 3/23/21 at 9:20 AM V28 (R14's Family Member) stated: R14 fell twice, two hours apart, on 3/18/21. V28 stated a nurse told V28 that R14 was found on the floor by staff after staff had assisted R14 into the bathroom and left R14 unattended. On 3/17/21 R14 had complained of feeling unsteady and feeling like R14 was going to fall when R14 would transfer. V28 reported R14's complaints to an unidentified nurse on 3/17/21. R14's Progress Notes document: On 3/17/21 at 2:44 PM V28 reported that R14 complained of [CONDITION(S)] (dizziness) and V29 Nurse Practitioner was notified. On 03/18/2021 at 12:15 PM staff found R14 lying on R14's left side in the bathroom with a bump to R14's forehead and a scrape to the left arm. R14 did not use R14's call light and urine was on the bathroom floor. V29's Progress Note dated 3/18/21 at 12:51 PM documents: R14 was evaluated for complaints of [CONDITION(S)] and a fall. R14 had transferred R14's self into the bathroom and did not ask for help. R14 has increased weakness and is suppose to have assistance with transfers. R14 has been receiving Physical and Occupational Therapy. V29 recommended to obtain orthostatic blood pressures every shift for 3 days, Complete Blood Count and Basic Metabolic Panel on 3/19/21, [MEDICATION(S)] 25 milligrams three times daily as needed, and a urinalysis. This note documents R14's fall was possibly related to weakness and noncompliance with asking for help. R14's Progress Note dated 03/18/2021 at 2:35 PM documents R14 was found on the floor in the bathroom and R14's call light was not used. R14 stated R14 was trying to walk back to the bed after using the toilet. The Witness Statement dated 3/18/21 at 2:40 PM signed by V32 Certified Nursing Assistant (CNA) documents: V32 assisted R14 to the bathroom and instructed R14 to use the call light when R14 was finished. V32 left R14 in the bathroom to obtain R15's vitals (R14's room mate), and when V32 returned R14 was sitting on the bathroom floor. On 3/23/21 at 9:03 AM R14 was lying in bed. R14 had bruising to both eyes and a hematoma to R14's left forehead. On 3/23/21 at 11:13 AM R15 stated R14 would frequently forget to use the call light and R14 would get up unassisted and without using R14's walker. R15's Progress Note dated 3/14/21 documents R14 is alert and oriented to person, place, and time. On 3/23/21 at 11:16 AM V33 Registered Nurse (RN) stated: On 3/23/21 around 2:00 PM V32 CNA told V33 that R14 was found on the bathroom floor and R14's call light was not on. R14 told V33 that R14 was trying to self transfer from the toilet to the bed. V32 told V33 that V32 had assisted R14 into the bathroom, instructed R14 to use the call light, and left R14 unattended to obtain R15's vitals. When V32 returned to the bathroom, R14 was sitting on the floor. On 3/23/21 at 11:45 AM V32 CNA stated: V32 worked 2nd shift on 3/18/21. During shift report at the beginning of V32's shift, V34 CNA reported to V32 that R14 had fallen during day shift. Around 2:00 PM on 3/18/21 V32 assisted R14 into the bathroom. R14 requested privacy, so V32 instructed R14 to use R14's call light, V32 left R14 unattended in the bathroom leaving the door open a crack. V32 stated V32 left the bathroom to enter R14/R15's room to obtain R15's vitals. When V32 returned to the bathroom a couple minutes later, R14 was sitting on the floor, and R14's bathroom call light was not on. V32 stated V32 did not witness R14 fall, or hear R14 fall. On 3/23/21 at 11:55 AM V41 Physical Therapist stated R14 should not be left unattended in the bathroom, since R14 may try to attempt to self transfer. R14 needs staff assistance with use of a gait belt and wheeled walker for toileting, transfers, and ambulation. On 3/23/21 at 1:01 PM V29, Nurse Practitioner confirmed with R14's history of [CONDITION(S)] and fall on 3/18/21 at 12:15 PM, staff should not have left R14 unattended in the bathroom. V14 stated R14 being left unattended in the bathroom could have contributed to R14's fall. b.)2.) R5's MDS dated [DATE] documents R5 is cognitively intact, uses supervision of one staff person for ambulation, and limited assistance of one staff person for transfers. R5's Care Plan revised on 3/15/21 documents R5 has history of falls, is at risk for injury, and tells staff that R5 will sit on the floor as a behavior. This care plan documents interventions including on: 3/4/21 Physical Therapy and Occupational Therapy to screen R5, 3/10/21 a low bed was implemented, 3/15/21 encourage R5 to ask for assistance with repositioning while in the wheelchair, and 3/22/21. R5's Care Plan dated 3/22/21 documents R5 self reports that R5 has fallen with interventions dated 3/22/21 including a psychiatry referral, obtain information to determine how the fall occurred and when the fall occurred at the time of the fall. R5's Physician Order Report dated 2/22/21-3/22/21 documents a physician order dated 3/5/2021 for Physical Therapy and Occupational Therapy to evaluate and treat. R5's Event Report dated 3/3/21 documents R5 had an unwitnessed fall on 03/03/21 at 6:20 PM. R5 was found kneeling on the floor mat beside R5's bed. R5 attempted to get on the floor to clean up food and the post fall intervention was for Physical Therapy and Occupational Therapy to screen R5. R5's Rehabilitation Screen dated 3/4/21 documents R5 has had recent falls/history of falls and per an unidentified CNA R5 has had a decline in transfers and balance. This screen also documents R5 has not had a decline in Activities of Daily Living (ADL's) per the CNA and an evaluation of Physical Therapy is indicated. There is no documentation in R5's medical record that an Occupational Therapy Evaluation was completed as ordered. R5's Event Report dated 3/10/21 documents R5 self reported at 4:15 PM that R5 attempted to self transfer from the bed to the wheelchair, fell , and self transferred back into the bed. This report documents R5 did not remember details of the fall, R5 complained of back pain at the time of reporting R5's fall, and an x-ray was ordered. This report documents the Interdisciplinary Team reviewed R5's fall and determined R5 was not capable of transferring R5's self from the floor to the bed. R5 has had multiple falls in the past six months with several related to behavioral issues. This root cause of R5's fall on 3/10/21 was R5 displayed a behavior of self reporting a fall and it is not likely that R5 could transfer R5's self from the floor if R5 had fallen. This report documents R5's care plan was updated to include a psychiatric referral. The post fall investigation for R5's fall documents interviews were conducted with R5, V22 Registered Nurse (RN), and V23 Licensed Clinical Social Worker (LCSW). V3 Assistant Director of Nursing (ADON) provided a list of employees who worked on 1st and 2nd shifts on 3/10/21. The list documents V24-V27 Certified Nursing Assistants were assigned to care for R5 on 3/10/21 and there is no documentation that V24-V27 were interviewed about R5's self reported fall on 3/10/21. R5's Event Report dated 3/12/21 documents on 3/12/21 at 2:50 PM R5 staff witnessed R5 slide out of R5's wheelchair onto the floor. R5's Progress Notes document: Post fall nursing assessments were not completed after R5's fall on 3/3/21 for 3rd shift on 3/3/21, 2nd and 3rd shifts on 3/4/21, all shifts on 3/5/21 and 1st and 2nd shifts on 3/6/21. Post fall nursing assessments were not completed after R5's fall on 3/10/21 for 3rd shift on 3/11/21 and first shift on 3/12/21. Post fall nursing assessments were not completed after R5's fall on 3/12/21 for 3rd shift on 3/12/21, 1st and 2nd shifts on 3/13/21, 1st shift on 3/14/21, and 3rd shift on 3/14/21. On 3/22/21 at 9:30 AM V5 Director of Rehabilitation stated therapy staff do not always complete an evaluation if a resident has orders for Occupational or Physical Therapy to evaluate and treat. V5 stated sometimes a screen is completed instead of an evaluation to determine if there has been a decline in ADL's. V5 stated R5 did not have an Occupational Therapy evaluation completed in March 2021, and a rehabilitation screen was completed due to R5 having a fall. On 3/18/21 at 2:04 PM V3 ADON stated V3 completes the post fall investigations and R5's fall investigations were not completed yet for R5's falls on 3/10/21 and 3/12/21. V3 stated R5's post fall intervention for the fall on 3/3/21 was to have Occupational Therapy and Physical Therapy to evaluate and treat. On 3/22/21 at 11:07 AM V3 stated post fall nursing assessments should be documented in the nursing notes and completed immediately following the fall, and then every shift for 72 hours after the fall. V3 stated sometimes the nurses do not document post fall assessments and V3 has to remind them. On 3/22/21 at 12:35 PM V3 stated the floor nurses are instructed to obtain interviews with staff who were working at the time the fall occurred and then turn the interviews into V3. V3 stated V3 often does not receive the staff interviews and V3 has to complete the interviews the following day. V3 stated V3 was not able to identify the time and date that R5's self reported fall on 3/10/21 actually occurred. V3 stated V3 interviewed R5, V22 RN, and V23 LCSW and confirmed V3 did not interview any other staff that were assigned to care for R5 on 1st and 2nd shifts on 3/10/21. V3 stated R5 has behaviors of putting R5's self on the floor, and R5 would not have been able to self transfer from the floor to the bed if R5 had fallen. V3 stated V3 didn't think R5 had actually fallen. On 3/24/21 at 9:28 AM V3 stated R5's post fall investigation for the fall on 3/10/21 was completed on 3/22/21. The facility referred R5 for psychiatric services on 3/22/21 (12 days after R5's reported fall on 3/10/21) for R5's behaviors of putting R5's self on the floor. b.)3.) R3's MDS dated [DATE] documents R3 has short and long term memory impairment, uses limited assistance of one staff person for transfers, and extensive assistance of one staff person for ambulation and toileting. This MDS documents R3 is occasionally incontinent of bowel and bladder. R3's Care Plan revised on 1/7/21 documents R3 needs assistance with toileting and transfers. R3's Care Plan revised on 2/18/21 documents R3 has had multiple falls and is at risk for injury due to medications, poor safety awareness, and impulsivity. This Care Plan documents an intervention dated 2/17/21 to transfer R3 to the emergency room for evaluation and treatment. R3's Fall Event Report dated 2/17/21 documents: R3 was found sitting on the floor on 02/17/21 at 6:00 PM. R3 was bleeding from R3's nose and mouth. R3 was unable to give details of the fall, and was alert and oriented to self. This report documents R3's care plan was updated with an intervention to send R3 to the emergency room for treatment and the root cause of R3's fall was R3 ambulated independently and lost R3's balance. The Witness Statement dated 2/23/21 at 1:15 PM signed by V42 CNA documents on 2/17/21 V42 heard R3 yell out for help and found R3 sitting on the floor with R3's back against the bed. V42's statement documents V42 last saw R3 sitting on the side of the bed about an hour prior to the fall on 2/17/21. There is no follow up documentation if V42 responded to R3 sitting on the edge of the bed. There is no documentation that the facility determined the last time R3 was toileted or if R3 was incontinent at the time of R3's fall. R3's Progress Notes do not document post fall nursing assessments were completed for 2nd and 3rd shifts on 2/18/21, 2nd and 3rd shifts on 2/19/21 and day shift on 2/20/21. On 3/22/21 at 2:50 PM V3 stated: V3 completed R3's 2/17/21 fall investigation. The root cause of R3's fall was determined to be that R3 ambulated independently, lost R3's balance, and fell . V3 was unsure of the reason why R3 got up on R3's own. V3 confirmed there is no documentation of when R3 was last toileted prior to the fall, or if R3 was incontinent at the time of the fall. V3 stated V3 could not say if V42 assisted R3 when V42 saw R3 sitting on the edge of the bed an hour prior to R3's fall. V3 stated staff assist R3 with toileting after meals and it would be ok to leave R3 sitting on the side of the bed even with R3's history of falls. V3 confirmed the post fall intervention was to transfer R3 to the emergency room . V3 confirmed there were no other post fall interventions implemented following R3's fall. The facility's undated Documentation policy documents Clinical rehabilitation documentation will conform to all federal requirements. Documentation will include, but not limited to the following: Information necessary to communicate patient/resident need, Evidence of medical necessity of services provided, Rehabilitative services provided, Progress made and discharge status. This policy documents COMPONENTS: Evaluation/Pla[TRUNCATED]

Based on observation, interview, and record review, the facility failed to identify pressure ulcers, failed to document pressure ulcer monitoring/measurements and failed to implement pressure ulcer relieving/prevention interventions, and treatments for three of three residents (R1, R2, R3) reviewed for pressure ulcers in the sample of 40. These failures contributed to R2 developing a Necrotizing Soft Tissue Infection of a pressure ulcer requiring hospitalization with three surgical debridements due to infection and necrosis of the pressure ulcer wound. Findings include: 1. R2's Progress Notes dated 2/19/21 document R2 readmitted to the facility on [DATE] with a stage 3 on coccyx with no documentation of wound measurements on admission. R2's Progress Notes dated 2/24/21 at 6:41pm document R2 was seen today (2/24/21) by V49, R2's Wound Physician for wounds including a wound to right buttock. New treatment orders per V49. R2's Minimum Data Set (MDS) dated [DATE] document R2 is cognitively intact. This MDS documents R2 has one unstageable pressure ulcer. R2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders document R2's orders including the following: Hemodialysis three times weekly on Tuesday, Thursday and Saturdays at 6:00pm. Order start date 2/19/21 - Cleanse buttocks with soap and water, pat dry and apply house barrier cream every shift and as needed. Order start date 2/26/21 - Right Buttock: Cleanse with normal saline or wound cleanser and pat dry. Apply honey alginate wafer and cover with silicone border foam and change daily and as needed. R2's facility Wound Management notes document R2 has a pressure ulcer to the left buttock that was identified on 12/2/2020 at 3:50pm. These notes document this wound's measurements on 2/24/21 of 0.5cm (centimeters) length by 0.3cm width by 0.2cm in depth. There is no documentation of an assessment or measurements for R2 in the these notes regarding R2's Right Buttock pressure ulcer or a coccyx pressure ulcer. R2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's skin assessment documents R2 had the following skin impairments: 2/22/21 - open areas to the coccyx and bilateral feet, redness to the coccyx 2/25/21 - open areas to the coccyx and left heel, redness to the buttock and that a current treatment was in place. R2's Treatment Administration Record (TAR) dated February 2021 documents R2's treatment to cleanse the buttocks with soap and water, pat dry and apply house barrier cream every shift including evening shift which is scheduled for administration between 2:30pm and 10:00pm and as needed documents this was not administered on: 2/20/21 at 9:12pm Not Administered: Resident (R2) unavailable, 2/23/21 at 6:42pm, Not Administered: Resident (R2) unavailable, Comment: resident (R2) is out for [CONDITION(S)], and 2/25/21 at 9:21pm Not Administered: Resident (R2) unavailable, Comment: [CONDITION(S)]. There is no documentation of an attempt to administer this treatment prior to R2's [CONDITION(S)] treatment and/or within the scheduled time frame on these days. R2's Wound Evaluation and Management Summary documented by V49, R2's Wound Physician dated 2/24/21 documents R2 has multiple wounds. This summary documents R2 has an Unstageable (due to necrosis) pressure ulcer of the right buttock with measurements of length 7cm by width of 5cm and depth of 0.1cm with moderate serous exudate with 25% of thick adherent devitalized necrotic tissue. This summary documents R2 received surgical debridement of the right buttock pressure ulcer at the facility on 2/24/21. The dressing treatment plan is to apply honey alginate wafer and cover with a foam silicone border once daily for 30 days. This summary also documents R2 has a Stage III left buttock pressure ulcer with measurements of length 0.5cm by width of 0.3cm by depth of 0.1cm with light sero-sanguineous exudate. This summary documents R2's left buttock pressure ulcer has abnormal granulation present within the wound margins and a dressing treatment plan to apply honey alginate wafer and cover with a foam silicone border once daily for 30 days. Chemical cauterization of abnormal granulation tissue was performed to facilitate healing. There is no documentation in R2's Electronic Medical Record/physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's TAR dated February 2021 documents R2's treatment to cleanse the right buttock with normal saline, or wound cleanser and pat dry. Apply honey alginate wafer and cover with a silicone border foam dressing daily and as needed with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .). This TAR documents R2's right buttock pressure ulcer treatments were not completed due to refused on 2/26/21, 2/27/21, and 2/28/21 with no documentation as to reason for refusal or attempts to complete the treatment by other nurses or at another time. There is no documentation V49, R2's Wound Physician was notified of the refusals or delay in starting the treatment as ordered. This TAR also does not document the facility was completing the left buttock pressure ulcer dressing change as ordered on 2/24/21 by V49. There is no documentation in R2's medical records documenting V40, Registered Dietician was notified of R2's pressure ulcers after R2 readmitted to the facility on [DATE] with multiple pressure ulcers. There is no documentation the facility attempted to contact V18, R2's Family related to R2's pressure ulcer wounds after readmission on 2/19/21. On 3/10/21 at 1:34pm, V4, Wound Nurse stated R2 had an open wound to R2's coccyx/buttock area. V4 stated V49 Wound Physician was following that wound. V4 stated the staff should be measuring and documenting wounds upon admission and when treatments are completed but many times the measuring and documenting of the wounds/measurements does not get completed. V4 stated refusal of treatments should be documented in the residents medical record as well as a reason for refusal and notification of the resident's physician and family of the refusals. V4 stated V4 thought there were measurements for R2's right buttock pressure ulcer but V4 was unable to find facility wound management notes for R2's right buttock pressure ulcer. On 3/23/21 at 2:30pm, V8, Nurse Manager stated V4 rounds with V49, Wound Physician. If the wound nurse rounds with the wound physician V4 is responsible for entering orders and measurements. V8 stated wound treatment orders should be immediately entered in the resident's medical record and started/implemented upon receiving the order. V8 stated R2's treatment orders should have been started on 2/24/21 instead of waiting two days before entering the orders and implementing the dressing change orders on 2/26/21. V8 stated V50, RD should be consulted to evaluate when a resident has pressure ulcers. V8 stated the staff should make multiple attempts to complete wound dressing changes and notify the physician of refusals and chart all of that. V8 stated ,I (V8) tell them (staff) to reattempt/document/continue to encourage resident (to allow wound dressings to be changed) R2's Progress Notes on 3/1/21 at 10:33pm document R2 was sent to the hospital from the [CONDITION(S)] center for a temperature and was noted to have an infection in buttock. R2's Hospital notes dated 3/1/21 document R1 reported feeling ill since R2 woke up on 3/1/21. These notes document R2 was sent to the hospital emergency room for a temperature obtained at the [CONDITION(S)] center of 101.4 degrees Fahrenheit (F) with the emergency medical technician's obtaining a temperature of 99.0 degrees F. These notes document R2 had pressure wounds to the right medial buttocks and sacrum. Additional hospital notes document R2 has a draining wound on the right buttock which is greater than the left buttock wound. R2's Hospital History and Physical (H&P) dated 3/1/21 documents R2 presented to the hospital with likely necrotizing soft tissue infection of the right gluteal region which may extend in to the left gluteus as well. This H&P documents this is likely a complication of a long standing pressure injury that has been secondarily infected. R2 would benefit from urgent operative exploration and debridement of any devitalized tissue. This H&P documents R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Post Op (operative) note dated 3/1/21 documents R2 had a procedure of sharp excisional debridement of the right gluteus to the level of the periosteum, gluteus muscle and fascia. This note documents Findings: Approximately 20cc (cubic centimeters) of purulent material drained with surrounding tissue necrosis. Final wound was approximately 10 by 15 by 5cm (centimeters) to the level of the sacral periosteum. R2's hospital Acute Care Progress Note dated 3/2/21 documents R2 would benefit from additional debridement in the operating room R2's Procedure Note dated 3/2/21 documents R2 had a sharp excisional debridement of right gluteus to level of periosteum, gluteus muscle and fascia (total dimensions 24 x 15 x 5cm). R2's Hospital Progress Notes dated 3/6/21 at 12:16pm document R2's right gluteal wound looks worse with multiple necrotic regions and that R2 would benefit from a third surgical debridement. R2's Surgical Note dated 3/6/21 documents R2's wound had sharp excisional debridement of right gluteal wound with excision of necrotic muscle, fascia, and subcutaneous fat. On 3/15/21 at 10:30am, V17, R2's Registered Nurse stated R2's pressure ulcer wounds are a big problem. V17 stated the wounds were obviously not taken care of prior to hospitalization and infected upon admission. On 3/15/21 at 10:30am, R2 was observed in the hospital [CONDITION(S)] unit receiving [CONDITION(S)]. R2 stated the facility had a dressing on R2's wounds. R2 stated R2 has had severe pain in R2's pressure ulcers to the buttock, sometimes more severe than others while a resident at the facility. R2 stated sometimes the facility staff would come in and ask if (R2) want my dressing to the pressure ulcers changed and sometimes R2 hurts too bad to have them change the dressings. R2 stated R2 does try to make sure they get changed as much as possible. R2 stated staff do not ask R2 why if R2 refuses to have staff complete a dressing change, offer pain medications prior to dressing changes or to perform the dressing changes at a different time. 2. R1's Face Sheet dated 2/25/21 documents R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Census List documents R1 went to the hospital from the facility on 1/20/21 and readmitted to the facility on [DATE]. R1 went to the hospital on 2/22/21 and returned to the facility on [DATE]. R1 went back to the hospital on 3/3/21 and did not return to the facility. R1's undated handwritten notes from report from the hospital scanned in with from date of 2/3/21 for R1's readmission to the facility documents R1 has a Stage I (pressure ulcer) to the left heel. There is no documentation of this pressure ulcer was measured/evaluated on R1's readmission to the facility on [DATE]. R1's Progress Notes dated 2/3/21 at 6:13pm document no skin issues. R1's Nutritional Assessment completed by V50, Registered Dietician on 2/6/21 documents R1's skin as intact. There is no documentation V50 was notified of R1's pressure ulcer to the left heel. R1's Progress Notes dated 2/8/21 at 12:00pm document wounds noted on examination. See wound care notes for specifics There are no wound care notes documented on 2/8/21. R1's Progress Notes dated 2/9/21 at 1:12pm document no skin issues at this time. Progress notes dated 2/10/21 at 12:12pm and 2/13/21 at 12:08pm, 2/15/21 at 12:16pm, 2/17/21 at 11:34am, and 2/22/21 at 10:20am document wounds noted on examination. See wound care notes for specifics with no wound care notes associated with this progress note documented for R1 on 2/10/21, 2/13/21, 2/15/21, 2/17/21 and 2/22/21. R1's Progress Notes dated 2/22/21 at 11:40am document a close wound/pin point in the middle with black color in the middle and reddish edges, warm to touch, measuring 6.5 X 13 was noted on R1. New orders were received for a [MEDICATION(S)] dressing to be applied and changed every 3 days on the buttock. R1's Medication Administration History dated February 2021 documents R1's weekly skin checks to be completed on Mondays. This medication record documents R1 did not have any skin impairments on 2/8/21 and 2/15/21. This record documents R1 had an order dated 2/22/21 for [MEDICATION(S)] dressing to right buttock to be changed once every three days and as needed. This record also documents R1's treatment orders dated 2/22/21 to apply Skin prep to bilateral heels and outer left foot once daily . R1's treatment order dated 2/26/21 documents coccyx: Cleanse with normal saline (NS), apply calcium alginate and cover with bordered foam dressing to change once daily. R1's Skin Integrity Event dated 2/22/21 at 11:20am documents R1 had open wound on right buttock. This event documents this wound as a pressure ulcer measuring 6.5 x 13 (no unit of measurement documented) and contained necrotic tissue. There is no documentation V51, R1's Family was notified of R1's pressure ulcer at this time. R1's Admission Observation dated 2/25/21 documents R1 had a coccyx ulcer and that it was present at the facility prior to being sent to the hospital (on 2/22/21). This document does not contain measurements for R1's coccyx ulcer. R1's Progress Note dated 2/25/21 at 6:39pm documents R1's Stage I coccyx pressure ulcer but does not document an assessment or measurements of this pressure ulcer. There is no documentation in this document that V51 was notified of R1's coccyx ulcer. R1's Skin Integrity Event dated 2/26/21 at 11:28am documents R1 has an open area on coccyx with type of skin condition documented as Other- Deep Tissue Injury with measurements of 10 x 6 with no units of measurement documented. This event documents the pressure ulcer contains necrotic tissue with a scant amount of exudate. R1's Medication Administration History dated March 2021 documents R1's weekly skin assessments once daily on Tuesdays. This record documents R1 did not have skin alterations on 3/2/21 but documents R1 was receiving the following treatments for R1's pressure ulcers per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] dressing to R1's right buttock change once every three days Skin prep to bilateral heels and outer left foot once daily Cleanse R1's coccyx with normal saline, apply calcium alginate and cover with bordered foam dressing once daily. On 3/9/21 at 10:37am, V51 stated the facility did not notify V51 of R1's skin condition with the multiple areas of pressure ulcers and breakdown. V51 stated on 3/3/21, V4, Wound Nurse called V51 to notify V51 of R1's coccyx pressure ulcer worsening. V51 stated V51 questioned if the facility were monitoring R1's skin for pressure ulcers or providing treatments for R1's pressure ulcers. On 3/10/21 at 1:34pm, V4 stated V4 had not been following R1's pressure ulcers. V4 stated V4 happened to be assisting with cares for R1 when V4 observed R1's deep tissue injury to the coccyx. V4 stated the staff are to measure the wounds and document them. V4 stated V4 tries to educate the staff about assessing wounds, documenting the assessments and notifying V4 as soon as a wound is observed. In event notes and/or progress notes is where the measurements should be documented for each resident. V4 stated V4 documents resident wound notes in the facility wound management program but was unsure if R1 had measurements in that program. V4 attempted to find pressure ulcer notes for R1's coccyx pressure ulcer in the facility wound management program but was unable to find any. V4 stated the facility should have notified V50, Registered Dietician of R1's pressure ulcers and skin impairments, but V50 was not notified. V4 stated there is minimal documentation to monitoring, assessing and/or measuring R1's pressure ulcers and that there should have been more detailed monitoring and documentation. 3. R3's Care Plans dated 2/19/21 document R3 has a Stage II Pressure Ulcer with infection to the right second toe due to Shoes not fitting correctly. These care plans document interventions including to administer antibiotics as ordered and to evaluate, record, report effectiveness and signs of [CONDITION(S)]. These care plans also include an intervention to leave shoes off and use nonskid socks. R3's Initial Wound Evaluation & Management Summary notes dated 2/18/21 document R3 has an Unstageable (Due to Necrosis) Pressure Ulcer to the right second toe. These notes document the periwound to have [CONDITION(S)] and light serous exudate with 100% thick adherent necrotic tissue. These notes also document No shoes until wound heals and to use non skid socks. These notes document orders to administer [MEDICATION(S)] (Antibiotic) 100mg (milligrams) twice daily and [MEDICATION(S)] (Antibiotic) 500mg twice daily by mouth for 10 days until 2/27/21 (or 10 days total.) There is no documentation a wound culture was obtained for R3's right 2nd toe pressure ulcer infection prior to beginning R3's antibiotics. R3's Wound Evaluation & Management Summary dated 2/24/21 documents R3 has a Stage 4 Pressure Wound of the right second toe with moderate serous exudate. These notes document R3's pressure ulcer to the right second toe has persistent [CONDITION(S)] and to change R3's antibiotics to [MEDICATION(S)] 400-80mg by mouth twice daily for 10 days. There is no documentation a wound culture was performed to ensure proper antibiotic use. On 3/10/21 at 1:34pm V4 stated reported R3 had an open wound on the second right toe before. V4 stated when V4 assessed the wound it was pressure due to shoe - too small. V4 stated R3's shoe had hardened blood and drainage inside of R3's shoe and that the pressure ulcer had been going on for some time prior to V4 being notified. V4 stated the pressure ulcer hurt (R3) V4 stated R3's foot kept rubbing on the shoe and when V4 observed the wound, it looked infected. V4 stated R3's right second toe pressure ulcer was causing R3 pain and had infection- visible characteristics of infection, warm, swollen, puffy V4 stated the facility did not do a wound culture but V49, R3's Wound Physician had ordered antibiotics for R3. V4 stated V4 questioned obtaining a wound culture and stated V49 typically puts residents on oral antibiotics without culturing the wound. V4 stated after a week of the [MEDICATION(S)] and [MEDICATION(S)] antibiotics, V4 and V49 assessed R3's wound and noted the infection was not getting better, so V49 changed antibiotics at that time. V4 stated the change in antibiotics helped R3's toe to finally heal and had a culture been done sooner, it would have identified the appropriate antibiotic the wound needed. On 3/18/21 4:34-5:04 AM V46 Certified Nursing Assistant (CNA) entered R3's room. V46 removed R3's socks and R3 had a dressing to the right foot dated 3/17/21. V46 transferred R3 back to bed after toileting, changed R3's clothes and transferred back into R3's wheelchair. V46 applied R3's black tennis shoes on R3's bilateral feet. 3/18/21 6:19 AM V4 Wound Nurse stated R3 has had wound to right 2nd toe since 2nd week of February. V4 stated V4 believed it was from R3's shoes because R3's toes curl up and rub against R3's shoes. V4 stated V49, R3's Wound Physician had cut a hole in R3's white pair of shoes that were believed to be the cause of R3's pressure ulcer to the right 2nd toe to relieve the pressure to the wound. V4 stated family were going to get R3 some new house slippers or shoes. V4 stated V4 was not sure if R3's black shoes were the new pair. V4 stated the facility tries to have R3 wear the nonskid socks at times. R3 was sitting up in R3's wheelchair wearing black tennis shoes at this time. V4 confirmed these black tennis shoes were not the tennis shoes V49 had cut out for pressure relief. V4 removed R3's shoe and completed R3's dressing change to the pressure ulcer to the 2nd toe on the right foot. After administering R3's treatment V4 reapplied R3's black shoe to the right foot instead of only a non skid sock. The facility's Prevention of Pressure Ulcer policy dated November 2015 documents general preventative measures including to routinely assess and document the condition of the resident's skin for any signs and symptoms of irritation/breakdown. Immediately report signs of a developing pressure ulcer to the nurse. Risk Factor - Friction and Shear, shoes need to be monitored for proper fit to avoid the development of blisters, corns and calloused areas, Risk Factor - Poor Nutrition a. Dietician will assess nutrition and hydration and make recommendations based on the individual resident's assessment This policy documents additional clinical conditions and treatments that indicate a resident is at risk for pressure ulcers including impaired/decreased mobility, co-morbid conditions such as end stage [CONDITION(S)], Diabetes Mellitus, resident refusal of some aspects of care and treatment, cognitive impairment and a history of a healed ulcer. The facility's Assessment of Skin Alteration policy dated November 2017 documents residents with skin alterations will be assessed and treatment will be provided as ordered by the physician. The assessment of any skin alteration should be started immediately upon identification of a pressure ulcer or other skin ulcer with findings to be documented in the medical record. Wound Assessment should be completed and documented in the medical record to reflect progress. The facility is to review and update appropriate interventions/changes as necessary and notify appropriate interdisciplinary team members as appropriate, physician, resident and family member as appropriate. Once the wound is healed, update the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Pressure Ulcer Risk Assessment policy dated November 2015 documents the skin assessment helps identify the resident who is refusing care and treatment. If the resident is refusing care, an evaluation of the basis of the refusal and the identification and evaluation of potential alternatives is indicated. This policy documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Wound Treatment policy dated November 2015 documents, As ordered by the physician, wound treatment will be provided to the resident's needing one. This policy documents to verify the order for the wound treatment and see if the resident requires [MEDICATION(S)] prior to assessment or dressing change. The facility will address the resident's concerns and offer relevant alternatives if the resident has refused treatments/interventions. The facility's Change in Condition Clinical Practice Guidelines dated 3/20/2020 document the Charge Nurse or Designee will notify the resident's attending physician, physician assistant, nurse practitioner, Clinical Nurse Specialist or on-call physician when there has been a significant change in the resident's physical condition, there is a need to alter the resident's medical treatment significantly or refusal of treatment or medications (for example two or more consecutive times.) These guidelines document the Charge Nurse or Designee will notify the resident's family or representative when there is a change in the resident's physical status. Information relative to the changes in the residents condition or status will be recorded in the resident's medical record. The facility's Wound Culture policy dated November 2015 documents culturing and reculturing of wound will only be completed to wounds showing signs and symptoms of infection and or as ordered by the physician. To be considered infected, your resident has to exhibit 3 or more signs and symptoms of infection. Infection is evidenced by induration, fever, [CONDITION(S)], [CONDITION(S)], increased pain in wound area and exudates (purulent or serous exudates, increase in exudates)

Based on record review, and interview, the facility failed to provide supervision and assistance with transfers and ambulation for one of three residents (R2) reviewed for falls on the sample list of 18. This failure resulted in R2 ambulating outside independently and being left outside unattended, where R2 fell and sustained a [MEDICAL CONDITION]. Findings Include: R2's Fall Risk assessment dated [DATE] documents R2 is at high risk for falls. R2's Speech Language Pathology Evaluation dated 7/12/19 by V25 SLP (Speech Language Pathologist) documents R2 was referred to ST (Speech Therapy) by PT (Physical Therapy) due to frequent falls and a concern for safety awareness. Cognitive Communication Skills are impaired. R2 is oriented to person, purpose and caregivers but has impaired insight. R2 has 75% problem solving processes, 60% in new situations, 70% in judgement/inferencing, and 80% short term memory. R2 presents with mild to moderate cognitive linguistic impairment characterized by deficit in complex problem solving, recall, reasoning judgement, planning, and also with impulsive, unsafe and confused behavior. R2's MDS (Minimum Data Set) dated 7/16/19 documents R2 requires extensive assist of 2 staff for transfers and limited assist of one staff for ambulation. R2's Care Plan dated 7/16/19 documents R2 was admitted to the facility with acute pain due to trauma with fractured ribs and is at risk for falls and injuries related to having a history of falls prior to admission and poor safety awareness. R2's Discharge SLP Summary dated 7/29/19 documents R2 continues to benefit from staff supervision to decrease confusion, unsafe and impulsive behavior and cue for safety, especially relating to wheelchair. R2's Progress Notes dated 7/28/19 by V41 LPN (Licensed Practical Nurse) documents, around 2:50 pm, it was reported that R2 was on the ground outside in the courtyard, with R2's left leg bent slightly underneath R2 and unable to move the leg. R2 had been observed pulling dead flowers out of a flower pot prior to the fall. An unidentified CNA (Certified Nursing Assistant) previously seated R2 on the bench with the flower pot next to R2. R2 had ambulated outside. R2 was taken a wheelchair and educated on walking unassisted. R2's Fall Investigation includes a witness statement from V42 CNA dated 7/29/20 that documents, R2 walked outside to pick dead flowers out of a flower pot. We took R2, R2's wheelchair outside to R2. We locked R2's wheelchair in place and told R2 to use it if R2 got up. About ten minutes later, an {unidentified} family member came to V42 and told V42 that the family member seen R2 fall to the ground. V42 went back out there {outside} and found R2 on the ground. R2's Final Investigation Report dated 8/2/19 documents, R2 was transferred to the Emergency Department and a closed comminuted intertrochanteric [MEDICAL CONDITION] hip was confirmed by x-ray. R2 underwent surgical repair to the left hip on 7/29/19. On 9/15/20 at 10:15 am, V22 NP (Nurse Practitioner) stated, V22 did not work at the facility 1.5 years ago so V22 didn't know R2 however based off V22's medical experience, R2 should not have been left outside unattended with SLP, just two days prior, saying R2 needed supervision for safety recall. Had staff been outside with R2, they could have assisted with the transfer when R2 stood up, and prevented the fall.

Based on interview and record review, the facility failed to complete ordered laboratory testing and report findings to the physician for one of three residents (R1) reviewed for laboratory testing. This failure resulted in R1 having a increased blood glucose level including critical levels, that resulted in R1 being hospitalized with a [DIAGNOSES REDACTED]. Findings Include: On 11/5/18 at 10:17 am, V4 (R1's grand-daughter) stated V4 came to the facility on [DATE] to see R1 and that R1 just wasn't R1's usual self. R1 would not speak but just mumble, was not able to feed herself as usual, and required much more assistance with toileting. V4 alerted the staff and the staff agreed that R1 was not her usual self. V4 requested R1 be sent to the hospital. Upon hospitalization , R1 was found to have a blood glucose level of greater than 900. R1's POR (Physician order [REDACTED]. This POR documents an order received on 9/7/17 for CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) to be completed every six months. There are no results of these laboratory test results in R1's medical record. R1's physician progress notes [REDACTED]. Concerns of [DIAGNOSES REDACTED] are more of an issue than [MEDICAL CONDITION]. We will restart medications as clinically indicated. I've also asked that a Hemoglobin A1C be drawn next week and every 6 {six} months. There is no results of this laboratory test result in R1's medical record. R1's physician progress notes [REDACTED]. Concerns of [DIAGNOSES REDACTED] are more of an issue than [MEDICAL CONDITION]. We will restart medications as clinically indicated. I've also asked that a Hemoglobin A1C be drawn again as there have not been labs in the system since (YEAR). There is no results of this laboratory test result in R1's medical record. R1's Progress Notes dated 10/29/18 by V6 RN (Registered Nurse) documents, an unidentified CNA (Certified Nursing Assistant) notified V6 that R1 was acting weird, was confused and not at R1's baseline. R1's Blood Pressure at the time 106/75, Pulse 107 beats per minute, and Temperature 97.4 degrees Fahrenheit. R1's blood glucose level was checked twice and each reading was hi. V7 Physician was notified and V7 ordered a CBC, CMP, Hemoglobin A1C, and Urinalysis to be completed on 10/30/18. R1's Progress Notes dated 10/30/18 by V8 RN documents R1 was assessed by V9 Advanced Practice Nurse and new orders received to send R1 to the ER (emergency room ) for decreased L[NAME] (Level of Consciousness), and increased blood glucose levels. R1's History and Physical by V13 Hospital ER (emergency room ) Physician dated 10/30/18 documents, History {is} obtained from chart review as there was no family at bedside. R1 was having high blood sugars for the last week. At baseline R1 follows simple commands and is oriented to herself, and now she is disoriented, and does not follow any commands. Laboratory tests were completed and shows the following: glucose level of 909 HH (high critical), Potassium level of 5.6 H (high) and BUN level of 70 H, Creatinine level of 2.06 H. R1's Active Problems: Hyperosmolar hyperglycemic coma due to diabetes mellitus without ketoacidosis. On 11/7/18 at 12:45 pm, V14 LPN (Licensed Practical Nurse) produced CBC and CMP results from 9/9/17, 1/29/18, 5/25/18, and 9/24/18, and a Hemoglobin A1C from 10/3/18. V14 stated the laboratory tests had been completed and that V14 had to pull the results from the laboratory. V14 stated V14 was unsure if the results were ever given to V7 Physician, since they were not in R1's medical record. The laboratory results that V14 produced document the following: 9/9/17 - glucose level - 120 H; normal fasting range is 65 - 99 1/29/18 - glucose level - 168 H; normal fasting range is 65 - 99 5/25/18 - glucose level - 200 H; normal fasting range is 65 - 99. These results did not include results for the hemoglobin A1C that was ordered on [DATE]. 10/3/18 - glucose level - 240 H; normal fasting range is 65 - 99. Hemoglobin A1C - 12.3%; normal range is 4.1% - 6.1% 10/30/18 - glucose level - 794 RCH(reading critically high); normal fasting range is 65 - 99. Hemoglobin A1C - 14.2% RH (reading high); normal range is 4.1% - 6.1%. On 11/7/18 at 12:48 pm, V1 Administrator stated, staff should be documenting in the medical record when the physician is notified of any changes and laboratory results. Obviously they aren't doing it. On 11/7/18 at 1:17 pm, V7 Physician stated, R1 has never been on diabetic medication while residing at the facility. V7 stated V7 had ordered laboratory testing on many occasions but since there wasn't any laboratory results in (R1's) medical record since (YEAR), V7 did not know the CBC, CMP and A1C tests were ever completed. V7 stated the facility has never notified (V7) of the {laboratory} results. V7 stated R1's hospitalization and diabetic coma was a direct result of no treatment. If V7 had been made aware of R1's rising glucose levels, V7 would have started treatment of [REDACTED]. The facility Request for Diagnostic Services Policy dated (MONTH) 2007 documents orders for diagnostic services will be promptly carried out as instructed by the physician's orders [REDACTED].

Based on observation, interview and record review, the facility failed to reposition, provide pressure relieving measures, accurately assess a pressure wound, and failed to provide pressure wound treatment for two of six dependent residents (R208, R69), reviewed for pressure ulcers in the sample of 21. This failure resulted in R208 developing two Suspected Deep Tissue Injuries to the Sacrum. Findings Include: 1.) R208's Care Plan dated 9/11/18 documents a [DIAGNOSES REDACTED]. This Care Plan documents R208 has limited Range of Motion to bilateral upper and lower extremities due to [MEDICAL CONDITION] resulting in a decreased functional status, and that R208 is at risk for skin breakdown. R208's Skin Risk assessment dated [DATE] documents R208 as High Risk for skin breakdown. R208's MDS (Minimum Data Set) dated 7/11/18 documents R208 requires extensive assistance of two staff for bed mobility. R208's Progress Notes dated 9/4/18 by V11 RN (Registered Nurse) documents R208 returned to the facility from the hospital and the only skin condition R208 had was, Bottoms of both feet calloused, dry, and cracked; toenails long and yellowed. Small bruise on shin just below R shin. Scabbed area to top of R foot, 1cm x 1 cm. On 9/09/18 at 9:10 AM, 10:49 AM, 11:17 AM, 11:44 AM, 12:36 PM, 1:30 PM and 2:00 PM, R208 was observed lying on R208's back in bed. On 9/10/18 at 2:38 PM, V9 CNA (Certified Nursing Assistant) stated, R208 is totally dependent on staff for all cares and is completely bed bound. R208 should be repositioned every two hours going from one side to her back, then to her other side. V9 stated, R208 has no opens areas now or ever to my knowledge. On 9/11/18 at 9:56 AM, V6 RN stated, a new pressure area was found on R208's left sacral area this morning measuring 2 cm (centimeters) x (by) 2.5 cm. On 9/11/18 at 10:02 AM, V6 RN entered R208's room to observe the pressure area. R208 was lying in bed, on her back with a pillow under her right hip. V6 stated, this pressure area has bruising around the open area, but I didn't measure that. V6 exposed R208's sacral area. R208 had a dark purple area on the left sacrum measuring approximately 4.5 cm x 3 cm with open area in the middle of it measuring 2 cm x 2.5 cm, and an approximate 1.5 cm x 1.5 cm dark purple area on the right sacrum, that was not open. V6 stated it looks like a sDTI (Suspected Deep Tissue Injury) and confirmed the approximate sizes. V6 then measured the entire bruised area and stated, it is 8.5 cm x 6 cm. V6 stated the open area is now, a stage II but who knows what it will look like when it totally opens. On 9/11/18 at 2:32 PM, V2 DON (Director of Nursing) stated, if a resident is dependent on others for cares, they need turned and repositioned every two hours. R208 not being turned for five hours could most definitely cause the breakdown. V2 stated at the time with the sDTI not being fully opened, the pressure area is considered unstageable. The facility undated Prevention of Pressure Ulcers Policy documents the purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Pressure Ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. For bed fast residents, Change position frequently as needed. 2. The Admission Minimum (MDS) data set [DATE] documents R69 is cognitively intact, is at risk for the development of pressure sores with no current pressure sores and that R69 requires extensive assistance for bed mobility and transfers. V24's Admission Observation dated 8/1/18 documents R69 has no skin alterations and only has redness to inner thighs and buttocks, redness under breasts. The Treatment Administration Records dated 8/1/18 through 8/31/18 and 9/1/18 through 9/12/18 document no treatment orders for sores on R69's thighs until 9/12/18. On 9/10/18 at 9:22 am R69 was seated in R69's wheelchair. R69 stated R69 has sores on R69's thigh that are not being treated. R69 stated R69 came to the facility with the wounds. R69 stated last evening R69 told the evening nurse (V24 Registered Nurse) about the sores and V24 did nothing. R69 stated there is a hard area on R69's wheel chair that hits the back of R69's legs and R69 has asked nursing staff and maintenance staff to fix wheel chair seat. R69 stated facility staff keep telling R69 they will fix the wheel chair seat but no one has fixed it. At that time an uncushioned metal area was observed on the front edge of R69's wheel chair seat which was in contact with the back of R69's thighs. On 09/11/18 at 12:49 PM V24 Registered Nurse confirmed that R69 asked V24 about a treatment to R69's thigh. V24 stated V24 looked at the Treatment Administration Record and R69 had no treatment ordered so V24 did not do anything. On 09/11/18 at 4:40 PM V21 Certified Nurses Aide (CNA) and V22 CNA transferred R69 to the bed with the mechanical lift and removed R69's slacks and incontinence brief. At that time two open sores were observed on the back of R69's right thigh. V22 stated R69 has had the sores since R69 was admitted to the facility (8/1/18). V22 stated the sores are from pressure from the exposed metal area on R69's wheel chair that R69 brought to the facility. On 09/11/18 at 05:15 PM V2 Director of Nurses and V6 Wound Nurse stated they did not know about the wounds on R69's right thigh or the uncushioned area on R69's wheelchair. V2 confirmed R69 asked the maintenance staff to fix R69's wheel chair but it has not been fixed. V2 stated the CNA staff first documented skin issues on R69's thighs on 8/2/18. V2 stated staff should have reported R69's skin issues. V2 stated if V2 had known about the uncushioned area on R69's wheelchair V2 would have had therapy staff evaluate the wheelchair. On 09/12/18 at 08:41 AM V6 Wound Nurse stated V6 evaluated R69's skin this morning and found three pressure areas on the back of R69's thigh. V6 stated a treatment of (occlusive gauze strips) twice daily was ordered for R69's wounds this morning. V6 stated V6 believed R69 was admitted to the facility with the wounds and R69's skin was not accurately assessed at admission. V6 stated staff should have reported the wounds to V6 on admission. V6 confirmed the exposed metal area on R69's wheel chair could have been a source of pressure. V6's Wound History Notes dated 9/12/18 document the following pressure sores for R69: right posterior thigh stage two pressure wound measuring 4.5 centimeters (cm) length by 1.5 cm width with a depth of UTD (unable to determine); right superior thigh stage two pressure wound measuring 1.5 cm length by 0.5 cm width; and right inner posterior thigh stage two pressure wound measuring 6.0 cm length by 1.0 cm width with a depth of UTD.

Based on observation, interview and record review, the facility failed to serve diets in the right consistency for one resident (R5). This failure resulted in R5, with a known history of choking, being served a diet that was not cut into bite size pieces as ordered. R5 choked and ultimately died of anoxia (lack of oxygen to the brain) from the choking incident. R5 was one of three residents reviewed for therapeutic diets in the sample of 46. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at severity level two. The facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures to ensure all residents receive the appropriate diets at all meals. Findings include: The Physician order [REDACTED]. The same POS has the order for R5's diet to be Low Concentrated Sweets (LCS), thin liquids/Regular and Special Instructions: Staff to cut up food into bite size pieces. R5's Progress Note dated [DATE] at 11:30 AM documents (R5) downstairs in sports lounge room eating a chicken dinner. At this time restorative aide came into room and noted (R5) eating chicken and (R5's) face and lips cyanotic. (R5) continued to eat chicken, no coughing noted. Restorative aide performed the (abdominal thrust maneuver) and loosened food and called first floor nurse and a code was initiated. Progress note dated [DATE] at 1:11 PM for R5 states received new order for mechanical soft diet with thin liquids per (V26), Speech Language Pathologist due to choking. R5's assessment titled Minimum Data Set ((MDS) dated [DATE] states R5 is cognitively intact, requires setup help with one person physical assist and has a swallowing disorder with the signs and symptoms of coughing or choking during meals or when swallowing medications. R5's Speech Therapy Daily Treatment Note dated [DATE] documented by V26 states: Recertification documentation completed. (R5) educated regarding : diet upgraded to regular solids and need for small bites. Educated nursing staff regarding : diet order for small bites and prepared meals. Staff verbalized understanding. Diet order written. R5's dietary tray card documents for every meal the following information : Other: Cut up food into bite size R5's Progress note dated [DATE] at 7 PM reads : (R5) was found in the dining room unresponsive, no pulse, not breathing. (R5) had choked on food and had a lot in (R5) throat. Started CPR (cardiopulmonary resuscitation), called 911 and was doing chest compression and hooked up defibrillator and was advised no shock. Continued compressions till ambulance arrived. Inserted 18 gauge to right arm with 2 rounds of [MEDICATION NAME] given. Ambulance personnel hooked up there own defibrillator and took (R5) to hospital. Notified the doctor. R5's table mate R15, who MDS dated [DATE] documents R15 is cognitively intact, stated on [DATE] at 10:17 AM I sit with (R5) at the table in the dining room. (R5) was used to eating very fast. (R5) was usually done with eating before we received our trays. (R5's) food was not cut up into small pieces, I would of remembered that. No staff was around (R5). No employee came over and prepared (R5's) plate. (R5) was eating fast and got too much food in (R5s) mouth and started choking. I had yelled and got someone's attention that (R5) was choking. (R5) was unresponsive, one of the CNA's (certified nursing assistant) called 911 and I remember the fireman and policemen got there fast. They worked on (R5). (R5) was unresponsive when the staff put (R5) on the floor. V26, Speech Language Pathologist stated on [DATE] at 1:55 PM The facility restorative nurse (V62) and myself educated the CNA's for (R5) diet . If (R5) received regular textured food always cut the food into small pieces because (R5) tends to eat fast. I always individually train the staff on how to set up the meal tray for residents. (R5) always needed to have small bites. I expected the staff to cut (R5's) food into small pieces. That was the order. My expectations was for the staff to cut up (R5's) food as they were all trained to do so. (R5's) Pizza should of been cut up into bite size pieces because this was regular textured food. This information for (R5's) food to be cut up into bite size pieces should be on (R5's) care plan because it was the order. V39, CNA stated on [DATE] at 3:43 PM We were in the dining room [ROOM NUMBER] of us CNAs were passing trays to the residents. We were passing trays and (R5's) table mate (R15) called loudly to get our attention for (R5). Me and (V43) CNA went there and saw (R5) sitting in the chair not responding and not saying a word. The resident had a pizza wedge with sausage and cheese for the meal. I did not notice if it was cut up. I did not pass (R5's) tray. We was trained by therapy and restorative nurse to cut (R5's) food into small pieces. I was not the one who passed (R5s) tray. (V43) was the one who called 911. Staff (nurses) started CPR they laid (R5) on the floor. V37, LPN stated on [DATE] at 4:29 PM The CNAs were in the dining room passing trays, I had been working with a new nurse (V60, LPN) so I found her and asked her to go get help for V8, RN (Registered Nurse) who was doing CPR on (R5). I don't remember if (R5's) food was bite size we pulled lots of food out of (R5's) mouth and throat, the ambulance driver arrived and put a tool down (R5) and pulled out lots more of food. (R5) eats really fast (R5) and will stuff her mouth full. You really need to sit by (R5) when (R5) eats. I had a feeling it was going to happen to (R5). On [DATE] at 3:29 PM V42, Licensed Dietician verified R5 was served a pizza wedge and stated, (R5) was on regular thin liquid diet with special instructions to cut regular textured food into bite size pieces. My expectation is the CNA staff who delivers the tray is to cut up residents food into the bite size pieces. The dietary staff only prepares special diets. They do not cut up the food into pieces. V17, Head Dietary Cook stated on [DATE] at 9:02 AM The kitchen does not cut up residents food. We only prepare the special diets like pureed, mechanical soft. The CNAs serving the trays to the residents are responsible to prepare the trays for the residents. Pizza would be placed on the tray in slices not cut up. V26, Speech Pathologist stated on [DATE] at 8:50 AM Staff in the dining room on 2nd floor were responsible to prepare (R5's) tray. CNAs should cut up (R5's) food. V8, RN (Registered Nurse) stated on [DATE] at 8:40 AM I was not the nurse who was taking care of (R5) but I was up at the medication cart and another nurse (V60) who was brand new came and told me they needed help in the dining room because there was a resident who needed help. I saw V39, CNA waving her arms and yelled 'hurry'. I found (R5) slumped over in her chair, (R5) was not breathing and no pulse and (R5's) color was very gray. I immediately placed (R5) on the floor and started CPR. I yelled at other staff to get me the equipment and told someone to call 911. I did 20 minutes straight of compression and was then relieved by the emergency crew. (R5) had a pulse when the emergency crew left for the hospital . I tried to sweep food from (R5's) mouth but was not able to because of doing compressions. When the emergency crew arrived they had to remove food from (R5) with a clamp of some type because they were not able to intubate (R5). This happened twice. They removed a large amount of food from (R5's) mouth. I did not see any food cut up and I did not look at (R5's) tray. There is never enough staff for all the residents that require assist with eating. More residents need assist than we have staff available. (R5) should have not died . R5's care plan dated [DATE] does not address R5's eating requirement per speech pathologist requests and doctor's order for R5 to have all regular textured food cut up into bite size pieces. V48, Care Plan Coordinator confirmed on [DATE] at 11:15 AM R5's care plan did not address choking incident on [DATE] and did not state R5's food needed to be cut up into bite size pieces. R5's hospital report titled Discharge Summaries- Medical Death Summary dated [DATE] states Cause of Death: Perimortem Circulatory Collapse. Admission Diagnosis: [REDACTED]. Active Hospital Problem: [MEDICAL CONDITION], [MEDICAL CONDITIONS], Cardiogenic Shock and Acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. V38, Medical Doctor (R5's) Attending Physician Hospital stated on [DATE] at 12:35 PM. (R5's) death was [MEDICAL CONDITION] from choking. Choking is what caused (R5) to have [MEDICAL CONDITIONS] and [MEDICAL CONDITION] with [MEDICAL CONDITION], (R5) choking that is what lead to (R5's) death. On [DATE] an Immediate Jeopardy was identified. The Immediate Jeopardy situation began on [DATE] when the facility failed to serve a diet in the right consistency for one resident (R5) requiring all regular texture food being cut into bite size pieces as ordered. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 10:00 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy on [DATE]: 1. The facility's Therapeutic Diet Policy was reviewed and updated by V63, Regional Nurse Consultant on [DATE]. 2. A complete audit of residents that have been assessed for difficulty chewing , being edentulous, loose or broken teeth has been re-evaluated by V26 and V59 Speech Language Pathologists on [DATE]. 3. A complete audit of residents with Therapeutic Diets has been completed to ensure the diet follows the physician's orders [REDACTED]. 4. Training occurred on [DATE] and is ongoing to ensure residents receive the appropriate diets as ordered by their physicians receive the correct diet and consistency and matches each resident's tray card before being served. The training was completed by V4 ADON, V64 Admissions, V17, Dietary Head Cook and V65 Facility Newly Hired DON. 5. Department Heads and Nurses are assigned to dining room during meals beginning [DATE]. confirmed on [DATE]. 6. V1, Administrator and V65, Director of Nurses will be responsible for compliance of all processes ongoing.

Based on record review and interview the facility failed to administer medications as ordered by the physician for one of three residents (R1) reviewed for medication administration in the sample of four. R1's [MEDICAL CONDITION] medication was omitted for 63 days, resulting in R1 being hospitalized with a [DIAGNOSES REDACTED]. Findings include: The physician's orders [REDACTED]. The July POS has an order for [REDACTED]. Z1, (R1's physician) dictated a telephone order on July 3, 2013 for [MEDICATION NAME] 50 mcg to be discontinued every other day on odd days and for [MEDICATION NAME] 75 mcg to be discontinued on even days. The new medication order for R1 was to receive [MEDICATION NAME] 75mcg one tablet every day. R1's POS and MAR (Medication Administration Record) for August and September 2013 documents the medication [MEDICATION NAME] 75mcg was discontinued on 7/3/13. R1 did not receive the medication [MEDICATION NAME] 75mcg , as ordered, for the month of August or September. The POS and MAR for the month of October does not document the medication [MEDICATION NAME] 75mcg at all for R1. E5, Licensed Practical Nurse (LPN) stated on 10/10/13 at 2:25PM "I did not transcribe the order for [MEDICATION NAME] 75mcg onto the POS's for August and October. I did not do the POS for September but (E6,LPN) did do the September POS and (E6) followed my POS from the previous month which did not have [MEDICATION NAME] 75 mcg on it. " E2, Director of Nurses confirmed on 10/11/13 at 3:45 PM that R1 did not receive [MEDICATION NAME] 75mcg for a total of 63 days. Nurses Notes dated 10/2/13 at 2PM documents "(Z1) (R1's Physician) called and order was received to send (R1) to emergency department. (R1) sent to emergency department by ambulance services..." Z1, stated on 10/11/13 at 2:27 PM "I was not notified of (R1) not receiving her [MEDICATION NAME] 75mcg until 10/4/13 after (R1) was hosptalized on [DATE]. (R1) was admitted to the hospital and it is possible (R1) was admitted to the hospital due to omission of her [MEDICAL CONDITION] medication but it was not the main reason for hospitalization . One of (R1's) admitting [DIAGNOSES REDACTED]. My expectation is for the facility to administer medications as I order." The Hospital Progress Note dated 10/3/13 documents under "Assessment" one of the admitting [DIAGNOSES REDACTED]." The same progress note under " Laboratory Data" documents R1 TSH ([MEDICAL CONDITION] Stimulating Hormone) 83.28 uIU/mL (International unit per milliliter) normal TSH level is 0.270-4.200 uIU/mL. R1's TSH level was extremely elevated. R1's Care Plan dated 7/10/13 reads "Potential for altered health related to [MEDICAL CONDITION]" Approaches for this potential problem is "Administer (R1's) medications as ordered. See Medication Administration Record." Facility policy titled "Administering Medication" dated April 2010 #3 states "Medications must be administered in accordance with the orders, including any required time frame."

Based on record review and interview, staff failed to use a shower chair with a back, when bathing one of three residents (R5) reviewed for falls in a sample of five. This failure resulted in R5 falling and sustaining a fractured hip. Findings include: R5's Physician order [REDACTED]. The MDS documents R5's functional status as not steady and only able to stabilize with staff assistance when moving from seated to standing, moving on and off toilet and surface to surface transfer. R5's Care plan dated February 2013 documents that a reclining shower chair is to be used during bathing. The Fall Risk assessment dated [DATE] assesses R5 as a high fall risk. R5's Nursing Notes dated 2/19/13 at 5:50 am documents R5 slid out of a shower chair while E9 Certified Nursing Assistant was giving her a shower, no injury was assessed at this time. R5's Nursing Notes dated 2/19/13 at 10:30 am document that R5 was not able to bear weight on her right leg and complained of pain. R5 was transported to the hospital. The hospital notes for R5 dated 2/19/13 document under Assessment - Right Subcapital Femoral Head Fracture with some displacement. Plan - Admit to hospital with Right Hip Hemiarthroplasty 2/20/13. The facility's investigation (of R5's fall of 2/19/13) is dated 2/20/13 and documents an interview with E6, Certified Nursing Assistant stating that she had been coming down the hall at the time of R5's shower and heard a thud (like a boom) and heard R5 calling for help. E6 stated that she looked in the shower room and saw R5 on the floor and E9 standing over R5. An investigation interview by the facility dated 2/21/13 documents E8, Licensed Practice Nurse stating that E9 had used a shower bench instead of a shower chair while giving R5 a shower. On 3/1/13 at 11:50 am E1, Administrator stated that E9 had used the wrong shower chair while giving R5 her shower. E1 stated that during the investigation E9 had told the facility that she had used a chair with a back, but the facility's fall investigation revealed that a bench without a back was used during R5's shower. E1 stated that since false information was given by E9 and E9's actions of using an unsafe chair caused injury to R5, E9 was terminated. On 3/8/13 at 2:45 pm E6 acknowledged that she was coming down the hall with another resident in a shower chair when she heard R5's voice in the shower room and thought..."Oh she's in the shower room, and I wondered what shower chair she was using since I had the only one for that particular shower room." E6 stated she then heard a loud thud and went to the shower room to find R5 on the floor and E9 leaning over her. E6 stated that the staff are aware that the backless shower benches are not to be used on the residents while giving showers. "They are used to put towels and clothes on. We all know residents are not to be in them during a shower and (E9) used the wrong chair because she did not want to wait for the right one."

Based on observation, interview and record review, the facility failed to identify inappropriate touching by R10 toward an unidentified resident and R8 as sexual abuse. This failure resulted in repeated resident to resident sexual abuse by R10. R8 is for one of four residents (R8) reviewed for abuse in the sample of ten. This failure allowed the alleged perpetrator to have continued access to R8 and other female residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 03/23/12, the facility remained out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identifying, reporting, investigation, and resident protection related to abuse. Findings include: R8's physician's orders [REDACTED]. R8's Minimum Data Set ((MDS) dated [DATE] indicates that she is moderately cognitively impaired. R10's POS dated 03/01/12 to 03/31/12 documents the following Diagnoses: [REDACTED]. R10's MDS dated [DATE] indicates that he is moderately cognitively impaired. On 03/23/12 at 1:00pm R8 stated that R10 came into her room and put his hand under her blanket and clothing and ran his finger up the front of her lower leg, over her knee, and touched her lower thigh (just above her knee). R8 stated she was seated in her chair in her room. R8 also demonstrated R10's touch by touching her lower leg and bringing her fingers up her lower leg, over the knee, and slightly above her knee. R8 stated again that he touched her bare skin, and indicated that she perceived this to be sexual in nature. R8 stated that she then began yelling for him to stop and get out of her room. R8 states he stopped and left her room. R8 stated that she does not remember the date of this incident. The Occurrence Report dated 03/10/12 indicates that the incident occurred on 03/10/12; the time on the Occurrence Report was 1:05pm. On 03/23/12 at 1:00pm R8 stated that R10 returned to R8's room and confronted her, stating that he used to think she was a nice lady, but that he didn't think so anymore. R8 told R10 to leave her room and he left. R8 was unable to recall the date that R10 returned to her room. R8 also stated that some time after this incident R10 was moved downstairs (the first floor). A Social Service Progress Note dated 03/13/12 written by E5, Licensed Social Worker (LSW), reports that R8 told E5 that R10 that R10 "has been coming to her room to visit and last week he came into her room and ran his finger up the side of her leg." After yelling at R10 to get out of her room, "he laughed at her and thought it was funny." On 03/12/12, R10 "came back to her room and told her he was mad at her and that it was her fault that he was being moved downstairs." E5 also documented at that time that R8 stated "no one has the right to do that to me and I do not feel safe with him around." E5 did not report the allegation to E6, previous Administrator. According to a statement written 03/13/12 (no time recorded), E12, Certified Nursing Assistant (CNA), reported to the North Hall nurse that R8 told her about the inappropriate touching by R10 on 03/10/12 (Saturday). On 03/23/12 at 4:33pm, E4, Licensed Practical Nurse (LPN) stated that a CNA reported to her the allegation by R8 on 03/10/12. E4 stated that she talked to R8 and R10. E4 stated that R8 was very upset by the inappropriate touching. E4 stated that R10 said little and seemed to not remember the incident. E4 stated that R8 and R10 were separated, and that she directed the other nurses and CNAs working that evening to keep R8 and R10 separated and to watch both of them. E4 stated that all staff knew to keep R8 and R10 separated and watch them 03/10/12 (Saturday) and 03/11/12 (Sunday). E4 states that neither resident was sent out for evaluation and neither resident was assigned one to one observations on 03/10/12 or 03/11/12. The In-House Transfer Sheet dated 03/12/12 indicates that R10 was moved from the second floor (where R8 lives) to the first floor on 03/12/12, two days after he inappropriately touched R8. E4 stated that she reported the allegation to E3, Registered Nurse (RN) and Nursing Supervisor, on 03/10/12 but does not remember the time she notified her. On 03/23/12 at 4:33pm E4 confirmed that she did not notify the Administrator. A document written 03/12/12 at 4:59pm by E2, Director of Nursing (DON), reports that E2 spoke with E4, regarding her direction to the staff working 03/10/12 and 03/11/12. E2 reports that E4 stated "She (E4) notified (E10's) nurse and other CNAs to keep an eye out on (R10) due to the fact that E8 did not want him in her room." E2 and E4 failed to identify this incident of sexual abuse. The 24 Hour Report dated 03/10/12 directs staff to "notify staff of incident with (R10). Separate the two (R10 and R8)." The 24 Hour Report dated 03/11/12 directs staff to "Notify staff of incident with (R10)." A Social Service Progress note dated 10/20/11 written by E7, Licensed Social Worker (LSW) also indicates R10 was involved in another incident of inappropriate, sexual touching which occurred on 10/19/11 with an unidentified resident. The Progress note dated 10/20/11 documents "(R10) was witnessed by nurse on 10/19/11 evening touching other resident between legs. SW (Social Worker) asked if he remembered doing that. (R10) replied yes." On 03/28/12 at 8:35am E7, LSW, stated that she was asked by a nurse (E7 could not remember her name) to talk to R10 on 10/20/11 because of the incident of inappropriate touching. E7 stated that she did not report the allegation to E6, Previous Administrator, because she thought it had been reported the day it occurred. Nurse's Notes dated 10/20/11 indicate that R10 was "on 15 minute observational checks today." There is no documentation of 15 minute checks beyond 10/20/11. No other interventions for R10 were implemented. R10 was not removed from resident contact. R10 was allowed unrestricted access to the alleged victim and other female residents. On 03/23/12 at 4:30pm, an Immediate Jeopardy was identified to have begun on 03/10/12 when facility staff failed to prevent, identify, and immediately report a repeated incident of inappropriate touching of a secoond resident (R8) by R10. E1, Administrator, was notified of the Immediate Jeopardy on 03/23/12 at 4:42pm. The Immediate Jeopardy was removed on 03/23/12. The surveyor confirmed through observation, interview, and record review on 03/23/12, that the facility took the following actions to remove the Immediate Jeopardy: 1. R10 was placed on constant, direct visual one to one supervision as soon as the Immediate Jeopardy was identified on 03/23/12. 2. All staff scheduled to work on 03/23/12 after the Immediate Jeopardy was identified were trained on the abuse policy prior to working their shift. The training included educating staff to report all forms of suspected abuse to the administrator, protecting the alleged victim, and separating the alleged perpetrator. Nursing will interview 10 staff members weekly for six weeks to ensure that staff understand the Abuse Prevention Policy.

A. Based on observation, interview, and record review, the facility failed to immediately report an allegation of inappropriate sexual touching of an unidentified resident by one of four residents (R10) reviewed for abuse in the sample of ten. This failure resulted in a second incident of R10 inappropriately touching another resident (R8) in the sample of ten. The Facility failed to protect R8 from R10 after the alleged touching incident, which allowed R10 to reapproach R8 two days later. The Facility also failed to conduct a thorough investigation of allegations of sexual abuse, and failed to immediately report allegations of sexual abuse to the Facility Administrator and to the State Survey and Licensing Agency. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was determined to have begun on 3/10/12. While the immediacy was removed on 03/23/12, the facility remains out of compliance at a severity level two in that the facility is in the process of monitoring the effectiveness of staff retraining directed at identification, reporting, investigation, and resident protection related to abuse. Findings include: R8's physician's orders [REDACTED]. R8's Minimum Data Set ((MDS) dated [DATE] indicates that she is moderately cognitively impaired. R10's POS dated 03/01/12 to 03/31/12 documents the following Diagnoses: [REDACTED]. R10's MDS dated [DATE] indicates that he is moderately cognitively impaired. A Social Service Progress note dated 10/20/11 written by E7, Licensed Social Worker (LSW), documents that R10 was involved in an incident of inappropriate, sexual touching which occurred on 10/19/11 with an unidentified resident. The Progress note dated 10/20/11 documents "(R10) was witnessed by nurse on 10/19/11 evening touching other resident between legs. SW (Social Worker) asked if he remembered doing that. (R10) replied yes." On 03/28/12 at 8:35am E7, LSW, stated that she was asked by a nurse (E7 could not remember her name) to talk to R10 on 10/20/11 because of the incident of inappropriate touching. E7 stated that she did not report the allegation to E6, previous Administrator, because she thought it had been reported the day it occurred. Nurse's Notes dated 10/20/11 indicate that R10 was "on 15 minute observational checks today." There is no documentation in the Nurse's Notes on 10/19/11 recording R10's behavior. No other interventions for R10 were implemented. R10 was not removed from further resident contact. R10 was allowed unrestricted access to the alleged victim and other female residents. No other documentation or investigational evidence for this incident could be produced by the Facility. On 03/28/12 at 3:30pm, E1, Administrator, confirmed that no investigation of the incident was located. On 03/28/12 at 4:00pm, E1 confirmed there is no documentation that a report was made to the State Licensing and Certification Agency. On 03/23/12 at 1:00pm R8 stated that R10 came into her room and put his hand under her blanket and clothing and ran his finger up the front of her lower leg, over her knee, and touched her lower thigh (just above her knee). R8 stated she was seated in her chair in her room. R8 also demonstrated R10's touch by touching her lower leg and bringing her fingers up her lower leg, over the knee, and slightly above her knee. R8 stated again that he touched her bare skin, and indicated that she perceived this to be sexual in nature. R8 stated that she then began yelling for him to stop and get out of her room. R8 states he stopped and left her room. R8 stated she did not remember the date of this incident. The Facility Occurrence Report dated 03/10/12 indicates that the incident occurred on 03/10/12; the time on the Occurrence Report was 1:05pm. On 03/23/12 at 4:33pm E4, Licensed Practical Nurse (LPN) stated that an unidentified Certified Nursing Assistant (CNA) told her that R8 reported to her the inappropriate touching by R10 on 03/10/12 (Saturday). E4 stated that she talked to R8 and R10. E4 stated that R8 was very upset by the inappropriate touching. E4 stated that R10 said little and seemed to not remember the incident. E4 stated that R8 and R10 were separated, and that she directed the other nurses and CNAs working that evening to keep R8 and R10 separated and to watch both of them. E4 stated that all staff knew to keep R8 and R10 separated and watch them 03/10/12 (Saturday) and 03/11/12 (Sunday). E4 states that neither resident was sent out for evaluation and neither resident was assigned one to one observations on 03/10/12 or 03/11/12. On 03/23/12 at 1:00pm, R8 stated that R10 returned to R8's room and confronted her, stating that he used to think she was a nice lady, but that he didn't think so anymore. R8 told R10 to leave her room and he left. R8 was unable to recall the date that R10 returned to her room. R8 also stated that some time after this incident R10 was moved downstairs (the first floor). The In-House Transfer Sheet dated 03/12/12 indicates that R10 was moved from the second floor (where R8 lives) to the first floor on 03/12/12. R10's Behavior Tracking Sheet dated 03/15/12 documents that R10 went back to his old room on the second floor of the facility: "Upstairs CNA said (R10) was in his old room and would not come out...He was on the toilet. When he finished he stood up and started hitting the wall." On 03/23/12 at 4:33pm, E4 stated that she reported the allegation to E3, Registered Nurse (RN) and Nursing Supervisor, on 03/10/12 but does not remember the time she notified her. On 03/23/12 at 4:33pm E4 confirmed that she did not notify the Administrator. A written document dated 03/12/12 at 4:59pm by E2, Director of Nursing (DON), reports that E2 spoke with E4, regarding her direction to the staff working 03/10/12 and 03/11/12. E2 reports that E4 stated "She (E4) notified (E10's) nurse and other CNAs to keep an eye out on (R10) due to the fact that (E8) did not want him in her room." The 24 Hour Report dated 03/10/12 directs staff to "notify staff of incident with (R10). Separate the two (R10 and R8)." The 24 Hour Report dated 03/11/12 directs staff to "Notify staff of incident with (R10)." A Social Service Progress Note dated 03/13/12 written by E5, LSW, reports that R8 told E5 that R10 "has been coming to her room to visit and last week he came into her room and ran his finger up the side of her leg." R8 yelled at R10 to get out of her room, and "he (R10) laughed at her and thought it was funny." On 03/12/12, R10 "came back to her room and told her he was mad at her, and that it was her fault that he was being moved downstairs." E5 also reported in the Social service Progress Note that R8 stated "no one has the right to do that to me, and I do not feel safe with him around." E5 did not report the allegation to E6, Previous Administrator, and did not provide protection for R8. On 03/28/12 at 3:30pm, E1, Administrator, confirmed that a thorough investigation was not conducted by the Facility. On 03/28/12 at 4:00pm, E1 confirmed there is no documentation that a report was made to the State Licensing and Certification Agency. R10's Behavior Tracking Sheets document the following inappropriate sexual behaviors toward staff: 02/02/12 When getting resident ready for bed, "(R10) began scratching his testicles, then wiped his hands all over my uniform top," When (the CNA)turned around, "(R10) started grabbing my behind." R10 then "started laughing saying you know you like it." 02/08/12 R10 told a CNA "I have a tickle down here--pointing to his groin area--and asked if CNA would take care of it." 03/14/12 R10 "Placed his hand on my lower back and and continued to move it downward." 03/18/12 R10 "Yelled throughout the day, masturbating every time I answered his call light. This behavior went on from 7:00am to 10:50pm." 03/21/12 R10 told CNA "he wanted to touch me and hold me." On 3/23/12 at 4:42pm E1, Administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy was removed on 03/23/12. The surveyor confirmed on 03/23/12 through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R10 was placed on constant, direct visual one to one supervision as soon as the Immediate Jeopardy was identified on 03/23/12. 2. All staff scheduled to work on 03/23/12 after the Immediate Jeopardy was identified were trained on the abuse policy prior to working their shift. The training included educating staff to report all forms of suspected abuse to the administrator, protecting the alleged victim, and separating the alleged perpetrator. Nursing will interview 10 staff members weekly for six weeks to ensure that staff understand the Abuse Prevention Policy. B. Based on interview and record review, the Facility failed to notify the State Licensing and Certification Agency of an injury of unknown origin within 24 hours of discovery, and failed to conduct an investigation to determine its root cause for one of four residents (R8) reviewed for abuse in the sample of ten. Findings include: R8's physician's orders [REDACTED]. R8's Minimum Data Set ((MDS) dated [DATE] indicates that she is moderately cognitively impaired. On 03/23/12 at 12:15pm, R8 stated that one morning she awoke with a painful right shoulder. R8 was unable to recall the date she awoke with the painful right shoulder. Furthermore, R8 was not able to recall any injury to the shoulder. The Geriatric Rounding Service Note dated 02/22/12 indicates that R8 was seen by Z2, Primary Care Physician, on 02/22/12 for pain in her shoulder. Nurse's Notes dated 02/22/12 do not document R8's shoulder pain or any investigation of the circumstances surrounding R8 acquiring the shoulder pain. Nurse's Notes dated 02/23/12 do not document any investigation of the circumstances surrounding R8's shoulder pain. R8's shoulder was xrayed on 02/23/12 and the X-ray report indicated "A partial dislocation of the right humerous upon the glenoid." Emergency Department (ED) Provider notes dated 02/24/12 document that R8 went to the ED for evaluation and treatment on that date. R8's shoulder injury meets the two conditions for an injury of unknown origin: source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury. According to the State Licensure and Certification Agency records, no report was made to the State Licensing and Certification Agency regarding R8's suspicious injury. The facility had no documentation for reporting R8's injury to the State Licensure and Certification Agency. C. Based on interview and record review, the Facility failed to immediately report an allegation of employee to resident sexual assault for one of four residents (R9) in the sample of ten. Findings include: R9's POS dated 03/01/12 to 03/31/12 indicates the following Diagnoses: [REDACTED]. History and Physical Summary Notes dated 12/30/11 document "Fully disoriented, dementia." On 03/23/12 E8, Licensed Physical Therapy Assistant (LPTA), stated that on 01/31/12 at approximately 3:30pm R9 told her during her therapy that "(E10) raped me." E8 states that she immediately reported the allegation to E9, LPN, who was the nurse on duty at that time. According to a written statement completed on 01/31/12 by E11, previous Director of Nursing, on 01/31/12 at approximately 4:35pm, E6, previous Administrator, notified R9's son of the allegation and received consent to send R9 to the hospital for evaluation. The Police were also notified 01/31/12 and conducted an investigation. E6 submitted the initial report of the allegation to the State Licensure and Certification Agency on 02/02/12 at 5:07pm, more than 24 hours after the allegation of sexual assault was reported.

A. Based on observation, interview and record review the facility failed to follow facility policy or the plan of care in the transferring or the supervision of the following residents: R5, R4, R3, and R2. The failure of the facility resulted in serious injury to each of these residents. R5, R4, R3, and R2 are four of fourteen residents sampled for falls and fractures. The particular failures are as follows: The facility failed to provide immediate attention per the plan of care to R5 one of 14 residents sampled for falls and fractures. R5 had exhibited behaviors of non-compliance and self transfer when she refused immediate attention. As a result R5 attempted to transfer herself to bed and fell . This fall resulted in a fracture of the right leg. The fracture succeeded to a gangranous infection that shortly necessitated a below the knee amputation of the right leg. The facility failed to have two staff in attendance when bathing R4. R4 was a resident who required total care and the assistance of two while bathing. R4 (who requires total care and the assist of two while bathing) was being showered with the assistance of one Certified Nursing Assistant (CNA). The CNA turned away from R4 and R4 fell from the shower chair striking his head on the floor. This required hospitalization and stitches to close the wound in R4's head. The facility failed to assess for an adequate posture device to ensure R3 could not fall from his wheelchair. R3 is a resident who is confined to a "special" wheelchair when out of bed. R3 has [DIAGNOSES REDACTED]. R3 has poor safety awareness and was able to remove his own seatbelt. R3 sustained a fall from the wheelchair that resulted in a fractured hip. The seat belt that was supposed to keep R3 in his chair was not fastened at the time R3 had the fall. The facility failed to use two staff to assist in a mechanical lift transfer of R2. R2 is a resident who requires total assist with a mechanical lift for transfer. The facility policy requires two staff members to be in attendance with a mechanical lift. R2 was being transferred with the mechanical lift by a single CNA. As a result R2 was dropped from the lift and suffered a head injury that required stitches to the back of the head. Findings include: 1) The September 2011 physician's orders [REDACTED]. The December 2010 Minimum Data Set documents R5 is cognitively impaired, is not ambulatory, is an extensive two person transfer, and is incontinent of both bowel and bladder. The falls assessment and care plan dated December of 2010 shows R5 is a high fall risk with a previous fall. A 12/14/10 "Occurrence Report" shows R5 had attempted to self transfer and sustained a fall. The report states, "...Root cause: pt. (patient) self transfer on slide board without supervision, (and) lose balance r/t (related to) decrease muscle strength..." The care plan dated December of 2010 states, "...can be inpatient at times. Does not always want to wait for help/assistance..." Z1, R3's daughter stated on 9/27/11 at 11:00 AM that she had informed the facility by way of E2 Director of Nursing, that her mother was mentally deteriorating and that she would not listen when told she would have to wait. She stated, "...I told them in December (2010) she would not wait to be laid down - that she would try to lay herself down..." The Director of Nurses (DON) stated on 9/28/2011 at 10:00 AM, "...yes, she would try to self transfer. She would not wait for help after she asked for it - I told all the staff to lay her down as soon as she asks..." E3 CNA stated on 9/27/2011 at 2:25 PM that R5 had asked her to be put to bed after supper on 3/16/2011. E3 stated, "...I had heard she (R5) would try to transfer herself if she was not laid down right away. I don't think we have enough staff to safely care for the residents with the staffing we have now..." E5 CNA stated on 9/28/2011 at 3:00 PM, "...I was part - time taking care of (R5). She tried to transfer herself the night before (she fell ). We do not have enough staff to provide safe care. We have five or six people that require two assist to lay down..." E4, Registered Nurse (RN) on 9/27/2011 at 4:00 PM stated, "... She (R5) had come out of her room 3 times(the evening of 3/16/2011) asking (me) to go to bed. I told the CNA's (E3 and E5) myself. They were working with another resident. They said they would be right there. Then (R5) came out one more time and asked to be put to bed...I knew she had a fall history but I did not know about her behavior of self-transfer. I didn't know she would do it that fast..." The "Occurrence Report" dated 3/16/2011 reads as follows: "...Resident requested to be put to bed x (times) 3 over the course of 10-15 minutes and was reassured that the CNA's (Certified Nursing Assistants) would do this next for her after they were done with previous task. Resident was then found on floor with distressed look on face asking for help..." Nurses notes dated 3/18/2011 (no time recorded) states "...Night nurse passed on concern for pt (patient)...I looked at pt. and saw discolored areas on her Rt. (right) foot white bands across top and blackened areas on toes. Rt. leg was lying on lateral side and thigh was swollen...I called and (was) instructed to call (doctor) and send her to ED (emergency department) ASAP (as soon as possible)...Pt. later reported to have broken right femur..." The Consult Notes dated 3/21/11 through 3/28/11 reads as follows: "...Assessment: 1. Right distal femur comminuted bicondylar (possible intercondylar) femur fracture. 2. Right medial tibial plateau fracture with compression and step-off. 3. Comminuted distal third fibula/tibial fractures with angulation , right...9. Possible gangrene, right little toe...Plan: 3...Due to the right foot wound, compromised circulation and severe bone demineralization, we do not feel that hardware can be anchored to stabilize the lower leg fractures and due to the presence of the wounds and impaired circulation it is felt that the leg is not salvageable and would most likely require below vs (versus) above the knee amputation..." R3 was eating lunch with her daughter on 9/27/11 at 12:30 PM. R3 was in a wheelchair at the table with a right below the knee amputation. 2.) The June 2011 physician's orders [REDACTED]. The most recent Minimum Data Set (MDS) dated April of 2011 indicates R4 is total assist for all activities of daily living. The MDS shows R4 is a total 2 person assist for hygiene/bathing. The MDS indicates R4 is not steady in a surface to surface transfer and is only able to stabilize with assistance. The "Occurrence Report" dated 6/01/11 documents R4 was being showered by E9 CNA alone when he (R4) fell from the shower chair and sustained a head laceration that required stitches to close. The report states, "...Notified by CNA res fall in shower room. Assess contusion to (right) forehead...Also, 2 cm (centimeter) skin tear to (right) forehead...Resident sent to (Emergency Department)...Resident received sutures to right forehead area... The statement written by E9 states, "...took resident to shower room to give shower. I turned to turn the water on and resident leaned forward and as I turned back around the shower chair was off the ground and he fell out of chair on the floor and hit his head..." E2 DON stated on 9/29/2011 at 3:00 PM that the policy of the facility is that two staff are to give showers/baths to residents. 3.) The September 2011 physician's orders [REDACTED]. The 8/14/11 assessment shows R3 is a high risk for falls. The June 2011 Minimum Data Set documents R3 is cognitively impaired, is a two person extensive assist for transfers, is incontinent of bowel and bladder, is not ambulatory and is extensive to total assist for all other activities of daily living. The Occupational Therapy notes dated 2/3/09 to 2/17/09 states, "...My suggestion is that we make sure that he is all the way back into his seating system and that we use some type of seat belt to make sure that he maintains the position..." Z7, Director of Therapy stated on 9/28/11 at 11:00 AM that "...yes, I know who (R3) is - he was assessed as needing a seat belt to maintain his posture. He would be unsafe to sit in the wheelchair without a positioning device. He has poor safety awareness..." The March 30, 2011 Physical Therapy Evaluation and Plan of Treatment states, "...Range of Motion (ROM) (lower extremities) (right lower extremity) Impaired (75 degree contracture at B(Both) knees, patient has had contractures for years per nursing staff. Increased [DIAGNOSES REDACTED]. Unable to extend knees passively or extend hips past 20 (degrees) flexion...LLE ROM (left lower extremity range of motion) = impaired...increased [DIAGNOSES REDACTED]..." The Care Plan dated 7/7/2011 states, "...seat belt on when up in w/c (wheelchair)..." The Fall Investigation Report dated 8/7/11 reads as follows "...CNA called (nurse) at 3:30 PM to look upon the resident, he (R3) was on the floor..." The report documents "Staff did not follow plan ? Seat belt off..." On 9/28/2011 at 9:30 AM Director of Nursing stated, "...res could remove (unfasten) seat belt. He has done so before on numerous occasions, espescially when he sees the (mechanical lift) because he is trying to help. (R3) has never tried to transfer himself but he does have [DIAGNOSES REDACTED]. The report to the State Survey and Certification Agency Regional Office dated 8/9/2011 reads as follows: (R3) has been a resident since 11/4/09...On August 7th, 2011 (R3) fell out of his geri chair after he removed his safety belt...An x-ray was ordered for August 8th which determined (R3) had a left hip fracture. He was sent to emergency room for further evaluation. (R3) will be returning to (the facility) after his surgery. A new "alarming safety seat belt" will be in place when (R3) returns..." On 9/28/11 at 1:30 PM R3 was in his wheelchair. An attempt was made to interview R3. He did not readily respond to questions but did respond to a request for him to unfasten his safety belt. There was no sound when the belt was unfastened that signified the alarm was working. A request was then made that a staff member, E38, Licensed Practical Nurse who had entered the room, try the seat belt. Again the alarm did not sound. After examining the alarm and pushing some buttons the alarm sounded. E38 stated the alarm was not turned on. 4. The October 2011 physician's orders [REDACTED].The June 2011 MDS (Minimum Data Set) indicates R2 is an extensive to total assist for all activities of daily living. The MDS shows R2 is a total 2 person assist for transfers. The 6/15/11 assessment rates R2 as a high fall risk. The 8/14/11 "Fall Investigation - Nursing Home - Internal Report reads as follows: Describe the incident: Res (resident) was in process of transfer per (mechnical sling lift) (and) fell ... Injury Type: Head Trauma... Witness statement regarding occurrence: I (CNA E55) went into his room to get him up. I put the sling under him and went into the hall to ask a CNA to help me. She said she will be there in a min (minute) so I went in hooked the sling up and lifted him (R2) just a little...Follow - up comments: Root cause - poor transfer technique body shifted in sling when lifted. Intervention - staff education and discipline..." The nurses notes dated 8/14/11 at 4:30 PM states the resident was non-responsive after the fall with fixed pupils non-reactive to light. The notes state R2 was transferred to the hospital with a laceration on the back of his head. The Care Plan dated 6/15/11 states, "...(mechanical lift) (with) 2 assists..." The physician's orders [REDACTED]. The Care Plan dated 6/16/11 states, "...Assistive Devices as ordered - use (mechanical lift) for all transfers...(mechanical lift (with) 2 assist..." R1 identifed by the facility as an interviewable resident and selected for an individual interview stated on 9/27/2011 at 10:30 AM, "...Sometimes when they transfer me with the lift only one person comes in...This morning when I was transferred (at 6:00 AM), I was transferred by one person..." The DON stated on 9/29/11 at 1:00 PM the staff members who transferred R1 and R2 admitted that they transferred R1 and R2 by theirselves. The DON stated that both staff members were terminated for their failure to follow facility policy regarding mechanical transfers. B. Based on observation, record review, and interview, the facility failed to provide a safe environment and appropriately supervise one of 11 sampled cognitively impaired residents, out of a sample of 27, by having the electrical cord to the bed plugged into the wall beside and within reach of the resident (R26), resulting in R26 putting the cord around her neck, and attempting to put her fingers into the same electrical socket. Findings include: According to admission records and the POS (physician's orders [REDACTED]. The Geriatric Rounding Service Note by the Nurse Practitioner on 8/19/11 also added "anorexia and dehydration. . .appetite very poor. . . .refusing to eat. . . .refuses IV (intravenous) fluids. . . .more confused than normal. . . ." The MDS (Minimum Data Set) of 8/19/11 assesses R26 as moderately cognitively impaired, has verbal behaviors, and requires assistance for ADLs (activities of daily living). According to the Occurrence Report dated 8/23/11, at 7:10am, R26 was found with the "black plug-in cord wrapped around her neck. Cord was not tight. Small amount of emesis was noted on pillow. . . .no red marks. . . " The family was notified and they declined to send R26 to the hospital. A progress note dated 8/23/11 states that a psychological assessment was attempted but "pt (patient) declined services." E39 (day nurse) stated on 9/28/11 that R26 had been asleep when found, and there had been no evidence or verbalizations of suicidal ideations. E39 stated that R26 had been declining and was "just confused." E39 demonstrated how the bed was set up and where the outlet and plug were. The bed was set with the side of the bed next to the wall (parallel), so the outlet was approximately 18 inches above the mattress toward the head of the bed, within easy arm reach of a resident in the bed. E39 stated they removed the plug and plugged the bed into another outlet. E39 also stated that they placed plastic outlet protector plugs. E39 stated they had talked about moving the bed the other way (perpendicular to the wall), but they did not move the bed into a different position at that time. Also, E41 (evening nurse) made a written statement that she observed R26 attempting to "put her fingers in the light socket. . . . don't recall seeing plastic protector in outlet. . ." E41 also stated that she lowered the bed and moved the bed "away from the wall so she couldn't reach it." At 5:30pm on 8/23/11, the Physician Communication and Progress Note by E41 states that R26 "continued to become increasingly confused. . . .would continue these behaviors (fingers in light socket) shortly after being redirected. . . .unable to get IV fluids into her due to the continued taking out of the IVs. . . .also refusing to eat/drink anything. . . ." R26 was then sent to the hospital, where R26 was admitted with confusion, tachycardia, UTI (urinary tract infection), and lactic acidosis, according to the Emergency Department Initial Milestone.