Every finding on record at Alden Estates of Northmoor

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent elopement for a cognitively impaired resident with impaired safety awareness and wheelchair dependence. This affected 1 (R1) of 3 residents reviewed for supervision and elopement. This failure resulted in R1 exiting the facility without staff knowledge or supervision and was later located approximately one block from the facility.Findings Include:On 6/1/26, R1 eloped from the facility. Upon return, R1 was noted to be emotionally distressed, confused, and unable to explain the circumstances surrounding the elopement.R1's MDS (minimum data set) with review date of 04/01/2026, BIMS (brief interview of mental status) of 7, indicating that R1's cognition is moderately impaired.R1's Care plan with review date of April 1, 2026, documents that R1 has difficulties in effectively communicating his needs and at times does not reflect signs of comprehension or understanding during simple communication with staff, peers, family or friends. R1 has the diagnoses of CVA (cerebrovascular accident) & Aphasia (language disorder) which may be contributing factors in diminishing communication abilities. R1 may show signs of wellbeing and opportunities to socially connect by some of the following: Answer questions appropriately/able to complete task at hand/follow directions/smiling/relaxed facial expressions/relaxed postures by next review.On 06/14/2026 at 9:45 AM, this surveyor observed R1 sitting in his wheelchair while watching television on the second-floor dining room. R1 appears to be dressed appropriately for the weather. R1 is clean, there are no odors coming from the residents. R1 is alert and oriented to self, with some confusion. On 06/15/2026 at 9:50 AM, V4 (Registered Nurse) stated R1 has never exhibited exit seeking behavior. V4 stated on the day of the elopement (6/1/26), R1 was able to wheel himself to the elevator and get past the nurse's station to go outside. V4 stated an incoming staff member found him outside and brought him back safely to the facility. V4 stated R1 currently has a 1:1 supervision, and a wander guard bracelet on his left ankle. V4 stated after the incident R1 is now deemed an exit seeker.On 06/14/2026 at 10:53 AM, V9 (Activity Director) stated she was not working on the day R1 left the facility. V9 stated the last time she had an Inservice on elopement was last week. V9 stated there is a Jogger Binder that is kept at the nurse's station on each unit and in one by the receptionist. V9 stated the binder makes staff aware of the residents that need to be monitored for elopement. V9 stated the day that R1 left the facility was in the morning, there was no receptionist at that time, since the receptionist starts her shift at 8:00 AM. V9 stated a staff member might have left the door unlocked, and due to that reason R1 was able to leave the facility unsupervised.On 6/14/26 at 1:23 PM, V1 (Administrator) stated R1 left the facility between 6:40 AM to 6:50 AM. She stated R1 was found by incoming CNA 10 minutes after he left the facility about a block away. V1 stated unfortunately the front sliding door was left unlocked by one of the staff in the facility. V1 stated the door is supposed to be locked until 8:00 AM when the receptionist is around. V1 stated R1 can use the elevator by himself, and he did not exhibit exit seeking behavior prior to this incident. On 06/15/2026 at 9:24 AM, V14 (Certified Nurse Aide) stated she was on the way to work at approximately 6:30 AM. V14 stated while she was on the bus she was passing through the intersection, and she recognized R1 sitting in his wheelchair. V14 stated once she got off the bus she ran into the facility and told the first staff member she came across. V14 stated she accompanied the 4 nurses and one aide to R1's location, which was 1 block away from the facility. R1 was sitting in his wheelchair and appeared to be lost and confused. V14 stated R1 was brought back to the facility safely, and with no injuries. V14 stated she just received an elopement in service after that incident, which will help in identifying residents who are at risk for elopement. V14 stated she always starts her shift with a head count. V14 stated if her head count does not correlate with her assignment, then she will right away let the nurse know. V14 stated she is still surprised that R1 left the facility unattended and unsupervised, because R1 is always watching television in his room or the dining room.On 06/15/2026 at 9:44 AM, V13 (Registered Nurse) stated on the day of the elopement morning at approximately 6:00 AM, she administered medication to R1, and then after that R1 was up in the wheelchair. V13 stated the last time she seen R1 was at approximately 6:15 AM in the dining room near the television. V13 stated she did not personally see R1 getting on the elevator, and there was no one in the nurse's station at that time. V13 stated there is only one nurse and two aides for the night shift. V13 stated she is surprised in how R1 was able to leave the facility, because she has never seen any exit seeking behaviors with R1. V13 stated R1 can make his needs know, and has a communication board in his room, however R1 never told anything about wanting to leave the facility to V13. V13 stated she was made aware by the first shift nurse about R1 leaving the facility. V13 stated she immediately went outside to go look for R1. V13 stated at that time that R1 was accompanied by staff members, and they were seen coming towards the facility. V13 stated she did a head-to-toe assessment and R1 did not have any injuries on the body. V13 stated R1 appeared confused and scared, he was not responding to her questions, instead he kept his head down.On 06/15/2026 at 11:17 AM, V15 (Certified Nurse Assistant) stated that around 5:00 -5:30 AM, she performed ADL (Activities of Daily Living) and got him up in his wheelchair, and she continued with her assignment with other residents. V15 stated that around 6:00 AM, she heard about R1 leaving the facility. V15 stated she immediately reported this incident to V1. V15 stated she has never had an Inservice for and Elopement and has never done an elopement drill since she has been working in the facility, which has been 1 year.On 06/15/2026 at 10:35, V12 (Social Services Director) stated when she arrived to work on the morning of the elopement, she was notified by V1 that the R1 had left the facility unsupervised and unattended. V12 stated R1 has never displayed any behavior issue with exit seeking. V12 stated after completing her assessment, V27 (R1's Daughter) was notified and a consent form was signed for a wander guard bracelet. V12 stated R1 also has a 1 to 1 sitter. V12 stated an elopement assessment should be completed yearly, quarterly or as needed. V12 stated that after completing R1's elopement assessment, he is not at risk for elopement. V12 stated she expects staff to be familiar with signs of elopement such as a resident is noticed starting to wander, start making statements they want to go home, packing all of their belongings, and hanging out near the elevators or the exit doors. V12 stated the dietary elevator on the second floor is easily accessible to anyone, and it does not have an alarm for the wander guard bracelet. V12 stated however it would be difficult for the resident to leave the facility because there are double doors on the first floor that will immediately detect the sensor on his wander guard bracelet, and the alarm will go off. V12 stated when R1 left the building it was unattended and unsupervised.On 06/15/2026 at 10:07 A, V2 (Assistant Director of Nursing) stated she received a call from one of the supervisors and was notified that R1 was back in the facility, V2 was made aware at roughly at 7:00 AM. V2 stated R1 has never had the exit seeking behaviors and stated that once the provider was notified, he ordered some labs and collected a urine sample.On 06/14/2026 at 1:32 PM, V7 (Restorative Nurse/ License Practical Nurse) stated R1 is alert and oriented to self, he is contracted on the right- side, he has a split cone and can wheel himself. She stated he is a 2-person assistant with transfer and his ADL's. V7 stated R1 requires a 1 assist when going to another floor because of his right-side contracture. V7 stated R1 will benefit from a locomotion because he is a fall risk.On 06/15/2026 at 11:20 AM, V27 (Physician) stated R1 has never had any exit seeking behaviors before the incident on 06/01/2026. V27 stated R1 is mobile in his wheelchair. My interactions with him are not always the best. V27 stated R1 seems to be confused, and not always in his right mind. V27 stated upon R1's return to the facility, he ordered labs, urine culture, and there were no physical issues, or any signs of infections. V27 stated R1 has not yet seen a neurologist due to his insurance, and the family being particular and hostile. V27 stated R1 is currently on a 1 to 1 monitor and has a wander guards' bracelet. V27 stated on the day of the elopement the doors were left unlocked, there was no harm however R1 was left unsupervised and unattended while exiting the facility.On 06/15/2026 at 11:30 AM, this surveyor is located on the first unit near the double doors and the exit door that goes to the patio. The wander guard sensor was functional and reliable. The back door exit also has a functional sensor.Facility's elopement binder kept in the reception room reviewed. R1 was included in elopement risk dated 06/2026 with R1's picture and face sheet. Policy titled Wanderers (Elopement) with review date of 09/2020 documents in part, Residents identified as wanderers will have a preventative program to prevent possible injuries.Policy titled Missing Resident, with review date of 09/2020 in part, It is the policy of this facility to report and investigate all reports of missing residents. Should an employee discover that a resident is missing from the facility he or she should immediately report the missing resident to the charge nurse or the nursing supervisor. Call a code green.

Based on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that are accurately documented for one (R1) out of three residents reviewed for resident records. On 01/24/26 at 10:30 AM, V3 (Licensed Practical Nurse) stated that she does not know exactly the date that she was notified by V7 (Certified Nursing Assistant) that R1 was noted with discoloration/bruising on her left side of R1's body. V3 stated but it was after lunch, V7 who is the regular CNA called V3 to the shower because she wanted to show R1's discoloration. V3 said R1 had a bruise on the left side, below armpit, next to the breast. V3 said I asked V2 (Director of Nursing) to see R1 after we transferred her to the bed. V2 looked at it and maybe 20 minutes later, V2 called me (V3) back, she said, let's take an x-ray (electromagnetic radiation). V3 stated R1 is on long-time blood thinner medication. V3 stated that R1's results were negative for any fractures. V3 stated that R1 does tend to lean towards her left side and requires frequent repositioning. V3 stated that V3 was the one who notified the doctor of the results. V3 stated I didn't chart this because I was waiting for the DON (director of nursing) to tell me what to do. She told me just to order an x-ray stat (immediately). V3 said that when this was going on, V4 was present and made aware. V3 stated that it is important to chart and document what is happening to residents because the next shift nurses could continue to follow up. V3 stated I have not documented anything in R1's electronic health record regarding the bruising/discoloration. On 01/24/2026 at 11:31AM, V7 (Certified Nursing Assistant) stated that on Monday January 5th, R1 had a scheduled shower so V7 assisted R1 to the shower and when V7 removed R1's clothes, V7 noted R1 with discoloration/bruising to her left side of R1's body. V7 stated I reported it to V3 (Licensed Practical Nurse) and I put in my charting in the computer. Then when the daughter came in, the nurse told the daughter. The daughter asked me what happened. V7 stated that it was the first time she saw the bruise and V7 did not witness R1 suffer any fall or injuries. V7 said that she told R1's daughter that when I saw the bruise I (V7) immediately notified the nurse.On 1/24/26 at 12:19 PM, V5 (Assistant Director of Nursing) stated if the CNA (certified nursing assistant) is providing care to the resident and notices a skin injury they need to report it to nurse on duty after they take care of the resident. From there on (if there is a skin tear) the nurse will call the doctor depending on the severity. V5 stated that skin injury can include anything such as a scratch, open skin tear, anything out of the ordinary such as skin discoloration. V5 stated that nurses are supposed to chart this in the progress notes and notify the doctor.R1's face sheet documents R3 is a [AGE] year-old individual admitted to the facility on [DATE] and has diagnoses not limited to type 2 diabetes mellitus with diabetic polyneuropathy, dementia, pressure ulcer of sacral region, stage 3.R1's radiology note dated 01/06/2026 9:29 PM documents in part above X-ray (electromagnetic radiation) results relayed to R1's doctor with no new orders.No documentation regarding R1's new discoloration noted to skin and what interventions were done following this discovery.Facility document dated 09/20, titled Change of condition (resident) documents in part to ensure that the resident's physician and responsible party is kept informed regarding the resident's change in condition. Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received. Change in Condition: When to report to the doctor. Discoloration of Skin; any new skin discoloration without any other symptoms.

Based on observations, interviews and record review, the facility failed to ensure that urinary catheter bag was not on the ground touching the floor; failed to wear Personal Protective Equipment (PPE) during high-contact care of a resident on Enhanced Barrier Protection (EBP); failed to perform hand hygiene prior to entering, and after exiting resident room on EBP after providing direct care and between residents during meal service while passing trays; and failed to perform sanitation of medication cart during medication pass in a manner that prevents the spread of infection. These failures affected four residents (R5, R11, R31, and R120) reviewed for infection control and have the potential to affect all residents residing in the facility.Findings include: R11's admission records and face sheet showed R11 was admitted to the facility on [DATE]. R11's Diagnosis included but not limited to Hypertensive Heart Disease with Heart Failure, Encounter for Palliative Care; Cardiomyopathy, Atrial Fibrillation; Hypothyroidism; Hyperlipidemia; Unspecified Dementia; Anemia; Age-related physical debility; Long term use of anticoagulants; Dependence on supplemental oxygen and Peripheral Vascular Disease. R11's Minimal Data Sheet (MDS) in section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 3, which shows severe cognitive impairment. R11 care plan ([DATE]) documents in part that R11 experiences bowel and bladder incontinence due to the Inability to sense urge to void consistently and that R11 should be clean and dry and to monitor R11 for signs and symptoms of infections and provide assistance with toileting and continue to perform routine checks. R11's active orders ([DATE]) showed in part, that R11 should be monitored for signs and symptoms of adverse reactions and adverse consequences. On [DATE] at 12:40 PM, observed V16 (Registered Nurse/RN) providing high-direct care to R11, resident on Enhanced Barrier Precautions (EBP), without personal protective equipment (PPE) and without performing hand hygiene prior entering R11's room, during direct care and after exiting R11's room. On [DATE] at 12:07 PM, Observed EBP sign on R11's door. Observed a PPE cart with gloves and gown in the hallway by R11's room. R11 was not in the room. Observed an oxygen nasal cannula with tubing, laying on R11's bed not contained. On [DATE] at 12:22 PM, observed R11 in the dining room, siting in the wheelchair, dressed and groomed well, eating lunch. Observed urinary catheter in the privacy bag hanging on R11's wheelchair. R11 stated, that R11 is doing good and has no concerns for the care. Observed R11 to be alert and orientated and very pleasant. On [DATE] at 12:40 PM, with V16 (RN) in R11's room, EBP sign on the door, observed V16 going into the R11's, EBP room without performing hand hygiene or donning gloves or gown. R11 was in the bathroom, opened the door and wanted to go to bed. V16 started assisting R11 to get back to bed. V16 did not perform hand hygiene or don gown or gloves. R11 was in the wheelchair and had a urinary catheter in place. Observed V16 touching R11's hands, arms, and urinary catheter, while helping R11 to transfer from wheelchair to bed. V16, after transferring the resident from wheelchair to the bed, then touched the tubing and nasal cannula, dropped it on the floor and then placed it back on the resident. V16 did not perform hand hygiene or don gloves and gown at any point during the high contact care. V16 continued to provide care and help positioned R11 in a bed, brought R11's bedside table next to the bed and tidied up R11's belongings without using PPE, or performing hand hygiene. Prior to exiting room, V16 touched and scratched V16's face, and exited R11's room with no hand hygiene performed. On [DATE] at 12:47 PM, V16 (RN) stated, that any resident that has urinary catheter or a wound, is placed on EBP precautions and should have EBP sign on the door and staff should wear PPE and perform hand hygiene during high contact care and prior and after exiting resident's room. V16 said, that V16 was nervous and V16 affirmed that, V16 did not perform hand hygiene, nor wore gown and gloves during R11's direct care and that V16 made a mistake and will be more careful. V16 stated, that EBP, and hand hygiene is important to prevent contamination and infection spreading. On [DATE] at 12:47P PM, V13 (Medical equipment supplier) stated that isolation carts in the facility should have gowns and gloves in them for nursing staff to use while performing care for EBP or other isolation residents to prevent infection spread and contamination. On [DATE] at 10:11 AM, V22 (Unit manager/CNA) stated that Enhanced Barrier Precautions (EBP) precautions should be utilized for residents with catheters, and nurses and CNAs should be wearing gowns and gloves and perform hand hygiene, when providing direct resident care. V22 stated that, there are signs posted on the doors for each resident on EBP or other isolation and that the facility provides in service education for infection prevention and hand hygiene, daily and training quarterly. On [DATE] at 10:50 AM, V1 (Administrator) stated that expectation is when nursing is performing high contact care with resident on EBP or isolation, gown and gloves should be used. V1 also said, that hand hygiene should be performed before and after care and that PPE should be brought to the room and could be put on in the room when performing high contact care. V1 stated, that using gloves and gowns and performing proper hand hygiene is very important for infection prevention and infection control and the staff should be aware of that. On [DATE] at 1:08 PM, V41 (Ombudsman), stated that one of the concerns for the facility was infection prevention and control. On [DATE] at 2:25 PM, V2 (Director of Nursing/ DON) stated, that hand hygiene should be performed before and after resident's care and if something falls on the floor it is considered dirty and it should not be placed back with clean items because it would contaminate the items. V2 stated, that EBP are used for residents with drains, catheters and wounds.V2 said, that if staff is providing direct care to a resident, gowns and gloves should be worn to prevent contamination and infection to themselves or other residents. V2 said, that hand hygiene and washing hands frequently should be performed regularly and for residents on EBP, gowns and gloves should be worn when directly touching resident, when helping resident to the bathroom or helping residents with transfers. On [DATE] at 12:19pm V18 (Certified Nursing Assistant/CNA) observed removing a used cup from in from of R31, throwing the cup in the garbage. V18 then observed getting a bowl of soup and placing it in front of R120. V18 did not perform hand hygiene between R31 and R120. On [DATE] at 12:20pm V18 (CNA) stated that R31 put soup in the juice cup and that's why she discarded the cup. V18 stated that she did not sanitize her hands between R31 and R120, but she should have. V18 stated that hand hygiene is part of being sanitary. On [DATE] at 8:44am V20 (Licensed Practical Nurse/LPN) observed placing white foam tray on R43's dresser then removing white foam tray and placing tray on top of medication cart without cleaning tray. On [DATE] at 8:47am V20 LPN stated that the white foam tray is disposable but is used throughout the entire shift and disposed of at the end of the shift. V20 stated that as long as the tray is not brought into an isolation room, that it is okay to continue to use the tray. V20 stated that he should have wiped the tray off before bringing it out of a resident's room. On [DATE] at 2:25pm V2 (Director of Nursing/DON) stated that the facility's white foam trays can be reused if sanitized between uses. V2 stated that V20 should have sanitized the white foam tray before placing the tray on the medication cart. V2 stated that the medication cart would then be considered contaminated. R31's medical diagnoses include but are not limited to essential hypertension, depression, Parkinson's disease, senile degeneration of brain, generalized anxiety disorder. R31's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 0, indicating R31's cognition is severely impaired. R120's medical diagnoses include but are not limited to hypertensive chronic kidney disease, major depressive disorder, vascular dementia. R120's MDS dated [DATE] has a BIMS score of 3, indicating R120's cognition is severely impaired. On [DATE] at 11:08 AM, R5 was observed in bed with bed in low position. Mats on both sides of the bed. R5's urinary catheter bed was observed on the floor with 400 ml of yellow urine in the drainage bag. R5's urinary catheter was not in a privacy bag. On [DATE] at 11:08 am, V4 (Licensed Practical Nurse) verified R5's urinary catheter bag was affixed to the non-movable part of the bed frame touching the floor with the bed in its lowest position. V4 stated R5 is a fall risk and the bed is in its lowest position but the urinary catheter bag should not be touching the floor. V4 stated R5's urinary catheter bag should be in a privacy bag for dignity purposes. Surveyor noted R5's urinary catheter bag is not visible to anyone who walks pass the room because of how R5's bed is situated in the room. V4 stated R5's urinary catheter bag should be draining to gravity and should not be sitting on the floor to prevent backflow of urine which can cause infection to the urinary tract. On [DATE] at 11:09 am, V16 (Registered Nurse) stated a residents urinary catheter bag should be hung on the non-movable part of the bed and it should not be hanging above the floor and it is stored in the safety or privacy bag to protect a resident's privacy. On [DATE] at 2:25 pm, V2 (Director of Nursing) stated a residents urinary catheter bag should be placed in a privacy bag hanging below the bladder. V2 stated the purpose of a resident's catheter bag being placed in a privacy bag is to protect a resident's dignity. On [DATE] Facility's policy titled Hand Hygiene (10/2024) showed in part, that it is the policy of the facility to perform hand hygiene (hand washing and/or Alcohol-based hand rub (ABHR) to reduce the potential spread of pathogen. Document also showed in part, that hand hygiene with ABHR should be performed immediately prior to touching a resident; when caring for a resident; when moving from a soiled body site to a clean body site of the same resident; after touching a resident or the resident's immediate environment; immediately upon removal of gloves and PPE. Document also showed in part that hand hygiene with soap and water should be performed after any contact with body fluids or contaminated surfaces. Facility's document titled Enhanced Barrier Precautions (Undated), showed in part that everyone must clean hands, including before entering and when leaving the room. Document also showed in part, that staff must wear gloves and a gown for transferring, assisting with toileting, and for care or use of urinary catheter care. Facility's policy titled Enhanced Barrier Precautions (8/2025), showed in part that Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. Guidelines of the policy showed in part, that EBP involves gown and gloves use during high-contact resident care activities for residents with indwelling medical device. Procedure part of the policy showed in part that high-contact resident care activities include but not limited to dressing and transferring, providing hygiene, or assisting with toileting and device care and that residents that have indwelling medical devices would be on EBP. In the 4a section of the procedure, document showed in part, that gown and gloves use prior to the high-contact care activity and change PPE before caring for another resident. Part 8 of procedure showed in part that when not providing high-contact resident care, hand hygiene should be performed prior to entering and exiting the room. Facility's Job Description document titled Staff nurse (Registered Nurse/License Practical Nurse) (1/2015), showed in part, in job summary section, that to ensure the highest degree of quality care is always maintained, the staff nurse is responsible to provide direct nursing care to the customer, and to supervise the day-to-day nursing activities performed by the nursing assistants. Document also showed in part, that one of essential functions is to assume all nursing procedures and protocols are followed in accordance with established policies. Facility's Job Description document titled Director of Nursing (1/2015), showed in part, in job summary section, hat the director of nursing (DON) is responsible to plan, organize, develop, direct and delegate the overall operation of the Nursing Department in accordance with current federal, state, and local standards, guidelines and regulations, and facility policies to ensure the highest degree of quality care is always maintained. The document showed in part, in the essential functions section C, that Director of Nursing should assure all nursing procedures and protocols are followed in accordance with established policies. The document also showed in the essential functions section P, that DON should make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed.

Based on observation, interview, and record review the facility failed to conduct a Pre-admission Screening Resident Review (PASRR) for a resident with a newly diagnosis of a serious mental illness. This failure affected 1 of 1 (R101) resident reviewed for PASRR with Diagnosis in a sample size of 58. The findings include:R101 initially had a diagnosis of Parkinson's Disease and Insomnia on admission 1/21/2025. R101 was diagnosed with Dementia in Other Diseases Classified Elsewhere, Alzheimer's Disease, Major Depressive Disorder, and anxiety disorder on 7/8/2025. R101 does not have a Preadmission Screening Resident Review (PASRR) Level II for his (R101's) new diagnosis.R101 has a Minimum Data Set Indicator in iQIES that documents No Preadmission Screening Resident Review with Diagnosis. R101's Face Sheet dated 12/3/2025 documents a diagnosis of but not limited to Parkinson's Disease without Dyskinesia and Insomnia on 1/21/2025 and Dementia in Other Diseases Classified Elsewhere, Alzheimer's Disease, Major Depressive Disorder, and anxiety disorder on 7/8/2025.R101's Care Plan dated 1/21/2025 documents, in part, a focus for receiving anti-depressant medication related to the diagnosis of Depression/Anxiety, Dementia, Elopement Due to Cognitive Impairment, and Insomnia.R101's Minimum Data Set Section C documents BIMS (Brief Interview Mental Status) score of 14 which is an indication of an intact cognition. R101's Preadmission Screening Resident Review (PASRR) Level II dated documents a Determination Date of April 4, 2024: PASRR Determination Level II- Excluded From PASRR- No Diagnosis-No LOCR101's Preadmission Screening Resident Review (PASRR) Level I Review Date: February 5, 2025PASRR Level | Determination: No Level Il Required - Resolved symptomsOn 2/03/2025 at 12:30 PM, V25 (Social Services Director) stated all residents must have a PASRR Level I on admission. V25 stated she (V25) reviews Level I Preadmission Screening and Resident Review (PASRR) results during the initial assessment on admission, which includes questions about diagnosis, medications, and behaviors. V25 stated many PASRR Level I's are inaccurate; if discrepancies are found, I (V25) request a Level II or a new Level I. V25 stated R101 has a change in diagnosis, a Level II PASRR is required.Facility Policy titled Preadmission Screening and Resident Review (PASRR) Policy and Procedure (Illinois) dated 12/2022 documents, in part, Prior to admission and upon any changes in status, resident will be screened for a known or suspected diagnosis of severe mental illness, developmental disability, or intellectual disability to ensure resident is appropriate for nursing facility services and to incorporate treatment recommendations into the resident's care plan.

Based on observation, interview, and record review the facility failed to administer medications in accordance with professional standards for one resident (R90). This failure affected one resident (R90) in a sample size of 58.Findings include:R90's medical diagnoses include but is not limited to hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, asthma, major depressive disorder.R90's physician order dated 09/18/2025 documents in part, Clotrimazole External Solution 1% .Apply to all toenails of both feet topically two times a day for onychomycosis (toe fungus) for 3 months.On 12/02/2025 at 9:13am surveyor observed V20 (Licensed Practical Nurse/LPN) administer oral medications to R90. Surveyor did not observe V20 administer any topical medications to R90. Surveyor observed V20 document medications given to R90.R90's Medication administration audit record dated 12/02/2025 at 9:13am has documentation from V20 (Licensed Practical Nurse/LPN) that Clotrimazole External Solution 1% was administered to R90.On 12/03/2025 at 12:53pm V20 (LPN) stated that he did not administer R90's topical medication during the observed medication pass. V20 stated that he should not have documented that the medication was administered to R90 without administering the medication. V20 stated that medication should not be documented if it's not given because it can cause a medication error.On 12/03/2025 at 2:25pm V2 (Director of Nursing/DON) stated that medication should not be documented if it is not administered.Facility's policy titled Medication Administration dated 09/2020 documents in part, Policy: Medications will be administered in accordance with the established policies and procedures.Procedure: 1. Drugs must be administered in accordance with the written orders of the attending physician.Facility's document titled Job Description documents in part, Title: Staff Nurse (Registered Nurse/License Practical Nurse).I. Job Summary: Responsible to provide direct nursing care to the customer, and to supervise the day-to-day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current Federal, State and local standards, guidelines and regulations, facility policies. The objective is to ensure the highest degree of quality care is maintained at all times. IV. Essential Functions: C. Assume all Nursing procedures and protocols are followed in accordance with established policies. X. Prepare and administer medications and treatments if appropriate as ordered by the physician. Y. Review medication record for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop orders policies.

Based on observations, interviews, and record reviews the facility failed to ensure the nasal cannula was contained when not in use by the resident. This failure has the potential to affect 2 residents (R98 and R11) reviewed for respiratory care out of a total sample of 58 residents. Findings include: R11's admission records and face sheet showed R11 was admitted to the facility on [DATE]. R11's Diagnosis included but not limited to Hypertensive Heart Disease with Heart Failure, Encounter for Palliative Care; Cardiomyopathy, Atrial Fibrillation; Hypothyroidism; Hyperlipidemia; Unspecified Dementia; Anemia; Age-related physical debility; Long term use of anticoagulants; Dependence on supplemental oxygen and Peripheral Vascular Disease. R11's Minimal Data Sheet (MDS) in section C for Cognitive Patterns showed Brief Interview for Mental Status (BIMS) score of 3, which shows severe cognitive impairment. R11' care plan (5/13/2020) documents in part that R11 requires oxygen therapy related to congestive heart failure (CHF), to administer oxygen per doctor orders and for staff to assist R11 with putting oxygen on. R11's physician order summary (12/3/2025) showed active orders as of 9/2/2025 for Oxygen per nasal cannula at 2 liters per minute continuous every shift. On 12/1/2025 at 12:07 PM, observed oxygen nasal cannula, laying on top of R11's bed R11's room. Nasal cannula and tubing were on top of the sheets and not contained in a plastic bag. Enhanced Barrier Precautions (EBP) sign was observed on R11's. R11 was not in the room, R11 was in the dining room eating lunch. Observed in R11's room, oxygen machine turned on and connected to the tubing that was laying on the top of R11's and not contained. On 12/1/2025 at 12:22 PM, observed R11 in the dining room, siting in the wheelchair with no oxygen on. R11 was dressed well and groomed well, eating lunch. R11 stated, that R11 is doing good and has no concerns for the care. On 12/1/2025 at 12:35 PM, observed R11's room with EBP sign on the door and R11's nasal cannula and tubing still laying on R11's bed and not contained. On 12/1/2025 at 12:35 PM, V16 (Registered Nurse/ RN), stated that the oxygen tubing and nasal cannula should be always contained in the plastic bag and changed weekly. V16 stated that facility provided in-service education on oxygen equipment, hand hygiene and EBP during orientation, and provides various in-service trainings throughout the year. On 12/1/2025 at 12:40 PM, surveyor together with V16 (RN) in R11's room, V16 looked at the bed and confirmed that R11's oxygen tubing and nasal cannula are laying on the bed and are not contained. V16, once again, stated that the tubing and nasal cannula, when resident is not using, should be always contained in the plastic bag. On 12/1/2025 at 12:47 PM, V16 (RN) stated that, V16 made a mistake, was nervous and that V16 should not place the uncontained tubing and cannula on R11. On 12/2/2025 at 10:11 AM, V22 (Unit manager/CNA) stated, that when nasal cannula is not in use, it should be contained and stored in a plastic bag to prevent the spread of infection. V22 said, that the nurses and the CNA's should be checking and making sure that the oxygen equipment is stored safely and in a matter that would prevent the spread of infections. On 2/3/2025 at 10:50 AM, V1 (Administrator) stated the expectation is that when oxygen tubing and nasal cannula is not in use, the equipment should be contained in a plastic bag and labeled and dated. V1 also said, that the residents do remove the nasal cannula, but during rounding, the staff should address it and replace tubing with new one and contain the new nasal cannula and tubing in a plastic bag. The nasal cannula should not be touched with bare hands, in the EBP room, ideally, the staff should wear gowns and gloves. On 12/3/2025 at 2:25 PM, V2 (Director of Nursing/ DON) stated that if equipment or other resident's items fall on the floor it is considered dirty and should not be placed on a resident or back with clean items, because it would cause contamination. V2 also stated that oxygen tubing or nasal cannula should be contained in a plastic bag when not in use. V2 said, that if the oxygen cannula is found uncontained, then it should be replaced with new one and placed in a plastic bag, labeled, and dated. On 12/01/2025 at 10:59am observed R98's nasal cannula sitting on R98's bed, not in use by R98, the nasal cannula was not contained in a bag. Nasal cannula was attached to tubing which was attached to an oxygen concentrator machine. On 12/01/2025 at 11:05am observed R98 sitting in the second-floor dining room, without oxygen tank or nasal cannula in nares. On 12/01/2025 at 11:07am V3 (LPN /Licensed Practical Nurse) accompanied surveyor into R98's room and surveyor pointed out to V3 the nasal cannula on top of R98's bedsheets. V3 stated the nasal cannula should be stored in a plastic bag when not in use by the resident. The nasal cannula is stored in the bag so that the nasal cannula does not get dirty. On 12/03/2025 at 12:16pm V36(ADON/Assistant Director of Nursing) stated for residents utilizing nasal cannulas, the nasal cannula should be stored in a plastic bag. The nasal cannula is stored in a plastic bag when not in use by the resident for infection control reasons. On 12/03/2025 at 2:47pm V2(DON/Director of Nursing) stated the nasal cannula should be placed in a storage bag when not in use by the resident, if the nasal cannula is found not contained when not in use by the resident, the nasal cannula should be replaced for the resident. This is done for cleanliness. R98's diagnosis includes but are not limited to, chronic obstructive pulmonary disease, unspecified, chronic respiratory failure with hypoxia, other emphysema, other nonspecific abnormal finding of lung field, other pulmonary embolism without acute cor pulmonale, and dependence on supplemental oxygen. R98's Physician Order Sheet (POS) with active orders as of 12/03/2025 documents in part, Respiratory: Oxygen per nasal cannula @(at) 2 liters per minute continuous every shift. R98's Brief Interview for Mental Status (BIMS) dated 10/17/2025 documents R98 has a BIMS score of 14, which indicates R98's cognition is intact. Facility's policy titled Respiratory Equipment Change Procedure (11/2025) showed in part, that all respiratory equipment will be changed by nursing to prevent nosocomial infections and that nasal cannula and oxygen tubing should be changed every month and as needed. Facility's policy titled Oxygen Therapy Devices-Nasal Cannula (9/2020) showed in part, that oxygen delivered per nasal cannula should be used to prevent or reverse hypoxia and improve tissue oxygenation and that nasal cannula should be placed in resident's nostrils and changed monthly and as needed. Facility's document titled Inservice/Meeting Attendance Record (October 2025) showed in part, on the first page, respiratory equipment topic presented by V2 (DON). Document showed in part that respiratory equipment should be stored in a storage bag when not in use and that the equipment includes nasal cannula, and oxygen masks (nebulizer, BIPAP and CPAP) Document also showed in part that staff should complete hand hygiene before and after handling respiratory equipment. Document showed 66 employees' attendance with signatures, including nurses and nursing assistants. Facility's document titled Inservice/Meeting Attendance Record (12/1/2025-12/2/2025) showed on the first page, nasal cannula topic presented by V2 (DON). Document showed in part that when resident removes nasal cannula and does not place it in the bag, staff should replace the cannula with a new one and date it. Document also showed in part, that the nasal cannula should be placed in the storage bag when not in use and that the staff should perform hand hygiene prior to and after applying nasal cannula on the resident. Document is signed by 52 members of nursing staff including nurses and nursing assistants. Facility's Job Description document titled Staff nurse (Registered Nurse/License Practical Nurse) (1/2015), showed in part, in job summary section, that to ensure the highest degree of quality care is always maintained, the staff nurse is responsible to provide direct nursing care to the customer, and to supervise the day-to-day nursing activities performed by the nursing assistants. Document also showed in part, that one of essential functions is to assume all nursing procedures and protocols are followed in accordance with established policies. Facility's Job Description document titled Director of Nursing (1/2015), showed in part, in job summary section, hat the director of nursing (DON) is responsible to plan, organize, develop, direct and delegate the overall operation of the Nursing Department in accordance with current federal, state, and local standards, guidelines and regulations, and facility policies to ensure the highest degree of quality care is always maintained. The document showed in part, in the essential functions section C, that Director of Nursing should assure all nursing procedures and protocols are followed in accordance with established policies. The document also showed in the essential functions section P, that DON should make daily rounds to ensure nursing personnel are performing required duties and to ensure that appropriate procedures are being followed.

Based on interview and record review, the facility failed to ensure a resident's representative was notified of an allegation of abuse. This failure affected 1 (R2) resident reviewed for notification of representative in the total sample of 10 residents. Findings include: On 07/05/2025 at 11:02am, V2 (Director Of Nursing) stated it was reported to her on 06/206/2025 by (V7- CNA/Certified Nursing Assistant) that (V3 LPN/Licensed Practical Nurse) told (R2) show me your n***r strength. (V2) pulled (V3) to investigate. (V3) stated he was just repeating the story about (R2) spilling the water and (V3) gave (R2) a paper towel and refused to give back the paper towel to him, she was resisting, and he said to her, Wow, you are so strong. and she (R2) said to him I am N***r Strong. He (V3) was repeating the story to the staff on 6/26/25. V2 stated that she told (V3) I understand you are repeating a story but that is inappropriate language and should not be used in the building. On 07/05/2025 at 11:19am, V2 stated that she did not inform R2's POA (Power of Attorney) about the racial slur. On 07/09/2025 at 8:12am, V2 stated she did not notify R2's POA, because the allegation is not toward the resident. V2 added that she understands now, it is an allegation of verbal abuse. That it is the policy of the facility, if there is an allegation of abuse, the POA should be notified. R2's admission Record documented that R2's diagnoses (include but not limited to) dementia, age related osteoporosis, and history of falling. R2's (04/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 6. Indicating R2's mental status as severely impaired. R2's Initial reportable, dated 07/09/2025, documented, in part On 06/26/25 a staff member reported that another staff member made a racial slur towards a resident while providing care. The resident could not recall this incident. The staff member was suspended on 06/26/2025. R2's Progress Notes, dated 06/25/2025 to 07/09/2025 were reviewed with no notes for notification of R2's POA regarding allegation of verbal abuse on 06/26/2025. The Abuse Policy, dated 03/25, documented, in part Policy: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. The facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done: 7. Filing accurate and timely investigative reports. 7. Reporting. a. The administrator or designee will also inform the residents representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted.

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported to the State Agency within the mandated timeframe and failed to ensure an allegation of abuse was reported to the State Agency. These failures affected 2 (R1 and R2) residents reviewed for reporting of abuse allegations in the total sample of 10 residents. Findings include: 1. On 07/07/2025 at 2:43pm, V13 (Unit Manager) stated that on 07/01/2025 (Tuesday) she was standing by the 3rd floor's nurse's station putting the transportation form back in the binder when (R1) stated she wanted to speak with the Administration. She (R1) did not want to tell her. She just kept repeating I want to talk to somebody. V13 stated that she (R1) seemed upset and that she (V13) ended up going downstairs to talk to (V11 - Assistant Administrator). V13 stated that she told (V11) that something is going on, on the 3rd floor, she (V11) needed to talk to the resident (R1), and that she (R1) is upset. (V11) was on a call and she (V11) said she would talk to the resident. V13 stated she did not see her (V11) talk to the resident (R1). V13 stated she went back along with her day. V13 stated that she (V13) saw (V7 -CNA/Certified Nurses Assistant) who informed her (V13) that (R1) was saying that a nurse stuck up the middle finger at her (R1). V13 stated she went straight to the office and informed V11. V13 stated sticking up a middle finger is considered mental abuse. She went straight to the admin office and told (V11) that a nurse stuck up the middle finger at (R1). V13 stated that she (V11) will deal with it. On 07/07/2025 at 3:20pm, V11 (Assistant Administrator) stated she started about a month ago. Somebody reported to her that (R1) was upset. She thinks it was (V13) who told her on Tuesday probably sometime in the morning. V11 stated (V13) might have come to her twice and that she (V11) was busy with 'payroll'. V11 stated if a nurse stuck up the middle finger at (R1) it is probably mental abuse. V11 stated if there was an allegation of abuse, whether true or not, it should be investigated and it should be reported to IDPH as soon the facility has the information. At this time, this surveyor handed V11 the facility abuse policy and procedure. V11 then stated an allegation of abuse should be reported within 24 hours. If there was an allegation of mental abuse on Tuesday (07/01/2025) then it should be reported immediately within 24 hours. V11 stated the allegation of mental abuse was reported on 07/03/2025, the facility is not within the regulation of reporting the allegation of abuse. R1's admission Record documented that R1's diagnoses (include but not limited to) presence of right artificial knee joint, open angle bilateral glaucoma, and dementia. R1's (06/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R1's mental status as cognitively intact. R1's Initial reportable, dated 07/03/2025, documented, in part Resident reported that a staff member on her floor told her to shut up. Resident could not recall when this occurred. Resident could not describe staff member other than he was a male. Of note, initial reportable was submitted more than 24 hours after the facility was made aware of the allegation on 07/01/2025. 2. On 07/05/2025 at 11:02am, V2 (Director Of Nursing) stated it was reported to her on 06/26/2025 by (V7- CNA) that (V3-LPN/Licensed Practical Nurse) told (R2) show me your n***r strength. She (V2) pulled (V3) to investigate. (V3) stated he was just repeating the story about (R2) spilling the water and (V3) gave (R2) a paper towel and refused to give back the paper towel to him, she was resisting, and he said to her, Wow, you are so strong. and she (R2) said to him I am N***r Strong. He was repeating the story to the staff on 6/26/25. V2 stated that she told (V3) I understand you are repeating a story but that is inappropriate language and should not be used in the building. On 07/08/2025 at 12:52pm, V2 (Director of Nursing) stated she did the investigation and did not find anything, and she did not submit an initial reportable to the State because the racial slur was not directed to the resident. V2 added she should have reported it to the State as an allegation of verbal abuse. R2's admission Record documented that R2's diagnoses (include but not limited to) dementia, age related osteoporosis, and history of falling. R2's (04/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 6. Indicating R2's mental status as severely impaired. R2's Initial reportable, dated 07/09/2025, documented, in part On 06/26/25 a staff member reported that another staff member made a racial slur towards a resident while providing care. The resident could not recall this incident. The staff member was suspended on 06/26/2025. Of note, R2's initial reportable was sent to State Agency more than 24 hours after the allegation was made. The Abuse Policy, dated 03/25, documented, in part Policy: affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facility will report reasonable suspicion of a crime. The facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done: 7. Filing accurate and timely investigative reports. 7. Reporting. Initial reporting of allegations shall be completed immediately upon notification of that allegation. The written report shall be sent to the Department of Public Health. g. the report must be made not later than 24 hours after forming a suspicion.

Based on observations, interviews, and record reviews, the facility failed to follow manufacturer's guidelines for food storage and failed to follow their policy to ensure ready to eat food items were not refrigerated for longer than seven days. These failures have the potential to affect all 163 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 9:19 AM, V34 (Dietary Supervisor) stated items should be labeled with a delivery date, an opened or prepared date and a use by date. V34 stated prepared foods and/or ready to eat items should be used within seven days of preparation and/or when opened. V34 stated the reason food items should be labeled and dated is so the staff knows the expiration date of items and when to discard them so expired items are not served to the residents. On [DATE] at 9:38 AM, during initial kitchen tour with V34 and V35 (Company Dietary Coordinator) observed in the Walk-In Refrigerator the following items: 1.) Opened Pre-Sliced Cooked Turkey wrapped in plastic wrap dated with delivery date [DATE], opened date [DATE]. There was no use by date labeled on the product. 2.) Opened package labeled Buffet Ham wrapped in plastic wrap dated with delivery date [DATE], opened date [DATE]. There was no use by date labeled on the product. On [DATE] at 9:41 AM, V35 stated there is no use by date labeled on the items and there should be. V35 stated V35 did not know how long the products are good for once opened and will have to check. On [DATE] at 9:58 AM, observed opened 1-quart Lemon Juice labeled with delivery date [DATE]. No opened or use by date was labeled. Observed manufacturer label on Lemon Juice bottle printed, Refrigerate After Opening. V25 stated whether the Lemon Juice needs to be refrigerated is debatable but yes it should have been stored in the refrigerator based on the manufacturer's guidelines. On [DATE] at 8:48 AM, V34 stated the precooked ham/turkey found in the Walk-In Refrigerator during the initial kitchen tour should have been thrown out after seven days from the opened date as per the facility policy. Facility provided policy titled, Labeling & Dating dated ,d+[DATE] documenting in part, ready-to-eat time/temperature control for safety foods may be stored in the refrigerator held at 41 degrees F (Fahrenheit) for 7 days and the purpose is to reduce the risk of food borne illness. Facility provided document titled, Food Expiration Dates Guidelines Chart undated documents in part, fully cooked ham whole 7 days, fully cooked ham half 3 to 5 days, fully cooked ham slices 3 to 4 days. Facility provided document titled, Diet Type Report dated [DATE] listing residents with their diet orders indicating there are six residents who are receiving nothing by mouth (NPO).

Based on observations, interviews, and record reviews, the facility failed to follow their policy by not ensuring that medications are stored in original containers and labeled for one out of four medication carts reviewed for medication storage and labeling. This failure was found in the third floor's Team A medication cart and affected 24 residents. Findings include: On 10/29/2024 at 10:04 AM, V6 (Nurse) stated the facility assigned V6 to the third floor's Team A medication cart. V6 stated the cart housed medications for 24 residents. In one of the top drawers, observed three white round tablets in a clear plastic bag. The bag did not have a label to indicate what the tablets were or who they belonged to. V6 stated [V6] didn't know what medications the tablets were or who placed them in the plastic bag. V6 stated nurses should not have done that and should discard the tablets instead. During an interview with V4 (Assistant Director of Nursing) and V30 (Assistant Director of Nursing) on 10/31/2024 at 9:34 AM, V30 stated that unknown tablets should be discarded in the sharps' container. V30 stated no medication should be saved on the side. If a nurse needs a medication, they can always access the electronic dispensing system for additional medications. Facility's policies and procedures for Storage/Labeling/Packaging of Medications (dated 01/2022) documents in part: To store medications and biologicals under proper conditions of temperature, light, and security. Each resident's medications are stored in original containers and must be properly labeled. Medications are only administered from their originally dispensed containers. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from the pharmacy as applicable.

Based on observation, interview, and record review the facility failed to follow standardized pureed recipe during food preparation. This failure has the potential to affect 4 residents (R34, R71, R95, R160) receiving pureed diets prepared in the facility's kitchen based on Diet Type Report dated 10/31/24. Findings Include: On 10/29/24 at 12:30 PM, observed vegetable soup being served with lunch meal which contained pasta, fresh spinach, carrots, and celery. Residents on pureed diets received thin broth. The pureed broth was not blended with anything. V42 (Dietary Aide) stated that is the way the pureed soup usually looks (broth only). On 10/30/24 at 10:38 AM, V37 (Chef) stated when preparing soup for a meal first, the soup is made for the regular diets and then portions of the regular soup are placed in a large strainer to separate the liquid from the solids. V38 stated the strained off liquid is then used as soup for the pureed diets. V37 stated no solids from the regular soup are given to the pureed diets only the broth is given. V37 stated the soup for the pureed diets is not prepared using a blender. On 10/30/24 at 10:52 AM, observed V37 added an unmeasured but large amount of cream of mushroom soup into an industrial sized strainer. The solids from the regular soup appeared to be celery, potatoes and mushrooms were left in the strainer and the strained liquid was then placed in a container to be served at lunch to the residents on pureed diets. On 10/31/24 at 8:51 AM, V34 (Dietary Supervisor) stated the cooks should be following the recipes especially the procedure on how to prepare the item. V34 stated it is important for the cooks to follow the recipes to ensure standardization and to make sure the item being prepared has the right amount of nutritional value it is supposed to have. V34 stated based on the recipe pureed soup should be prepared using the food processor to blend the regular soup to pureed consistency. V34 stated the recipe does not call for the cooks to strain out the solids of the soup. V34 stated it is important for the cooks to blend the soup for the pureed diets to make sure they are getting all the nutrition needed from the soup. On 10/31/24 at 11:30 AM, V36 (Consultant Registered Dietitian) stated via phone interview that the menus are put together to provide adequate nutrition for the resident. V36 stated tor this reason, all items listed on the menu should be provided and the kitchen should follow the standardized recipes. V36 stated if the recipes are not followed the amount of calories, protein, and fat provided in the diet could be off which could change the nutritional quality of the diet. V36 stated residents on a pureed diet are potentially at higher nutritional risk due to chewing/swallowing problems. V36 stated residents receiving pureed diets should receive the same items as residents on regular diets except in pureed form unless contraindicated. For example, if regular diet consistencies are being served soup, then the pureed diets should also receive the same soup except in pureed form. V36 stated recipes for pureed soup should be followed and if the cooks are straining regular soup of the solids and only giving the pureed diets the strained broth then those residents are missing out on protein and carbohydrates. V36 stated pureeing the regular soup in a blender with the solids would provide more nutrition and the extra calories and protein could be helpful in providing more nutrients to the resident and potentially prevent weight loss and/or muscle loss if the resident is having decreased oral intake and/or only eating the soup. R34's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, thin liquids ordered 06/11/24. R71's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, nectar consistency ordered 07/19/24. R95's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, honey consistency ordered 06/21/24. R160's diet order per Order Summary Report dated 10/31/24 documented in part, pureed texture, honey consistency ordered 10/14/24. Summer/Fall Regular Menu 2024 documents in part, Tuesday lunch vegetable soup and Wednesday lunch cream of mushroom soup. Summer/Fall Regular Menu 2024 Spreadsheets documents in part, 10/29/24 lunch vegetable soup for regular diet and pureed vegetable soup for pureed diet. Summer/Fall Regular Menu 2024 Spreadsheets documents in part, 10/30/24 lunch cream of mushroom soup for regular diet and pureed cream of mushroom soup for pureed diet. Kitchen recipe titled Pureed Soup Vegetable documents in part, 1.) Prepare according to regular recipe. 2.) Measure desired # of servings into food processor. Blend until smooth. Add commercial thickener if product needs to be thickened. Kitchen recipe titled Pureed Soup Cream of Mushroom documents in part, 1.) Prepare according to regular recipe. 2.) Measure desired # of servings into food processor. Blend until smooth. Add commercial thickener if product needs to be thickened. Document titled Job Description for Chef/Cook undated documents in part, essential functions - prepare food in accordance with standardized recipes. Kitchen document titled, Puree dated 07/2013 document in part, this diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway.

Based on record review and interview the facility failed to follow Influenza and Pneumococcal Immunization policy related to determining, offering, and providing the vaccine for five [R93, R124, R145, R150, R158] residents reviewed in the sample of 33. Findings Include: On 10/31/24 at 9:22 AM, R145 stated, I would like my Influenza and pneumonia shot, but I was not offered. R145's minimum data set [MDS]section [C] brief interview dated 10/9/24, indicates R145 is alert, oriented and cognitively intact. R145's MDS section [O] dated 10/9/24 indicates R145 was not offered influenza vaccine, and R145 was not eligible to receive pneumococcal vaccine. R145 is a [AGE] year-old with the following medical diagnosis in part; Peripheral vascular disease, type II diabetes, essential hypertension, and long-term use of insulin. On 10/31/24 at 9:26 AM, R158 stated, I was admitted here in July. The nurse told me they did not give out the flu shots until October, but tomorrow is November, and I have not received my flu shot, I don't want to get sick, and I have heart problems. I would like the pneumonia shot as well to help me. R158's minimum data set [MDS]section [C] brief interview dated 10/14/24, indicates R158 is alert, oriented and cognitively intact. R158's MDS section [O] dated 10/14/24 indicates R158 was not offered influenza vaccine because not in season, and R158 was not offered the pneumococcal vaccine. R158 is a seventy-five-year-old with the following medical diagnosis in part; chronic atrial fibrillation, essential hypertension, adult failure to thrive, and obesity. On 10/31/24 at 9:43 AM, observed R93 sitting his recliner wheelchair. Alert and confused. R93's minimum data set [MDS]section [C] brief interview dated 9/25/24, indicates R93 is moderately cognitively impaired. MDS section [O] dated 8/23/24 indicates R93 received influenza vaccine on 11/16/23, pneumococcal vaccine was not offered dated 8/23/24. R93 is a seventy-two-year-old with the following medical diagnosis in part; cerebral infarction, atherosclerotic heart disease, essential hypertension, type II diabetes, age related debility, and long-term use of insulin. [R93 was not offered the influenza vaccine this flu season nor the pneumococcal vaccine] On 10/31/24 at 9:55 AM, R124 stated, I finally received my influenza vaccine on 10/1/24, but I been asking for my influenza since March. The pneumococcal vaccine I consented to in March, and I have not received it. R124's minimum data set [MDS]section [C] brief interview dated 8/7/24, indicates R124 is alert, oriented and cognitively intact. R124's MDS section [O] dated 8/7/24 indicates R124 was not offered influenza vaccine because not in season, and R124 was not offered the pneumococcal vaccine. R124 is a ninety-year-old with the follow medical diagnosis in part; chronic congestive heart failure, chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease stage 3, and squamous cell carcinoma of skin. On 10/31/24 V10 [Registered Nurse] stated, If a resident expresses to the floor nurse that they want the influenza or pneumococcal vaccine. I would first check with the physician or nurse practitioner to ensure it would be okay to given, then I would place in the order. Once the vaccine is received from the pharmacy, then the floor nurse would administer the vaccine, and document under the immunization tab in the resident's electronic chart. On 10/31/24 at 11:00 AM, V30 [Assistant Director of Nursing/Psychotropic Nurse/Infection Preventionist] stated, Flu season is from October first to March thirty first. All new admissions are offered the influenza and pneumococcal vaccinations. If the resident is admitted from April to September, which is not flu season then the resident is not offered the flu shot, but should be offered the pneumonia shot, and documented under the immunization tab in the resident's electronic chart. The nurse should also ask the resident if they received the pneumonia shot previously and look at their medical paperwork from the hospital to observed which pneumococcal vaccination and when it was administered. On 10/31/24 at 11:15 AM, V4 [Assistant Director of Nursing/Infection Control Preventionist] stated, I usually start asking all residents consents for the influenza, pneumococcal, and covid at the beginning of September. Then I have a head count to give the pharmacy. The pharmacy will set up dates that they will come out for a vaccination clinic. We had a vaccination clinic on 10/18/24. The next clinic will be on 11/21/24. Some residents did not want to take all vaccinations at the same time. If a resident is admitted and requests a vaccination, and is appropriate, the resident should receive the vaccination within a week. Pneumococcal vaccine has guidelines; The age is [AGE] years or older, or have chronic health problems such as alcoholism, heart disease, lung disease, leukemia, kidney disease or failure, diabetes, HIV infections, cirrhosis, sickle cell disease, lymphoma, Hodgkin's disease or organ transplants should be offered the Pneumococcal vaccine at any age. The influenza vaccine is offered from October first to March 31st, annually to all residents. I believe the admitting nurses may have indicated some of the residents was not eligible for the vaccine due to their age alone and did not investigate the qualifying medical diagnosis. I will in-service the nursing staff. On 10/31/24 at 12:10 PM, V3 [Director of Nursing] stated, All residents should be offered the influenza vaccine during flu season and administered. The staff nurses should not wait for the vaccination clinic. The staff nurse is able to order the vaccine and administer. All residents of [AGE] years or older and or any one with chronic illness should be offered the Pneumococcal vaccine, and not wait for the vaccination clinic. The vaccination is offered to give the resident an extra layer of protection. The vaccines do not prevent the infection, but it will help the resident's immune system fight the infection, and hopefully prevent hospitalization . If a resident does not receive the requested vaccine, it could potentially cause a negative outcome on a resident's health with some one that has a chronic illness. Policy documented in part: Pneumococcal vaccine [ No date] It is the policy of this facility that residents will be offered in immunizations against pneumococcal disease. Pneumococcal vaccine guidelines by the CDC; residents aged [AGE] years or older or and residents with immune compromising conditions, chronic renal failure, HIV, Hodgkin's disease, leukemia, myeloma, organ transplant, alcoholism, chronic heart disease, liver disease, lung disease, chronic renal disease, cigarette smoking, diabetes, cancer, sickle cell disease or other hemoglobin diseases. If consented or declined it will be documented in the resident's medical records. Historical information will be entered, if available. Influenza Vaccination Influenza vaccinations to be offered October 1st through March 31st annually. All new admissions will be offered the influenza vaccine during October 1st through March 31st unless ordered otherwise or has received the vaccine. If consented or decline it will be documented in the residence's medical records. 47304 R150's health record showed admitted on 4/25/2024 with diagnoses not limited to Acute and chronic respiratory failure with hypoxia, Chronic obstructive pulmonary disease, Unspecified systolic (congestive) heart failure, Hypertensive heart disease with heart failure, Dementia in other diseases classified elsewhere, Vascular dementia, Alzheimer's disease, Schizophrenia, Anxiety disorder, Type 2 diabetes mellitus, Benign prostatic hyperplasia, Insomnia, Spinal stenosis, Other pulmonary embolism without acute cor pulmonale, Dependence on supplemental oxygen, Unspecified chronic bronchitis, Other emphysema, Polyosteoarthritis. On 10/29/24 11:32 AM R150 Observed sitting on the side of the bed, alert and oriented x 3, verbally responsive. R150 said he has been residing in the facility since April, with oxygen inhalation via nasal cannula at 2L (liters)/min. He (R150) stated he wanted to receive pneumonia vaccine but was not offered and was not given. R150 order summary report dated 10/30/24 with active order not limited to: May receive pneumonia vaccine as appropriate for age and date of last dosage unless contraindicated. MDS (Minimum Data Set) dated 9/27/24 showed R150 was cognitively intact, did not receive pneumococcal vaccine and was not offered.

Based on observation, interview and record review, the facility failed to treat 1 (R17) resident with respect and dignity by standing over the resident while assisting to eat. This failure affected 1 (R17) resident reviewed for dignity during dining observation in a sample of 33. The findings include: R17's health record documented admitted on 1/26/2018 with diagnoses not limited to Multiple sclerosis, Pseudobulbar affect, Attention-deficit hyperactivity disorder, Dysphagia oropharyngeal phase, Flexion deformity right wrist, Peripheral vascular disease, Anemia, Anxiety disorder, Bipolar disorder. On 10/30/24 at 12:36 2nd floor dining observation conducted. Observed R17 sitting in wheelchair, alert with confusion. Lunch tray observed with bread, grounded meat, and green beans. Observed V26 (Certified Nursing Assistant/CNA) standing over R17 while feeding R17 in the dining room. 2 other residents (R115 and R5) were also seated at the same table with R17. On 10/30/24 at 4:03pm V3 (DON/DIRECTOR OF NURSING) stated when staff is feeding the resident, the staff should be sitting at eye level with the resident, not standing. She stated we do not want the staff standing over the resident because it is a dignity issue. V3 stated we want to make the resident feel comfortable while we are feeding them and not to make them feel as if we are rushing them through the meal. Sitting next to the resident while assisting at mealtime is more comfortable and provides dignity to the resident. R17's order summary report dated 11/1/24 showed active order not limited to: General diet Mechanical Soft texture, Thin Liquids consistency, Feeder. MDS (Minimum Data Set) dated 9/16/24 showed R17 was cognitively impaired, rarely or never understood. She needed total assistance or dependent to staff with eating. Facility's policy for Feeding a resident dated 9/2020 documented in part: Tell the resident that you are going to be seated during the feeding, staff to position a chair where it will be convenient for both them and the resident.

Based on observations, interviews, and record reviews, the facility failed to follow standards of practice during medication administration for one (R63) out of three residents reviewed during medication administration observations. Findings include: R63's Admission Record documents in part medical diagnoses of Alzheimer's disease; dementia; muscle wasting and atrophy; weakness; age-related physical debility; and adult failure to thrive. R63's Order Summary Report documents in part orders for Aspirin, Ferrous Sulfate, Jardiance, and Sertraline. It also documents in part that staff may crush medications if manufacturer allows or give liquids if R63 is unable to take intact dosage form. On 10/30/2024 at 9:59 AM, Observed V10 (Nurse) prepare R63's morning medications which included one tablet of Aspirin 81 mg (milligram), one tablet of Ferrous Sulfate 325 mg, one tablet of Jardiance 10 mg, and one tablet of Sertraline Hydrochloride 50 mg. At 10:04 AM, V10 placed all four tablets in a clear, plastic packet and crushed them using a pill crusher. V10 poured the crushed contents into a medicine cup and mixed it with apple sauce. V10 administered the mixture to R63 at 10:09 AM. On 10/30/2024 at 2:30 PM, V29 (Pharmacist) stated nurses must crush each medication individually and administer each medication one at a time with the liquid or food they're mixing it with. Facility's Medication Administration: General Guidelines (dated 01/2022) documents in part: To ensure that medications are administered safely as prescribed. Facility's Crushing of Medications policy (dated 06/2022) does not include guidelines or procedures for when administering multiple crushed medications. An article from the American Association of Post-Acute Care Nursing (dated 2/12/2019) documents in part: A best practice for administering crushed medication is to crush and administer each medication separately. Crushing and combining medication may result in physical and chemical incompatibilities, leading to an altered therapeutic response.

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a timely manner for 1 (R66) resident who is dependent in toileting reviewed for activities of daily living (ADL) in a total sample of 33. The findings include: R66's health record documented initial admitted on 4/1/2024 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart and chronic kidney disease with heart failure, Type 2 diabetes mellitus, Unspecified atrial fibrillation, Heart failure, Atherosclerotic heart disease of native coronary artery, Hyperlipidemia, Major depressive disorder, Insomnia, Post-traumatic stress disorder, Unspecified asthma, Other sequelae of cerebral infarction, Chronic kidney disease, Gastro-esophageal reflux disease, Gout, Dependence on supplemental oxygen, Anemia. On 10/29/24 at 11:14 AM R66 was observed lying in bed on moderate high back rest with oxygen inhalation via nasal cannula at 2L(liters)/min. Alert and oriented x 3, verbally responsive. R66 said she is using an incontinence brief and is incontinent of bowel and bladder. R66 stated at times she is not changed for almost 6 hours, lying on soiled brief. R66 stated she needed to pee at least 4-6x in her incontinence brief then she will be changed by staff. She stated she was last changed about an hour ago. At 2:44pm R66 was observed lying in bed on moderate high back rest, alert and oriented x 3, verbally responsive. R66 stated she was last checked and provided incontinence care an hour or so after breakfast. She stated she is wet and needed to be changed. At 2:46pm V11 (Licensed Practical Nurse/LPN) stated he (V11) has been working in the facility for 2 years and regularly assigned on the 2nd floor. V11 stated he is working with R66, incontinent of bowel and bladder. V11 stated rounding is done at least every 2 hours and as needed including incontinence care. V11 stated assigned CNA/Certified Nursing Assistant (V12) was sent home and R66 is assigned to V13 (CNA). Surveyor requested assigned CNA in R66's room. At 2:49pm V13 (CNA) and V14 (CNA) came to R66's room. Incontinence care observation conducted, R66 incontinence brief was soiled. Buttocks observed reddened and excoriated, V13 applied moisture barrier cream. Incontinence care was completed. At 2:55pm V14 (CNA) said she was with V12 when incontinence care was provided to R66 between 10-11am. She said rounding should be done at least every 2 hours including checking for incontinence episode and providing incontinence care. She said incontinence care should be done timely to prevent sore/breakdown. She said earlier during incontinence care between 10-11am, R66 buttocks was observed raw/reddened. V14 stated, R66 claimed that during night shift, it takes a little longer for her to be changed so it itches at times and she (R66) is scratching her bottom. On 10/30/24 at 4:03pm Interview with V3 (DON/DIRECTOR OF NURSING) stated rounding should be done by staff at least every 2 hours and as needed. Staff should be asking residents if they need to be changed and provide care, check if the resident is okay, and attend to their needs. If Incontinence care is not done in a timely manner the resident could develop a possible skin condition such as rash or redness. MDS (Minimum Data Set) dated 9/25/24 showed R66 was cognitively intact. She needed substantial/maximal assistance with toileting hygiene. MDS showed R66 was frequently incontinent of bowel and bladder. Care plan dated 4/2/24 documented in part: R66 displays functional incontinence due to weakness. Will show no complications secondary to incontinence. Skin will remain intact. Provide assistance with toileting. Facility's policy for perineal care dated 9/2020 documented in part: To cleanse the perineum. To maintain skin integrity.

Based on observation, interview and record review the facility failed to follow plan of care and apply splint to both hands as prescribed by doctor for 1 (R136) resident reviewed for limited range of motion in a sample of 33. The findings include: R136's health record showed initial admitted on 7/21/2023 with diagnoses not limited to Permanent atrial fibrillation, Encounter for attention to gastrostomy, Hypertensive heart disease with heart failure, Chronic systolic (congestive) heart failure, Anemia in chronic kidney disease, Rheumatoid arthritis, Pressure ulcer of sacral region stage 4, Pressure ulcer of right upper back stage 4, Hypothyroidism, Adult failure to thrive, Anxiety disorder, Dependence on supplemental oxygen, Chronic embolism and thrombosis of other specified veins, Gastro-esophageal reflux disease, Adjustment disorder with mixed anxiety and depressed mood. On 10/29/24 12:04pm R136 Observed lying in bed, alert and oriented x 4, and verbally responsive. R136's hands were both contracted, with no splint or device in place. R136 stated she has crippled rheumatoid arthritis. She stated staff is putting a splint on both hands x 2 hours each hand. R136's POS (Physician order sheet) showed: Splint to: right resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl care and skin checks. Splint to: left resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl care and skin checks. Between 1:30pm to 3pm R136 lying in bed, no device or splint observed on either hand. She said hand splint is applied between 7am - 9am on 1 hand then removed after 2 hours and applied to another hand between 9 - 11am, removed after 2 hours. She said in the afternoon it is applied between 1pm to 3pm. On 10/30/24 between 10am to 12noon R136 Observed lying in bed, alert and oriented x 4, verbally responsive with contractures on both hands. No splint or device observed on either right or left hand. She said splint is applied 2 hours in the morning and 2 hours in the afternoon on each hand. On 10/31/24 at 10:05am interview with V3 (Director of Nursing / DON) said has been working in the facility for over 6years, transitioned as DON for over 2 years. Stated she oversight Restorative currently, 2 new restorative nurses are still on orientation. Stated the purpose of splint is to assist resident with prevention of further contractures or maintain current mobility. Splint could be put in 2 hours on or 4 hours off every day, could be twice a day. There should be a doctor's order and should be care planned. If splint is not provided or applied could sustain further contracture. V3 stated R136 has contractures to both hands. Reviewed electronic health record (EHR) with V3 and stated R136 has active order of resting hand splint to be applied twice a day. Apply 2 hours in am and 2 hours in pm. Restorative aid and nurses applying the device. Should be documented in the task or R136's record that splint was applied. Nursing standards of practice if not documented it was not done or provided. Refusal of splint application should also be documented. Reviewed R136's task record for splint application showed splint were not documented as applied twice daily as ordered on 10/5/24, 10/9/24, 10/14/24, 10/17/24, 10/20/24, 10/26/24, 10/29/24. R136's order summary report dated 10/31/24 showed active order not limited to splint to: right resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl care and skin checks. Splint to: left resting hand - apply 2 hrs in am, 2 hrs in pm. May remove during adl (activities of daily living) care and skin checks. Care plan dated 4/1/24 showed in part: SPLINT RESTORATIVE PROGRAM: R136 requires a splint secondary to Rheumatoid Arthritis. R136 to wear left and right resting hand splint 2 hours in the morning and 2 hours in the afternoon with assistance of CNA/Nurse. Apply splint/brace per MD order to affected area. MDS (Minimum Data Set) dated 10/8/24 showed R136 was cognitively intact. She needed total assistance or dependent with staff with oral, toileting and personal hygiene, upper and lower body dressing. MDS showed restorative nursing programs - splint or brace assistance. Facility's policy for splint or brace assistance dated 3/10/22 documented in part: Splint or brace assistance refers to a scheduled program of applying and removing a splint or brace These sessions are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record.

Based on observations, interviews, and record reviews, the facility failed to have a spare tracheostomy (trach) tube at bedside for R14 for one of two residents reviewed for tracheostomies. Findings include: R14's Admission Record documents in part medical diagnoses of chronic respiratory failure with hypoxia and encounter for attention to tracheostomy. R14's Order Summary Report documents in part the type and brand of trach tube for R14. Trach size of 7.5 mm (millimeter). It also documents in part an order for Trach Care: In case of emergency, trained nurse may reinsert outer cannula of tracheostomy as needed (active 07/01/2024). On 10/29/2024 at 12:05 PM, R14 was alert and oriented to person, place, and time. During interview, R14 did not know the type of trach [R14] had or the size of the trach tube. R14 gave permission for surveyors to search tracheostomy care supplies at bedside. Surveyors did not find a spare trach tube. At 12:16 PM, V6 (Nurse) entered the room. V6 stated V6 regularly cared for R14 but could not recall the type or size of R14's trach tube. Surveyor inquired about a spare trach tube for R14. V6 searched R14's room, and stated there wasn't a spare trach tube for R14 at bedside. At 12:17 PM, V6 searched the supply room by the nurses' station but there were no extra trach tubes. At 12:18 PM, V6 went into the unit's medication room. V6 found a box of 6.5 mm inner cannulas but no spare outer trach tube for R14. On 10/30/2024 at 10:15 AM, V3 (Director of Nursing) stated the facility did not have a policy on respiratory services specifically related to tracheostomies. However, V3 stated the facility does have a respiratory therapist (V7) that assists with care for residents with tracheostomies on a regular and as needed basis. During a telephone interview on 10/30/2024 at 10:54 AM with V7 (Respiratory Therapist), V7 stated there should be a spare trach at R14's bedside in case it comes out. V7 stated the facility should have one that is the same size or smaller if the resident's trach is difficult to put back in. V7 stated that a spare trach at bedside is required for all tracheostomy residents, and it should be care planned as part of the interventions. R14's comprehensive care plan contains focus of R14's potential for complications secondary to tracheostomy. It documents in part that [R14] has been noted to take out [R14's] trach at times despite education and redirection (initiated 6/10/2024). Interventions do not include to keep a spare tracheostomy tube at bedside in case of emergency. Facility's clinical practice guidelines for Comprehensive Care Plans (dated 11/2017) documents in part: An individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet Resident's physical, psychosocial and functional needs, is developed and implemented for each Resident. Care plan interventions are initiated based on an analysis of information collected throughout the comprehensive assessment process. Facility's clinical practice guidelines for Tracheostomy Care (dated 09/2020) did not contain interventions to keep a spare tracheostomy tube at bedside in case of emergency.

Based on observation, interview and record review, the facility failed to recognize and offer pain medication to resident experiencing pain and failed to update or revise comprehensive care plan to reflect resident's pain status, goals and preferences. These failures affected 1 (R35) resident reviewed for pain management in a sample of 33. The findings include: R35's health record showed initial admitted on 5/26/2021 with diagnoses not limited to Chronic obstructive pulmonary disease, Hypertensive heart and chronic kidney disease with heart failure, Heart failure, Cervicalgia, Non-pressure chronic ulcer of left calf with fat layer exposed, Type 2 diabetes mellitus with diabetic polyneuropathy, Schizoaffective disorder, Gastro-esophageal reflux disease, Chronic venous hypertension (idiopathic) with ulcer of unspecified lower extremity, Other specified peripheral vascular diseases, Anxiety disorder, Hypothyroidism, Hyperlipidemia, Other specified arthritis, Anemia, Dependence on supplemental oxygen, Chronic kidney disease, Chronic respiratory failure. On 10/29/24 At 11:36AM R35 was observed lying in bed on moderate high back rest, alert and oriented x 3, verbally responsive. R35 stated she has been residing in the facility for 3 years. R35 stated she has constant neck and shoulder pain. R35 stated she was unable to turn neck on her left side and requested surveyor to stay on right side. She said she has been getting Tylenol #3 with some relief and she is also on scheduled pain medication. On 10/30/24 at 12:30PM R35 observed lying in bed on moderate high back rest, alert and oriented x 3, verbally responsive. R35 claimed she has constant neck and shoulder pain, and as needed pain medication was not given yet. Observed R35 with stiff neck unable to turn to left side. V11 (Licensed Practical Nurse/LPN) said he is working with R35. Reviewed R35's EMAR (Electronic Medication Administration Record) and stated Prn (as needed) Tylenol #3 was last given yesterday 10/29/24 and 2pm. Surveyor informed V11 that R35 needed pain medication due to neck pain. On 10/31/24 at 10:17am Interview with V3 (DON/DIRECTOR OF NURSING) said nurses are expected to assess pain every shift and as needed. V3 stated scheduled pain medication should be given as ordered or offer PRN pain medication. V3 stated nurses should also provide Nonpharmacological interventions. V3 stated nurses should asess and evaluate pain level, acknowledge pain, and inform MD accordingly if pain is not managed. V3 stated resident will be uncomfortable and in pain, if PRN pain medication is not given or offered. Reviewed electronic health record with V3 noted R35's care plan documented potential for pain. V3 said R35's care plan should reflect the pain status of the resident. R35's October MAR (Medication Administration Record) showed pain evaluation recorded pain level from 1-5/10 almost every day. MAR showed order of Acetaminophen-codeine oral tablet 300-30mg (milligrams) give 1 tablet by mouth every 8 hours as needed for pain management, documented that it was given on 10/29/24 at 2:14pm and on 10/30/24 at 12:40pm after surveyor alerted V11 due to R35 complaint of neck pain. R35's care plan dated 9/13/21 documented in part: (R35) has the potential for pain related to cervicalgia, diabetic neuropathy, arthritis. Administer pain strategies according to MAR. Monitor for nonverbal indicators of pain daily with care tasks and activities. MDS (Minimum Data Set) dated 10/7/24 showed R35 was cognitively intact. MDS showed numeric pain rating scale of 4/10. Facility's pain management evaluation policy dated 9/2020 documented in part: Facilitate resident independence, promote resident comfort and preserve resident dignity. During pain evaluation, determine the most workable pain rating scale for the resident. The following scales are available: 1-3 (mild), 4-6 (moderate), 7-10 (severe). Pain will be evaluated every shift.

Based on observations, interviews, and record reviews, the facility failed to account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion. This failure affected two residents (R2, R115) during narcotic reconciliation for one out of four medication carts. Findings include: R2's Admission Record documents in part a medical diagnosis of chronic pain syndrome and osteoarthritis. R2's Order Summary Report documents in part an order for Tramadol HCl (Hydrochloride) 50 mg (milligram) one tablet by mouth every eight hours as needed for pain. R115's Admission Record documents in part a medical diagnosis of polyosteoarthritis, adjustment disorder with anxiety, and encounter for palliative care. R115's Order Summary Report documents in part an order for Lorazepam 1 mg one tablet by mouth every two hours as needed for anxiety and restlessness. It also contains an order for Oxycodone HCl 5 mg one tablet by mouth every four hours as needed for pain management. On 10/29/2024 at 10:20 AM, surveyor reviewed the Team Two medication cart with V9 (Nurse). In the narcotics bin, there was a blister packet for R2's Tramadol HCl 50 mg. There were ten tablets in the blister packet. The number ten slot was compromised and had a piece of transparent tape over the back. V9 was not sure if the white, round tablet in the number ten slot was Tramadol. V9 stated the nurse who broke the seal should have thrown out the tablet in the sharps and had it witnessed by another nurse. In the same narcotic bin, there was a blister packet for R115's Oxycodone HCl 5 mg. There were four remaining tablets. R115's Controlled Drug Record corresponding to the Oxycodone blister packet documents in part that there should be three remaining tablets. In addition to R115's Oxycodone, there was a medication bottle for R115's Lorazepam 1 mg. There were two tablets left in the bottle. R115's Controlled Drug Record corresponding to the Lorazepam documents in part that there should be three tablets left in the bottle. V9 stated administering a Lorazepam dose to R115 earlier that morning and must have signed in the wrong Controlled Drug Record. During an interview with V4 (Assistant Director of Nursing) and V30 (Assistant Director of Nursing) on 10/31/2024 at 9:34 AM, both stated if a resident refuses a controlled substance, the nurse should discard the medication in the sharps or flush it with two nurses present. Nurses should recount the controlled substances and make sure the drug records are correct. V4 and V30 stated nurses should not attempt to return controlled medications once their original seal or packaging is broken. Facility's policies and procedures for Storage/Labeling/Packaging of Medications (dated 01/2022) documents in part: To store medications and biologicals under proper conditions of temperature, light, and security. Each resident's medications are stored in original containers and must be properly labeled. Medications are only administered from their originally dispensed containers. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from the pharmacy as applicable. Facility's policies and procedures for Disposal/Destruction of Discontinued Controlled Drugs (dated 09/2022) documents in part: Purpose: To provide for the disposal/destruction of any discontinued controlled substances in a safe and controlled manger in accordance with the regulations set forth by the Drug Enforcement Agency (DEA). Disposal of controlled drugs will be conducted within the facility. This may be done by two licensed healthcare professionals. Under no circumstances should controlled substances be returned to the pharmacy.

Based on interview and record review the facility failed to follow their policy to complete AIMS (Abnormal Involuntary Movement Scale) Assessment in a timely manner. These failures could potentially affect one (R26) of seven residents reviewed for Unnecessary Psychotic Medication Use in a sample of 33. The findings include: R26's electronic health record (EHR) documented admitted [DATE] with diagnosis includes but not limited to Unspecified Dementia, Unspecified Psychosis, Unspecified Mood Affective Disorder, Dysphagia, Atherosclerotic Heart Disease. R26's MDS (Minimum Data Set) from 10/22/24 documents in part, R26 is taking high risk drug class antipsychotic on a routine basis and on 08/19/24 GDR (Gradual Dose Reduction) has been documented by a physician as clinically contraindicated. R26's Order Summary Report dated 10/31/24 documents in part, Olanzapine 7.5 mg (milligram) give 0.5 tablet by mouth two times a day related to Unspecified Psychosis with start date of 06/26/23. Review of R26's EHR discontinued orders shows order for Olanzapine 7.5 give 0.5 mg tablet by mouth two times a day started initially upon admission on 04/12/22. R26's Consent for Psychotropic Medication in R26's EHR documents in part for Olanzapine 7.5 mg give 0.5 tablet by mouth two times a day dated 04/12/22. R26's care plan initiated 04/11/22 documents in part, R26 is receiving antipsychotic medication Olanzapine noted to have diagnosis of Unspecified Psychosis and interventions include but not limited to AIMS per protocol for anti-psychotic use, monitor for signs and symptoms of side effects. On 05/31/24, V30 (Assistant Director of Nursing/Psychotropic Nurse/Infection Preventionist) provided copy of R26's Nursing: Abnormal Involuntary Movement Scale (AIMS) Assessment started 04/11/22 but not signed to complete it and R26's Nursing: AIMS Assessment completed 11/23/22. On 10/31/24, reviewed in R26's EHR Consultant Pharmacist's Medication Record Regimen Review dated 10/23/24, 09/23/24, 08/05/24, 07/17/24, 06/20/24, 05/08/24, 04/09/24 with no recommendations. On 10/31/24 at 10:15 AM, V30 stated AIMS Assessments are completed upon admission, and then quarterly/annual/significant change/readmission for residents receiving antipsychotic medications. V30 stated the purpose of the AIMS Assessment is to see if the resident is having any potential side effects from the psychotropics medications including involuntary movements such as tremors, gait change, abnormal facial/oral movements. V30 stated it is important for the AIMS Assessment to be done for safety because if the medication is causing side effects the facility would want to notify the doctor. V30 stated the potential problem if the AIMS Assessment is not done is that no one would see if there were any changes in side effects potentially caused by the psychotropic medication which would be a safety concern. V30 stated the doctor would need to be informed of any changes so they could evaluate if the medication dose needed to be lowered or changed. V30 stated the AIMS Assessments are filed under Assessments in the resident's EHR and if the AIMS Assessment is not in the resident's EHR then they were not done. V30 stated they do not do paper AIMS Assessments. V30 reviewed R26's EHR and AIMS Assessment completed 11/23/22. V30 stated V30 did not know why that was the last AIMS completed for R26 and that an AIMS Assessment should have been completed as part of the last quarterly MDS which was on 10/22/24. Facility provided policy titled Psychotropic Medications - Use of dated 09/2020 which documents in part ongoing monitoring for side effects of all psychotropic medications will be completed and a baseline AIMS assessment, will be initiated when receiving antipsychotic medications. A re-assessment will be completed every six months.

Based on interviews, observations and records reviews, the facility failed to follow a resident's (R1) fall care plan intervention with multiple history of falls to ensure non-skid footwear was applied for 1 (R1) out of 3 residents reviewed for accidents and hazards. This failure resulted in R1 having an incident on 2/5/24. R1 was found on the bathroom floor, sustained a left elbow skin tear, and a laceration on the left forehead that was repaired with stitches in the acute hospital. Findings Include: R1's clinical records show an initial admitted [DATE] with listed diagnoses not limited to Chronic Obstructive Pulmonary Disease, Depression, Dementia with Mood Disturbance, Syncope and Collapse, and Primary Insomnia. R1's physician order sheet (POS) shows R1 is on antidepressant medication (Mirtazapine 7.5 mg) given at bedtime. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively impaired with cognition and is dependent with staff on toileting and requires substantial/maximal assistance for putting on/taking off footwear. R1's Post Occurrence Documentation dated 2/5/24 at 8:25 PM documented by V6 (Licensed Practical Nurse) reads in part: At approx 2025, NOD [Nurse on Duty] heard sound coming from room, call light was not initiated. [R1] observed alert and awake laying on bathroom floor, no footwear noted at time of incident. [R1] was observed sleeping in bed peacefully 10 mins prior to fall. [R1] is A&O x2 with poor safety awareness confused per baseline, able to make needs known. Neuro, LOC [Level of Consciousness], ROM [Range of Motion] and head to toe assessment done. Noted 2.5x2.0 abrasion to LT [Left] forehead/temple and skin tear to LT [Left] elbow. LT [Left] hard cast noted intact, neuromuscular assessment of the left hand done. Verbalized c/o [complains of] pain to head and LT [Left] arm. Assisted with transferring to the chair by two staff and continued to monitor. [R1] is on scheduled Eliquis daily. NP [Nurse Practitioner] order to send out to ER [emergency room ] noted and carried out. Ar approx 1835 [R1] transported to [Acute Hospital] ER via 911. DON [Director of Nursing], ADON [Assistant Director of Nursing], Nurse managers made aware. R1's progress notes dated 1/2/24 at 2:30 AM documents that at approximately 2:10 AM, R1 was noted lying n R1's right side on the floor at the end of the footboard because R1 was trying to get to R1's chair. R1's progress notes dated 2/1/24 at 6:59 PM documents that at approximately 6:25 PM, R1 was observed lying in the bathroom floor with head against the wall and wearing no footwear. R1's hospital records printed on 2/6/24 shows that R1's diagnoses were initial encounter for fall, initial encounter for injury of head, and initial encounter for laceration of scalp status post laceration repair. R1's progress notes dated 2/6/24 at 8:30 AM documented by V6 shows R1 came back in the facility from the acute hospital at approximately 3:00 AM with stitches on R1's left lateral forehead and wound dressing on R1's left elbow skin tear. R1's fall risk assessment dated [DATE] shows R1 is high risk for fall. This fall risk assessment also shows R1 has unsteady gait, has impaired memory, had 3 or more falls in the past 3 months, and on drugs that affect the thought process. R1's fall care plan initiated on 11/15/23 shows R1 is high risk for falls due to poor cognition, poor safety awareness, weakness, activity intolerance, poor endurance, impaired balance, unsteadiness on feet, lack of coordination, pain, and incontinence with one fall intervention initiated on 2/1/24 that reads: Use proper fitting, non-skid footwear. R1's progress notes on 2/5/24 does not document R1 refused to wear non-skid socks. On 3/17/24 at 8:49 AM, R1 was noted alert and verbally responsive with some forgetfulness and confusion. When Surveyor asked R1 about the incident on 2/5/24, R1 stated, The fall happened years ago. I got off from the toilet I slipped and fell over. On 3/17/24 at 10:18 AM, V5 (Restorative Nurse/Fall Coordinator) stated that fall interventions in the resident's care plan are implemented based on the root cause of the resident's previous falls and based on the needs of the resident. V5 stated that R1 had multiple falls on 1/2/24, 2/1/24, and 2/5/24. V5 stated that R1 is confused, tries to get up on his own without calling for help at times, and is high risk for falls. V5 stated that based on R1's fall that happened on 2/1/24, one fall intervention that was added in the care plan is for R1 to use proper fitting non-skid footwear. V5 stated that a non-skid footwear could be a non-skid socks or non-skid shoes. V5 stated that R1 is confused and has very unsteady gait. V5 stated that V5 expects the staff to apply R1's non-skid socks and R1 needs to wear the non-skid socks at all times even when sleeping just in case R1 tries to get up on his own and needs to go to the bathroom in the middle of the night. V5 stated that according to the progress notes, when R1 fell on [DATE] and 2/5/24, R1 was not wearing proper footwear. On 3/17/24 at 11:08 AM, V8 (Registered Nurse) stated that R1 is confused and needs one person assist with activities of daily living (ADL). V8 stated that R1 needs assistance to go to the toilet and that R1 forgets to use the call light to call for help when needed. V8 stated that R1 is high risk for falls. On 3/17/24 at 11:23 AM, a phone interview conducted with V9 (Certified Nursing Assistant). V9 stated that on 2/5/24 at around 7:00 PM, V9 put R1 to bed and after 10 minutes, V6 (Licensed Practical Nurse) told V9 that R1 was on the floor. V9 stated that when V9 put R1 in bed, V9 did not put R1's non-skid socks on. V9 stated that R1 did not refuse to wear it, but V9 just did not put it on because V9 thought R1 was going to sleep. V9 stated, I thought [R1] was going to sleep. I put [R1] to bed and I put [R1's] blanket on. V9 stated that V9 does not know why R1 got up. V9 stated that R1 is confused. V9 stated that when V9 and V6 went back to R1's room, R1 was lying down on the floor on R1's left side in the bathroom. V9 stated that R1 said R1 hit R1's head and V9 saw blood around R1's head. V9 stated that R1 could not state what happen. V9 stated that R1 would get up without calling for help. V9 stated that R1 side rails were not up. On 3/17/24 at 12:06 PM, V10 (Resident Care Coordinator) stated that care plans should be individualized. V10 stated that the purpose of the fall care plan is for the resident to avoid more falls in the future and for the staff to know what to do for the resident. V10 further stated that all interventions in the care plan should be implemented and followed by the staff on the floor working with the resident. On 3/17/24 at 2:52 PM, a phone interview conducted with V6 (Licensed Practical Nurse). V6 stated that V6 was the nurse in-charge of R1 on 2/5/24. V6 stated that 10 minutes before R1's incident, R1 was resting in bed with bilateral half side rails up. V6 stated that around after 8:00 PM, V6 heard a sound in R1's room and when V6 went to R1's room, and V6 found R1 on the bathroom floor. V6 stated that it looks like R1 went to the bathroom finished up and tried to go back to bed, and the way R1 was leaning, R1's head was close to the bathroom entrance door, leaning on R1's left side facing the outside door. V6 stated that R1 did not have any footwear at that time, no pants, no shoes, and no non-skid socks. V6 stated that the call light was not initiated. V6 stated that R1 knows how to use the call light but does not remember all the time to use it. V6 stated that R1 tries to be independent and tries to do things on his own. V6 stated that V6 assessed R1 and noted a bump and bleeding on R1's head. V6 stated that R1 pointed to R1's head that it was hurting. V6 stated that R1 was unable to state what happen. V6 stated that R1 was sent to the hospital via emergency paramedics. On 3/17/24 at 12:50 PM, V2 (Director of Nursing) stated that R1 came back from the hospital the morning of 2/6/24. V2 stated that R1 sustained a laceration on the forehead and was treated in the emergency room with stitches. The facility's policy titled; MANAGEMENT OF FALLS dated 8/2020 reads in part: POLICY: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. PROCEDURE: 3. Develop a plan of care to include goals and interventions which address resident's risk factors.

Based upon interview and record review, the facility failed to supervise a cognitively impaired resident at risk for fall. This failure affected one resident (R2) of two residents reviewed for falls. As a result of this failure, R2 fell from the wheelchair to the floor and sustained multiple fractures to the pubic/pelvic area. Findings include: On 3/13/23 at 10:15am after the entrance conference, V1 (Administrator) presented the facility's census which shows that there were 42 residents on the fourth floor, which is the Dementia Floor. The nursing staff assignment sheet for the 3-11 shift of 1/29/23 shows 2 nurses and 2 CNAs (Certified Nurse Assistants) took care of all residents on the Dementia floor for that shift. R2's face sheet shows that admission diagnoses include but are not limited to Anxiety Disorder, Overactive Bladder, Insomnia, and Dementia with Agitation. On 3/14/23, during this investigation, V2 (Director of Nursing/DON) presented the facility's incident reports of R2's fall event that was sent to the State Agency. This report states that R2 was noted by multiple staff members sitting in the wheelchair in the dining room watching TV with other residents, and later observed on the floor next to the wheelchair. On 3/16/23 at 11:30am, V19 (Licensed Practical Nurse/LPN) was interviewed about which staff was with R2 in the dining room when R2 fell . V19 stated, It was on a 3-11 shift and (R2) was yelling and trying to get out of the wheelchair. I was busy passing medications and I put her (R2) in the dining room to watch movie with other residents, and I was watching her through the dining room window while passing medications. I saw her (R2) sliding out of the wheelchair, and by the time I got to her, she already was on the floor. The surveyor inquired from V19 if there was any staff watching R2 and the other residents in the dining room at that time; V19 responded, I think there was a CNA assigned to watch the residents in the dining room, but I don't remember who the CNA was. On 3/16/23 at 3:34pm, V2 (DON) was asked about the staff that was watching the residents in the dining room. V2 stated that she (V2) would look at the schedule to know the CNA assigned. V2 stated, V20 (Certified Nursing Assistant/CNA) was the CNA assigned. On 3/16/23 at 4:05pm, V20 (CNA) was interviewed regarding being assigned to R2 on the 3-11 shift of 1/29/23. V20 stated, she (V20) was the CNA. V20 stated, after dinner on that day, R2 was yelling and trying to get up from the wheelchair and she (V20) put R2 in the dining room with other residents to watch TV. The surveyor inquired from V20 if she (V20) was there in the dining room when R2 fell from the wheelchair. V20 responded, I (V20) was changing another resident at that time and was not in the dining room when R2 fell . On 3/16/23 at 3:47pm, V10 (Physician) was interviewed regarding R2's supervision, fall, pelvic fracture, pelvic fracture treatment, and the eventual placement of R2 on hospice care. V10 stated, You don't have to fix pelvic fracture, you just need proper management - No weight-bearing, and since the patient is bed-bound, that can be achieved. Inquired from V10 if R2's fall and fracture with the associated pain was the reason R2 was placed on hospice care; V10 responded, That could be part of the equation, but not the only reason; the patient has several medical conditions. R2's records reviewed include but are not limited to the following: Hospital Records dated 1/30/23 was reviewed. Results of the CT (Computed Tomography) scan of pelvis states in part: There is an acute left pelvic sidewall hematoma, measuring approximately 6 x 4.5 cm(centimeters) in the CC, transverse dimension. In the AP dimension of this hematoma measures 7 cm. There is an impacted fracture involving the left superior pubic ramus with extension into the pubic symphysis. There is an impacted but nondisplaced fracture involving the left inferior pubic ramus on series 4 image 278. There is also a posterior inferior right pubic ramus fracture, with minimal disruption of the cortex. This is seen on series 4 image 279. Fall Risk assessment dated [DATE] and 2/6/23 both show that R2 is at risk for falls. MDS (Minimum Data Set) section G dated 12/23/22 and MDS dated [DATE] both show that R2 needs extensive assistance for locomotion on unit and for transfers. MDS section C dated 2/8/23 shows BIMS (Basic Interview for Mental Status) score of 3 out of 15 (severe cognitive impairment). Care Plan dated 9/19/22 states R2 is at high risk for falls related to medical several medical conditions; Intervention states: Rounding frequently and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. Another intervention states to encourage appropriate use of wheelchair. Care plan dated 2/1/23 states R2 has an ADL (Activities of Daily Living) self-care performance deficit related to medical conditions; Intervention states to assist with locomotion as needed, and to assist with ADL tasks as needed. Care Plan dated 2/1/23 states that R2 is at high risk for falls related to weakness, poor balance, unsteadiness on feet, pain, physical limitation r/t recent hospitalization with dx of fracture left superior and inferior pubic rami and right inferior pubic rami. POS (Physician Order Sheet) dated 2/6/2023 states: Hospice Evaluation per family request. POS dated 2/1/23 states in part: Comfort-Focused Treatment; Relieve Pain and suffering through the use of medication . Facility's Fall Policy dated 08/2020 states in #6: Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. Facility's CNA job description (undated) states in #F: Makes rounds to assure customers are safe and comfortable.

Based on observations, interviews and record reviews, the facility failed to feed a cognitively impaired resident(R28) lunch who required extensive staff assistance with ADL's. The facility failed to address R28's daily nutritional intake and monitor R28's weight resulting in weight loss of 8 % in the span of 1 month. This affected 1 resident(R28) of 3 reviewed for nutrition and hydration in a sample of 30. Findings include: On 07/05/22 R28 was observed from 12:20PM to 1:30PM lying in bed, soiled in urine and feces, awaiting ADL care and waiting to be feed. R28 had not received his lunch tray. On 07/05/2022 at 11:00 AM, the surveyor observed R28 lying in his bed with no food or water at the bedside. On 07/05/2022 at 11:30 AM, the surveyor observed dietary staff bring lunch meal up to the floor. On 07/05/2022 at 11:37 AM, the surveyor observed V6 (Certified Nursing Assistant/CNA), V7 (CNA) and V22 (Resident Assistant) pass trays to the residents in the dining room. And at 11:45 AM, the surveyor observed them (V6, V7, and V22) pass lunch trays to the residents sitting in their rooms. On 07/05/2022 at 12:00 PM, the surveyor observed R28 lying in his bed without any food or water. On 07/05/2022 at 12:15 PM, 12:30 PM, 12:45 PM, 1:15 PM, 1:30 PM, and 1:45 PM the surveyor observed R28 did not receive his lunch meal tray. On 07/05/2022 at 1:41 PM, the surveyor observed the dining room empty and V22 cleaning up the tables and no more trays were being passed out. On 07/05/2022 at 2:00 PM, V4 (Licensed Practical Nurse/LPN) stated that R28 is a feeder and needs help eating his meal. V4 stated that she (V4) did not take the meal tray to R28 nor feed him (R28). V6 stated that she (V6) did not feed R28. V7 stated that she (V7) did not feed R28. V22 stated that she (V22) did not feed R28. On 07/05/2022 at 2:05 PM, V4 stated that R28 did not receive his lunch meal tray because no one took it to him (R28), so he (R28) was not able to eat his lunch. Surveyor asked if there was anything that could be given to R28. V4 stated. Because he (R28) is on a puree diet, and lunch is over there are no more puree meals. We can get him some pudding. On 07/06/2022 at 12:59 PM, V2 (Director of Nursing) stated that if a resident does not get a meal tray nor do they get fed then that could lead to a nutritional deficit and weight loss. Nutritional deficit and weight loss could lead to skin breakdown, vitamin deficiency and overall deterioration of health. R28's Weights in electronic medical record documents in part: 4/12/2022: R28 was 186.3 lbs. 5/12/2022 R28 was 171.6 lbs. On 07/08/2022 at 11:30 PM, V21 (Dietician) stated that an 8% weight loss in a span of 1 month is significant. V21 stated that if R28 was receiving all his (R28) meals he should not have that significant of a weight loss. V23's (Dietician) progress note for R28 (6/23/2022) documents in part: wt-172.8 lbs (6/23/22), 171.6 (5/12/22), 186.3 (4/12/22), 185.8 (4/5/22), weight loss noted. res with previous sig weight loss. R28's care plan (4/5/2022) documents in part: Focus- R28 has an ADL Self Care Performance Deficit due to Communication Problems, Decreased Functional Ability, Dementia/impaired cognition, Impaired Balance, Limited Mobility, Limited ROM, Musculoskeletal Impairment, Weakness, Contracture of muscle, Spinal Stenosis, Cerebral infarction. R28 requires extensive staff assistance with ADLs. R28 experiences bowel and bladder incontinence due to Advancing Disease Process, Confusion, Functional Incontinence, Inability to communicate toileting needs, Inability to sense urge to void. R28 requires extensive staff assist with toileting. Intervention- Assist R28 with ADL tasks as needed. May be fed by a feeding assistant. Rounding at a minimum of every 2 hours and prompt or assist for change in position, toileting, offer fluids, and ensure resident is warm and dry. Check residents for incontinence. Facility's Feeding A Resident policy (9/2020) documents in part: Residents who need assistance will be fed a well-balanced meal by a nurse, CNA, or an individual who has completed a state approved feeding course.

Based on observation, interview, and record review, the facility failed to assess a resident (R1) who was at high risk for developing a pressure ulcer, and failed to follow physician orders for wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These facility failures contributed to R1 developing a stage 3 pressure ulcer. Findings include: 1. R1's medical record face sheet documented R1 was admitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was placed on Hospice care on 5/10/22. On 6/07/22 at 12:53pm, R1 was observed in bed lying on R1's left side. The repositioning schedule posted on the side of the bed showed R1 should be repositioned on R1's back side at 12:00pm. Surveyor showed this to V7, LPN (Licensed Practical Nurse). V7 stated, The CNA (referring toV4) should have followed the turning schedule. V4, who was standing at R1's bedside, asked R1 if R1 was in pain. R1 replied, No, I am not in pain. During the same observation, R1 was noted with an open pressure ulcer with serosanguinous drainage in the sacrum area that was not identified or assessed until the surveyor insisted on observing the site. V7 (Licensed Practical Nurse) told the surveyor the sacrum wound had been healed. V7 did not know R1 had a pressure ulcer on the sacrum. V7 stated, I did not know (R1) had a pressure ulcer on the sacrum because I float to different floors. The surveyor then asked V7 to measure the wound and stage the site. R1's sacrum pressure ulcer, measured: length 5cm x 4.5cm width x 1cm depth. V7 then checked the electronic treatment record. V7 cleaned the pressure ulcer with normal saline, applied zinc ointment, and covered with a foam dressing to the sacrum (7x7cm/Centimeter), without notifying V15 (Physician) or V12, (Wound care physician) for an order. R1's treatment order showed there was no order for the sacrum pressure ulcer, and the treatment applied was for the ischium. V7 stated, That was the only treatment ordered The surveyor showed V7 the treatment order was for the right ischium. On 6/07/22 as at 4:00pm, the facility could not present a treatment order for the sacrum, or the assessment documentation. V2 stated all treatment orders must be ordered by the physician. On 6/08/22 at 3:16pm, V2 (Director Of Nursing/DON) stated, I was confused yesterday when you asked me about the treatment order. There should be a dressing order for wound treatment and the nurses are expected to match the dressing with the order. The Wound care physician, or the primary physician should be notified before any dressing is applied. V2 presented a treatment order sheet, dated 6/07/2022 timed 3:59pm for R1, stating that was the order V12 gave yesterday when she contacted V12. V2 stated no wound should be left uncovered unless it was ordered. V2 explained the wound was a newly opened pressure ulcer, and it should have been covered with a protective preventative dressing, followed by a call to the physician. On 6/09/22, at 9:26am, surveyor asked V12 (Wound Care Physician) about R1's pressure ulcer. V12 stated, I saw (R1) two months ago. (R1) had a wound on the buttocks and the wound had healed. V12 further stated, (V2) called me yesterday about a new wound, and I asked them to apply Medi-honey to the pressure ulcer. V12 stated, According to (V2), it was not that bad (referring to the pressure ulcer wound), therefore there was no need to send (R1) to E.R (emergency room ). V12 stated, (R1) is now on Hospice comfort care. V12 stated wound care is not to heal the pressure ulcer now, but most of the care now is comfort care because of other co-morbidities. V12 stated, If (R1) is in pain, there is no need to turn (R1) every two hours, but if possible, we (referring to facility staff) should do it (referring to the repositioning). V12 stated, Due to malnutrition, these residents can have pressure ulcers. (R1) has malnutrition, and can easily get a pressure ulcer. These residents can have fluctuating blood pressure and some of them develop Kennedy ulcers. 2. R2's medical record face sheet documented [CONDITION(S)], Infection As The Cause Of Diseases, Acute [CONDITION(S)] With [CONDITION(S)],Pneumonia, Unspecified ,[CONDITION(S)], Unspecified Dementia Without Behavioral Disturbance , Type 2 Diabetes Mellitus Without Complications,Chronic [CONDITION(S)], Pressure Ulcer Of Sacral Region, Stage 3,Dysphagia, Unspecified Falls, Pressure Ulcer, Chronic [MEDICATION(S)] Without Hematuria, Anxiety Disorder, Unspecified Long Term (Current) Use Of Anticoagulants, [CONDITION(S)] With Lower Urinary Tract Symptoms, Essential (Primary) Hypertension. On 6/07/22 at 11:54am, surveyor observed R2 in a bed wet with urine. Surveyor observed R2 trying to get out of bed. R2 stated to the surveyor Help. The surveyor called V5, CNA (Certified Nursing Assistant), who identified self as the direct caregiver for R2 to assist R2 with incontinence care. During the incontinence care, R2's wound at the sacrum was noted without a dressing, exposing the wound to the urine and bowel movement noted on the disposable incontinent pad. Wound noted with serosanguinous drainage. Surveyor asked V5 when was the last time R2 had incontinence care. V5 replied V5 had not been able to check on R2 during the shift. Surveyor asked V5 what time did you start your shift? V5 stated her shift is 7am to 3pm. V5 stated the night shift staff did the last incontinence care because V5 had been busy with another resident. On 6/07/2022 at 12:07pm, V6, RN (Registered Nurse), came into R2's room identifying self as the nurse for R2. V6 stated, (R2's) wound should not be left uncovered. There should be a treatment dressing over the wound as ordered all the time. V6 stated, I should have been notified when it (referring to treatment dressing) came off. V6 further stated, I was not notified by the CNA staff that the dressing was not in place on the wound, so that boo-boo (referring to stool) and the urine would not get into the wound which will not help in healing. V6 stated, We (referring to facility nurses) have to remind the CNAs to let the nurses know when a dressing comes off any wound area. The facility Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Listed procedure includes but not limited to at least daily, staff should remain alert for potential changes in the skin condition during resident care

Based on interview, and record review, the facility failed to use the mechanical lift for 1 of 3. R4 upon transferring in accordance with the residents' individualized care plan. This failure resulted in R4 suffering a traumatic nondisplaced tibia and fibula fracture to the left lower leg. Findings Include: R4 was admitted to the facility on [DATE] with diagnosis not limited to: Chronic Embolism and [CONDITION(S)], Essential (Primary) Hypertension, [CONDITION(S)], Neuromuscular Dysfunction of Bladder, Major Depressive Disorder, Dementia with Behavioral Disturbance, [CONDITION(S)] and Urinary Tract Infection. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. On 08/17/21 at 01:00 PM, R4 stated I broke my left leg when I fell out of bed. They usually have to use the mechanical lift with one to two people. R4 was observed in bed on a low air loss mattress with a splint to R4's left lower extremity. On 08/17/21 at 01:06 PM, V4 (Licensed Practical Nurse )LPN stated R4 is alert/oriented times two to three, is forgetful at times. V4 said, R4 has a broken left lower leg. 08/17/21 V5 (Certified Nurse Assistant) CNA was transferring R4 from the bed for a shower. V5 was doing a manual one-person transfer and did not use a mechanical lift. R4 is supposed to be transferred using the mechanical lift with 2-person assist. V5 came and got me and told me what happened, and I went to assess R4, R4 was in a sitting position with her legs extended. Four of us transferred R4 by lifting her from the floor to the bed. V4 stated I was going to flush R4's suprapubic catheter and give her medication. When I pulled the cover back, I saw R4's left leg swollen and starting to bruise. When turning R4, she had discomfort. The x-ray was done that day, I was told R4 had a fracture of the left tibia and fibula. Staff is aware R4 is a two person assist with mechanical lift for transfers. On 08/17/21 at 01:23 PM, V5 (Certified Nurse Assistant) stated I went to give R4 a shower. I got the shower chair, turned her to the edge of the bed and picked her up to transfer R4 to the shower chair. She was too heavy to transfer so I lowered her to the ground. She was on her knees, she was put into a lying position. I needed help getting her up, I went to get help to get her up into the shower chair. We lifted her and put her in the bed. R4 is a mechanical lift with two persons assist for transfers. At the time I did not know she was a mechanical lift for transfers. I asked her how she transfers, and she stated, I could just transfer her to the shower chair V5 stated I can look in the computer to see how the residents are transferred. R4 is alert and oriented times two, with confusion, and forgetful. I received the mechanical lift in service after the incident. On 08/17/21 at 05:05 PM, V8 (Nurse Practitioner) stated I got a call that R4 fell . After the incident she developed pain and discoloration. I ordered an X-ray and it showed a fracture to the left tibia and fibula. She does not walk and is essentially on bed rest. I asked her what happened, she said she forgot, she could not walk. I thought that it was odd, and I had them check for a urinary tract infection because she was not totally herself. The CNA was helping her and she fell . R4 was not in her right mind but under normal circumstance she could tell staff how she transferred. R4 has [CONDITION(S)], is basically dead weight and cannot assist staff because she is severely limited with [CONDITION(S)]. If staff are not using the mechanical lift she can fall. When it comes to safety her words should not be taken that she is totally with it, and should be taken that she is confused. On 08/18/21 at 12:54 PM, V3 (Director of Nursing) stated staff should know how a resident transfer's, use a gait belt, use two people if required. We did an in service for transfer's, the intervention has been put in the Kardex. There is a list who uses the mechanical lift for transfers. If resident's uses a mechanical lift, or sit to stand, it is always a 2-person assist. V5, CNA was trying to transfer R4 to the shower chair. R4 told her she was able to transfer, V3, CNA, took her for her word, attempted to transfer R4 by herself. The shower chair slid a little and she lowered R4 to the floor. Two days later R4's leg started swelling, X-ray was done and there was a fracture. R4 is not able to stand at all, she has [CONDITION(S)]. R4 should not be transferred by one person. She has a potential to fall and get a serious injury. We did competencies with V5 (Certified Nurse Assistant) on what to look for before a transfer. R4 was care planned for a mechanical lift with,, 2-person assist. On 08/12/21 at 02:17 PM, V16 (Licensed Practical Nurse) stated care plan has type of transfer rather mechanical lift, or maximum assist in R4's Care Plan. Anyone that uses a mechanical lift is at least a 2-person assist. There is a risk for fall or injury if residents are not properly transferred. On 08/18/21 at 03:49 PM, V20 (Certified Nurse Assistant) stated there is a folder for transferring to know which device to use. Mechanical lift transfers have a 2-person assist. There is a potential for a fall and the resident can get hurt. On 08/18/21 at 03:53 PM, V22 (Registered Nurse) stated the day nurse endorsed that an X-ray was ordered for R4 left foot discoloration and swelling. Report came back with R4 having a nondisplaced fracture of the left tibia, and fibula. R4 is supposed to transfer using a mechanical lift with a 2-person assist. R4 cannot stand, she is paralyzed from the waist down. If the mechanical lift is not used for R4 there is potential for a fall, she is dead weight and it's dangerous. R4 does have periods of confusion. On 08/18/21, The facility administrator provided a Competency document for V5 (Certified Nurse Assistant) dated 07/16/21 and 07/29/21 titled Total Mechanical Lift, and In -Service/Meeting, Attendance Record dated 07/20/21 Topic: Use of Hoyer lift. Progress note dated 07/15/21, reads in part around 14:15 during transfer to shower chair R4 was lowered down to the floor in sitting position by assigned V3, CNA (Certified Nurse Assistant). Progress note dated 07/17/21, reads in part X-ray stat done around 3:30pm due to R4's left leg swollen and noted with reddish discoloration per day shift nurse. Upon assessment, resident complains of pain only upon movement of the leg. Radiology Results Report dated 07/17/21, document X-ray exam of lower leg. Significant Findings Left Tibia/Fibula - 2 view: The tibia and Fibula on the left demonstrates nondisplaced fractures of the proximal tibia and fibula. The findings are likely acute. Initial Report dated 07/18/2, document R4 requires total assist with bed mobility, and transfers. On 07/15/21 R4 was being transferred to shower chair from bed, when shower chair moved and V3, CNA (Certified Nurse Assistant) lowered resident to floor. On 07/17/21, R4 complained of pain to left lower leg. Swelling, and discoloration noted. MD (Medical Doctor) notified and X-ray ordered. X-ray results returned showing nondisplaced fracture of proximal tibia and fibula. Care Plan documents: R4 requires extensive assistance with bed mobility due to weakness related to MS ([CONDITION(S)]). R4 has an ADL (Activities of Daily Living) Self Care Performance Deficit due to impaired mobility, non-ambulatory related to [CONDITION(S)]. Date Initiated: 12/17/2020. R4 requires the use of a mechanical lift with 2 staff assist for transfers due to weakness; impaired mobility; non ambulatory related to [CONDITION(S)]. Date Initiated: 06/11/2021. Provide 2 staff assistance for transferring. Date Initiated: 06/11/2021. R4 demonstrates impaired cognitive functioning related to/cognitive deficit related to dx (Diagnosis) of Dementia. Date Initiated: 08/10/2015. R4 is with impaired decision-making abilities secondary to Advancing Dementia. Date Initiated: 10/16/2015. R4 is noted with no voluntary movement of the legs related to [CONDITION(S)]. R4 is at risk for fall due to weakness related to [CONDITION(S)]. Facility provided document dated 07/20/21 titled In-service/Meeting Attendance Record Use of Hoyer Lift and Competency for V5 (Certified Nurse Assistant) dated 07/16/21 and 07/29/21 titled Total Mechanical Lifts. Policy: Titled Incident/Accident Reports dated 09/20 document an accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. 4. All situations requiring the emergency services of a hospital. 15. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Titled Total Mechanical Lift dated 01/14/21 document Purpose: 1. To lift, transfer and move a resident from one surface to another.

Based upon observation, interview, and record review, the facility failed to follow (R4's) wound care orders, failed to turn and reposition (R1, R3, R4, R6) as directed, and failed to provide timely incontinence care for four of six residents (R1, R3, R5, R6) reviewed for pressure ulcers. These failures resulted in R2 and R3 developing (facility acquired) pressure ulcers and R1 developing a (facility acquired) DTI (Deep Tissue Injury). R3's sacrum wound became necrotic and required surgical intervention on 3/4/21. Findings include; The pressure injury list affirms R3 developed a (Facility Acquired) sacrum DTI on 2/24/21. R3's (3/4/21) sacrum skin assessment affirms an unstaged pressure ulcer was identified with 30% necrotic/eschar tissue present, and an excisional debridement was conducted. R3's (12/27/16) care plan states; keep skin clean and dry. Turn and reposition every 2 hours. On 3/8/21 at 11:10am, an individualized turning schedule was observed on the wall above R3's bed stating 10:00 (Left) however she was lying on her back. Surveyor inquired why R3 was not on her (left) side as directed V5 (LPN/Licensed Practical Nurse) responded She can go back to her back on her own. [There was nothing in place to ensure that R3 laid on her side]. V5 removed R3's incontinence brief and stated There's BM (Bowel Movement) on the bandage (referring to her dressing). Diarrhea was present, her skin excoriated, and a dark brown discoloration encircled the sacral wound (debrided 4 days prior). On 3/10/21 at 12:49pm, surveyor inquired about R3 V3 (Wound Care Coordinator) stated She has a time clock for turning and repositioning we turn her left, right to offload the sacral area. She's compliant with her care so we would put a pillow above the area where the wound is to make sure she's lying on the side. R2's (8/14/20) care plan states turn and reposition every two hours and as needed. R2's (2/9/21) skin assessment includes a (Facility Acquired) right buttock DTI. The (undated) pressure injury list affirms R2 developed a (Facility Acquired) right buttock stage 3 pressure ulcer. On 3/4/21, IDPH (Illinois Department of Public Health) received allegations that R1 has pressure ulcers due to lack of turning and being left dirty/unchanged for hours. R1 was discharged from the facility prior to this investigation however (3/4/21) wound assessment affirms he sustained a (Facility Acquired) right buttock DTI (Deep Tissue Injury) measuring 3 x 3 x 0cm (Centimeters) described as 100% Deep Maroon Patches. On 3/10/21 at 12:33pm, surveyor inquired about R1's (3/4/21) DTI V3 (Wound Care Coordinator) stated I did rounding with the wound care Nurse Practitioner and found the DTI. The entire area was darkened, it was non-blanchable. Surveyor inquired how someone develops a DTI V3 responded Constant pressure on that area will cause a pressure injury. [R1's care plan includes; (8/21/20) turn and reposition every two hours and as needed. (8/24/20) Resident is incontinent of bowel needs extensive assistance with toileting. (9/14/20) Resident requires assistance from staff for bed mobility; unable to turn and reposition self in bed without physical assistance from staff]. R6's (3/28/20) care plan states resident has potential for alteration in skin integrity related to; cognitive impairment, contractures, decreased mobility, and incontinence. Turn and reposition every 2 hours. On 3/8/21 at 11:39am, surveyor requested to inspect R6's incontinence brief V4 (Certified Nursing Assistant) affirmed he was assigned to R6 (7am-3pm) and stated I haven't changed her yet. V4 removed R6's incontinence brief and stated She's wet, soaking wet and she's having menstruation too. R6's brief was completely saturated with urine and blood, the sheet beneath her was also soiled. A repositioning schedule was posted on the wall above R6's bed stating 10:00 (left) however she was lying on her back. Surveyor inquired about R6's current position V4 stated She's lying flat, she should be on the left side. R4's (6/30/11) care plan states resident requires extensive assistance with bed mobility. On 3/8/21 at 12:10pm, V5 (LPN) affirmed that she was assigned to R4. Surveyor requested V5's assistance to inspect R4's incontinence brief and advised that her assigned CNA was assisting another resident. V6 (Licensed Practical Nurse) and surveyor waited for V5's assistance (outside R4's room) for several minutes but she never came. An individualized turning schedule was posted on the wall above R4's bed stating 12:00 (right) however she was lying on her back at 12:15pm. [R4's (2/18/21) physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply [MEDICATION(S)] gel on collagen, apply collagen, cover with foam, apply tegaderm]. Surveyor inquired about R4's wound V6 stated It doesn't close, it's been here since she came here about 9 years now. V6 removed R4's (undated) foam dressing and an deep sacrum wound was observed (additional treatments were not present). Surveyor inquired about R4's dressing V6 stated It's an [MEDICATION(S)]. Surveyor inquired if only a foam dressing was beneficial to healing R4's wound V6 responded Yeah, I believe so, in case she poop. On 3/10/21 at 12:57pm, surveyor inquired if R4 is able to turn herself V3 responded She needs to be turned and repositioned. She also has a turning clock right, left to offload the sacral area. R5's (11/12/20) care plan states; check resident for incontinence. On 3/8/21 at 10:59am, V4 (CNA) removed R5's incontinence brief and stated It's soaked. Surveyor inquired when his brief was last checked and/or changed R5 stated It was 5:00 in the morning when I got up. On 3/8/21 at 3:17pm, surveyor inquired about potential harm if residents are not turned every 2 hours and soiled incontinence briefs are not timely changed V9 (Medical Director) stated You run into skin problems, deconditioning, things of that nature. Surveyor inquired about the prescribing and following wound care orders V9 responded Typically we get a wound care consultation, I'm expecting them to follow the orders the wound care people make. The (09/2020) perineal care policy includes PURPOSE: to maintain skin integrity. The (3/2/21) prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. At least daily, staff should remain alert for potential changes in the skin condition during resident care.

Based on interview and record review the facility failed to follow its policy to keep one of three residents (R1) who was at risk for abuse free from sexual assault by an employee. This failure resulted in R1 being transferred to the emergency room with a [DIAGNOSES REDACTED]. Although R1 showed no negative response to the incident of 7/12/2019, using the reasonable person concept it is likely this vulnerable person who is unable to defend herself could experience fear and anxiety, when the facility failed to protect her from being sexually assaulted by V16. Findings include: On 10/15/19 at 9:25AM, R1 noted up in a wheelchair in front of nursing station. She is well groomed, clean and neat. She is alert x1 (oriented to person), no verbal response, making eye contact, and smiling and giggling. On 10/15/19 at 10:02AM, V1 (Administrator) and V2 (Director of Nursing - DON) stated they reported sexual abuse allegation of R1 to the state agency on 7/12/19. V1 stated V7 (Registered Nurse) saw V16 (Housekeeping aide) in R1's room with his hand inside her brief when she was passing her evening medications. V7 informed V2 who is still in the building at that time and reported the abuse. V2 called V1 and was advised to remove V16 from the floor. V2 instructed V7 to do head to toe assessment of R1. V16 stayed in his car until police officer arrived. V1 and corporate manager came to the facility. Police were called and abuse report filed. V7 notified R1's family and physician. R1 was sent out to the hospital for evaluation as ordered by physician. The family requested to be with R1 when transferring to the hospital. R1 came back with family the following morning. R1 was transferred to room closer to nursing station. No male staff assigned to work with R1. V16 was suspended pending investigation and eventually was terminated. V1 stated he did not communicate with V16 after he was terminated. On 10/15/19 at 10:52AM, V7 (Registered Nurse) stated on 7/12/19 she worked double shift 7-3 and 3-11 shift. She was passing her evening medication near 8:00PM when she observed V16 (Housekeeping aide) standing next to R1's bed with his hand inside R1's disposable brief. V7 stated before she could speak to V16, he was defensively explaining he was only picking up a diaper inside the trash bin and immediately left the room before she could ask him more questions. V7 called another nurse to watch R1 while she reported the incident to the V2 (DON) who was still in the facility. V2 called V1 (Administrator) to report the incident. Police were called. Head to toe assessment was done of R1. Family and Physician was notified. R1 was sent out to the hospital for evaluation. On 10/16/19 at 1:42PM V16 (Housekeeping aide) refused to be interviewed and stated he is not allowed to talk to anyone about the case. On 10/17/19 at 3:11PM, V31 (Police Detective) stated she followed up with V30's (Police Officer) initial report on 7/12/19. The State's attorney gave the approval for release of warrant for arrest and the case was filed for aggravated criminal sexual abuse against V16 (Housekeeping aide). V16 was arrested on 7/26/19. R1's incident report dated 7/12/19 documented by V7 (RN) indicated during evening rounds, V7 went inside R1's room to give medication. V7 noted V16 (Housekeeping aide) touching R1 inappropriately in her private area. Immediately separated staff from resident. Head to toe assessment performed with no visible injury, no trauma and denies any pain or discomfort. Informed V2 DON and V1(Administrator), with pending investigation. Facility protocol followed. Physician informed by DON with orders to send to hospital ER for evaluation. POAs (Power(s) of attorney) were both notified by DON and had been aware of transfer. Ambulance called for transfer. Hospital record dated 7/12/19 to 7/13/19 reads R1 is [AGE] year old female with history of [MEDICAL CONDITION], anxiety and depression who presents to emergency room with chief complaint of sexual assault. R1 is here with mom and aunt, POA, who is and for concern of sexual assault. R1 lives at a nursing home due to her MS and per nurses at the nursing home she saw a male employee inappropriately touching R1. Male employee is immediately removed from the room and was reported, and family immediately brought the patient here. Per R1, she is unsure exactly of the events that happened however family wants to make sure there is no trauma to the genitalia area or bruising to the body. R1 herself has waxing and waning memory and cannot always recall events accurately, cannot remember the exact event that is in question. Laboratory test for [MEDICAL CONDITION],[MEDICAL CONDITIONS] were sent off. At this time R1's mom and aunt are making medical decisions for R1. R1 is on a good amount of medication for MS. They do not [MEDICAL CONDITION][MEDICATION NAME] or gonorrhea chlamydia treatment at this time. They are aware these are options. Evidence kit was collected. R1 does have a Urinary Tract Infection [MEDICAL CONDITION]. Bactrim will be given. Physical exam indicated: Genito urinary: Vaginal discharge found. Whitish vaginal discharge. No lesion to the vaginal walls or the cervix. R1 has small vaginal wall polyps. No active bleeding in the vagina. Labia minora and majora without signs of bruising, bleeding, tears or [MEDICAL CONDITION]. Laboratory data 7/12/19: Urinalysis (UA) results: Bacteria - Many; Pregnancy Test- Negative. emergency room Diagnosis: [REDACTED]. R1's sexual abuse initial report on 7/12/19 indicated Nurse on duty reported to the administrator she witnessed V16 (Housekeeping aide) with his hands inside R1's brief. V16 was suspended pending investigation notified. Police notified, POA (Power of Attorney) and Physician notified. Investigation initiated. Final report to follow. R1's sexual abuse final report on 7/17/19 at 4:20PM indicated an investigation was initiated. V7 (RN) nurse on duty was going to pass medications in R1's room when she saw the housekeeper with his hand inside R1's brief. R1 was sent to the hospital for evaluation and returned with treatment for [REDACTED]. Other residents were interviewed that have their room regularly cleaned by V16 and no residents voiced any concerns with V16. Staff were interviewed, and no staff members voiced concerns about V16. V16 is no longer employed at the facility. R1's safety/abuse assessment dated [DATE], 10/4/18, 5/13/19 and 7/12/19 indicated R1 is at risk for abuse. R1's care plan indicated she is at risk for abuse related to [DIAGNOSES REDACTED]. R1 is confused and forgetful at times, may use foul language and may have tangential thinking and may have looseness of thought during conversation as related to [MEDICAL CONDITION] disorder and pseudobulbar effect. Facility's Abuse Policy dated 6/2019 indicated: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment neglect or abuse of our residents. Definitions: Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Sexual abuse is non-consensual sexual contact of any type with a resident. This includes, but not limited to sexual harassment, sexual coercion or sexual assault.

Based on interview and record review the facility failed to monitor and provide supervison while in the dining room, failed to follow the facility fall management program and failed to appropratly care plan for 1 of 3 residents R1 reviewed for fall prevention and supervision. This failure resulted in R1 being left in the dining room and falling from the wheel chair and being sent to the local hospital and was admitted with a [DIAGNOSES REDACTED]. Findings Include: R1 admitted to facility on 2/17/19 with [DIAGNOSES REDACTED]. R1's Brief interview for mental status dated 2/28/19 documents a score of 3. A BIMS score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. On 4/23/19 at 11: 50 AM, V2 (DON) said R1 requires supervision and required redirection. Upon admission R1 would attempt to stand from wheelchair and ambulate. Staff would try to use distraction, activities or place near nursing station. On 4/23/19 at 2: 53 Pm V18 (physician) said R1 was confused and needed redirection every 5 minutes. R1 required close supervision. On 4/23/19 at 1:38 Pm, V16 (Restorative nurse) said R1 had behavior from admission of trying to get up from R1's wheelchair and attempting to ambulate. R1 was unsteady and would fall if R1 got up unassisted. R1 needed constant redirection and required supervision. Interventions for this behaviors including contacted family to calm resident or give R1 a specific time of when family would be coming to visit. These interventions are not documented in R1 's care plan. On 4/23/19 at 10:09 AM, V13 (Physical therapy Director) said R1 was not safe to use or be in her wheelchair by herself. R 1 was not cognitively aware of how to use wheelchair or safety concerns. R1 required very close supervision at all times. On 4/19/19 at 3:44 PM, V11 (nurse) said R1 would stand up from wheelchair and require cueing to sit back down. R1 required low bed and frequent monitoring at least every 15 minutes. On 4/19/19 at 3:13 PM, V10 (nurse) said R1 required supervision when in wheelchair because R1 would stand up from wheelchair and try to ambulate. R1 was fall risk and needed constant redirection. On 4/19/19 at 1: 39 PM, V6 (CNA) said R1 required supervision and R1 was usually by nursing station or common dining room. R1 would stand up from wheelchair and try to walk unassisted since admission. On 4/9/19, I assisted R1 in her wheelchair to common room. I locked R1's wheelchair and turned around to assist another resident with feeding. I heard a noise and R1 had fallen out of her wheelchair. R1's incident report dated 4/9/19 documents R1 alert to person. Under notes documents R1 has habit of getting up from wheelchair and likes to attempt to walk. She requires constant re-directing from staff to remain seated in her wheelchair to prevent injuries from fall. Local hospital records dated 4/9/19 document an admitting [DIAGNOSES REDACTED]. On 4/19/19 at 4:00 Pm, V12 (CNA) said R1 required one to one due to confusion. R1 will stand up as soon as you turn your back. She needed to be by the nurses. R1 's Physical Therapy evaluation and plan of treatment dated 2/18/19 to 5/18/19 under functional assessment section titles gait analysis documents; Gait pattern: slow, unsteady, needs physical assistance to prevent falling. Fall predictors: Reduced insight for unsafe situations, reduced recognition of unsafe situations, poor negotiation of obstacles, inadequate postural control and discontinuity of steps. R1's Incident report dated 3/6/19 documents R1 sitting on floor next to wheelchair in dining room/ TV area at 15:30. Fall unwitnessed. Under mental status documents disoriented and oriented to person. Under notes documents R1's falls are triggered due to need of extensive assist from staff. R1's care plan with date initiated 4/9/19 document R1 is high risk of falls due to recent fall, weakness, unsteady gait, poor safety awareness and cognitive impairment. She utilizes a wheelchair as a primary mode of transportation and requires assistance from staff with mobility. R1 is observed to have habit of standing up and attempting to walk, and doing things on her own. Staff need to constantly redirect R1. Intervention documented on 2/17/19; provide proper well maintained footwear; environment free of clutter; call light within reach. Interventions documented on 3/7/19 include: Dycem to wheelchair; Educate resident on the importance of complying with safety measures. Document resident understanding of education and instances of noncompliance; encourage appropriate use of wheelchair; encourage resident to call don't fall; encourage to report fall; notify family and md of any new fall. Interventions on 4/9/18 include provide activities that R1 may enjoy to keep her focused on task. Facility policy titled comprehensive care plans dated 11/2017 documents an individualized, person centered comprehensive care plan, including measurable objectives with timetables to meet residents physical, psychosocial and functional needs, is developed and implemented for each resident. Facility fall management program dated 2/2019 documents it is in the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. R 1's resident/education sheet dated 3/6/19 documents R 1 noncompliant of staff redirection. Getting up on her wheelchair without assistance which may lead to fall incident. Under readiness to learn documents no interest. Under outcomes documents needs practice and reinforcement. R 1's resident/education sheet dated 3/16/19 documents R1 does not understand basic information and under readiness to learn documents no interest. Barriers to learning document R1 confused and under outcomes unsuccessful.

Based on closed record review and interview, the facility failed to conduct and document timely assessment, monitoring and provision of emergency treatment for 1 resident (R26) in a sample of 28. R26 tested positive for [MEDICAL CONDITION] 13 days after completing treatment. R26 became acutely ill after developing bilateral pedal [MEDICAL CONDITION] and diminished breath sounds. R26 expired approximately 16 hours after arriving at the hospital. Primary cause of death was "Septic Shock Most Likely From [MEDICAL CONDITIONS] And Pneumonia." Findings include: Minimum Data Set ((MDS) dated [DATE] shows R26 is an [AGE] year old resident admitted from an acute care hospital on [DATE]. MDS progress notes shows admitting [DIAGNOSES REDACTED]. R26 has been receiving skilled physical and occupational therapy. MDS documentation shows no cognition, mood nor behavior concerns. R26 was the sole informant for Resident Assessment and Care Screening, with an expectation to be discharged to the community. R26 requires extensive, 2 persons assistance for transfer and toilet use and is continent of bowel. Physician's Order Sheet dated [DATE] shows order for contact isolation for [MEDICAL CONDITION] in stool, urinary catheter for Urinary Outlet Obstruction secondary to Enlarged Prostate. Medication regimen includes [MEDICATION NAME] ([MEDICATION NAME]) 500 milligrams (MG) every 8 hours for 8 days (1500 MG in 24 hours for 8 days). Lexi-Comp's Drug Reference Handbook states that for the treatment of [REDACTED]. R26's weight on admission was 217 pounds (98.6 kilograms), requiring 1,972 MG of [MEDICATION NAME] every 24 hours. R26 compiled the prescribed treatment on [DATE]. There was no evidence that a test of cure was done. Bowel Movement Monitoring flow sheet for [DATE] does not support R26 being asymptomatic (absence of loose stools) upon completion of treatment. The flow sheet dated [DATE] through [DATE] shows frequency of bowel movement (,[DATE] per day) but does not describe characteristic of bowel movements. E2 (Director of Nursing) stated on [DATE] at approximately 1:50pm that the certified nurses aids (CNA) complete the flow sheet and it is the facility's policy to record the number of occurrence only, not consistency nor characteristic. E2 went on to say that the nurses document bowel pattern for residents. R26 had 2 bowel movements on [DATE] but nursing documentation addresses 1 of the 2 movements. There was no activity entered on 2 of 3 shifts on [DATE]. Nursing Notes dated [DATE], 2:05pm, states family member complained to staff regarding R26's complaint of numbness in his bilateral lower extremities. Upon assessment the nurse documented swelling of both lower extremities which were cold to touch. Staff observed R26's room to be cold, adjusted the room temperature and covered resident with a warm blanket. Pitting [MEDICAL CONDITION] of lower extremities continued through [DATE]. Family also inquired about the when urinary catheter would be removed as resident seemed to be more confused than usual. R26's physician ordered urinalysis, urine culture, complete blood count (CBC) and basic metabolic panel. Urine specimen was collected on [DATE] (no time noted) and results reported to facility [DATE] at 1:01pm. Urinalysis showed presence of yeast, trace of protein, small occult blood, small leucocytes. Platelet count was critically low. These results were not reported to the physician until [DATE]. The CBC was repeated [DATE], showed elevated white blood cells (WBC) and further drop in the platelet count. The results was reported to the facility at 12:03pm and relayed to physician at 6pm. Nursing Documentation dated [DATE], 5pm, states R26 had 3 episodes of foul smelling diarrhea. Notes also states R26 was feeling weak and experiencing shortness of breath during physical therapy. Nursing assessment shows diminished lung sounds. R26's physician was notified of these symptoms and notified of low blood Potassium level (2.7 milli-equivalent per liter) and gave order to increase potassium medication and repeat potassium level on [DATE], administer oxygen at 2 liters per minute as needed for shortness of breath and obtain stool specimen for [MEDICAL CONDITION]. Nursing documentation on the 11pm - 7am shift of [DATE] shows oxygen saturation decreased to 94% on room air, lung sounds diminished and R26 incontinent of loose bowel movement. R26 was not receiving Oxygen. Stool specimen was received by the laboratory on [DATE] and reported positive for [MEDICAL CONDITION] to the facility on [DATE]. E27 (Nurse) documented on [DATE] at 11am that R26 complained of weakness, numbness in all extremities, shortness of breath, mouth breathing and pale. R26's blood pressure was ,[DATE] (low), pulse 124 beats per minute and respiratory rate 22 per minute. Temperature was documented as 97.9 degrees Fahrenheit and Oxygen saturation at 95% at room air. Z7 (attending physician) was paged and call not returned until 1 hour later, with order to send R26 to the hospital for evaluation. A private ambulance company was called and informed E that they would arrive at facility in 20 minutes. R26 was transported out of the facility at 12:30pm. There is no evidence to support continued monitoring of R26's condition over the 90 minutes period. E27 wrote at 1pm that R26 was diverted in transit to the nearest hospital due to unstable vital signs. E27 told surveyor on [DATE] at approximately 2:25pm that he took care of R26 off and on as he floats to other units. E27 observed R26 in bed, complaining of weakness and numbness in lower extremities and slouching as if lethargic. R26's blood pressure was observed to be lower than normal. E27 further stated that he spoke with Z7 less that 30 minutes after the page was placed. E27 said he observed no further decline in R26's condition and had no explanation for why he did not document evidence of further monitoring. Paramedic report dated [DATE] states R26 was diverted to hospital which was 3 minutes away due to drop in blood pressure. The destined hospital was estimated to be 20 minutes away. Emergency Department Record shows R26 arriving at 12:55pm with temperature of 102 degrees Fahrenheit, blood pressure ,[DATE], pulse rate 122 per minute and respirations at 24 per minute. R26 was diagnosed with [REDACTED]. Hospital record also states R26 had a Stage I and Stage II pressure sore to the buttocks and Deep Tissue Injury to the right great toe. These conditions were not documented in the facility records. Z7 stated on [DATE] at approximately 11:55am that R26's decline was insidious while in the emergency room and R26 had little chance of recovery given his multiple co-morbid conditions. Z7 listed all of R26's current and past medical history. Regarding the elevated WBC on [DATE] (from 5,000 k/mm cu to 10.3 k/mm cu) within one week, Z7 stated he didn't consider this as significant. Regarding treatment for [REDACTED]. Z7 went on to say that [MEDICATION NAME] is a more aggressive choice of treatment for [REDACTED]. Z7 went on to say that after treatment for [REDACTED]. R26's WBC was noted to be 35.8 k/mm cu within 3 hours of being seen in the emergency room . It was last checked in the facility on [DATE]. On [DATE] at approximately 9:30am, Z2 (nurse Consultant) stated nurses cannot transport resident to hospital without a physician's order even in the event of a life threatening emergency. Z2 went on to say that the facility has no policy that addresses when nurses can make decisions to send resident out to the hospital in the event of an emergency and physician not responding to a page in a timely manner. Regarding R26's change in condition, Z2 stated that there were multiple co-morbid conditions in question and, when R26 developed lower extremity [MEDICAL CONDITION] and numbness, the family refused treatment. Z2 was not able to provide documentation to support this. Z2 went on to say that facility staff kept a diligent eye on R26, but again could not provide any written evidence to support this. Regarding timeliness of getting R26 to the hospital Z2 stated that, after physician's order for transport to the hospital, facility nurses did not call emergency response (911) because there was no physician's order for this and R26 had a DNR (do not resuscitate) status and emergency response paramedics usually attempt resuscitation.