Every finding on record at Alden Lakeland Rehab & HCC

Based on record review and interviews, the facility failed to notify the resident's physician and court-appointed State Guardian of a significant change requiring physician intervention and representative involvement for 1 (R1) of 1 sampled resident reviewed for notification requirements. Findings include:R1 had diagnoses including serious mental illness and medical conditions requiring ongoing treatment and stabilization such as schizophrenia, gestational hypertension, post-traumatic stress syndrome, mood disorder due to known physiological condition with depressive features, psychotic disorder with hallucinations, anxiety disorder, hypomagnesemia and history of falling. The resident's clinical record identified a court-appointed State Guardian, V11, as the legally authorized representative responsible for healthcare decision-making and participation in care planning.R1's hospital records titled Clinical Intake Snapshot document the following:Patient 101: R1 is a [AGE] year-old female requiring high-acuity psychiatric and medical stabilization following a decompensation of schizophrenia and a recent delivery. Her complex history of self-harm, physical aggression, and lack of stable housing necessitates 24-hr clinical environment to manage severe mental health symptoms and ensure safety. Formal post-acute care is essential to provide the medication management, therapeutic monitoring, and assistance with activities of daily living that cannot be safely or effectively managed in a home setting.Behavioral & Cognitive Status: R1 demonstrated a volatile clinical course characterized by active psychosis, attempts at self-harm to terminate her pregnancy, and physical aggression toward hospital staff. While her psychotic symptoms have improved with Haldol (30-32mg TDD) and Lithium, she remains intermittently irritable, blunted, and anxious with limited insight into her condition. Her cognitive status shows a decline with a Modified Short Blessed Cognitive Test score of 16, and she requires ongoing 24-hour supervision to manage unpredictable behaviors and ensure medication adherence.Progress Notes dated 5/29/2026 19:20 by V4, Licensed Practical Nurse, documents:Resident remain persistent on leaving AMA (Against Medical Advice) post education and encouragement. Risks of leaving AMA were thoroughly explained, including potential complications and worsening condition (sic). Alternatives and recommended plan (sic) of care were discussed with patient. Patient verbalized understanding of education provided but continues to refuse treatment and requests discharge. NP (Nurse Practitioner) notified and has given consent for AMA request. Resident left the unit ambulatory with personal belongings. No acute distress noted at time of departure. All appropriate departments made aware. There was no documentation showing the attending physician was informed of the resident's departure to provide medical direction regarding medication management, follow-up treatment, or interventions to mitigate risks associated with interruption of care. Additionally, there was no evidence that the State Guardian was informed of the resident's departure, current status, healthcare needs, or the risks associated with leaving the facility without ongoing psychiatric and medical treatment. V1 presented a document titled Against Medical Advice (AMA) Form: Release from Responsibility for Discharge which bears the signature of R1 and an unknown Facility Representative's Signature/Witness which V1 identified as V4, Licensed Practical Nurse. V1 also stated that it is not in their policy to provide emergency medications when discharging against medical advice.On 6/5/2026 at 10:55 A.M., V11, R's State Guardian, affirmed that the facility informed V11 on 6/1/2026, 2 days after R1 left the facility. V11 stated she was not informed of R1 discharging from the nursing home. Instead of contacting the State Guardian, they contacted their in-house psychiatrist. V11 is new to her case, hasn't met R1, doesn't know where R1 went and has no way of contacting R1. Previously, before hospitalization, R1 was in jail and was homeless. R1 is unmedicated with metal health issues, post-partum and as State Guardian, V11 has no ability to oversee R1's well-being. V11 also stated that if the facility had called her, V11 would not give consent for R1 to leave the facility without proper discharge placement. V11 confirmed that the facility contacted the State Guardian after-hours number on 5/30/2026, 1 day after R1 left the facility.On 6/6/2026 at 1:13 P.M. V8, Psychiatric Nurse Practitioner, stated that if a resident abruptly stops taking psychotropic medications, behaviors can get worse, and psychosis can kick right in.On 6/5/2026 at 12:39 P.M., V4, Licensed Practical Nurse (LPN) stated on 5/29/2026 R1 verbalized wanting to leave the facility and V4 explained to R1 that it isn't safe for R1 to leave but R1 insisted on leaving the facility. V4 explained the risks of discharging against medical advice, was not offered other alternatives and R1 still demanded to leave and stated R1 was going to a shelter house. V4 stated she is not aware of R1's past medical and psychiatric history but knows R1 has anxiety and agitation, and she was aware that R1 had a State Guardian but did not call the State Guardian about wanting to leave AMA.On 6/5/2026 at 12:41 P.M., V4, Assistant Director of Nursing, stated she called R1's state guardian on 5/30/2026, day after R1 left the facility by calling the after hours on call number, left a message and somebody returned her call soon after. V4 informed the on-call guardian that R1 was aggressive and agitated and wanted to leave against medical advice.On 6/5/2026 at 1:58 PM, V7, R1's Primary Doctor, stated he recalls being informed about R1 leaving AMA but can't recall the date and time he was informed and asked to call V9, V7's Nurse Practitioner who rounds routinely at the facility for specifics.On 6/5/2026 at 2:04 P.M., V9, Nurse Practitioner, stated V9 is not familiar with R1, and has not seen R1 because V9 was told R1 left Against Medical Advice. V9 stated they didn't call me about request to leave, V9 doesn't allow discharges against medical advice on the unit where R1 resided because it's a behavioral unit. If they called me about R1 wanting to leave against medical advice, V9 would have said no.On 6/5/2026 at 2:25 P.M., V8, Psychiatric Nurse Practitioner stated V8 contacted regarding R1 on 5/29/2026 but it is not in his capacity to discharge a resident from the facility because his job is to get the the patient psychiatrically stable and does not discharge anybody. V8 also stated In this situation, I did not believe or understand that I am being asked to make a discharge decision because that is not something I do even for the patient's I have seen 20 times if I am the sole provider. I would say they need to talk to the primary, DON and everyone involved in admissions and discharges. My job is to get patient psychiatrically stable, but I do not discharge anybody. The facts of the call were nursing reported that this resident wanted to leave AMA, nursing reported that this patient is stable. I asked if PRN (as needed) medications were needed, they said No. I asked if this needed to be escalated, is this agitation about wanting to leave needed a PRN or a send out. Because those are the things that I handle throughout the weekend. The nurse said the resident was mostly fine except for being there and wanting to go. The nurse said the resident wanted to leave against medical advice and the nurse also stated that she can't stop her from leaving. What was not reported to me was psychosis, suicidality, aggression, delirium, concerns for incapacity, guardianship issues, concerns that the resident was unsafe to leave, request for emergent psychiatric evaluation or disposition order. Why did I not escalate further? Because I'm the on-call provider for 250 facilities, I rely on the facility staff to communicate material, safety, legal and clinical concerns that require escalation. These concerns were not communicated, denied need for PRN intervention, denied need for hospitalization, did not mention guardian. It was presented to me as an independent resident, choosing to leave against medical advice. The issue is I'm not giving a discharge order and was asked if they are safe to leave with these medications. R1 has an order for Lithium, if the patient is decisional, stable, I would send R1 home with Lithium, which does not present an abuse or diversion concern. The nurse said there's nothing they can do to stop her. As far as guardianship is concerned, if this patient was a known patient to us, we would have known that R1 has a guardianship, and I would have caught that. My reviewing the medications and if R1 is safe to go home with those medications was misconstrued as a go signal for the facility to discharge this resident.On 6/6/2026 at 10:36 A.M. V2, Assistant Administrator, acknowledged that the Against Medical Advice (AMA) Form: Release from Responsibility for Discharge was signed by R1. V2 stated that the form should be signed by the resident, their decision maker and facility representative. If someone had a Guardian, the State Guardian should be signing this form. For R1, before R1 signed against medical advice (AMA), they should have contacted the State Guardian to let the Guardian know that R1 is wanting to leave AMA and it's ultimately up to the guardian to make that decision because the State Guardian is the decision maker at the end of the day. V2 also acknowledged speaking with V11, State Guardian on 6/1/2026, 2 days after R1 left the facility against medical advice. V11 requested V2 to file a missing report with the police agency. Review of the an undated policy titled AMA Release (Leaving Against Medical Advise) required staff to inform the attending physician/Nurse Practitioner of desire to leave the facility and required to give the resident's legal representatives an explanation concerning the risks involved in leaving the facility.

Based on interview and record review, the facility failed to ensure an appropriate and safe discharge process, failed to involve the legally authorized State Guardian, without necessary medications and without arrangements for placement and ongoing psychiatric or medical care. This affected one (R1) of three residents reviewed for discharges.As a result of the deficient practice, the resident experienced a disruption in continuity of care and was placed at significant risk for worsening psychiatric symptoms, behavioral destabilization, medication interruption, deterioration of medical conditions, emergency department utilization, hospitalization, and inability to safely manage healthcare needs following discharge. Findings include: R1 had diagnoses including serious mental illness and medical conditions requiring ongoing treatment and stabilization such as schizophrenia, gestational hypertension, post-traumatic stress syndrome, mood disorder due to known physiological condition with depressive features, psychotic disorder with hallucinations, anxiety disorder, hypomagnesemia and history of falling. The resident's clinical record identified a court-appointed State Guardian, V11, as the legally authorized representative responsible for healthcare decision-making and participation in care planning.R1's hospital records titled Clinical Intake Snapshot document the following:Patient 101: R1 is a [AGE] year-old female requiring high-acuity psychiatric and medical stabilization following a decompensation of schizophrenia and a recent delivery. Her complex history of self-harm, physical aggression, and lack of stable housing necessitates 24-hr clinical environment to manage severe mental health symptoms and ensure safety. Formal post-acute care is essential to provide the medication management, therapeutic monitoring, and assistance with activities of daily living that cannot be safely or effectively managed in a home setting.Behavioral & Cognitive Status: R1 demonstrated a volatile clinical course characterized by active psychosis, attempts at self-harm to terminate her pregnancy, and physical aggression toward hospital staff. While her psychotic symptoms have improved with Haldol (30-32mg TDD) and Lithium, she remains intermittently irritable, blunted, and anxious with limited insight into her condition. Her cognitive status shows a decline with a Modified Short Blessed Cognitive Test score of 16, and she requires ongoing 24-hour supervision to manage unpredictable behaviors and ensure medication adherence.R1's care plan showed the PASRR agent identified the following critical areas of focus for the resident crisis intervention, development of self-care skills, formal behavior modification program, pharmacotherapy, psychotherapy and structured socialization. Progress Notes dated 5/29/2026 19:20 by V4, Licensed Practical Nurse, documents:Resident remain persistent on leaving AMA (Against Medical Advice) post education and encouragement. Risks of leaving AMA were thoroughly explained, including potential complications and worsening condition (sic). Alternatives and recommended plan (sic) of care were discussed with patient. Patient verbalized understanding of education provided but continues to refuse treatment and requests discharge. NP (Nurse Practitioner) notified and has given consent for AMA request. Resident left the unit ambulatory with personal belongings. No acute distress noted at time of departure. All appropriate departments made aware.V1 presented a document titled Against Medical Advice (AMA) Form: Release from Responsibility for Discharge which bears the signature of R1 and an unknown Facility Representative's Signature/Witness which V1 identified as V4, Licensed Practical Nurse. V1 also stated that it is not in their policy to provide emergency medications when discharging against medical advice.On 6/5/2026 at 12:39 P.M., V4, Licensed Practical Nurse (LPN) stated on 5/29/2026 R1 verbalized wanting to leave the facility and V4 explained to R1 that it isn't safe for R1 to leave but R1 insisted on leaving the facility. V4 explained the risks of discharging against medical advice, was not offered other alternatives and R1 still demanded to leave and stated R1 was going to a shelter house. V4 stated she is not aware of R1's past medical and psychiatric history but knows R1 has anxiety and agitation, and she was aware that R1 had a State Guardian but did not call the State Guardian about wanting to leave AMA. V4 affirms that R1 was not physically or verbally aggressive that day but was just demanding to be discharged . V4 called V8, Psychiatric Nurse Practitioner (NP) and informed V8 that R1 wanted to leave AMA. V8, NP, discussed R1's medications with V4 and gave consent for AMA request. V4 stated she did not call R1's primary doctor and did not give any medications or prescriptions for medications when R1 left. V4 stated she informed V6, Director of Nursing (DON) after R1 had already left about R1 leaving against medical advice. On 6/5/2026 at 10:55 A.M., V11, R's State Guardian, affirmed that the facility informed V11 on 6/1/2026, 2 days after R1 left the facility. V11 stated she was not informed of R1 discharging from the nursing home. Instead of contacting the State Guardian, they contacted their in-house psychiatrist. V11 is new to her case, hasn't met R1, doesn't know where R1 went and has no way of contacting R1. Previously, before hospitalization, R1 was in jail and was homeless. R1 is unmedicated with metal health issues, post-partum and as State Guardian, V11 has no ability to oversee R1's well-being. V11 also stated that if the facility had called her, V11 would not give consent for R1 to leave the facility without proper discharge placement. V11 confirmed that the facility contacted the State Guardian after-hours number on 5/30/2026, 1 day after R1 left the facility.On 6/5/2026 at 11:37 A.M., V3, Behavioral Health Director, stated R1 wasn't necessarily in an active mental health episode, not to my estimation but I didn't get a huge impression on her, she appeared stable mentally, but you can tell that there is an underlying psychosis. If a resident has a State Guardian and wants to leave against medical advice (AMA) or if someone is mentally unstable, V3 would explain to the resident that it is not safe to be discharged at this time, call the primary doctor and the psychiatrist and get their recommendations, call the State Guardian. If resident becomes verbally aggressive and violent, V3 would petition for involuntary discharge. V3 met with the police on 6/1/2026 and filed a missing person report. On 6/5/2026 at 2:25 P.M., V8, Psychiatric Nurse Practitioner stated My capacity when I am on call is I am covering up to 250 facilities. My role is to manage emergent and urgent changes in the patient condition. Or medication questions, orders, clarifications. And decisions whether to send to the hospital or not. In this case, this is a building I have never been to, a patient I have never met, and my company has not evaluated. So, if I was to get a call about a patient I have not met or not evaluated, I can still triage and make those orders. To be clear, they also were not in our company's electronic health record so the only information I have is from the nurse. In this situation, I did not believe or understand that I am being asked to make a discharge decision because that is not something I do even for the patient's I have seen 20 times if I am the sole provider. I would say they need to talk to the primary, DON and everyone involved in admissions and discharges. My job is to get patient psychiatrically stable, but I do not discharge anybody. The facts of the call were nursing reported that this resident wanted to leave AMA, nursing reported that this patient is stable. I asked if PRN (as needed) medications were needed, they said No. I asked if this needed to be escalated, is this agitation about wanting to leave needed a PRN or a send out. Because those are the things that I handle throughout the weekend. The nurse said the resident was mostly fine except for being there and wanting to go. The nurse said the resident wanted to leave against medical advice and the nurse also stated that she can't stop her from leaving. What was not reported to me was psychosis, suicidality, aggression, delirium, concerns for incapacity, guardianship issues, concerns that the resident was unsafe to leave, request for emergent psychiatric evaluation or disposition order. Why did I not escalate further? Because I'm the on-call provider for 250 facilities, I rely on the facility staff to communicate material, safety, legal and clinical concerns that require escalation. These concerns were not communicated, denied need for PRN intervention, denied need for hospitalization, did not mention guardian. It was presented to me as an independent resident, choosing to leave against medical advice. The issue is I'm not giving a discharge order and was asked if they are safe to leave with these medications. R1 has an order for Lithium, if the patient is decisional, stable, I would send R1 home with Lithium, which does not present an abuse or diversion concern. The nurse said there's nothing they can do to stop her. As far as guardianship is concerned, if this patient was a known patient to us, we would have known that R1 has a guardianship, and I would have caught that. My reviewing the medications and if R1 is safe to go home with those medications was misconstrued as a go signal for the facility to discharge this resident.On 6/6/2026 at 1:13 P.M. V8 also stated that if a resident abruptly stops taking psychotropic medications, behaviors can get worse, and psychosis can kick right in. On 6/6/2026 at 10:36 A.M. V2, Assistant Administrator, acknowledged that the Against Medical Advice (AMA) Form: Release from Responsibility for Discharge was signed by R1. V2 stated that the form should be signed by the resident, their decision maker and facility representative. If someone had a Guardian, the State Guardian should be signing this form. For R1, before R1 signed against medical advice (AMA), they should have co tacted the State Guardian to let the Guardian know that R1 is wanting to leave AMA and it's ultimately up to the guardian to make that decision because the State Guardian is the decision maker at the end of the day. V7, R1's primary doctor was contacted to inquire if V7 was notified regarding R1. V7 wants V9 (Nurse Practitioner) to be interviewed regarding this matter. On 6/5/2026 at 2:04 P.M., V9, Nurse Practitioner, stated V9 is not familiar with R1, and has not seen R1 because V9 was told R1 left Against Medical Advice. V9 stated they didn't call me about request to leave, V9 doesn't allow discharges against medical advice on the unit where R1 resided because it's a behavioral unit. If they called me about R1 wanting to leave against medical advice, V9 would have said no.Review of the an undated policy titled AMA Release (Leaving Against Medical Advise) required staff to required to give resident's legal representatives an explanation concerning the risks involved in leaving the facility.

Based on interview, and record review, the facility failed to ensure the rights of 1 (R1) of 1 sampled resident were protected by failing to notify and involve the resident's court-appointed State Guardian when the resident left the facility against medical advice (AMA). The facility failed to communicate the resident's departure to the State Guardian, failed to involve the State Guardian in decisions affecting the resident's discharge and continuity of care, and failed to ensure the resident representative was provided information necessary to assist in securing ongoing psychiatric and medical treatment. As a result of the noncompliance R1 was deprived of the protections and advocacy afforded by the court appointed State Guardian and left the facility without coordinated psychiatric and medical follow-up, medication access, or continuity-of-care arrangements and has the potential to affect resident's health, safety and welfare through interruption of treatment, loss of representative support and increase risk of psychiatric and medical deterioration. Findings include: R1 had diagnoses including serious mental illness and medical conditions requiring ongoing treatment and stabilization such as schizophrenia, gestational hypertension, post-traumatic stress syndrome, mood disorder due to known physiological condition with depressive features, psychotic disorder with hallucinations, anxiety disorder, hypomagnesemia and history of falling. The resident's clinical record identified a court-appointed State Guardian, V11, as the legally authorized representative responsible for healthcare decision-making and participation in care planning.R1's hospital records titled Clinical Intake Snapshot document the following:Patient 101: R1 is a [AGE] year-old female requiring high-acuity psychiatric and medical stabilization following a decompensation of schizophrenia and a recent delivery. Her complex history of self-harm, physical aggression, and lack of stable housing necessitates 24-hr clinical environment to manage severe mental health symptoms and ensure safety. Formal post-acute care is essential to provide the medication management, therapeutic monitoring, and assistance with activities of daily living that cannot be safely or effectively managed in a home setting.Behavioral & Cognitive Status: R1 demonstrated a volatile clinical course characterized by active psychosis, attempts at self-harm to terminate her pregnancy, and physical aggression toward hospital staff. While her psychotic symptoms have improved with Haldol (30-32mg TDD) and Lithium, she remains intermittently irritable, blunted, and anxious with limited insight into her condition. Her cognitive status shows a decline with a Modified Short Blessed Cognitive Test score of 16, and she requires ongoing 24-hour supervision to manage unpredictable behaviors and ensure medication adherence.Progress Notes dated 5/29/2026 19:20 by V4, Licensed Practical Nurse, documents:Resident remain persistent on leaving AMA (Against Medical Advice) post education and encouragement. Risks of leaving AMA were thoroughly explained, including potential complications and worsening condition (sic). Alternatives and recommended plan (sic) of care were discussed with patient. Patient verbalized understanding of education provided but continues to refuse treatment and requests discharge. NP (Nurse Practitioner) notified and has given consent for AMA request. Resident left the unit ambulatory with personal belongings. No acute distress noted at time of departure. All appropriate departments made aware.V1 presented a document titled Against Medical Advice (AMA) Form: Release from Responsibility for Discharge which bears the signature of R1 and an unknown Facility Representative's Signature/Witness which V1 identified as V4, Licensed Practical Nurse. V1 also stated that it is not in their policy to provide emergency medications when discharging against medical advice.On 6/5/2026 at 10:55 A.M., V11, R's State Guardian, affirmed that the facility informed V11 on 6/1/2026, 2 days after R1 left the facility. V11 stated she was not informed of R1 discharging from the nursing home. Instead of contacting the State Guardian, they contacted their in-house psychiatrist. V11 is new to her case, hasn't met R1, doesn't know where R1 went and has no way of contacting R1. Previously, before hospitalization, R1 was in jail and was homeless. R1 is unmedicated with metal health issues, post-partum and as State Guardian, V11 has no ability to oversee R1's well-being. V11 also stated that if the facility had called her, V11 would not give consent for R1 to leave the facility without proper discharge placement. V11 confirmed that the facility called the on-call State Guardian after hours number on 5/30/2026, a day after R1 had left the facility. On 6/6/2026 at 1:13 P.M. V8, Psychiatric Nurse Practitioner, stated that if a resident abruptly stops taking psychotropic medications, behaviors can get worse, and psychosis can kick right in.On 6/5/2026 at 12:39 P.M., V4, Licensed Practical Nurse (LPN) stated on 5/29/2026 R1 verbalized wanting to leave the facility and V4 explained to R1 that it isn't safe for R1 to leave but R1 insisted on leaving the facility. V4 explained the risks of discharging against medical advice, was not offered other alternatives and R1 still demanded to leave and stated R1 was going to a shelter house. V4 stated she is not aware of R1's past medical and psychiatric history but knows R1 has anxiety and agitation, and she was aware that R1 had a State Guardian but did not call the State Guardian about wanting to leave AMA.On 6/5/2026 at 12:41 P.M., V4, Assistant Director of Nursing, stated she called R1's state guardian on 5/30/2026, day after R1 left the facility by calling the after hours on call number, left a message and somebody returned her call soon after. V4 informed the on-call guardian that R1 was aggressive and agitated and wanted to leave against medical advice.On 6/6/2026 at 10:36 A.M. V2, Assistant Administrator, acknowledged that the Against Medical Advice (AMA) Form: Release from Responsibility for Discharge was signed by R1. V2 stated that the form should be signed by the resident, their decision maker and facility representative. If someone had a Guardian, the State Guardian should be signing this form. For R1, before R1 signed against medical advice (AMA), they should have contacted the State Guardian to let the Guardian know that R1 is wanting to leave AMA and it's ultimately up to the guardian to make that decision because the State Guardian is the decision maker at the end of the day. V2 also acknowledged speaking with V11, State Guardian on 6/1/2026, 2 days after R1 left the facility against medical advice. V11 requested V2 to file a missing report with the police agency. Review of the an undated policy titled AMA Release (Leaving Against Medical Advise) required staff to required to give resident's legal representatives an explanation concerning the risks involved in leaving the facility.

Based on interview and record review, the facility failed to perform a dependent resident's transfer from the reclining wheelchair to the bed with a mechanical lift machine as assessed and care planned which affected one resident (R93) reviewed for transfers in a total sample of 73. This deficient practice resulted in R93 immediately experiencing left shoulder pain, transferred to the hospital and computerized tomography (CT) imaging results showed displaced mildly comminuted fracture of the surgical neck of left humerus bone.Findings include:R93's admission Record documents that R93 was admitted to the facility on [DATE] with diagnoses including but not limited to, Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; Chronic respiratory failure with hypoxia; Liver transplant status; Kidney transplant status; Dependence on renal dialysis; Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral. R93's Minimum Data Set (MDS) documents, in part, a Brief interview for Mental Status (BIMS) score of 14, indicating R93 is cognitively intact. R93's care plan, dated 04/24/2024 reads in part: FOCUS: R93 requires the use of a mechanical lift for transfers due to impaired balance related to cerebral vascular accident (CVA). INTERVENTIONS: Ensure care during transfer (dated 04/24/2024) and use total body (mechanical lift) when transferring resident (dated 10/13/2025).R93's MDS Section GG Functional Abilities reads R93 is dependent on staff for sit to lie and chair/bed-to-chair transfers. This indicated R93 is dependent on the helper doing all the effort, where resident does none of the effort to complete the activity, or the assistance of 2 helpers is required for the resident to complete the activity.On 06/01/2026 at 12:45PM, R93 states, sometime back in November of 2025 (unable to recall exact date), R93 had returned from his hemodialysis session, and V22 (Certified Nurse Assistant/ CNA) with V48 (CNA, Former Employee) were transferring R93 into bed. R93 states V22 insisted R93 can transfer without the mechanical lift and proceeded to transfer R93 by grabbing the back of R93's incontinence brief and the back of R93's gown at the neck area and shoved R93 onto the bed. R93 states that V22 then proceeded to reach down and grab both of his legs to place them up on the bed. R93 states V22 raised his legs very high, and R93's upper body fell unto the bed landing on his left side and immediately caused pain in R93's left shoulder. R93 states most times, CNAs transfer him into bed with a mechanical lift, but V22 does not use the mechanical lift. R93 states V22 did not use a gait belt during this transfer. R93 states his left shoulder still hurts a little bit but not as much as when this happened.R93's hemodialysis servicer report indicates R93 arrived in the in-facility dialysis center on 11/05/2025 at 11:45AM. R93's dialysis treatment start time was 12:00PM and treatment end time was 3:30PM. On 06/03/2026 at 10:44AM via a telephone interview, V22 (CNA) stated, sometime in November of 2025 (V22 unable to recall exact date), V22 and V48 were transferring R93 into bed using a mechanical lift. V22 states R93's arm got stuck behind R93's body and V48 pulled R93's arm out. V22 states V22 reported the incident to V25 (Registered Nurse, RN) on duty, and V25 went to R93's room to check in on the resident. V22 states R93's arm should not have been pulled out from under his body because this would cause a lot of pain to R93. On 06/03/2026 at 12:45PM, 12:59PM, and 1:10PM surveyor attempted to contact V48 (CNA, Former Employee) via telephone with no success.On 06/03/2026 at 1:20PM V25 (RN) was interviewed while sitting at the nurse's station on the 4th floor. V25 states this incident was a long time ago and V25 does not remember much. V25 states V25 did not witness the incident but recalls V22 reporting R93 got injured while transferring R93 from the reclining wheelchair unto the bed. V25 stated that V25 assessed R93 and gave R93 pain medication.On 06/03/2026 at 2:11PM V2 (Director of Nursing, DON) states that resident transfers should be performed as outlined in the care plan. When the care plan states a resident requires a mechanical lift, then 2 people should do the transfer as follows: first they must make sure the resident is secured on the lift pad, next 1 person lifts the resident with the (lever, button) from the machine, then 1 person guides the resident to the bed while the other person guides the lift machine that is holding the resident in the air moving the resident from the wheelchair to the bed. If a transfer requiring a mechanical lift is performed without the mechanical lift, there is a risk of accident which can potentially result in a serious injury.On 06/03/2026 at 2:36PM V13 (Therapy Director/Occupational Therapist, TD/OT) states, if a resident is unable to move their body or has no balance they would require a mechanical lift for transfers. A gait belt is not considered a mechanical lift and should not be used for residents who cannot move their body or have no balance, as this would be a safety issue. Staff should follow the requirements as they are outlined in the care plan for transfers.On 06/04/2026 at 12:31PM, V44 (Nurse Practitioner, NP) states that R93 complained of shoulder pain and was sent out to the hospital for X-rays, and the hospital CT report showed it was a shoulder fracture. Surveyor asked if a gait belt should be used on R93 for transfers on a resident having left sided weakness due to CVA, V44 stated, No, because due to R93's impaired balance a mechanical lift provides more stability whereas a gait bait requires some strength on the resident's side. If the care plan states a mechanical lift should be used then that's what staff should use because this is what the resident was assessed as needing for transfers. Not using a mechanical lift for this particular resident (R93) can pose a risk for injury.R93's hospital records document, in part, that R93's left upper extremity CT scan results dated 11/07/2025 of read, in part, Minimally displaced mildly comminuted fracture of the surgical neck.Incident/Accident Notification Initial Report dated 11/07/2025, reads in part, Facility Response/Follow up: During the investigation, (V22) reported that upon resident's (R93) return from in-house dialysis, she assisted him back into bed. (V22) stated that she applied a gait belt and, with assistance from (V48) transferred (R93) from his wheelchair to his bed. (V48) corroborated this account, confirming (V48) assisted with the transfer and was positioned on the resident's left side. According to both CNA's the resident (R93) reported left-shoulder pain following the transfer.Statement dated 11/07/2025, given by V22 (unsigned) reads in part, After dialysis I assisted (R93) back to bed with the help of (V48). I applied the gait belt to his wait and with the help of (V48) we put him in bed. After putting him to bed he complained of pain in his left arm, and we reported it to the nurse (V25). This statement is not signed by V22 and is inconsistent with V22's interview from 06/03/2026 at 10:44AM.Statement dated 11/07/2025, given by V48 reads in part, (V22) asked me to help put (R93) to bed. After putting him to bed (R93) complained of pain in his left arm. We both told (V25) that (R93) had pain in his left arm. This statement is not signed by V48.Facility policy titled, Transfer Techniques, dated 02/2022 reads in part: Purpose: To safely transfer the resident from bed to chair or from one location to another. Procedure: Transfer from bed to wheelchair (resident unable to assist)- Obtain equipment from designated area and bring to bedside. Obtain assistance of another person, for safe transfer. Explain procedure to resident.

Based on observation, interview and record review, the facility failed to label and date opened food stored in the refrigerator and freezer, failed to discard expired food, failed to store fresh produce in an intact container. This failure has the potential to affect all 140 residents on oral diets.Findings include:On 06/01/26 at 9:37am observed facility's walk-in refrigerator with pan of carrots with a use by date of 05/30/26, container with yellow liquid with use by date of 05/28/26, open container of purple gelatin substance with no open or use by date, a box of broccoli with green fuzzy material covering the box.On 06/01/26 at 9:37am V30 (Dietary Supervisor) stated that the expired foods should be discarded. V30 stated that the box with broccoli has some type of residue on it. V30 stated that the residue is not safe, and the broccoli should have been discarded. V30 stated that all opened items in the refrigerator should have a use by date on it.On 06/01/26 at 9:50am observed facility's walk-in freezer with brown meat with ice on top of meat, no label or date. On 06/01/26 at 9:50am V30 (Dietary Supervisor) stated that the brown meat is some kind of beef. V30 stated that the beef has ice build up on it. V30 stated that the beef is not dated or stored properly and needs to be discarded. On 06/01/26 at 9:55am observed facility's dry storage room with container of dry cereal, no use by date.On 06/01/26 at 9:55am V30 (Dietary Supervisor) stated that the container of dry cereal is good for 6 months but does not usually last 6 months, so he does not date it.On 06/01/26 at 11:07am observed facility's 2nd floor nourishment room's refrigerator with a large black bag with food not contained in container or dated, bag of food with no resident label dated 05/11/26, 2 white foam containers with no resident label or date, bottle of thickened water with open date of 01/21/26, expiration date not legible.On 06/01/26 at 11:07am V2 (Director of Nursing/DON) stated that the 2nd floor nourishment room is used to store resident food. V2 stated that the food should be labeled and dated with name date and room number. V2 stated that the food should be labeled so that residents don't consume expired food.Facility's policy titled Food Storage dated 7/17 documents in part, Policy: Food storage areas will be maintained in a clean, safe and sanitary manner. Purpose: To reduce the risk of food borne illness. Procedure: 6. Foods taken from their original container will be label by common name.Facility's policy titled Labeling and Dating dated 7/24 documents in part, Policy: Ready to eat time/temperature control for safety foods may be stored in the refrigerator held at 41 degrees Fahrenheit for 7 days. Purpose: To reduce the risk of food borne illness. Procedure: 1. Ready to eat time/temperature for safety (TCS) food that is held for less than 24 hours may be labeled with the common name and date it is placed in the refrigerator. 2. On premise preparation of ready-to-eat TCS item that is to be held for longer than 24 hours in the refrigerator will be marked to indicate which date or day the food must be consumed or discarded. 3. Commercially processed TCS that is to be held for longer than 24 hours in the refrigerator will be marked to indicate which date or day the food must be consumed or discarded.Facility's policy titled Produce dated 8/18 documents in part, Policy: Produce that is fresh and wholesome will be used in food production. Purpose: To reduce the risk of food borne illness. Procedure: 1. Fresh produce will be accepted when outward appearance is fresh, box is intact, and wholesome. 2. When gathering fresh produce for preparation from storage, do not use produce that is moldy, crushed, cut, or otherwise unwholesome. Discard when observed.

Based on interview and record review the facility failed to have a qualified Infection Preventionist in the facility. This failure has the potential to affect all 179 residents who reside in the facility. Findings Include:On 06/01/2026 at 11:00 AM, V1 (Administrator) stated that V26 (Infection Preventionist Nursing Consultant/IP) was responsible for oversight of the facility's infection prevention and control program by providing guidance to V2 (Director of Nursing), as V2 had not completed Infection Preventionist (IP) training course hours.On 06/03/2026 at 11:03 AM, V2 stated that V26's documentation had been submitted because she completed the IP training course on 12/12/2020. V2 stated that he is the individual who manages the infection prevention and control program within the facility and acknowledged that he does not have IP training. V2 stated that the facility's last Infection Preventionist nurse resigned during the first week of May 2026.On 06/03/2026 at 1:45 PM, V26 stated that she serves as the Infection Preventionist consultant who oversees the infection prevention and control program and provides guidance to V2; however, she does not work in the facility full-time.The facility policy titled Infection Prevention and Control Program, dated 09/20/2024, documented in part: Mission of Program: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy: (Required Phase 3, November 28, 2019) The facility will designate one or more individuals as the Infection Preventionist (IP) who is responsible for the facility's infection prevention and control program and who is qualified by education, training, experience, or certification.

Based on observations, interviews and record review, the facility failed to place the call light within reach according to the facility's policy. This failure affected 4 of 4 (R10, R36, R155,169) residents reviewed for call lights in a total sample of 73. Findings include:R10's Face Sheet documents in part, R10 is a [AGE] year-old with diagnoses of Chronic Respiratory Failure, Encephalopathy, Epilepsy, and Cerebral Palsy. R36's Face Sheet documents, in part, R36 is an [AGE] year-old with diagnoses of Acute Respiratory Failure with Hypoxia, Hemiplegia, Hypotension, Type 2 Diabetes, and Chronic Systolic (Congestive) Heart Failure.R155's Face Sheet documents, in part, R155 is a [AGE] year-old with diagnoses of Cerebral Infraction, Acute Respiratory Failure with Hypoxia, Type 2 Diabetes, and Bronchitis. R169's Face Sheet documents, in part, R169 is a [AGE] year-old with diagnoses of Lensox-Gastaut Syndrome, Adult Failure to Thrive, Metabolic Encephalopathy, and Epilepsy. On 6/1/26 at 11:53 AM Surveyor observed R169's call light wrapper around the oxygen flow meter and R155's call light was observed on the floor and not accessible for the residents.On 6/1/26 at 12:11PM Surveyor observed R36's call light on the side of the bed and not within the residents' reach.On 6/3/26 at 9:43 AM Surveyor observed R10's call light on the floor and not within the resident's reach.On 6/3/26 at 9:45 AM Surveyor observed R36's call light on the floor under the bed not accessible for the resident.On 6/3/26 at 10:01 AM V40 (Certified Nursing Assistant-CNA) stated, we (staff) do rounds every 2 hours. If I'm not in the room they will call on the call light the ones that can or yell out. I check to make sure the call light is within reach. It is important for the call light to be in reach in case they (the residents) need something, or they are in painOn 6/3/26 10:09 AM V37 (License Practical Nurse-LPN) stated, the call light should be in the resident's reach for safety in case they need something. All the staff rounds, CNA, respiratory therapist and nurses. If the call light is not within reach, it should be placed within reach for safety.On 6/3/26 at 10:34 AM V5 (Assistant Director of Nursing- ADON) stated, staff are required to make sure all resident call lights are within reach. We provide Inservice for all staff on the floor. All staff should check and see what the resident needs. Education is provided during standup every day. I monitored compliance by making rounds and I put the clips on the residents' gown for the call light and remind the staff to attach the clip to the residents' gown after providing care. When the staff are rounding they go into the room to make sure the call light is in place. It is important to ensure residents have access to their call lights because if the resident is about to fall or in distress, they can call for help. The residents are educated to call for help.R10's Care Plan dated 6/11/2026, documents, in part, Keep call light within reach.R36's Care plan date 5/6/26, documents, in part, Promote placement of call light within reach. Keep call light within reach.R155's Care plan dated 4/7/2026, documents, in part, Promote placement of call light within reach.R169's Care Plan Date 4/22/26, documents, in part, Encourage use of call light when needed, Promote placement of call light within reach.Facility Policy dated 09/2020, titled Call Light, Use Of documents, in part: Be sure call lights are placed within resident reach at all times.

Based on observation, interview and record review the facility failed to ensure that three residents( R110,R137,R149) splints were applied to their extremities and also failed to provide one resident Restorative programs (R11).This failure has affected four residents reviewed for range of motion and mobility in a sample size of 72. Findings include:On 06/01/2026 at 11:15 AM, R11 was observed lying in bed watching television. R11 was alert, responsive, able to make needs known to staff, and denied pain or discomfort. During interview, R11 stated therapy would make her feel better and reported she would like to receive restorative therapy daily. R11 further stated it had been over a month since she had received any therapy services.R11's face sheet dated 06/03/2026 documented diagnoses that included chronic obstructive pulmonary disease, cardiomegaly, hypertensive heart disease, heart failure, atrial fibrillation, essential hypertension, myocardial infarction, chronic kidney disease, major depressive disorder, morbid obesity, and asthma.R11's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R11 was cognitively intact.R11's care plan dated 09/11/2018 documented R11 required staff assistance with bed mobility due to generalized weakness and morbid obesity. Interventions included assisting the resident with positioning and turning in bed.On 06/03/2026 at 09:20 AM, V29 (Therapy Director/Occupational Therapist) stated R11 last received therapy services on 09/13/2025 and, upon discharge from therapy, was recommended for restorative range-of-motion services to the upper extremities to maintain upper body function.On 06/01/2026 at 11:36 AM, R110 was observed resting in bed. R110 was nonverbal and unable to participate in an interview. No signs of pain or distress were noted. Both hands were resting on top of the blanket, and no hand rolls or splints were in place. Bilateral hand contractures were observed.R110's face sheet dated 06/03/2026 documented diagnoses that included anoxic brain damage, chronic respiratory failure, dysphagia, anemia, essential hypertension, muscle spasms, quadriplegia, anxiety, and encephalopathy.R110's MDS assessment dated [DATE] documented a BIMS score of 0, indicating severe cognitive impairment. The assessment further documented the resident was dependent on staff for dressing and grooming.R110's care plan dated 09/08/2015 documented the resident required splints secondary to limited range of motion. Interventions directed staff to apply bilateral hand rolls each morning and remove them each evening.On 06/01/2026 at 11:42 AM, R137 was observed resting in bed. R137 was awake but nonverbal and unable to participate in an interview. The resident appeared clean, comfortable, and free of distress. Bilateral hand contractures were observed.R137's face sheet dated 06/03/2026 documented diagnoses that included spastic quadriplegic cerebral palsy, diabetes mellitus, epilepsy, anemia, cortical blindness, encephalopathy, chronic respiratory failure, muscle wasting, scoliosis, and neuromuscular dysfunction.R137's MDS assessment dated [DATE] documented a BIMS score of 3, indicating severe cognitive impairment. The assessment further documented the resident was dependent on staff for dressing and grooming.R137's care plan dated 10/08/2025 documented the resident had bilateral arm contractures related to cerebral palsy and spastic quadriparesis. Interventions directed staff to apply splints and braces as ordered.On 06/01/2026 at 12:00 PM, R149 was observed lying in bed. R149 was alert, responsive, able to communicate needs, and denied pain. During interview, R149 stated staff had not applied her right-hand splint for a while, despite her understanding that it was supposed to be worn daily. R149 further reported she had not participated in restorative programming for a long time.R149's face sheet dated 06/03/2026 documented diagnoses that included hemiplegia and hemiparesis affecting the right dominant side, cerebral infarction, chronic obstructive pulmonary disease, morbid obesity, major depressive disorder, bradycardia, seizures, insomnia, anxiety, bipolar disorder, and diabetes mellitus.R149's MDS assessment dated [DATE] documented a BIMS score of 14, indicating the resident was cognitively intact. The assessment further documented the resident required substantial to maximal assistance with dressing and grooming.R149's care plan documented the resident required a resting hand splint to the right upper extremity at night due to limited range of motion. Interventions directed staff to apply the splint according to physician orders.On 06/02/2026 at 12:33 PM, R149 was observed on day two without right hand splint on. R149 states that early this am a female staff member came in an applied a splint on her right hand and the splint was oversized and when R149 received her shower the splint came off. On 06/02/2026 at 12:40 PM, V5 ( Assistant director of nursing/ADON) was called to the room and observed that R149 did not have on her splint to right hand because r149 stated the splint that was placed on her this morning was oversized and the V5 stated he would follow up with the restorative aide on the appropriate size for R149 and get r149 another splint that its her right [NAME] 06/03/2026 at 8:31 AM, V14 (Restorative Consultant) stated he was overseeing the restorative program because the facility did not have a full-time restorative nurse. V14 stated the purpose of splints and hand rolls was to prevent further decline in extremity function and that failure to apply these devices could result in worsening contractures and decreased functional abilities. V14 stated restorative aides were expected to monitor devices, implement restorative programs, and provide restorative care to maintain or improve residents' functional status. V14 further stated that although he had been out of the facility for two days, restorative programs should have continued, and splints and hand rolls should have been applied as ordered.V14 stated R149 had an active restorative program that included active range-of-motion exercises, splint use, and grooming activities. V14 further stated R137 had an order for a right-hand splint but, in his professional opinion, the resident did not require a splint because there was no increased muscle tone or fixed joint contracture. V14 stated he planned to reassess R137's needs.On 06/03/2026 at 09:07 AM, V21 (Restorative Aide) stated she was off on 06/01/2026 and was assigned to another floor on 06/02/2026. V21 stated that when she was absent, another restorative aide or the restorative nurse was responsible for completing restorative programs and applying splints to ensure residents continued receiving required services.On 06/03/2026 at 09:20 AM, V29 (Therapy Director/Occupational Therapist) stated the purpose of splint use was to prevent contractures from worsening and to help maintain functional positioning. V29 confirmed that R11 had been recommended for restorative range-of-motion services following discharge from therapy.On 06/03/2026 at 12:15 PM, V2 (Director of Nursing) stated his expectation was that splints and contracture devices be applied according to physician orders. V2 stated that if one restorative aide was absent, another restorative aide or the restorative nurse should ensure the devices were applied and restorative services completed. V2 further stated failure to apply splints could result in worsening contractures, extremity deformities, and decline in functional status. V2 stated all residents should be assessed by restorative nursing staff and therapy recommendations should be implemented to ensure residents receive recommended restorative services.Facility policy titled Splints dated 09/2020 documented adaptive devices would be used as ordered by the physician or nurse practitioner to prevent deformities and further contractures. The policy stated further splints would be applied according to physician orders.Facility policy titled Restorative Aide dated 01/2015 documented restorative aides were responsible for ensuring restorative procedures were followed in accordance with established policies and procedures.Facility policy titled Restorative Nurse dated 07/2024 documented the restorative nurse was responsible for planning, developing, implementing, and supervising restorative services; maintaining current restorative program lists that included splints, hand cones, and contracture devices; ensuring residents received necessary assistive devices; and coordinating with the therapy department to ensure therapy recommendations were implemented following discharge from therapy.

Based on observations, interviews and record review, the facility failed to label with the date and time the enteral feeding bag according to the facility's policy. This failure affected 4 (R10, R36, R155,169) of 6 reviewed for tube feedings.Findings include:R10's Face Sheet documents in part, R10 diagnoses of Chronic Respiratory Failure, Encephalopathy, Epilepsy, and Cerebral Palsy. R36's Face Sheet documents, in part, R36 diagnoses Acute Respiratory Failure with Hypoxia, Hemiplegia, Hypotension, Type 2 Diabetes, and Chronic Systolic (Congestive) Heart Failure.R155's Face Sheet documents, in part, R155 diagnoses of Cerebral Infraction, Acute Respiratory Failure with Hypoxia, Type 2 Diabetes, and Bronchitis. R169's Face Sheet documents, in part, R169 diagnoses of Lensox-Gastaut Syndrome, Adult Failure to Thrive, Metabolic Encephalopathy, and Epilepsy. R10's Order dated 7/10/25 documents, in part, Nothing by mouth (NPO) and Every shift TUBE FEEDING: NUTREN 2.0 TO INFUSE 800 ML/DAY AT 50 ML/HOUR, ON 12 PM AND one time a day TUBE FEEDING: NUTREN 2.0 TO INFUSE 800 ML/DAY AT 50 ML/HOUR, ON 12 PMR36's Ordered dated 5/6/26, documents, in part, Nothing by mouth (NPO) and one time a day TUBE FEEDING: START @ 12 PM. TYPE Glucerna 1.5. TO INFUSE 1300 ML/DAY @ 65 ML/HOUR off at 0800.R155's Order dated 3/31/26, documents in part, Nothing by mouth (NPO). And every shift TUBE FEEDING: START GLUCERNA 1.5 @ 5PM. TO INFUSE 1300 ML/DAY @ 90 ML/HOURR 169's Order dated 4/18/26, documents, in part, Nothing by mouth (NPO)R169's Order dated 4/21/26, documents, in part, in the afternoon TUBE FEEDING: START @ 12PM. TYPE ISOSOURCE 1.5 TO INFUSE 1000ML/DAY @ 55ML/HOUR AND every shift TUBE FEEDING: START @ 12PM. TYPE ISOSOURCE 1.5 TO INFUSE 1000ML/DAY @ 55ML/HOUR On 6/1/26 at 11:53 AM The tube feeding bag was connected to R169's enteral feeding system that was not labeled with the date and time the tube feeding was started. On 6/1/26 at 12:11 PM The tube feeding bag connected to R36's enteral feeding system was not labeled with the date and time the tube feeding was started. On 6/2/26 at 9:52 AM The tube feeding bag connected to R36's enteral feeding system was not labeled with the date and time the tube feeding was started. On 6/2/26 at 9:55 AM The tube feeding bag connected to R10's enteral feeding system was not labeled with the date and time the tube feeding was started. On 6/3/26 at 9:48 AM The tube feeding bag connected to R155's enteral feeding system was not labeled with the date and time the tube feeding was started. On 6/3/26 at 10:09 AM V37 (License Practical Nurse-LPN), stated the (tube) feeding bags should be labeled and dated to make sure the resident is getting the correct feeding and to make sure the feeding bag is not outdated. It is important for safety and to prevent the residents from getting sick. I check the feeding bag and pump when I round in the rooms every two hours and when I pass meds.On 6/3/26 at 10:26 AM V36 (License Practical Nurse- LPN), stated there should be a date and time on the (tube feeding) bag so that we know when it (tube feeding bag) was hung. V36 continued to state that the time and date are important so we will know how long it will be hanging because the (tube feeding) bag should only be hanging for a certain amount of time.On 6/3/26 at10:34 AM V5 (Assistant Director of Nursing-ADON), stated the feeding bags are required to be labeled with the date, time and flow per hour. All of the staff at the beginning of their orientation will get this training. We educated on the proper hanging of the bag. We monitor compliance by having manager that go into the room and check the tube feeding and the tube feeding bags. The risks associated with using a tube feeding bag that has not been labeled and dated are you wouldn't know the amount of the flow per hour, date, time it started. Labeling the tube feeding bags helps us to know how much the residents have taken in and if they are getting all their nutrients.Facility Policy dated 09/2020, titled Enteral Nutritional Feeding documents, in part: Enteral feeding in an open system bag should be changed every 24 hours (bag itself). A carton/can (250ml) should be used/infused with an 8hour hang time. Label bag/container with name, date, and time.

Based on observations, interviews and record reviews, the facility failed to label insulin and discard expired insulin medication. This applies to 4 residents (R1, R59, R155, and R183) of 4 in the sample reviewed for receiving insulin. Findings include: On [DATE] at 11:29 AM, there was an expired Humalog insulin vial on V36's (Licensed Practical Nurse/LPN) medication cart belonging to R155. According to the label, it was opened on [DATE] and the expiration date was [DATE]. V36 stated the insulin expired and R155 should no longer receive it. In V36's medication cart, there was no resident's name on insulin aspart. V36 stated the resident's name could have fallen off. In V36's medication cart, the expiration date from R183's Multidose Injection pen was missing. V36 stated it was important to have the expiration date on the label because no one would know when the 28 days were up without having to calculate it. V36's medication cart contained another multidose injection pen that did not contain a name, date opened, or expiration date. On [DATE] at 12:00 PM, V5 (Assistant Director of Nursing) stated all expired medication should be discarded. And they cannot use the insulin if there is no name on it. V5 said unlabeled and expired medication should not be on V36's cart. V5 added discarded medication is sent back to the pharmacy. On [DATE] at 12:13 PM, R1's expired Humulin was in V37's medication cart. According to the label, it was opened on [DATE] and expiration date was [DATE]. V37 said R1's medication was expired and it should not be used based on the information on the label. V37 stated it was on V37's cart due to an oversight. At 12:25 PM, V5 stated that when V37 discharged R1 to the hospital, V37 should have packed up R1's Humulin and removed it from the cart. V5 added the expired drug should not be on the cart based on their medication reconciliation process. On [DATE] at 1:31 PM, R211's two insulin injection pens were in V39's medication cart with no dates (expiration date/open date) and no initials on the labels. V39 stated that the insulin pens were not used because they were still unopened. On [DATE] at 1:40 PM, V5 stated R59's insulin injection pins were not opened and not refrigerated. V5 said there was a risk of the medication expiring because they have no idea how long R211's insulin pens were outside the safe zone. The facility failed to follow their Storage/Labeling/Packaging of Medications policy dated 12/2023 that documents Individual resident's medication are stored under proper conditions of temperature. 6.) Each resident's medication must be properly labeled. And 10.) Medication containers that are outdated are immediately removed and either returned or disposed of according to procedure.

Based on observation, interview and record review, the facility failed to perform hand hygiene during dining after touching contaminated surfaces. This failure has the potential to affect all 61 residents that reside on the 2nd floor that receive an oral diet.Findings include:On 06/01/26 at 12:23pm V34 (Certified Nursing Assistant/CNA) observed adjusting resident's wheelchair then adjust V34's eyeglasses. V34 then observed to continue passing meal trays without performing hand hygiene. On 06/01/26 at 12:30pm V34 (CNA) stated that she should have performed hand hygiene after adjusting the resident's wheelchair and her eyeglasses.On 06/03/26 at 1:22pm V2 (Director of Nursing) stated that hand hygiene should be done before meal tray pass and after touching contaminated surfaces. V2 stated that touching a resident's wheelchair is considered contamination. V2 stated that if a staff touches their eyeglasses, their hands are considered contaminated, and the staff member should sanitize their hands before continuing to pass the resident meal trays.Facility's policy titled Hand Hygiene dated 10/2024 documents in part, Policy: It is the policy of the facility that hand hygiene (HH) hand washing and/or Alcohol-based hand rub (ABHR), also known as Alcohol-based hand sanitizer (ABHS) is to be performed to reduce the potential spread of pathogens. Guidelines: 1. ABHS is the preferred method of use in most clinical situations. It is the most effective product for reducing the number of germs on the hands of healthcare providers. ABHS should be used: a. immediately prior to touching a resident. d. After touching a resident or the resident's immediate environment.

Based on interview and record review the facility failed to immunize and record accurate information for three residents R110, R137, R152 of 5 residents reviewed for immunizations. This failure has the potential to affect all 179 residents who reside in the facility. Findings include:On 06/01/2026 at 1:30 PM, R152 was observed after returning to the unit from dialysis. R152 was alert and responsive and able to make needs known to staff. R152 denied pain or discomfort and reported that she had requested to receive the influenza vaccine but had not yet received it.R152's face sheet, dated 06/03/2026, documents in part that R152 was readmitted to the facility on [DATE] with diagnoses including end-stage renal disease, dependence on renal dialysis, chronic respiratory failure, diabetes mellitus, anemia, hyperlipidemia, morbid obesity, legal blindness, and hypertensive heart and chronic kidney disease.R152's Minimum Data Set (MDS) for Cognitive Patterns, dated 03/02/2026, documents in part that R152 had a score of 12, indicating moderate cognitive impairment.R152's immunization report, dated 06/03/2026, documents in part that R152 refused influenza and pneumonia vaccines, and that the last COVID vaccine was also refused. The report documents that education was provided by the nurse on 10/31/2025. Medical records do not display that R152 was offered the vaccine again after 10/31/2025; however, the record documents that R152 declined all vaccines.On 06/03/2026 at 9:07 AM, V15, (Dialysis Nurse/RN), stated that R152 did consent to receive the influenza vaccine, but the vaccine would be administered by facility staff and consent should be signed at the time of vaccine administration.On 06/04/2026 at 1:10 PM, V46,(family member of R110), stated that she never declined any vaccinations for R110 and would like her son to be vaccinated to ensure he is protected from viruses in the facility. V46 stated that she was never called by anyone from the facility regarding vaccines and that R110 is compromised due to his condition and needs to be vaccinated.R110's face sheet, dated 06/03/2026, documents in part that R110 was readmitted to the facility on [DATE] with diagnoses including anoxic brain damage, chronic respiratory failure, dysphagia, anemia, convulsions, essential hypertension, muscle spasms, quadriplegia, and tachycardia.R110's Minimum Data Set (MDS) for Cognitive Patterns, dated 04/20/2026, documents in part that R110 had a score of 3, indicating severe cognitive impairment.R110's immunization report, dated 06/03/2026, documents in part that R110 refused influenza and pneumonia vaccines, and that the last COVID vaccine was administered on 11/07/2024. The report documents that education was provided by the nurse on 10/31/2025. Medical records do not display that R110 was offered the vaccine again after 10/31/2025; however, the record documents that family was notified and declined all vaccines.On 06/04/2026 at 1:20 PM, V47, (family member of R137), stated that she never declined any vaccinations for R137 and would like her son to be vaccinated to ensure he is protected from viruses in the facility. V47 stated that she would never decline any treatment that would protect her son from illness. V47 also stated that she was never called by anyone from the facility regarding vaccine administration and that R137 is compromised due to his condition and needs to be vaccinated.R137's face sheet, dated 06/03/2026, documents in part that R137 was admitted to the facility on [DATE] with diagnoses including spastic quadriplegic cerebral palsy, diabetes mellitus, epilepsy, anemia, cortical blindness, chronic respiratory failure, muscle wasting, scoliosis, and dysphagia.R137's Minimum Data Set (MDS) for Cognitive Patterns, dated 05/13/2026, documents in part that R137 had a score of 3, indicating severe cognitive impairment.R137's immunization report, dated 06/03/2026, documents in part that R137 refused influenza and pneumonia vaccines, and that the last COVID vaccine was administered on 11/07/2024. The report documents that education was provided by the nurse on 10/31/2025. Medical records do not display that R137 was offered the vaccine again after 10/31/2025; however, the record documents that family was notified and declined all vaccines.On 06/03/2026 at 3:00 PM, V2( Director of nursing stated) the nursing team will audit and check which residents who are interested in getting the vaccines and since the Influenza season for vaccines is over the nursing staff inform the families and document. V2 stated for pneumonia vaccines since that can be offered year-round if the residents want the vaccine when asked the staff will administer the vaccine. V2 stated for the next Influenza vaccine season the nursing department will audit and check on all residents to ensure they are offered the vaccine and document accurately.v2 stated for all new admits the nursing staff will audit all new admissions to assess if residents and or families would like to receive the pneumonia, covid or influenza vaccines.The facility policy, dated 09/20/2024 and titled Infection Prevention and Control Program, documents in part that the mission of the program is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The policy further documents, under required Phase 3, November 28, 2019, that the facility will designate one or more individuals as the infection preventionist who is responsible for the facility's infection prevention and control program. Under the structure of the infection control program, the policy documents that the facility will review influenza and pneumococcal vaccine compliance. The elements of the program include defining and managing appropriate resident health initiatives, such as the immunization program, including influenza and pneumonia vaccines.

Based on interview and record review, the facility failed to ensure that one resident (R117) had advanced directive in place. This failure affected one resident (R117) out of a total sample size of 73 residents. Findings include:R117's medical diagnoses include but are not limited to end stage renal disease, hypertensive heart and kidney disease, chronic systolic heart failure, type 2 diabetes.R117's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 15, indicating that R117's cognition is intact.Review of R117's active orders on 06/02/26 at 10:38am shows no active physician order for R117's code status.On 06/03/26 at 1:22pm V2 (Director of Nursing/DON) stated that every resident should have a code status. V2 stated that code status tells the staff how to care for a resident in an emergency and how to follow the resident's wishes.On 06/03/26 at 1:55pm V23 (Social Service Director) stated that a resident's code status should be entered upon admission to the facility.Facility's policy titled Advance Directives dated 11/22 documents in part, A. Policy: The Social Service Director and/or designee will assess, care plan and implement Advance Directives. B. Procedure: 9. The resident will have a code status order entered in their physician orders in accordance with advance directives on file.

Based on observation, interview, and record review the facility failed to ensure that a resident who depend on staff's assistance for their ADL (Activities of Daily Living) care received shaving and nail care. This failure affected one resident (R84) out of 73 residents reviewed for ADL care.Findings include: R84 has a diagnosis which includes but not limited to: anxiety, insomnia, muscle weakness, unsteadiness on feet, adult failure to thrive.R84 Brief Interview for Mental Status (BIMS) dated 08/13/26 shows that R84 has a BIMS score of 11 which indicates that R84 has some cognitive impairments.On 06/1/26 at 11:16 am, R84 was observed in bed, awake, alert ungroomed with facial hair, beard, and long nails. R84 stated Nobody shaves me. I ask all the time. R84 stated that he request to be shaved by the CNA's (Certified Nursing Assistants) however no one has assisted R84 with shaving in weeks.On 06/2/26 at 11:37 am, R84 was observed in bed, awake, alert still ungroomed with facial hair, beard, and long nails. R84 stated No I still have not been shaved. I have been asking. On 06/2/26 at 11:40 am, V12 (Certified Nursing Assistant, CNA) stated that residents nails are trimmed, and residents are shaved upon request and twice a week during showers. V12 explained she last shaved R84 about a week ago. V12 stated that she was assigned to R84 on 6/1/26 and 6/2/26, observed R84 in need of a shave and that she did not have time to shave or trim R84's nails. On 06/2/26 at 12:13 pm, V2 (Director of Nursing, DON) stated that the CNA's are responsible for providing the residents with shaving and nail care daily during care, twice weekly during showers, and upon the residents request. V2 then explained that CNA's should not say that they do not have time to shave a resident and explained if a resident cannot complete their assignment they should inform management. V2 stated that residents are provided with ADL care shaving and nail care to improve the quality of the residents life, improve the residents hygiene and for the dignity of the resident. R84's care plan dated 4/9/26 documents in part: R84 has an ADL Self Care Performance Deficit due to weakness, impaired balance, lack of coordination; activity intolerance; incontinence related to ESRD (end stage renal disease), CKD (chronic kidney disease), malignant neoplasm of the colon and Type 2 DM (diabetes), BPH (benign prostatic hypertrophy Interventions: Assist with personal hygiene as needed. R84's Minimum Data Set (MDS) dated [DATE] shows that R84 requires partial/moderate assistance with personal hygiene.The facility policy dated 9/2020 and titled Shaving documents, in part: Purpose: To remove facial hair and import the residents appearance and morale.The facility policy dated 9/2020 and titled Nail (Care of)) documents, in part: Policy: All residents will have clean, well-trimmed nails.The facility policy dated 3/10/2022 and titled Dressing and Grooming documents, part: Definition: Dressing/grooming refers to activities provided to improve or maintain the residents self-performance in dressing and undressing, bathing and washing, and performing other personal hygiene tasks. These activities are individualized to the resident's needs, planned, monitored, evaluated and documented in the residents medical record . Grooming: vii. Shaving . x. Trimming nails . 5. Maintain the residents self-esteem, privacy and confidentiality. The facility undated policy titled Activities of Daily Living (ADLS) documents, in part: Purpose: To preserve ADL function, promote independence, and increase self-esteem and dignity . Grooming Maintaining personal hygiene, including planning the task and gathering supplies combing and /or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder.

Based on observation, interview, and record review the facility failed to obtain a physicians order for a prophylactic dressing implemented and applied to a resident (R124); and failed to ensure that a resident (R17) ordered follow-up appointments were scheduled. This failure affected two residents (R17 and R124) out of the sample of 73 residents reviewed for physicians orders and services. Findings include: R124's face sheet shows that R124 has a diagnosis which includes but not limited to pressure ulcer of the left hip, other specified dermatitis, pressure ulcer of unspecified site and unspecified stage, persistent vegetative state, and cellulites of the left upper limb. R124's Brief Interview for Mental Status (BIMS) dated 4/14/26 shows no BIMS score for R124 and indicates that R124 is cognitively impaired. On 06/01/26 at 11:51 am, Surveyor observed R124 in bed, awake, tracheostomy in place, nonverbal and unable to communicate. Surveyor observed a dry dressing in place to R124's left arm/wrist area with the outer surface of the dressing, visibly soiled with brown-gray, yellowish discoloration staining, accumulation of debris, unclean appearance. O 6/1/26 at 12:02 pm, Surveyor brought this observation to V9 (Licensed Practical Nurse, LPN, Wound Care Nurse) and she stated, That dressing is dirty. I don't know how long it has been there. I placed a dressing there last Thursday (referring to May 28, 2026) before I was off. V9 explained that R124 had a wound to R124's wrist/hand area that V9 believed was healed and that she placed a dry dressing to R124's left wrist/arm to collect drainage and for protection. V9 explained that she did not know where R124's arm was draining from. Upon V9 removal of the soiled dressing from R124's left wrist/arm area Surveyor and V9 observed R124's left wrist with a yellow-colored dried scabbed area. V9 stated, I don't know when he got that. I was just putting a dressing there for prophylactically protection and the drainage. He does not have orders for a dressing. V9 then explained that residents should have orders for treatment dressings to ensure the dressing is being checked, changed and remains clean. V9 then explained if a resident does not have an order for a dressing that is in place the area can become neglected and increase the potential for an infection to occur. On 6/2/26 at 12:17 pm, V2 (Director of Nursing, DON) stated, Physicians orders are obtained in order to give directions on what should and should not be done for a resident. V2 also explained that if a resident has a dressing in place there should be a corresponding order for the residents dressing in the physicians' orders and Treatment Administration Record (TAR). V2 stated that it is important to obtain and follow physician's orders for treatments to avoid skin deterioration. V2 then explained that he was aware of R124's dressing to his left wrist/arm area that did not have a physician's order and that he educated V9 regarding obtaining physicians orders for treatments. R124's Physician Order Sheet (POS) dated active orders as of 06/1/26 shows that R124 had orders for right wrist cleanse with NSS (Normal Saline Solution) and pat dry and apply xeroform to the wound bed and cover with dry dressing every day and prn (as needed). As needed for Skin condition cleans with NSS and pat dry and apply xeroform to the wound bed and cover with a dry dressing every day and prn. (This order was implemented after Surveyor and V9's observation of R124'S left wrist/arm area dressing on 6/1/26). R124's Treatment Administration Record (TAR) dated June 2026 shows an order dated 6/1/26 for: right wrist cleanse with NSS (Normal Saline Solution) and pat dry and apply xeroform to the wound bed and cover with dry dressing every day and prn (as needed). (This order was implemented after Surveyor and V9's observation of R124'S left wrist/arm area dressing on 6/1/26). R124's Wound care plan dated 11/29/22 documents, in part: Focus: R124 has the potential for alteration in skin integrity r/t (related to) . left hand . Inspect skin daily. R124's Pressure Ulcer Risk assessment dated [DATE] shows a score of 11 and indicates that R124 is high risk for pressure ulcers. R124's Skin Issue assessment dated [DATE] documents in part: Left outer wrist . length 0.76 cm (centimeters), Width 0.83 cm, Depth 0, area 0.48 cm. The facility's policy dated 03/02/21 and titled Prevention and Treatment of Pressure Injury and other Skin Alterations documents, in part: Policy. 2. Identify the presence of pressure injuries and/or other skin alterations. 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Procedure: 8. At least daily, staff should remain alert for potential changes in skin condition during resident care The facility's policy dated 06/02022 and titled Physicians Orders for Medications and Treatments documents in part: Policy: . Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. Findings include: On 06/01/2026 at 12:09 PM, R17 was observed in bed watching television. R17 was alert and responsive and able to make needs known to staff. R17 sat up in bed and participated in an interview. During the interview, R17 expressed discomfort in the back of his oral cavity and reported difficulty attending scheduled appointments due to transportation not being available, causing him to arrive late or miss appointments. R17's Face Sheet, dated 04/10/2026, documented in part that R17 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, emphysema, acute respiratory failure with hypoxia, sepsis, pneumonia, and hemoptysis. R17's Minimum Data Set (MDS) for Cognitive Patterns, dated 04/16/2026, documented in part that R17 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. On 06/02/2026 at 12:36 PM, V20 (Social Worker) stated that he spoke with R17 regarding concerns related to a missed appointment but did not complete a concern form. V20 stated that he informed V1 and the Social Services Director of the concern. V20 further stated that the facility is responsible for ensuring that residents have transportation to and from appointments. On 06/03/2026 at 8:45 AM, V1 (Administrator) submitted a copy of an email from R17, dated 05/15/2026 at 10:43 AM. The email documented concerns repeatedly missing appointments and/or arriving late to appointments and the frustration this issue was causing R17. V1 stated that the email had been routed to his spam folder; therefore, he did not review the email and did not document the concern or allegations. V1 also submitted a receipt indicating that an Uber ride had been arranged for R17 after R17 contacted him and reported needing transportation back to the facility following a clinic appointment. V1 stated that the facility is responsible for ensuring that residents have transportation to and from appointments. On 06/03/2026 at 8:48 AM, V18 (Medical Records/Appointment Scheduler) stated that she spoke with R17 and that R17 informed her he did not want to reschedule his dental appointment. According to V18, the dental appointment had been scheduled for 05/28/2026; however, transportation did not arrive. V18 stated that three appointments needed to be rescheduled for R17, including Cardiology, Pulmonology, and Primary Care appointments. V18 further stated that the facility is sometimes informed of appointments on short notice, which may contribute to residents arriving late or missing appointments. V18 stated that she receives appointment information through the electronic medical record and/or from nursing staff. V18 stated that she was informed R17 had missed an appointment prior to her employment at the facility. V18 also stated that the facility is responsible for ensuring that residents have transportation to and from appointments. On 06/03/2026 at 9:14 AM, R17 stated that he never informed V18 that he did not want to reschedule his dental appointment. R17 reported experiencing oral discomfort in the back of his mouth and stated that he needed evaluation by a dentist. R17 stated that all appointments are scheduled either by the clinic or by clinicians who evaluate him at the facility. R17 further stated that following appointments, he returns with paperwork that he provides directly to nursing staff, who enter the information into the electronic medical record, including dates for future appointments and procedures. V18 was present during the interview and stated that a nurse informed her that R17 did not want to return to the dentist; however, she could not recall the nurse's name. The facility policy titled Appointments, dated 09/2020, documented in part: Policy: Assistance will be provided to residents who require help arranging and scheduling appointments. Procedure: Arrange transportation as appropriate.

Based on observation, interviews, and record review, the facility failed to accurately document the weight and failed to follow facility policy for weights for one resident (R1) out of three residents reviewed for weight loss. This failure resulted in R1 not having any interventions in place to treat R1's significant weight loss of 23 % in one month due to not accurately documenting R1 weight and due to staff not notifying the supervisor/RD (Registered Dietitian) with a significant change in R1's weight.Findings include:R1's admission record includes but is not limited to anoxic brain damage, hypertension, cerebrovascular disease, bipolar, convulsions, anxiety, depression, encephalopathy, cognitive communication deficit, cardiomegaly, and aphasia.R1's (4/15/26) Minimal data Set (MDS) Section C. Brief Interview for Mental Status (BIMS) score is 15. R1 is cognitively intact. Section GG. A. Eating is coded 1. Dependent. (Helper does all the effort, Resident does none of the effort to complete the activity).On 5/29/26 at 11:35 am, R1 observed in room lying in bed. R1 stated, The staff here does not weigh me. I was weighed yesterday but before that it had been months of not getting weighed. They say that they weigh me, but they don't. They say my weight is in the 170's (pounds) but I have not been 170 (pounds) in a while.On 5/29/26 at 11:42 am, R1 was weighed by V15 Certified Nursing Assistant (CNA) and V16 CNA with a mechanical lift scale with R1 only wearing an incontinent brief. V15 zeroed the scale before R1 was weighed. R1's weight registered on the machine at 134.4 pounds. V15 stated, Restorative does the weights. (R1) asked me to weigh him yesterday (5/28/26) after I gave him a shower and (R1's) weight was 132.5. Surveyor inquired to V15 why was R1's weight from 5/28/26 documented as 172.6 pounds? V15 stated that the nurses put in weights in the residents' electronic health record (EHR). V15 stated, I told the nurse (V19 License Practical Nurse) what R1's weight was. (R1) was not 172.6 pounds.On 5/29/26 at 11:57 am, R1 was weighed by V15 and V16 on a different mechanical lift scale with only an incontinent brief on. V15 zeroed the scale before R1 was weighed. R1's weight registered at 99.2 pounds.On 5/29/26 at 12:14 pm, R1 was weighed on the restorative mechanical lift scale by V16 and V3 DON (Director of Nursing) with only an incontinent brief on. V3 zeroed the scale before R1 was weighed. R1's weight registered at 132.2 pounds. There was a 33-pound difference between the two scales.R1's weight summary report documents R1's weight as follows: On 5/28/26 weigh 172.6 pounds. On 5/5/26 weigh 175.0 pounds. On 4/5/26 weigh 174.6 pounds. On 3/5/26 weigh 173.7 pounds. On 2/5/26 weigh 173.4 pounds. On 1/5/26 weigh173.4 pounds.The Medication Administration Record (MAR) for February 2026 and May 2026 did not show R1 was on any diuretics that would affect R1's weight. R1's active orders as of 5/30/26 show an intervention of fortified pudding for a nutritional supplement to be given two times a day at lunch and dinner. Med Pass three times a day for a nutritional supplement. These interventions were not ordered until 5/29/26.R1's nutrition progress notes dated 5/29/26 documents, in part, Follow up with weight changes. (R1) weighed today (5/29/26) 132.8. Previous weights 5/26 172.6, 4/26 174.6, 2/26 174.4, 11/25 171.2. (R1) have 39.8 (23%) loss in 1 day. Significant weight loss. Resident was reweighed multiple times with multiple scales. Weight loss was confirmed.R1's Nutrition Quarterly assessment dated [DATE] documents in part, 3. (a) Most recent weight (4/5/26) 174.6. Scale: Mechanical Lift. (c) Weight History: 4/26 (174.6), 3/26 (173.7), 2/26 (174.4), 1/26 (173.4). (d) UBW (Usual Body Weight): no significant weight changes for time frame. 4. (a) Significant weight change in past 1 month? No. (b) Significant weight change in past 3 months? No. (c) Significant weight change in past 6 months? No.On 5/29/26 at 1:06 pm, V6 Restorative Aide stated, The last weight I (V6) did on R1 was on the weekend and he weighed in the 130's (pounds). I gave the weight to (V7 Restorative Aide). I put a sticky note on her desk. I can't remember the exact number but R1 was not in the 170's (pounds), he was 130 something (pounds).On 5/29/26 at 1:18 pm, V7 Restorative Aide stated, (R1) is weighed monthly with the restorative mechanical lift scale. (R1's) weight was taken last weekend (5/24/26) by my co-worker (V6). I (V7) put the weight in the computer. (V6) said (R1's) weight was 135.4. (R1's) weight on 5/28/26 is not correct, it was a typo. I had brain fog, and I should have notified the nurse because that is a really big weight loss and that is a concern. The weight on 5/5/26 (175.0 pounds) was not a typo. I just realized the weight on 5/28/26 was a typo when I was called today (5/29/26) about (R1's) weight.On 5/29/26 at 3:30 pm, V17 Restorative Consultant stated, I (V17) am overseeing the restorative department. Restorative Aides are responsible for weights in the facility. They should document the current weight of the residents in the (facility's EHR system). It is expected of the Restorative Aide to document the correct weights. If the Restorative Aide doesn't document the correct weight of the resident, there can be discrepancies with the care the resident receives. There should have been an intervention for (R1's) significant weight loss. They first need to see if the scale is properly calibrated. That's a huge questionable difference for (R1's) weight. This should have been alerted to the managers if it was the machine and notified the doctor to prevent no further decline in (R1's) condition.On 5/29/26 at 3:55 pm, V18 Dietitian stated, I (V18) am familiar with (R1). I did a quarterly assessment in April this year. I looked at his weight and saw he is maintaining his weight. I was notified of the weight loss today (5/29/26) by staff. If I had known (R1) was in the 130's there would have been some intervention put in place. When I am aware of a weight loss with a resident, I would make recommendations as soon as the information is brought to my attention. I am recommending that (R1) be weighed twice a week for 3 weeks. I added fortified pudding for lunch and dinner. Med Pass 120 ml (milliliter) TID (Three Times a Week). It is a high calorie supplement. My recommendations are based on what I see in (facility's EHR system). I expect the documentation to be correct in (facility's EHR system). It is helpful to have accurate information, to see if the intervention put in place will make a difference.On 5/30/26 at 10:28 am, V19 License Practical Nurse (LPN) stated, (V15 CNA) did tell me the weight of (R1) when she (V15) gave him a shower. It was Thursday the 28th (May 2026). She said it was within 132 or 134. I don't remember the exact number, but it was in the 130's. I did not document the weight in the computer; restorative normally document weights in the computer. I am not aware of restorative weighting (R1) that day.On 5/30/26 at 10:48 am, V20 (Nurse Practitioner) stated, I see (R1) once a month. I review (R1's) weights. I have been seeing his (R1) weights stay 170's and being consistent so it was not alarming to me. He was maintaining his weight. I received a call from the nurse yesterday and she said his weight was in the 130's. I ordered some labs to see his protein level and a calorie count. If I had been aware of this sooner the order would have been sooner. Where is this 170-weight coming from? This is alarming, I am out of words right now, I don't know what to say. With this sudden weight loss, it's a concern that a certain condition could be going on, and he possibly should have been referred to see a specialist. I do rely on staff to document correct information that helps me make the decision for giving care to the residents. I base my care decisions on what is in the chart, and I expect it to be correct. They are supposed to follow standards of care which include accurate documentation.Facility's document titled, Weights dated 9/2020, Policy: Residents will be weighed to establish baseline weights and identify trends of weight loss or weight gain. Procedure: 1. A baseline weight will be established upon admission. The resident will be weighed weekly for 4 weeks after admission and monthly thereafter. 3. Report to nursing supervisor, physician/ NP, dietary supervisor, RD (Registered Dietitian) consultant and family/ responsible party of any weight loss or gain greater than 5% within one month, 7.5% within three months or 10% within six months.Facility's job description titled, Restorative Aide documents in part, I. Job Summary: Responsible for carrying out and documenting the activities of the Restorative Program 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.Facility's job description titled, Certified Nursing Assistant dated 3/2023 documents in part, Essential Duties: A. Ensure that all nursing procedures and protocols are followed in accordance with established policies.Q. Obtain .weights as needed. S. Observe customer's physical condition, attitude, reaction, appetite and report any changes and or unusual findings to the nurse. W. Report changes in residents eating habits to the staff nurse.

Based on interviews and records reviewed the facility failed to follow one resident's (R10) plan of care while on trials to be weaned off mechanical ventilation and failed to monitor R10's pulse oximetry alarm was on. The alarm is used to alert staff when R10's oxygen saturation drops below 92%. Subsequently, on [DATE] R10 was observed unresponsive, pulse less and breathless due to staff not monitoring and supervising a resident that depended on mechanical ventilation to sustain his life. Additionally, the facility failed to ensure pulse oximetry alarms and displays function properly for 3 (R11, R12, and R16) residents in a sample of 4 residents reviewed.This was identified as an Immediate Jeopardy. This Immediate Jeopardy began on [DATE].The Administrator (V1) and the Director of Nursing (DON) (V2) were notified of Immediate Jeopardy and a template was presented on [DATE] at 10:46am.On [DATE] an acceptable removal plan was received after revision from the original plan submitted on [DATE] at 4:41pm; [DATE] at 6:11pm; and on [DATE] at 8:20am: and [DATE] at 12:43pm.On [DATE] and [DATE] the surveyor confirmed by observation, interview, and record review that the removal plan was initiated, and the immediacy was removed on [DATE]. However, the non-compliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-services training.R10's medical diagnoses include but are not limited to chronic respiratory failure, dependence on respirator, tracheostomy, heart failure, atrial fibrillation, and essential hypertension. R10's Minimum Data Set (MDS) dated [DATE] indicates R10's cognition is severely impaired. R10's admission date to the facility is [DATE] and date of death at the facility is [DATE]. R10's physician order with start date of [DATE] documents in part, Trach: Aerosol trach collar FIO2 (Fraction of Inspired Oxygen) 50 % (percent) during the day as tolerated. R10's physician order start date [DATE] documents in part, Vent settings: Mode AC (Assist Control), rate 16, TV (Tidal Volume) 450, PEEP (Positive End Expiratory Pressure) 5, FIO2 40% at bedtime or if resident unable to tolerate trach collar trial. R10's physician order start dated [DATE] documents in part, 1:1 (one to one) with a sitter at all times. R10's respiratory progress note dated [DATE] at 9:45am documents in part, Placed on 40% trach collar for the day per order RR (respirations) 20 HR (heartrate) 84 SaO2 (arterial oxygen saturation) 94% no distress noted will continue to monitor. On [DATE] at 1:28pm surveyor made observations with V15 (Licensed Practical Nurse/LPN). Surveyor observed R11's pulse oximetry connected to R11's finger but no oxygen saturation observed on the monitor and monitor blinking with no sound. Surveyor observed V15 trying to troubleshoot the monitor. R11's monitor had no sound. V15 then observed removing R12's pulse oximetry to check the alarm. R12's pulse oximetry was removed by V15, R12 monitor had visual blinking but no alarm sounded.On [DATE] at 1:28pm V15 (LPN) stated that she doesn't know why the residents' monitors are not sounding. V15 stated that when the resident's oxygen is down or the sensor is removed, the alarm should sound.On [DATE] at 10:31am made observations with V23 (LPN). Observed R15's pulse oximeter sensor on the floor, R15's monitor alarm flashing, no alarm sound heard. V23 (LPN) stated that R15 probably removed the pulse oximeter herself, but the alarm should still sound. Observed R16's pulse oximeter on R16's finger, R16's monitor not showing an oxygen saturation and alarm observed flashing with no sound. V23 stated that she does not know what R16's oxygen saturation is because the monitor is not picking up R16's saturation. V23 stated that R16's monitor is showing that audio sound is off. V23 stated that she does not know how to turn audio sound on. V23 stated that it is important to hear the pulse oximetry alarm so that staff can know if the residents are getting adequate perfusion. V23 stated that if a resident is not getting adequate perfusion, the resident could die. V23 stated that if the resident's alarm sounds, it gives the staff the opportunity to respond to the alarm and possibly save the resident's life. On [DATE] at 12:55pm V14 (Respiratory Therapist/RT) stated that he placed R10 on trach collar then V14 left R10's room to continue rounds on other residents. V14 stated that R10 was not actively weaning and was just to be taken off the ventilator during the day. V14 stated that he had 16 residents and rounds normally take 2 or more hours. V14 stated that after rounding on all 16 of the residents that V14 was assigned to, V14 did not go back to check on R10, instead V14 sat down to chart. V14 stated that R10 was always busy with his hands and R10 would pull on and remove his tubes. V14 stated that R10 did not have a sitter at the bedside when V14 removed R10 from the ventilator and placed R10 on trach collar trials. V14 stated that he does not communicate with the nursing staff to inform them when he is removing a resident from the ventilator and placing the resident on trach collar trials. V14 stated that when a resident is placed on trach collar trials, they place the resident on continuous pulse oximetry. V14 stated that the pulse oximetry should alarm when the resident's oxygen saturation drops below 90. V14 stated that the facility's pulse oximetry's are pretty beat up and worn out. V14 stated that the staff sometimes pull the pulse oximetry off the resident when rendering care and don't replace them. V14 stated that he did not hear R10's pulse oximetry alarming at the time of R10' code and is unsure if R10 had the pulse oximetry on. V14 stated that the nursing staff take the pulse oximetry off when caring for the residents and replacing it when done is not important to them. On [DATE] at 3:50pm V19 (Registered Nurse/RN) stated that she found R10 unresponsive while doing her regular rounds. V19 stated that R10 did not have a pulse when she found him. V19 stated that R10 did not have any alarms sounding at the time that she found him unresponsive. V19 stated that sometimes the alarm settings are off or paused. V19 stated that sometimes families, CNA's or housekeeping go into resident rooms and turn the alarms off. V19 stated that R4 did not have a sitter the day that R10 coded. On [DATE] at 5:07pm V20 (Pulmonologist) stated R10 has only been able to tolerate 2 to 3 hours of weaning. V20 stated that R10 should have had continuous pulse oximetry while R10 was on trach collar. V20 stated that without continuous pulse oximetry monitoring, the staff would not know if R10 became hypoxic. V20 stated that it is not safe practice to have a resident like R10 off the ventilator without monitoring the resident's pulse oximetry and the alarm should be loud enough for the staff to hear and respond to it. On [DATE] at 5:20pm V2 (Director of Nursing/DON) stated that if a resident's pulse oximetry is not working properly, the nurse and the respiratory therapist should trouble shoot the alarms. V2 stated that when the alarms are not working properly, the staff should round on the residents more frequently. V2 stated that R10 should have had a pulse oximetry on, and it should have been alarming at the time that R1 was found unresponsive. V2 stated that he was unaware that R10 still had an active order for a 1:1 sitter. V2 stated that if R10 had an order for a sitter then he should have had a sitter at the time that R10 was found to be unresponsive. On [DATE] at 10:15am V14 (RT) stated that R10 was not actively weaning and was just to be taken off the ventilator during the day and placed back on the ventilator during the night. V14 stated that because R10 was not being weaned, R10 only required a routine check form respiratory and V14's plan was to check on R10 during his next set of rounds in 3 to 4 hours. V14 stated that he signed the wean form, acknowledging he removed R10 from the ventilator. V14 stated that R10's wean log form had previous documentation that R10 was taken off the ventilator on 3 other days already. On [DATE] at 1:36pm V20 (Pulmonologist) stated that R10 was actively weaning. V20 stated that R10's order should 100% be considered a weaning order. V20 stated that if the resident's order documents as tolerated, it is considered a weaning order. V20 stated that as tolerated is not added to the orders of residents that have successfully weaned from the ventilator. V20 stated that R10 should not have been strictly off the ventilator during the day and that R10 has only been tolerating a couple of hours of weaning. R10's wean log dated [DATE] documents in part, Start time: 07:30am. Stop time 10am. Decreased SPO2 (Peripheral Capillary Oxygen Saturation). R10's wean log dated [DATE] documents in part, Start time: 09:45am. Stop time: 11:45am. On [DATE] at 12:11pm V26 (Director of Respiratory) stated that all respiratory therapist know that if as tolerated is seen on an order, the as tolerated is the wean order. V26 stated that the facility does not have specific timing for rounding on residents being weaned, but the expectation is for staff to round on them more frequently because the resident is being weaned. V26 stated that when a resident is being weaned, the resident should be placed on the monitor to monitor their oxygen saturations. V16 stated that the monitor should alarm if the resident is having a change of condition. On [DATE] at 11:06am V24 (RT) stated that if a resident has an order to be on trach collar during the day and ventilator at night, the respiratory therapist should fill out the weaning form. V24 stated that the weaning form is how the staff know how the residents are tolerating being off the ventilator. V24 stated that resident's that are being weaned have to be on continuous pulse oximetry which monitors the residents' oxygen and heart rate. V24 stated that the pulse oximeter would alarm if the residents oxygen saturation dropped below 92%. V24 stated that the alarm lets the staff know that something is wrong and to check on the resident. R10's record review of care plans initiated on [DATE], no care plan found for R10's respiratory needs. On [DATE] at 12:22pm V2 (Director of Nursing/DON) stated that residents should have a baseline care plan upon admission. V2 stated that the baseline care plans are for the staff to understand the residents' basic needs. V2 stated that breathing is a basic need. V2 stated that the resident's pulse oximetry machine should alarm if it is in use and the resident either takes it off or if the resident desaturates. V2 stated that if the alarm is not sounding, then the staff won't know when to respond to a resident in distress. V2 stated that if a resident is in distress and not attended to, the resident could die. V2 stated that he was made aware by his staff on [DATE] after the IDPH surveyor left the unit that the resident's pulse oximeter alarms were not making sounds. V2 stated that he went to the unit and was able to troubleshoot and fix the monitors so that the alarms can be heard. On [DATE] at 3:16pm V2 stated that it is confirmed that R10 did not have a 1:1 sitter at the time that R10 died in the facility. V2 stated that the facility does not accommodate 1:1 sitters but there was an active physician's order then the order should have been followed. V2 stated that he is not sure why the nurse documented that R10 had a sitter the day that R10 died, but the nurse should not have documented what is not true. R10's progress note dated [DATE] at 12:50pm documents in part, patient to have a sitter 1:1 at all times d/t (due to) pulling on tubes, extubation, danger to self/others. On [DATE] at 1:56pm V2 (DON) stated that he was not aware that R10 had an order for 1:1 monitoring. V2 stated that the nurses are aware that the facility does not do 1:1 monitoring and if he was aware that R10 had an order for 1:1 monitoring, he would have instructed the nurse to get an order to send R10 to the hospital. V2 stated that the 1:1 monitoring order was active and should have been followed. V2 stated that a doctor's order creates necessity. Facility's undated job description titled Respiratory Therapist documents in part, Job Summary: To provide respiratory patient care, including but not limited to, ventilator management and weaning, airway management, bronchodilator therapy and diagnostic testing. Facility's untitled and undated manufacture's guidelines for the resident pulse oximeter monitors documents in part, 1. Purpose and Safety: Alarms: Monitor will alert for abnormal readings. Always respond promptly. 7. Alarms and Alerts: Test alarms periodically to ensure audio/visual alerts function. Facility's policy titled Ventilator Weaning dated 07/2025 documents in part, Purpose: Residents will be periodically evaluated for their continued need of a mechanical ventilator. Procedure: 1. Each resident will be evaluated on an ongoing basis for appropriateness of weaning from ventilator. 3. Continuous pulse oximeter may be required. 5. Staff will wean according to physician orders/weaning protocol. 10. Weaning will be logged on a weaning log sheet. Equipment: 1. Continuous pulse oximeter. Facility's policy titled Pulse Oximeter (Continuous) documents in part, Policy: To monitor residents for oxygen saturation. Procedure: Residents on mechanical ventilation, supplemental oxygen and artificial airways may be monitored for oxygen saturation with continuous oximetry every shift and PRN (as needed), unless ordered otherwise per physician.1. b. Continuous oximeter standard alarm setting. C. Low saturation for adults - 92%. Standard setting will be used unless otherwise ordered. Facility's policy titled Care Planning dated [DATE] documents in part, Policy: Each patient will be assessed for their individual risk factors to pulmonary disease at the time of intake, based on their documented medical history, nursing assessment, lifestyle, questionnaire, and patient's statements during the intake. Throughout the course of rehabilitation, the identified risk factors, goals, interventions, and outcomes on the care plans will be evaluated and revised as necessary. The patient care plan will encompass the Interim Care plan, the Pulmonary Care Plan, and the Nutritional Care Plan to ensure an individualized treatment plan for the patient by the interdisciplinary team. Procedure: 1. Nursing department will gather needed information on admission to provide date for the Interim Care Plan within 24 hours of admission. Facility's policy titled Resident Supervision and Continuous Care dated 09/2023 documents in part, Policy: Residents will receive the level of care and supervision necessary to meet their individual needs. Procedure: 3. In case of injury, illness, fire or other emergency, staff will be in-serviced to the procedures of providing prompt, ongoing and continuous appropriate care for all residents including residents: b. with exceptional care respiratory needs. 4. Each resident will be assessed by their physician or case manager upon admission to determine their needed level of supervision. If the resident requires close supervision, one-to-one supervision or a physician's medical plan of care, that information will be documented within their IPP. 10. The administrator is to be notified if at any time there is no staff member available to cover a one-to-one or close supervision staff assignment. The charge nurse is to cover the assignment until he/she is able to locate a staff member to cover the assignment. 14. Staffing patterns will be monitored to ensure that sufficient licensed, certified and registered nursing personnel are on duty to care for the residents that the facility serves. The Immediate Jeopardy began on [DATE], and was removed on [DATE], when the facility took the following actions to remove the immediacy: [NAME] Lakeland respectfully submits this Removal Plan, which also represents the facility's allegation of compliance with F695 on this date [DATE]. The IJ began on [DATE] and the facility requests the immediacy be removed as of [DATE]. Submitted on [DATE]. Residents who have suffered, or are likely to suffer, a serious adverse outcome because of the non-compliance: F695The facility failed to monitor a resident on ventilator weaning trials.The facility failed to follow physician orders for 1:1 observation.The resident (R10) affected by this failure expired on [DATE].This failure had the potential to impact on all residents on ventilator weaning trials.Actions taken for compliance: F695On [DATE] and [DATE], the Administrator, Medical Director, Nurse Consultant, Director of Respiratory Services, DON, ADON and the Interdisciplinary Team (IDT) conducted a meeting reviewing facility policies, procedures and practices for residents on ventilator weaning trials. The following policies, procedures and practices were reviewed and revised where indicated:Ventilator WeaningVentilator Weaning policy (Revised on [DATE] to include monitoring guidance outlined below)Equipment Back-Up for Ventilator Unit policy (Revised on [DATE])RT on duty will monitor availability of back-up ventilators on the unit and ensure units are tagged ready for use.Back-up ventilators are stored in the respiratory equipment room on the ventilator unit.Ventilators are rented and maintained by (Company Name). Units are tagged ready for use by Prism prior to delivery. Tags remain on the units until set up for use by a resident.A minimum of 1 ventilator for every 10 in use on the unit will be available and tagged ready for use in the respiratory equipment room.Facility Assessment was reviewed to ensure management of residents with ventilator weaning and/or trach collar trials was addressed (See Facility Assessment Special Care Needs) as well as:Physical plant, equipment and supplies necessary to care for residents with ventilator support and/or ventilator weaning.Staffing requirements, including training and competency requirements, needed to care for residents with ventilator support and/or ventilator weaning.Identification of residents eligible for ventilator weaning and/or trach collar trialsThe pulmonologist managing each individual resident, both newly admitted and long-term trach/vent, determines eligibility.Nursing and respiratory staff members will follow pulmonologist orders for initiation.Batch order sets are available in PCC for Ventilator, Ventilator Weaning, Trach and Trach Collar Trials to assist physicians with initiating vent weaning and trach collar trials. Batch Orders include levels of Oxygen and titration parameters, ventilator settings, vent check intervals, Oxygen saturation monitoring intervals, trach care and tube changes, suctioning intervals, and vent weaning/trach collar trial timeframes.Batch orders direct nurses and/or RTs to document parameters such as the number of hours the resident was on the vent or trach collar per shift.Vent Weaning Batch Order Example: Initiate Vent Weaning: ____% (FiO2) TC ______ (timeframe(s) when trach collar to be trialed). Document the number of hours resident was on the vent per shift.Trach Collar Trial Batch Order Example: Trach Collar Trials X___ Hours as tolerated with ___ % FiO2.The RT manager will review the ventilator unit census, including newly admitted residents as well as RT needs daily to determine the maximum number of residents simultaneously on ventilator weaning and/or trach trials.Monitoring residents on ventilator weaning and/or trach collar trialsResidents will be monitored using continuous pulse oximetry.Continuous pulse oximetry will be monitored by RTs and/or licensed nurses.Ventilator weaning and/or trach collar trials will be initiated by an RT. (RTs are scheduled 24 hours daily without interruption).Residents will be assessed at a minimum of hourly by RT or licensed nurse for the first two hours and then at a minimum of every 4 hours following a change in Oxygen administration dose and/or route. Residents may have end tidal CO2 monitored 1 hour post change and then every 4 hours when ordered.End tidal CO2 is monitored by an RT.CNAs (Certified Nursing Assistants) assist residents with ADLs (Activities of Daily Living) such as bathing, grooming, eating, transfers and bed mobility) and should report any changes in condition or alarms to a licensed nurse.Documentation during ventilator weaning trialsRT will document changes between ventilators and trach collars as well as resident response to those changes in the PCC progress notes.RT will document date, settings, start time, end time and total time on paper Respiratory Care Weaning Communication Log. When complete, the RT on duty will give the Weaning Communication Log (Revised on [DATE]) to the facility's Medical Records staff member who will upload the document into PCC under each resident's individual Miscellaneous tab.RT and/or licensed nurse will document vital signs assessed in PCC under the Weights & Vitals tab.Licensed nurse will document assessments done during ventilator weaning and/or trach collar trials in PCC progress notes.Communicating with the IDT when residents are on ventilator weaning and/or trach collar trialsResidents will be posted on the PCC Dashboard and/or Ventilator Unit Daily Staff Assignment sheet.The RT on duty or designee will update the PCC Dashboard or Ventilator Unit Daily Staff Assignment sheet with the list of residents currently affected.The RT on duty will attend daily standup meetings and update the IDT on the progress of these residents.The RT will notify the resident's nurse when making changes between ventilator and trach collar.Identification of residents on ventilator weaning trialsNursing and respiratory staff members will review the PCC Dashboard and/or Daily Staff Assignment Sheet for list of residents.Nursing and respiratory staff members on duty will attend daily standup meetings to receive information on these residents.Training for management of residents on ventilator weaning and/or trach collar trialsLicensed nurses and RTs will receive training on identification, communication, management and documentation of ventilator weaning and/or trach collar trials during their orientation to the facility (Reeducation initiated on [DATE] & ongoing. Anticipated completion date for regular, non-PRN [NAME] nursing and respiratory staff not currently on leaves of absence is [DATE]).Training for licensed nurses will be done by the nursing supervisor, ADON, DON, Respiratory Supervisor or preceptor assigned to each staff member's orientation to the facility.Agency nursing staff will not be utilized on the ventilator unit unless they have demonstrated competency using [NAME] approved Nurse Respiratory Unit Competency or similar competency tool. The nursing staff scheduler or clinical manager on call (Nursing Supervisor, PTCC, ADON or DON) is responsible for ensuring this competency has been reviewed prior to scheduling agency nursing staff.Training for RTs will be done by the Respiratory Supervisor or preceptor assigned to each staff member's orientation to the facility.Respiratory staff members are provided by Medical Staffing Solutions, Inc and receive training prior to providing care on the ventilator unit.Monitoring Pulse OximetryPulse Oximetry (Continuous Pulse Oximetry) policy (Revised on [DATE] to include identification of residents needing continuous pulse oximetry as outlined below)Monitoring pulse oximetry alarms to ensure functional and volumes audibleMuting of alarms will be limited to 60 seconds.Licensed nurses and RTs can mute an alarm after ensuring resident is stable.Identification of residents needing continuous pulse oximetryResidents with physician ordersOrders are placed in the PCC EMR.Staff members will review PCC to determine pulse oximetry requirements.Training requiredNursing and respiratory staff members will be trained in the use and proper functioning of pulse oximetry equipment, including Heart Med machines, during orientation and when needed (Heart Med refresher training was provided to nursing and respiratory staff members on [DATE], [DATE] and [DATE]).Nursing and respiratory staff members will be trained on proper placement of the pulse oximetry probes during orientation to the facility (Reeducation initiated on [DATE] & ongoing. Anticipated completion date for regular, non-PRN [NAME] nursing and respiratory staff not currently on leaves of absence is [DATE]).Nursing staff members are trained by the nursing floor supervisor, ADON, DON, Respiratory Supervisor and/or preceptor assigned during each staff member's orientation to the unit.Agency nursing staff will not be utilized on the ventilator unit unless they have demonstrated competency using [NAME] approved Nurse Respiratory Unit Competency or similar competency tool. The nursing staff scheduler or clinical manager on call (Nursing Supervisor, PTCC, ADON or DON) is responsible for ensuring this competency has been reviewed prior to scheduling agency nursing staff.Respiratory staff members will be trained by the Respiratory Supervisor and/or preceptor assigned during each staff member's orientation to the unit.Respiratory staff members are provided by Medical Staffing Solutions, Inc and receive training prior to providing care on the ventilator unit.Both licensed nurses and RTs are responsible for ensuring probes are in place and functioning properly and will replace displaced probes and restart monitors found to be shut off.Pulse oximetry levels are documented in the Weights & Vital Signs section of PCC by respiratory and nursing staff members.Equipment needs and repair issues will be reported to the floor supervisor (ADON) or Respiratory Therapy Supervisor.Managing a patient with orders for 1:1 supervision (Reeducation initiated on [DATE])The facility does not routinely provide or schedule 1:1 supervision or have a policy addressing 1:1 supervision.The need for 1:1 supervision is made on a case-by-case basis by the physician placing the order.Nurses who identify residents with orders for and/or a potential need for 1:1 supervision will report that information to the nursing supervisor, ADON or DON for further guidance.Residents identified with orders for or potential needs for 1:1 supervision will be assessed by the nursing supervisor, ADON or DON and managed temporarily with the direction of the provider until the resident is stabilized or transferred to a higher level of care.Nursing and/or respiratory staff members may be assigned to provide temporary 1:1 supervision to a resident when directed by the nursing supervisor, ADON or DON and are to report changes in condition as directed.Documentation of residents' medical care and interventions will be made in PCC by the caregivers involved and based on the scope of care provided. On [DATE], all residents on ventilator weaning trials were assessed with were assessed for changes in condition. (No residents on ventilator weaning or trach collar trials) Residents with orders for 1:1 supervision were reviewed to ensure orders were followed as indicated. (No current residents with 1:1 supervision orders and none with 1:1 supervision orders discontinued since date of event [DATE]). On [DATE], all Heart Med vital sign machines were reviewed to ensure probes were placed properly and that alarms were on and audible. Any issues were corrected and staff members were educated.On [DATE], [DATE] and [DATE], facility nursing managers reviewed resident orders to ensure residents with orders for pulse oximetry had monitoring probe applied appropriately.On [DATE], [DATE] and [DATE], Heart Med representatives evaluated each vital signs machine to ensure each unit was fully functional. On [DATE], facility administrator, DON, Nurse Consultant and Director of Respiratory Services met on-site with Heart Med representatives to review alarm settings (Heart Med owns and supplies the machines to the facility for temporary use).On [DATE], Heart Med representatives reviewed each unit's alarm settings and made modifications when indicated.Alarms at highest volumeAlarm blast interval at shortest setting (8 seconds)Alarm to sound if probe becomes disconnected from residentNight mode reduced volume feature disabled Alarm mute time limited to 60 secondsHeart Med representatives visit the facility monthly for preventative maintenance and additionally as requested. Heart Med representatives will also visit to evaluate any issues identified by the facility upon request. Documentation of service(s) provided is available upon request. On [DATE], education listed below (including details as listed in #1 of this removal plan) was started by the DON, ADON, Nurse Consultant and/or Director of Respiratory Care with nursing and respiratory staff who work on the ventilator unit. Education was initiated with nursing and respiratory staff members who were working and will continue to be conducted prior to the start of the next shift for each nursing and respiratory staff member on an ongoing basis until all nurses, CNAs (Certified Nursing Assistants) and RTs (Respiratory Therapists) scheduled to work have been educated and demonstrate understanding of the education through written quizzes and/or return demonstration of competency. The Director of Nursing and Director of Respiratory Care will be responsible for monitoring compliance with this process. Licensed Nurses will be educated on:Ventilator WeaningVentilator Weaning policyMonitoring residents on ventilator weaning trialsDocumentation during ventilator weaning trialsCommunicating with the IDT when residents are on ventilator weaning trialsIdentification of residents on ventilator weaning trialsMonitoring Pulse OximetryPulse Oximetry (Continuous Pulse Oximetry) policyMonitoring pulse oximetry alarms to ensure functional and volumes audibleManaging a patient with orders for 1:1 supervisionCNAs will be educated on:Ventilator WeaningVentilator Weaning policyMonitoring residents on ventilator weaning trialsIdentification of residents on ventilator weaning trialsMonitoring Pulse OximetryPulse Oximetry (Continuous Pulse Oximetry) policyMonitoring pulse oximetry alarms to ensure functional and volumes audibleManaging a patient with orders for 1:1 supervision RTs will be educated on:Ventilator WeaningVentilator Weaning policyMonitoring residents on ventilator weaning trialsDocumentation using the ventilator weaning form and EMR (Electronic Medical Record) during ventilator weaning trials Communicating with the IDT when residents are on ventilator weaning trialsIdentification of residents on ventilator weaning trialsMonitoring Pulse OximetryPulse Oximetry (Continuous Pulse Oximetry) policyMonitoring pulse oximetry alarms to ensure functional and volumes audibleManaging a patient with orders for 1:1 supervisionMonitoring, Audits, QAPI, and Facility Assessment F695Medical records of newly admitted and readmitted residents, including those with ventilator support, ventilator weaning and/or trach collar trials, and trach collars, are reviewed within 24 hours by a Clinical Support Nurse (CSN). Each resident's PCC records are reviewed to ensure admission orders are entered into PCC according to the orders written by each resident's physician. Additional documentation is reviewed to ensure assessments have been completed based on each resident's individual needs. The DON or their designee oversees this auditing process and ensures corrective actions are taken when indicated.A Quality Assurance (QA) audit tool was developed on [DATE] to monitor facility compliance with management of residents on ventilator weaning and/or trach collar trials. The audit reviews confirmation of the following: residents listed on PCC Dashboard, RT communication during daily IDT standup meetings, updating of nurses by RTs when changes between ventilators and trach collars are made, monitoring of vital signs and/or end tidal CO2 completed as ordered and documentation in both PCC progress note and paper weaning log. Each resident, both newly admitted and long-term care care, on ventilator weaning and/or trach collar trials will be reviewed. The audits started on [DATE]. The audits will be done daily for two weeks, then three times weekly for two weeks, followed by weekly audits for four weeks and monthly audits x 3. Audits will be done by the Director of Nursing and Director of Respiratory Services or their designees until compliance is maintained. The results of the QA

Based on observation, interview, and record review, the facility failed to ensure food was stored at safe temperatures, failed to maintain required temperature logs, and failed to discard potentially hazardous food stored above safe temperature ranges. This failure has the potential to affect 135 residents on an oral diet out of 172 residents in the facility.On 4/17/2026 at 9:36 AM, V4 (CNA) stated that while serving dinner on a unknown date, R4 brought to V4's attention a carton of milk appeared clumpy even though it was not expired; V8 (Licensed Practical Nurse) instructed her (V4) to remove all milk cartons from resident trays and notify dietary staff; and an unknown dietary staff member came and got the milk from the floor.On 4/17/2026 at 2:03 PM, V8 (Licensed Practical Nurse) stated R4 informed her (V8) his milk had curbs and lumps in it; removed the milk from R4 and informed other residents to return all milk to staff; dietary was notified and the milk was discarded by dietary; don't remember if the date on the milk carton was expired; the incident happened about two weeks ago; dietary does not serve leftover food; and no other clumpy milk has been served on the unit. On 4/17/2026 at 2:11 PM, R4 stated he (R4) was served milk that was curdy and spoiled for the first time. On 4/17/2026 at 1:16 PM, surveyor observed the refrigerator cooler temperature thermometer reading at 45 degrees; parmesan cheese with a manufacturer date stamped 3/10/2026 and a date written with a black marker dated 4/15/2026; deli ham with an expiration date of 4/11; leftover turkey with an expiration date of 4/15/2026 and no use by date; five 10 pound packages of ground beef in which V10 (Dietary Supervisor) obtained a temperature of 49 degrees. On 4/17/2026 at 1:23 PM, V10 (Dietary Supervisor) stated all refrigerated food should have an open date and expiration date; obtained and verified temperatures of the milk at 48 degrees, deli turkey has an expiration date of 4/11/2026; and ground beef temperature was 49 degrees Fahrenheit; bottle of Italian salad dressing was dated 3/4/2026; if there is no open or use by date the food should be tossed; cold foods should be held at 40 degrees to prevent bacterial growth; foods held above 41 degrees Fahrenheit can cause residents to become sick. On 4/18/2026 at 9:06 AM, V22 (Dietary Cook) verified with surveyor all of the following: the walk in freezer temperature measured 34 F on the internal thermometer, while the external thermometer read 42 F, placing frozen foods above the 0 degree Fahrenheit safe frozen temperature range; the refrigerator temperature measured 38 F and the outside refrigerator thermometer temperature reading was 53 F, exceeding the required maximum of 41 F indicating inconsistent internal temperature regulation; reviewed of the freezer temperature tracking log on 4/18/2026 showed no temperature entry completed for the date of 4/18/2026; two 10 pound rolls of ground beef measured 51 degrees Fahrenheit and 50.4 degrees Fahrenheit on the second shelf from the floor in a plastic container labeled with prepared dated of 4/15/2026 and a use by date of 4/21/2026. On 4/18/2026 at 9:16 AM, V22 (Dietary Cook) stated the cold foods should be held at 41 degrees Fahrenheit to preserve the food and prevent residents from getting sick. V22 stated foods not held a safe temperature can cause residents to have diarrhea, vomiting, and death. On 4/18/2026 at 9:46 AM, V10 (Dietary Supervisor) verified with the surveyor that the ground beef internal temperature reading was 49.9 F, above the safe limit of 41 F.On 4/18/2026 at 9:56 AM, V10 (Dietary Supervisor) stated the ground beef was placed in the refrigerator on 4/15/2026 and intended for use by 4/21/2026; the meat should be held at 41 degrees, but sometimes the staff leaves the refrigerator open. V22 stated I have never had an inspector ask me about the temperature being 49 degrees. If you want me to discard it, I will. V22 state the purpose of maintaining proper temperatures is to avoid any spoilage but stated he was not 100% sure at what temperature spoilage begins and planned to keep the meat until I talk to corporate.On 4/18/2026 at 10:04 AM, V22 (Dietary Supervisor) verified with surveyor the following: At 10:04 AM, pork sausage from the freezer internal temperature measured 23 F with a thermometer and was not frozen. At 10:06 AM, charbroiled Salisbury patties dated 4/15/2026 internal temperature measured 24.3 F with a thermometer and was not frozen. At 10:07 AM, vegan homestyle chicken tenders' internal temperature measured 30.9 F with a thermometer and was not frozen.On 4/18/2026 at 4:56 PM, surveyor reviewed work order invoice for the walk-in freezer with a diagnosis of low on refrigerant and leak test system found lead on the suction port and the walk-in cooler diagnosis with an evaporator coil fully iced up and drain line clogged.V1 (Administrator) stated he does not have a policy for refrigerator, freezer, and cooler tracking logs. Facility's policy titled Labeling and Dating dated 7/24 documents, in part, ready to eat time/temperature control for safety foods may be stored in the refrigerator held at 41 degrees Fahrenheit for 7 days and the purpose is to reduce the risk of food borne illness.Facility's policy titled Refrigerator Unit Temperatures dated 2/17 and 8/18 documents, in part, Refrigerators and Freezers will be maintained at the correct temperature to reduce the risk of food borne illness.

Based on interviews, review of records and observations, the facility's failures on respiratory care for 8 out of 11 residents (R7, R21, R22, R23, R24, R26, R28 and R16) are as follows:Facility failed to monitor one (1) resident (R7) with tracheostomy receiving oxygen at twenty (20) liters per minute via tracheostomy to be free from extubating/dislodging.Facility failed to ensure assigned healthcare professionals were screened, evaluated for competency to take care of residents with tracheostomy.Facility failed to report to State agency and investigate unusual occurrence resulted to death of one (1) resident (R7) due to dislodged tracheostomy in establishing parameters to prevent potential reoccurrence.Facility failed to ensure that initial assessments are made to tracheostomy residents to determine acuity and different levels of care.Facility failed to ensure that tracheostomy equipment is functional and/or readily available for reinsertion in case of dislodge for six (6) residents (R21, R22, R23, R24, R26 and R28) per their policy.Failed to follow doctor's order to perform and complete tracheostomy care and suctioning for one resident (R16).These failures resulted in 1 resident (R7) dislodged of tracheostomy being found unresponsive, pulseless, and apneic and was pronounced dead by paramedic. Failures have the potential to affect six (6) residents (R21, R22, R23, R24, R26 and R28) respiratory needs. Due to lack of equipment or equipment not functional as intended. Failures affected one (1) resident (R16) that sustained respiratory infection. These failures have the potential to affect all twenty (29) residents receiving tracheostomy care in the facility.Findings include: This was identified as an immediate jeopardy which began on [DATE] at 05:31 PM when R7 was pronounced dead after dislodging tracheostomy being found unresponsive, pulseless, and apneic by paramedics. V1 (Administrator) was informed of immediate jeopardy, and a template was presented on [DATE] at 11:40 AM. On [DATE] an acceptable removal plan was received after revision from the original plan submitted on [DATE]. On [DATE] the surveyor confirmed by observation, interview, and record review to confirm that the removal plan was initiated, and the immediacy was removed on [DATE]. However, the non-compliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-services training. R7 subject of the complaint expired on [DATE]. R7 was [AGE] year-old resident in the facility with medical diagnosis of toxic encephalopathy, respiratory failure with tracheostomy collar, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Prior to admission to the facility, R7 was in the hospital for ventilator support due to lethargy and worsening hypoxia requiring intubation for airway protection and ICU (Intensive Care Unit) admission. Hospital records documents that on [DATE] due to inability to wean from ventilator, R7 had a tracheotomy peg placed. R7 was admitted in the facility on [DATE] with physician order to receive high flow oxygen of twenty (20) liters per minute via tracheostomy collar. On [DATE] at 09:45 AM, V10 (Family of R7) stated that facility staff (V10 cannot remember specific name) told her that they (facility staff) were able to resuscitate R7. Upon arrival in the facility, somebody approached her and said, I'm sorry for your loss. V10 stated that R7 was completely swollen and unrecognizable. V10 stated that according to facility staff, R6 pulled out his tracheostomy. V10 emailed picture of R7's death certificate and multiple photos. Clinical notes of V9 (Licensed Practical Nurse) dated [DATE] are as follows: At 03:30 PM, R7 observed V9 with oxygen tubing connected to tracheostomy tubing in his finger. No intervention was documented to prevent tracheostomy from dislodging on V9's clinical notes. At 04:45 PM, V11 (Respiratory Therapist) found the resident with a dislodged tracheostomy tube. At 04:46 PM Cardiopulmonary Resuscitation (CPR) was performed to R7. At 04:47 PM 911 was called. At 04:55 PM 911 arrived and took over Cardiopulmonary Resuscitation (CPR). Paramedics informed facility that R7's time of death at 05:31 PM. On [DATE] at 02:52 PM, V9 (Licensed Practical Nurse) stated that R7 was alert but non-verbal, she saw R7's finger near tracheostomy tube and R7 was redirected and repositioned. Per R7's assessments and care plan, R7 cognition was impaired due to toxic encephalopathy, R7 rarely or never understood for any redirection. V9 stated that she heard an alarm and saw Respiratory Therapist and another nurse (V9 did not give any names when asked) trying to reinsert tracheostomy. According to V9 that was the time she knew that R7's tracheostomy was dislodged. V9 stated that she was not sure that R7 was assigned to her the day R7 expired. V9 stated that she does not know how much oxygen R7 is needed. V9 stated, I do not know off hand how much oxygen R7 needed. I don't know because, I mean the oxygen is always there. V9 was informed that an increase of FiO2 was ordered the day when R7 expired based on ABG (Arterial Blood Gas) result. V9 replied, ABG result? Increase of FiO2? If the doctor gave the new order, then maybe he (R7) was not saturating good. V9 stated facility did not provide any respiratory training for her. V9 stated that she does not have certificate or any training for tracheostomy care or specific to tracheostomy care. Here? I did not get any respiratory care class. V9 stated that there was no respiratory assessment for residents with tracheostomy. V9 stated, I don't know any assessment something needs to be done with that, because how would we know what to do. On [DATE] at 12:58 PM, after request from Human Resources, V35 (Human Resources/Business Manager) provided all records of V9 (Licensed Practical Nurse and V37 (Licensed Practical Nurse) during hiring. Both V9 and V37 nursing skills competency evaluation requirements for nursing positions were not done. V9 (Licensed Practical Nurse) assigned to R7 on [DATE] was not evaluated for competency during hiring on [DATE]. V3 (Director of Nursing) reviewed V9's employment records in full as follows: Under job description it covers, job summary, qualifications, physical requirements, essential functions signed by V9 and dated [DATE]. No Administrator signature or date. Registered Nurse / Licensed Practical Nurse Orientation that covers nursing skills or procedures, everything was not done. V9 just signed and dated [DATE]. Medication Pass Guidelines and Tips, Insulin Pen, Disinfecting Blood Glucose Monitoring Machine, Hand Hygiene, Intravenous Piggyback Competency, Validation of Qualitative Fit Test Procedure, Accessed and Reviewed Policies and Procedures on FTP Sites, Isolation and Personal Protective Equipment all evaluations were not done, V9 just signed and dated all evaluation forms. Per nursing schedule from [DATE] to [DATE], V37 was assigned to work on ventilator unit on [DATE], [DATE], [DATE] and [DATE] at 07:00 PM to 07:00 AM twelve (12) hour shift. On [DATE] at 10:49 AM, V43 (Registered Nurse) stated, Before they had RTs (Respiratory Therapists) assigned to all tracheostomy residents. Now they have cut down on RTs. This happened about last year like 4 to 5 months ago. On [DATE] at 01:24 PM, V3 (Director of Nursing) stated that it was V9 (Licensed Practical Nurse) who first knew that tracheostomy was dislodged. V3 stated that onboarding evaluation during hiring is basically to see if nurses need more training in a particular area. When asked about V9 tracheostomy or respiratory care training. V3 replied, There are no trach care or respiratory care training. Review of R7's clinical notes of the incident on [DATE] are as follows: V11 (Respiratory Therapist) clinical notes dated [DATE] documents at approximately 04:45 PM. V11 reinserted tracheostomy into R7. R7 with pulse and on labored breathing. In contrast with V9 (Licensed Practical Nurse) clinical notes with the same date [DATE]. Cardiopulmonary Resuscitation (CPR) was performed at 04:46 PM. Which was a minute after R7 reinserted tracheostomy into R7. According to V11, R6 with pulse and labored breathing. At 04:47 PM paramedics (911) were called. At 04:55 PM paramedics (911) arrived and took over CPR. Change in condition assessment dated [DATE] also documents that nurse was informed by RT (Respiratory Therapist) that tracheostomy was dislodged, reinserted R7 with breathing and pulse. CPR was performed. Paramedics (911) report dated [DATE] documents the following: Team was dispatched on [DATE] at 04:47:24 PM arrived at scene at [DATE] 05:52:37 PM, R7 was found unresponsive, pulseless, and apneic by ambulance crew members. Tracheostomy tube reportedly dislodged, nursing home staff attempting to reinsert. Crew arrived to find patient in asystole, CPR initiated immediately. Initial assessment revealed facial and tongue swelling. Intubation with laryngoscope was not attempted due to facial and tongue swelling. Patient received five rounds of Epinephrine, remained in asystole and PEA (Pulseless Electrical Activity) throughout resuscitation efforts. Hospital Emergency Department was contacted, and permission was granted to terminate resuscitation efforts in the field. R7 final acuity report: Dead with Resuscitation Efforts. R7's Death Certificate time of death documents 05:31 PM certified by V12 (Medical Doctor) primary care physician of R7 in the facility. On [DATE] at 01:24 PM, V3 (Director of Nursing) stated CPR will be performed only when there has no pulse, because the purpose is to resuscitate. Which is supported by facility's policy on Cardiopulmonary Resuscitation (CPR) dated 04/2025. It documents that facility does provide CPR to residents per American Heart Association guidelines. Guidelines instruct healthcare personnel to initiate CPR if there are no response and no breathing and do not definitely feel a pulse within 10 seconds. On [DATE] after request to V3 (Director of Nursing) for incident report and full investigation of unusual occurrence reported by facility to the State agency related to the death of R7 after tracheostomy was dislodged. At 12:28 PM, V36 (Nurse Consultant) stated that facility did not report R7's death to the State. V36 stated No incident report or investigation, it was just a medical case. Do we need to report all the residents that died in the facility? V36 was made aware that R7 expired after tracheostomy dislodging which is not expected outcome of a resident's condition or disease process. Per Incident / Accident Reports policy dated 09/2020, facility is required to report all accident or incident where there is injury or potential to result in injury. An accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. Policy requires reporting to State agency (IDPH) among others. More stringent reporting is required when death occurred due to accident or incident. It requires facility to call State Regional Office or to call IDPH hotline and verify that requirement for reporting was met. On [DATE] at 11:04 AM, V3 (Director of Nursing) stated that incident report to State agency needs to be done when it resulted death, any injury that resulted to stitches, sutures or any fracture, unexplained injury like bruises. Facility will investigate anything that can be done differently in order not to repeat similar incidents. V3 said, purpose of investigation is to prevent that if there is something that can be done differently. On [DATE] at 11:25 AM, V11 (Respiratory Therapist) stated he was able to reinsert tracheostomy, that R7 had vital signs after reinsertion of his tracheostomy. V11 stated that a person receiving twenty (20) liters per minute is a high flow oxygen. It means extra flow to keep airway open or keep lungs open. Per physician order, R7 was instructed to receive 20 liters per minute oxygen via tracheostomy collar. V11 denies that R7 has swelling on his face. V11 stated that there was no subcutaneous emphysema or facial swelling. V11 stated that he did not document any of these details including R7's vital signs or appearance during the incident because he forgot. According to an Article on Subcutaneous Emphysema Following Open Tracheostomy During Tracheostomy Mask Ventilation dated [DATE] from National Library of Medicine a government website by American Journal of Case Report. Tracheostomy is a surgical procedure that is done by creating an ostomy in the anterior wall of the trachea to facilitate airway access and ventilation. It is indicated for acute respiratory failure after prolonged intubation, upper airway obstruction, difficult airway, and extensive secretions. Early perioperative complications include bleeding, pneumothorax/pneumomediastinum from a false tract, sub-cutaneous emphysema, esophageal perforation, and tracheal ring fractures. Subcutaneous emphysema is rare but carries a high risk of morbidity and mortality, especially if progressed to pneumothorax and pneumomediastinum. It results from tight closure of tissues around the tracheostomy tube or tears in the posterior tracheal wall. On [DATE], via email V10 (Family of R7) provided photos of R7 that compare photos taken on [DATE] (R7's day of initial admission) from [DATE] (day R7 expired with dislodged tracheostomy). Per R7's photos it was clear that R7 has substantial swellings on his face and body. On [DATE] at 08:17 AM, V11 (Respiratory Therapist) after requesting writer to call. V11 changed his statement and stated that R7 had swelling, I saw it was swelling, if paramedic noted that they cannot intubate the swelling affected around the trach. It means there was substantial swelling. V11 stated that he was the first person who saw R7 with dislodged tracheostomy. V11 stated that before dislodging he saw the resident (R7) three (3) to four (4) hours ago. V11 stated that Respiratory Therapist (RT) was in charge of residents with tracheostomy and ventilator. Nurses are in charge of residents with tracheostomy without ventilator. On [DATE] at 03:11 PM, V11 (Respiratory Therapist) again changed his statement and stated that he had a hard time getting tracheostomy in. I was not able to totally insert it in. But when I suction, I did not get any resistance. It was not all the way in, or it was not totally inserted. I don't know if it was totally in. V11 stated first insertion of tracheostomy was not successful because he was trying to place a larger tracheostomy or tube. When he went to grab a smaller tube, he was able to insert but not sure if it was totally in. V11 stated that ABG (Arterial Blood Gas) let us know if patient breathing appropriately. When FiO2 increases after ABG results it means patients need additional oxygen. When it increased from 26% to 30% percent, it means patients need 30% FiO2 to have receive the right oxygen. On [DATE] the day when R7 expired after tracheostomy was dislodged. Facility received R7's ABG result, V12 (Medical Doctor) ordered to increase R7's FiO2 from 26% to 30%. On [DATE] at 11:08 AM, V19 (Respiratory Therapist) stated that physician standard order is to titrate oxygen down. If FiO2 was increased that means the patient needs more oxygen. V19 stated that she was not sure if R7 was taken care of the nurse or RT. V19 then said, Based on the progress notes the nurses was assigned to the patient. It is accurate to say that not all patients are assigned to Respiratory Therapist. V19 stated that Respiratory Therapist does not do CPR. It is the nurse that performs CPR. On [DATE] reviews on respiratory equipment availability for tracheostomy residents are as follows: At 01:31 PM with V39 (Registered Nurse) R21 during tracheostomy care pulse oximeter connected to R21's finger did not work. It did not show result on monitor/screen. V21 tried to reposition equipment attached to R21's finger but did not show any oxygen saturation results. V39 stated that it was defective and does not work. V21 performed suctioning three (3) times without oxygen saturation information. With V39 and V4 (Assistant Director of Nursing) R22 was seen with tracheostomy. V4 stated that R22 currently receiving high flow oxygen twenty (20) liters per minute via Airvo machine. V39 stated that she thought Airvo machine was a ventilator. V39 checked Airvo machine to confirm settings that R22 is receiving 20 liters per minute. V39 stated that the machine was off. V4 stated that it was possible that CNA (Certified Nursing Assistant) turned it off during bedside care. In the same room, R23 screen/monitor does not show oxygen saturation result. R23 has ventilator connected via tracheostomy collar. With V40 (Registered Nurse) and V4 (Assistant Director of Nursing) at the bedside of R24. V40 stated that R24 receives 35 liters per minute high flow oxygen via Airvo. V40 stated that R24 does not have pulse oximeter machine connected to a monitor like other residents with vital signs equipment. V40 stated that she has a portable pulse oximeter and takes R24's oxygen saturation from time to time. V4 and V40 were asked with 35 liters per minute high flow oxygen via Airvo machine does R24 tolerate room air in case tracheostomy accidentally dislodge? V4 and V40 did not reply to the question. V40 stated, I get what you mean, but did not elaborate. On [DATE] at 02:41 PM with V3 (Director of Nursing), inside R24's room, V3 cannot locate pulse oximeter inside room. On [DATE] at 01:08 PM with V14 (Licensed Practical Nurse) stated that she was assigned to respiratory unit. Respiratory equipment on the bedside was reviewed for residents that have tracheostomy with V14. The following residents do not have complete supplies per Reinsertion of Tracheostomy Tube with Accidental Extubation policy or equipment does not work: R26 was seen without spare tracheostomy tube, sterile 4 X 4 and tape. R27 without sterile 4 X4 and tape. R28 pulse oximeter disconnected does not read on the screen/monitor. V14 stated that it may be due to room deep cleaning or when R28 took shower. V14 was asked when was pulse oximeter disconnected? V14 replied It's been a while. R23 without spare tracheostomy, sterile 4 X 4 and tape. Policy on Reinsertion of Tracheostomy Tube with Accidental Extubation dated 09/2020 documents the following equipment needed: Gloves, Tracheostomy Tube, Ambu Bag, Sterile 4 X 4s, Tape, Sterile K-Y Jelly or Sterile Saline and Pulse Oximeter. On [DATE] at 01:24 PM, V3 (Director of Nursing) stated that residents that are found at risk of dislodging tracheostomy cannot be left alone. Residents need to be sent out to hospital for observation when they cannot be redirected or ask doctor for mitten/restraint. V3 said, If the resident is touching trach, I will not leave the resident, if not redirected send resident out for observation, or asked for restraint we can call doctor for mitten. V3 stated when the tracheostomy tube is dislodged, it may result in low oxygen or desaturation, confusion, altered mental status, or death. Per V3 (Director of Nursing) facility follows physician order currently there is no initial assessment specific for residents with tracheostomy to determine acuity of care. R7's plan of care was to obtain oxygen saturation by physician order. Under physician order R7 to monitor continuous pulse oximeter reading to check for oxygen saturation. Per oxygen saturation summary history under vital signs there was no documentation for [DATE], the day R7 expired. Medication Administration Record (MAR) for [DATE] have a single documentation at the morning shift of R7's oxygen saturation. Clinical notes did not document any vital signs on [DATE] when R7 expired. On [DATE] at 01:40 PM, V12 (Medical Doctor) stated that in general residents with tracheostomy are not breathing on their own. Generally, every patient with trach, they are not breathing on their own. They cannot breathe on their own. Soft tissue swelling that's a very high possibility due to dislodge of trach, Swelling can occur post manipulation of airway. V12 stated that R7 does not have any swelling during her initial assessment the day after R7 was admitted . Per list provided by facility dated [DATE]: There are twenty-nine (29) residents on tracheostomy in the facility. On [DATE] at 11:37 AM, V34 (Registered Nurse) stated that she is familiar with R16. V34 stated that R16 had a trach that was usually suctioned by the respiratory therapist. V34 stated that R16 did not have pneumonia when he was initially admitted on [DATE]th. V34 stated that 16 had an order to change his trach dressing every shift and as needed. V34 stated that R16 had an order to suction every 4 hours and as needed. V34 stated that there was an incident one time when R16's family was upset because R16 was not taken care off properly. V34 stated that she passed medications, and then changed his trach collar, inner canula. V34 stated that the family was worried because R16's trach gauze had mucus on it. V34 stated that it is expected of her to perform trach dressing change and change inner canula according to doctor's orders to reduce the risk of the resident collecting mucus in his trache which can lead to pneumonia if kept clean. On [DATE] at 12:47 PM, V2 (Director of Nursing/Infection Preventionist) stated that he is the current infection preventionist with the consultant. V2 stated that nurses and staff are expected to follow doctor's orders full and completely. The nurses are expected to document according to the order that the nurses complete. V2 stated that if it is not documented, that means it is not done. V2 stated that the purpose of doing trachea care is to clear the airway from mucus. V2 stated that if trachea care is not done, that leads to accumulation of mucus. V2 stated that an accumulation of mucus leads to difficulty breathing. V2 stated that nurses are expected to change the inner cannula for a trachea. V2 stated that the purpose of changing inner cannula is to limit the growth of bacteria and reduce the cause of infection. V2 stated that if inner canula is not changed, it increases the risk of that resident acquiring infection. V2 stated that the trachea and vent patients are very prone to infection. V2 stated that if nurses follow doctor's orders to perform trachea care and change inner cannula that reduces the risk of contracting pneumonia. V2 stated that he sees R16's chart. V2 stated that R16 missed trachea care on [DATE], [DATE] and [DATE]. V2 stated that R16 missed changing inner canula on [DATE]. This can increase R16's risk of contracting pneumonia. V2 stated that R16 was initially admitted to the facility on [DATE] without any infection. V2 stated that R16 was sent back to the hospital on [DATE] for difficulty breathing and infection. V2 stated that R16 was readmitted back in the facility on [DATE]. V2 stated that R16 had labs drawn on [DATE] which shows a white blood count of 18.3 which means infection. On [DATE] at 1:11 PM, V18 (Medical Doctor) stated that she has patients here in this facility. V18 stated that she oversees patients in the vent unit. V18 stated that any respiratory order is put in by the pulmonologist. V18 stated that trach care and inner cannula change is put in to prevent infections and maintain airway. V18 stated that if these tasks are not done then that can increase the risk of infection. V18 stated that he is familiar with R16. V18 stated that R16 was initially admitted in the facility in December. V18 stated that he was sent out on [DATE] for desaturation and was admitted back in the facility on 1/19. R16's treatment administration record for 12/2025 documents in part: Order for changing inner cannula was daily. R16 had missing treatment administration signatures on [DATE] and [DATE]. Order for trach care and collar was scheduled for every shift and as needed. R16 had missing treatment administration for trach collar care on [DATE], [DATE], and [DATE]. Order for cleaning inner cannula was every shift and as needed. Missing treatment administration for cleaning inner cannula on [DATE], [DATE] and [DATE]. Order for suctioning trach was every 4 hours and as needed. R16 had missing trach suctioning on [DATE] at 8:00 PM, [DATE] for midnight and 04:00 AM, [DATE] for 8:00 AM, 12:00 PM and 04:00 PM, [DATE] for 8:00 AM and 12:00 PM, and [DATE] for 8:00 AM, 12:00 PM and 04:00 PM. R16's progress notes on [DATE] by nurse on duty documents in part: R16 noted with a O2 sat that continues to fluctuate between 88-92. Respiratory therapist informed, treatments given as ordered. All tubing and inner cannular changed. Suctioned as ordered and prn but O2sat continues to be fall between 88-92 after bagging. V18 phoned and left message. Waiting for return call. R16's progress notes on [DATE] by V34 documents in part: 915:AM R16 wife is here this am. She asked writer to come into the bedroom to see that R16 had a runny nose and a stream of saliva on the side of his mouth. Writer said she will get it. Writer obtained a wet warm towel, cleaned his face and nose and replaced his bib around his neck. As writer returned to her task that she was doing, R16's wife came back to the writer with the phone. She had R16's sister on the phone, who began to yell and scream about other concerns she had. Then she said she was going to call the director of nursing (DON) to complain about the care. She was very angry and rude, so writer responded that the (DON) was the right person to talk to. V18 was in the room with the wife. V18 examined R16 about his condition and her concerns. Family still was not satisfied with the update she received. R16's hospital record on [DATE] documents in part (pg 75): R16's chest x-ray with superimposed pneumonitis. tachycardic and tachypneic upon arrival. leukocytosis present on admission white blood count of 16.28. Infectious disease is consulted for evaluation and treatment of sepsis. R16's hospital record on [DATE] documents in part (pg 117): Tracheal cultures on [DATE] results in serratia marcescens. Group G strep. Chest x-ray with super imposed pneumonitis. Overall source may be related to pneumonia with dyspnea/hypoxia. On [DATE], the surveyor made observations, conducted interviews and received documents to confirm the following removal plan was initiated: R7 expired on [DATE] at the facility. There are twenty-nine (29) residents on tracheostomy in the facility on [DATE]. Policies, procedures and practices for assessing and monitoring residents receiving Oxygen via tracheostomy tubes, including preparation for and management of medical emergencies were reviewed. Education for staff that were directly involved in this alleged failure (V9 and V11) was reviewed. Education that was conducted by the facility for Nurses Competency was reviewed. Education that was conducted by the facility for Respiratory Therapists was reviewed. Schedules of both nurses and RT assigned on the respiratory unit were reviewed to ensure they received facility-approved training and demonstrated competency using the Nurse Respiratory Unit and Tracheostomy Tube Competency Tools. Facility's respiratory unit was reviewed with Director of Nursing to ensure all respiratory equipment per policies were available. Quality Assurance Audit tools for monitoring residents who receive Oxygen via tracheostomy tubes to ensure emergency equipment is available at the bedside according to the Equipment Back-Up for Ventilator Unit and Reinsertion of Tracheostomy Tube with Accidental Extubation were reviewed. Facility's audits of 5 residents and 5 staff members three times a week for four weeks, then weekly for four weeks, then monthly x 3 months, and then randomly was reviewed. The QAPI committee on emergency equipment to be available at the bedside were reviewed.

Based on review of records and interviews the facility failed to provide preventive treatment for 1 out of 3 residents (R6) reviewed for wound and/or pressure ulcer prevention and treatment.These failures affected 1 resident (R6) who sustained a wound in the facility on the sacral/tailbone that became infected.Findings include:R6 a [AGE] year-old resident initially admitted in the facility on 01/13/2026 with diagnosis of cerebral infarction, anoxic brain damage, morbid obesity due to excess calories, diabetes mellitus among others.On 03/24/2026 at 09:40 AM, V28 (Family of R6) stated that facility failed to communicate to him the status of R6's wound. V28 said he was informed by the hospital that R6 had a Golf ball-size pressure ulcer a month after R6 was admitted in the facility. Currently, R6 is still in the hospital being treated for her wound.Per initial admission assessment clinical notes by V41 (Registered Nurse) dated 01/13/2026 documents that R6 skin assessment was done. R6 has intact skin, and no wounds. Clinical notes of V42 (Wound Nurse/Licensed Practical Nurse) dated 01/14/2026 documents that R6 skin were intact with MASD (Moisture-Associated Skin Damage) on the sacrum.R6's care plan intervention dated 01/27/2026 documents R6 needs barrier cream to areas exposed to moisture/incontinence. Review of R6 treatment administration records (TAR) for January 2026 does not document any treatment on the sacrum for MASD (Moisture-Associated Skin Damage). After eighteen (18) days without documented physician orders and treatment administration record of sacral MASD (Moisture-Associated Skin Damage) treatment, V43 (Registered Nurse) clinical notes dated 01/31/2026 documents: V12 (Medical Doctor) informed of MASD (Moisture-Associated Skin Damage) to sacral ad left buttock, V12 ordered Zinc Oxide cream to affected area every shift each incontinent care and to notify wound care team and wound consult. On 03/26/2026 at 10:49 AM V43 (Registered Nurse) stated that on 01/31/2026, R6's sacral wound has slight opening irritation on the skin. Zinc Oxide cream protects and dries the skin to help protect the skin. R6 was not seen by V27 (Advance Practice Nurse for Wound) until 02/17/2026 seventeen (17) days after V12 physician ordered for wound consultation.V27 (Advance Practice Nurse for Wound) notes and assessment dated [DATE] documents that R6 sacral wound worsen from previous wound area from 0 (skin intact) to 10 centimeters by 15 centimeters by 0.1 centimeter (length by width by depth). Per V27's notes first evaluation R6 previously had MASD (Moisture-Associated Skin Damage) to sacrum. Upon V27 examination, sacral MASD (Moisture-Associated Skin Damage) worsened. V27 ordered culture and sensitivity to rule out localized infection. And to refer to Infection Disease (ID) for culture and sensitivity results. V27 instructions was to perform the following test: Please refer to Infectious Disease specialist for Culture and Sensitivity sacral ulcer.On 03/25/2026 at 01:34 PM, V42 (Wound Nurse/Licensed Practical Nurse) stated that upon admission R6 skin was intact with MASD (Moisture-Associated Skin Damage). V42 reviewed R6 clinical records, upon knowing that R6 had MASD (Moisture-Associated Skin Damage) without physician order for treatment. V42 stated that there should have been an order for Zinc Oxide cream twice a day. V42 stated that Daikins solution (ordered on 02/17/2026), is used to treat open wounds to fight bacteria and to clean the area of the wound. While Zinc Oxide cream is only used if wound is not deep and no rawness. V42 stated that based on R6's culture and sensitivity result her (R6) sacral wound got infected. V42 stated that the expectation is for wound staff to address skin concerns as early as possible to prevent wound issues. It could help if it was addressed from the very beginning. Review of R6 treatment administration records (TAR) for February 2026 documents that on 02/17/2026 Dakins (1/2 strength) Solution 0.2-0.25 % was added as a new treatment.Per R6's census history, R6 was discharged on 02/18/2026. Clinical notes dated 02/18/2026 by V29 (Registered Nurse) documents that R6 was transferred to the hospital with elevated temperature or fever, Complete Blood Count blood results noted that [NAME] Blood Cell (WBC) results 18.5 which was high. Reference Range from 3.6 to 11.2. WBC elevates when there is infection. On 02/20/2026 facility received R6's culture and sensitivity result that documents R6 tested positive for wound infection.Per V29 (Registered Nurse) clinical notes dated 02/19/2026 during R6 transferred to the hospital documents R6 were admitted for sepsis and sacral region pressure ulcer evaluation.Centers for Disease Control (CDC) on 03/26/2026 defines Sepsis as follows:Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency.Anyone can get an infection, and almost any infection can lead to sepsis.Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body.Without fast treatment, sepsis can quickly lead to tissue damage, organ failure, and death.Prevention and Treatment of Pressure Injury and other Skin Alteration dated 03/02/2021:Policy is to implement preventive measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan.

Based on interviews and record review, the facility failed to ensure that a resident (R1) remains free from verbal abuse/assault from another resident (R3) and failed to follow their abuse policy. These failures caused psychosocial harm as evidenced by R1 feeling sad, nervous, scared, wanting to isolate self from community and not always feeling safe in facility's common areas due to R3's continuous verbal abuse/assault and despite R1's multiple notifications to various staff members. These failures affected one resident (R1) out of 3 residents (R1, R3 and R6) reviewed for verbal abuse/assault.Findings include:On 2/10/2026 at 10:34 AM, R1 stated, R3 is being verbally abusive/assaulting towards R1 and calling R1 names, such as stupid n-word, stupid pedophile, nasty and disgusting and other racial names and slurs and R3 would yell out false accusations about R1 such as R1 using the system, not taking care of own children, falsely pretending to be sick to use state funding. R1 also said that R3 knows which room R1 resides on R1 and R3's floor, and on multiple occasions, R3 would pass by R1's room and sit in the wheelchair in front of R1's room, screaming and cursing at R1 and showing R1 offensive finger gestures. R1 stated that R3's verbal abuse towards R1 is ongoing and continuous and has been occurring for about a year. R1 stated that R1 told multiple staff members on a different occasion throughout a year and feels that the facility is not doing anything to prevent R3's verbally abusing R1. R1 stated that R1 used to be more social and outgoing and would participate in group activities, speak with other residents and walk around the facility's common areas before R3's verbal abuse. R1 said that now R1 feels sad, nervous, scared and wanting to isolate self and stay in R1's room, to avoid contact with R3. R1 stated that R1 does not know why R3 is verbally abusing R1, because R1 never talks with R3, R1 always avoids and ignores R3. R1 also said that when talking to staff members about R1's concerns, the staff told R1 to ignore R3, not to look or talk with R3 and to avoid R3 as much as possible. R1 said that R1 enjoyed eating food at the dining room with other residents, but now R1 eats in R1's room and does not go out of room much and if R1 does go out of room, R1 makes sure that nurses are around. On 2/10/2026 at 10:50AM, V4 (Registered Nurse/RN) stated that V4 is aware of R1's concerns with R3 and that R1 talked with V4 about R3's verbal abuse on 2/2/2026. V4 stated that R1 told V4 that R3 continues to call R1 names and racial slurs and cursing at R1. V4 said that R1 told V4 that R3 would pass R1's room and sits in wheelchair in front of the door and curse at R1 and show R1 inappropriate finger gestures. V4 stated that R1 told V4 that verbal abuse from R3 is ongoing issue. V4 also said that once, (not sure of date), R1 was sitting in the dining room and R3 rolled up in the wheelchair towards R1 and called R1 the n-word and V4 heard it. V4 told the supervisor at that time. V4 said that the supervisor notified, does not work at the facility anymore. V4 affirmed that on 2/2/2026, V4 went to V1's (Administrator) office and V14's (Social Services Director) to report R1's concerns and that V4 documented it in R1's chart. V4 stated that V1 told V4 that V1 is aware of the issues between R1 and R3 and that V1 is working on the investigation. V4 stated that after V4 notified V1 and V14 on 2/2/2026, nobody spoke to V4 about those concerns. V4 stated, that in October 2025 (not sure of the exact date, but the same day that R3 was sent out to hospital) V4 observed R3 screaming and yelling at R1, and R3 calling R1 the n-word. V4 stated that R3 had to be sent out to hospital due to R3's verbally abusive behavior. V4 stated that R1 used to be more social and would go to activities and that now, V4 noticed that R1 mainly stays in R1's room, eats in the room, and is more isolated. V4 stated that when there is a conflict between residents, facility staff tries to separate residents to make sure they are comfortable and that R1 was told to avoid conflict. V4 stated that R3 knows where R1's room is located.On 2/10/2026 at 11:12 AM V12 (Licensed Practical Nurse/LPN) stated that R3 is known to have abusive behavior, and that V12 saw R3 few months ago (10/10/2025) yelling and screaming at residents when passed by R3's room. V12 also stated that the same day, V12 heard R3 calling R1 the N-word once when R1 was at the nurse's station and R3 was passing by. V12 said that R1 told V12 that R1 never did anything to R3 to start behaviors and that R1 does not understand why suddenly R3 started calling R1 names. V12 stated that V12 noticed social isolation in R1 and that he does not come out of room as much as before. V12 also said, that R1 eats in R1's room and before R3's verbally abusive remarks, R1 used to eat in the dining room.On 2/10/2026 at 11:35 AM, V4 (Registered Nurse/RN) and V12 (LPN) said that both heard R3 say the n- word in the past to R1 multiple times and that V4 and V12 redirected R3 and mentioned R3's behaviors to the supervisors at that time and that R3 was moved to a different room, but R3 still knows where R1 resides. The nurses also said that R3 usually eats in R3's room and does not come out, but both saw R3 wheeling around in the wheelchair in hallways and around R1's room.On 2/10/2026 at 11:54 AM R3 said that R3 knows R1 and that R3 did call R1 names a while ago (not sure when) but not the n-word. R3 said, that R3 thinks that R1 is revolting and repulsive and that R3 called R1 nasty man. R3 said that R1 does not talk with R3 and that R3 knows which room R1 resides.On 2/10/2026 at 12:07 PM, V16 (Certified Nursing Assistant/CNA)stated, that R3 has verbally abusive behaviors and that V16 heard R3 cursing, and yelling at R6, which used to be R3's roommate and other residents that would pass R3's room, but not sure of date.On 2/10/2026 at 12:10 PM, R6 said that R3 was R6's former roommate and that on daily basis R3 was calling R6 names and it was not nice. R6 said, that R3 would say nasty things, to R6 but is not sure or recalls the exact words used. R6 said that R3 was not nice person. R6 said that R6 did not feel verbally abused, but R6 is relieved and happy that the facility moved R6 out of R3's room. sOn 2/10/2026 at 12:14 PM, V9 (CNA), stated that R3 has a behavior where R3 would scream, yell and calls others with names and racial slurs and that R3 had to be sent out to hospital for behaviors evaluation because was verbally abusive.On 2/10/2026 at 12:59 PM V14 (Social Service Director) said, that R3 has history of being verbally abusive and is part of R3's diagnosis. V14 said that R1 mentioned to V14 few months ago that R3 is calling R1 names. When V14 spoke to R1, R1 told V14 that R1 was at the nurse's station and that R3 called R1 the n-word. V14 thinks that R1 reported it to V14 sometimes before December but is not sure of date and that V14 notified V1 (Administrator). V14 said that V14 remembers a nurse (not sure which one and what date) mentioned to V14 that R3 was in the wheelchair sitting in the front of R1's room thinks it was about 2wks ago. V14 said that R1 did not like R3's behaviors and that R1 does not understand the reason R3 calls R1 names. V14 stated that V14 told R1 to ignore R3 and to walk away from R3 when R1 sees R3 anywhere in the facility. V14 said that R3 knows where R1's room is and that maybe R3 should have been moved to another floor away from R1, but R3 is still on the same floor as R1. V14 stated that V14 could not prevent R3's behavior, that is hard to control what R3 will say. V14 stated that V14 cannot control R3, that all V14 could do is to educate R3 and speaks with therapist. V14 said that R1 did not express feelings about R3's calling R1 names to V14. V14 is aware of incident in October 2025 with R3 calling R1 names and racial slurs and that it was reported. V14 stated that any abuse incident should be reported to abuse coordinator (V1 Administrator) and that documentation should be in resident's progress notes. V14 stated that V14 is not aware of R1 not going to activities.On 2/10/2025 at 1:49 PM, V14 (Social Services Director) stated that V14 spoke to R1 about 2 weeks ago and that V14 does not have documentation in R1's progress notes about the conversation and that V14 does not remember details. V14 stated that V14 told R1 If you see (R3), try to walk the other way and that R1 would reply, I (R1) do. I don't even talk to (R3).On 2/10/2026 at 1:55 PM, V1 (Administrator) stated that V1 is the abuse coordinator and that V1 is responsible for investigating incidents, keeping residents safe, protecting residents, submitting reports to state agency, educating staff and that residents should be informed about abuse. V1 stated that V1 is aware of only the incident reported on 10/11/2025 between R1 and R3 and that does not remember exact details or who reported it to V1. V1 said that supposedly R3 was saying racial comments to R1 in the hallway. V1 said that V1 spoke to R1 and that R1 denied the allegations and that R1 said that nobody is verbally abusing R1. V1 stated that a week ago, (2/2/2026), V1 spoke to a nurse, (does not remember which nurse) and that the nurse asked V1 if V1 was aware of R3 calling R1 racially derogatory names, but the nurse did not report a new allegation and V1 assumed that the nurse was referring to the past incident between R1 and R3 (10/10/2025). V1 stated that V1 did not start new investigation and told the nurse that the situation was previously investigated. V1 affirmed that V1 did not speak to R1 or R3 about the new allegations and V1 did not report it to the state agency. V1 stated that is possible that verbal abuse between same residents could happen more than once and that V1 should report to state agency a new allegation of verbal abuse when the nurse came talk with V1 last week. V1 said that V1 should not assumed and should talk with R1 and R3. V1 stated that V1 speaks to R1 frequently and that R1 did not say anything about being verbally abused. V1 then stated that V1 did not ask R1 specifically about R3 and that R1 had hesitated with answers. V1 stated that R3 should have been moved to another unit, to benefit R1's concerns of verbal abuse, but V1 was not aware of repeated behaviors. V1 said that R1 told V1 that R1 feels safe.0n 2/10/2026 at 3:20 PM observed R1 in R1's room, laying on the bed, watching TV. R1 stated that after the incident on 10/10/2025, nobody talked with R1 about what happened and that R1 did not receive follow up information or investigation conclusion information. R1 said, that V1(Administrator), did not ask R1 about R3's continuous behaviors of verbal abuse towards R1 and that V1 barely speaks to R1. R1 said that R1 did not deny allegations of incident in October and did not say to V1, that incident did not happen. R1 does not recall anybody asking R1 if R1 feels safe, in the facility. R1 stated that R1 feel safe only in R1's room, but not in the facility's common areas, because R3 might be there and would start calling R1 names again. R1 said that V14 (Social Services Director) told R1 to go another way of R3, ignore and avoid R3.R1 also stated that CNAs asked R1 why R1 is not coming out of the room as much. R1 stated that R1 used to enjoy movie nights and socializing with other residents, but now R1 barely speaks to any of residents and does not go to movie nights and that if R1 sees nurses around, then maybe R1 will go out of room for a moment to try to socialize with other residentsOn 2/10/2026 at 3:40 PM, V4 affirmed that V4 heard R3 saying the n-word to R1 in the dining room and that R1 came to V4 on 2/2/02026 and reported all concerns ( n-word calling, sitting in front of R1's room and showing R1 middle finger) to V4 and that V4 went to V1's (Administrator) office and notified V1. V4 said that V1 told V4 that V1 is already investigating and looking into the situation. V4 stated that nobody spoke to V4 about those concerns later or gave V4 any information about investigation.On 2/10/2026 at 3:59 PM, V1 (Administrator). stated, that if V1 is given an allegation, V1 should report as soon as possible, and that the incident should be reported within 2 hours of allegation if harm, otherwise is ok to report within 24 hours. V1 said, while looking at the 10/10/2025 incident report, that V1 believes the incident happened on 10/10/2025, but V1 reported incident to state agency on 10/11/2025 and said that V1 is not sure why did not report on the 10th and that V1 is confused about the details. V1 stated that when the nurse notified V1 on 2/2/2026, V1 did not report the new allegations to state agency. V1 stated that V1 did not ask R1 about R3 verbally abusing R1 and that V1 noticed that when speaking with R1 in the past, R1 was hesitating with answers.R1's admission Record documents, in part, diagnoses of Encounter for orthopedic aftercare; Spinal Stenosis; Intervertebral disc degeneration, Lumbar region; Primary Hypertension; Unspecified Asthma; Type 2 Diabetes Mellitus; Morbid Obesity; Hyperlipidemia; Insomnia; Venous insufficiency; Non-pressure chronic ulcer of left calf; Radiculopathy, lumbar region; Lumbago with sciatica; Nicotine Dependence; Arthrodesis status and Vitamin D deficiency.R1's Minimum Data Sheets (MDS) (11/11/2025 ) in section C for Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score of 15 which showed intact/impaired cognition.R1's progress note (2/2/2026 at 7:53 AM), documented by V4 (RN) showed in part, that R1 verbalized concerns to V4 about another female resident making false accusations about R1 and continuing to approach R1 despite R1's expressing discomfort and that R1 notified social services. V4 documented that V4 notified social services and director of nursing. There is no documentation of concerns being reported to the state agency nor the facility investigating allegations. Interviews further showed that R1 was voicing concerns about R3's being verbally abusive towards R1.R1's Census List (2/10/2026) showed in part that R1 was in the same room (room [ROOM NUMBER] C) since 8/27/2025.R1's Abuse Risk Assessment (8/12/2025), documented by V14 (Social Services Director) showed in part that R1 answered all questions no and is not at risk for abuse. There is no later dated abuse risk assessment in R1's medical records.R1's Care Plan (Initiated on 8/29/2023) showed in part that the staff should monitor R1 for changes in activity level and adjust encouragement and types of activities offered.Reviewed R1's complete current care plan (8/28/2023- 2/10/2026) which showed in part that there is no focus on R1 being verbally abused or being at risk for verbal abuse.R3's admission Record documents, in part, diagnoses of End stage renal disease; Dependence on Renal Dialysis; Sequelae of Cerebral Infarction; Chronic Kidney Disease; Cerebral palsy; Major Depressive disorder; Mixed Anxiety disorders; Post-Traumatic stress disorder; Attention-Deficit Hyperactivity disorder; Anemia; Hypotension; and Hydrocephalus.R3's Minimum Data Sheets (MDS) (1/13/2026 ) in section C for Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score of 15 which showed intact/impaired cognition. Functional Abilities for Mobility Devices is a manual wheelchair.R3's progress note (10/10/2025 at 5:34 PM) documented by V14 (Social Services Director), showed in part that V14 was alerted by staff on 10/10/2025 that R3 was being verbally abusive and making racial slurs towards another resident. V14 documented that R3 was transferred out to hospital on [DATE] at 4:00 PM. R3' Petition for Involuntary/Judicial admission [DATE] at 3:30 PM) filled out by V14 (Social Services Director), showed in part that R3 demonstrated increased agitation, mood lability and aggression and that R3 was making threats unprovoked, racial comments using racial slurs to those walking by R3's room and making discriminating comments towards men.R3's Census List (2/10/2026) showed in part that R3 was on hospital leave from 10/10/2025 at 4:31pm and returned to the same room on 10/10/2025 at 9:25 pm.R6's admission Record documents, in part, diagnoses of Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side; Dysphagia; Cerebral edema; Essential Primary Hypertension; Type 2 Diabetes Mellitus; Unspecified Dementia, mild, without Behavioral Disturbance; Psychotic Disturbance; Spondylosis; Lack of Coordination; Contracture of muscle; Encephalopathy; Solitary Pulmonary nodule; Anorexia; Major Depressive Disorder; Anxiety; Overactive Bladder; History of Falling; Presence of Artificial Knee Joint;R6's Minimum Data Sheets (MDS) (12/3/2025 ) in section C for Cognitive Patterns showed the Brief Interview for Mental Status (BIMS) score of 7 which showed impaired cognition.Facility's booklet titled Residents' Rights for People in Long-term Care Facilities (3/17) showed in part that resident has the right to safety and good care and that resident must not be abused by anyone - physically, verbally, mentally, financially or sexually.Facility's document titled Abuse Policy (For Illinois Facilities) (3/25), showed in part that the facility supports the rights of the residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Document showed in part, that the facility must report suspicion of crime and that the facility prohibits abuse of its residents and attempted to establish a resident sensitive and safe environment. Policy also showed in part that the purpose is to ensure facility's prevention of occurrences of abuse and this should be performed by establishing resident sensitive environment and prevention of mistreatment; Identifying incidences and patterns of potential mistreatment; Protecting residents involved in possible abuse incidents; Implementing systems to inspect all reports and accusations of mistreatment and perform necessary changes to prevent future incidents; Filing precise and timely investigative reports. The policy showed in part that the facility is committed to residents' protection from abuse by other residents, facility staff or other individuals at the facility. The document classifies verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend or disability. The document classifies in part, that mental abuse includes humiliation, harassment and that it could occur through either verbal or nonverbal contact, that could potentially cause resident to experience humiliation, intimidation, fear and shame.Facility's document titled Abuse Prevention Program (For Illinois Facilities) (3/25) showed in part that during employee orientation, the facility would include topics such as Sensitivity of resident rights and needs; Staff's obligation to prevent and report abuse; Assessment, Prevention and management of aggressive resident's reactions; Types of abuse and Reporting of suspicion of crime. Document showed in part that the facility should prevent abuse by establishing secure environment and that the residents' concerns should be recorded, reviewed and responded to by using the facility's grievances and that the residents should be informed of the procedure and the staff should assess and identify residents that could be vulnerable to abuse or having behaviors that could cause a conflict. Document showed in part, that the employees should immediately report any incident that is observed, heard about or suspected to the supervisor or the administrator and the designee staff should initiate investigation. Document showed in part, that to prevent abuse during investigation, the facility should remove from contact a resident that is alleged to abuse another resident and evaluate resident's condition to determine the most preferrable therapy, care approaches and placement with consideration on their safety and safety of other residents at the facility.

Based on observations, interviews, and record reviews, the facility failed to provide ADL (Activity of Daily Living) care to residents who are dependent on staff assistance with ADLs for two (R4, R5) out of four residents reviewed for incontinence care. This failure resulted in R4 experiencing pain, feeling humiliated and crying. Finding include,R4's clinical indicates the following in part: lack of coordination, systemic inflammatory response syndrome, cauda equina syndrome, primary generalized osteoarthritis, and major depressive disorder. R4's minimum data set [MDS] Brief Interview Mental Status Score [15] indicates R4 is cognitively intact. R4's MDS section [GG] indicates R4 is dependent on toileting hygiene, bed mobility and requires extensive assistance from staff.R4's Care plan in part:R4 has a self-care performance deficit due to weakness, impaired balance, lack of coordination, activity intolerance, incontinence related to generalized weakness, and cauda equina syndrome. R5's clinical record indicates the following in part; R5's medical diagnosis of spinal stenosis, weakness, gastrostomy, pressure ulcer wound on sacral area, polyosteoarthritis.R5's minimum data set [MDS] Brief Interview Mental Status Score [5] indicates R5 is moderately cognitively impaired. R5's MDS section [GG] indicates R5 is dependent on toileting hygiene, bed mobility and requires extensive assistance from staff. R5's Care plan in part:R5 has a ADL self-care performance deficit due to weakness, impaired balance, lack of coordination, activity intolerance, incontinence related sepsis, seizures, depression, bilateral osteoarthritis of knee and spinal stenosis. On 1/27/26 during facility tour at 9:00AM, across from the nursing station surveyor observed a room with R4 resting in bed, alert and oriented x3. Surveyor noted a strong odor of feces. R4 stated, I'm doing alright. After breakfast I had a bowel movement, and I need to be changed I just turned on the call light. The staffing is terrible. I always wait a long time sometimes for hours before I get changed and cleaned up. I use my urinal. I just need assistant when I have a bowel movement. On 1/27/26 at 9:05 AM, Surveyor exited the room with R4's call light sounding and observed V9 [Licensed Practical Nurse] in the same hallway two doors down from R4's room at the medication cart. Along with V7 [Certified Nurse Assistant] walking past R4's room three times between 9:06AM to 9:20AM. V9 nor V7 entered R4's room. On 1/27/26 at 9:22AM, surveyor asked V9 if she was the nurse for R4, and who was the certified nurse assistant for R4. V9 stated, I am the nurse for R4, and V8 [Certified Nurse Assistant] is assigned to R4's room. V8 was sent out on a medical appointment with a resident, she left around 8:30AM. I am not sure what time V8 will return. V7 and V37 [Certified Nurse Assistant] are the other aids and will cover and provide care to V8's assigned residents. On 1/27/26 at 10:00AM, Surveyor observed V7 entered R4's room, turned off the call light and exited the room. On 1/27/26 at 10:15AM, surveyor entered R4's room, R4 stated while crying tears, V7 answered my call light, V7 said she was busy with another resident, but will come help me in a few minutes. Please don't make them clean me, I want you to see how long it really takes them to clean me up. This makes me feel like a dog, lying here in my own feces while but buttocks is itching and burning.Surveyor conducted surveillance of R4's room on 1/27/26 from 9:00 AM to 11:50 AM. V7 did not return back to R4's room. R4 turned back on his call light at 11:45 AM, V37 [Certified Nurse Assistant] answered the call light. V37 exited R4's room at 11:50AM, and V37 returned with supplies and initiated ADL incontinence care to R4 three hours later [9:00AM to 12:00PM R4 was soiled with feces]. On 1/27/26 at 12:24PM, V7 [Certified Nurse Assistant] stated, I answered R4's light he reported he needed to be cleaned up after having a bowel movement, I did tell him I would be back, but I forgot. I was so busy with my own assigned residents. There are only two of us on this floor with approximately forty or more residents that need assistance. I am not sure why they sent V8 out on a medical appointment. Staffing has been an issue working short for over two months. On 1/27/26 at 10:20AM, during surveillance of R4's room, a couple rooms down from R4's room, surveyor heard someone yelling out for help. R5 was in bed, stated, I am wet and need help. I been wet a long time.Surveyor turned on R5's call light. 10:22AM. V9 [Licensed Practical Nuse] turned off the call light and came out the room and went back to the nursing station. At 11:10AM, surveyor asked R5 was she still wet. R5 stated, Yes, I am still wet. The lady said she will be back. On 1/27/26 at 11:30 AM, surveyor asked V9 what did R5 requested, when she answered the call light. V9 stated, R5 needs to be cleaned up. I told one of the aides, I don't remember which one. I have an admission coming and need to get report. Staffing has been an issue for a while; we work together to do the best we can. Someone will help R5 soon as possible. On 1/27/29 at 11:58 AM, V8 [Certified Nurse Assistant] retuned back to unit from escorting a resident to medical appointment. At 12:15PM, surveyor asked V8 if she could provide ADL incontinence care to R5. V8 stated, I was sent out to go with a resident to their medical appointment. There are other aides that could have gone instead of me. There are restorative certified nurse assistants, and a wound care certified nurse assistant. They are not assigned to residents.V8 went to R5's room and provided care. R5 was wet from 10:22AM to 12:15PM [two hours]. On 1/27/26 R17, said the staffing is not sufficient and they have to wait a long time for assistance. They all said the facility needs more certified nurse assistants. On 1/27/26 at 3:05 PM V3 [Acting Director of Nursing/Nurse Consultant] stated, I became the acting director of nursing on 1/13/26. I was not made aware V8 [Certified Nurse Assistant] was sent out on a medical appointment. I rather had sent another certified nurse assistant such as restorative, or wound care aide. My expectation related to ADL incontinence care is that care is provided as soon as possible. For a resident to wait three hours for assistance is not acceptable. If a resident is left wet or soiled for two to three hours, it could potentially cause infection, skin breakdown, pain or feelings of sadness and/or dignity issues. Policy in part:Certified Nurse Assistant Job Description:Provide residents with daily nursing care in accordance with current federal, state and local standards, guidelines, and regulations.Provide ADL assistants to a specific number of residents and or directed by nursing staff. 483.24(a)(2) ADL Care Provided for Dependent ResidentsS483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain goodnutrition, grooming, and personal and oral hygiene.

Based upon interview and record review the facility failed to follow policy procedures, failed to schedule timely diagnostic tests, failed to ensure that staff follow-up on diagnostic results, and failed to notify the physician of abnormal duplex scan and increased pain for one of four residents (R2) reviewed for change in condition. These failures resulted in R2's delayed treatment for right lower extremity DVT (Deep Vein Thrombosis), severe swelling, and pain rated 8/10. Findings include: On 4/28/25, IDPH (Illinois Department of Public Health) received allegations that R2 was found to have blood clots of leg, the physician waited 2 days to read the ultrasound, and treatment was delayed as a result. R2's diagnoses include obesity, cellulitis, peripheral vascular disease, and history of pulmonary embolism. R2's (8/11/23) care plan states resident is admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including skilled nursing care, management and evaluation of the patient care plan, observation, and assessment of the patient's condition. Interventions: Communicate resident status related to skilled services and changes to plan of care as needed to the physician. R2's (2/15/25) progress note states writer noted unilateral swelling on the leg, warm to touch and capillary refill at 3 seconds. Resident complained of pain, rates pain at 5 on the pain numeric scale. Writer notified provider with other (typo) for venous and arterial doppler. Order noted and carried out. Medical Doctor progress note: patient was noted to have pain and swelling of the whole right leg. Patient has no fever, but right thigh looks mildly warm. Start patient for Keflex (antibiotic) for early cellulitis, check venous doppler to rule out DVT. R2's (2/1/24) Physician Order Sheets include pain evaluation every shift. R2's (February 2025) Medication Administration Record affirms on 2/17 pain was rated 7 (increased), on 2/20 R2's pain was rated 8 therefore increased further. R2's (2/18/25) right lower extremity (arterial) duplex scan (conducted 3 days later) affirms mild to moderate peripheral arterial disease & advised clinical correlation and follow-up as indicated. R2's (2/18/25) right lower extremity (venous) duplex scan states right common femoral, superficial femoral, and popliteal veins show deep venous thrombosis. R2's (2/18/25) radiology note states writer relayed orders to the provider, no new orders was given. R2's (2/22/25) progress note states on 2/15/25, patient was seen for mild swelling in the right leg. Venous and 10-year (typo) doppler requested. The Nurse send me (V14/Physician) the arterial doppler but nobody notified me about the results of the venous doppler. Patient was seen again today (7 days later) and the right leg is very swelling it looks like 2 times of the left leg. Patient said she has mild improvement, but she has pain in the leg and specially when she keeps the leg elevated. I (V14) reviewed the venous doppler myself, it shows right common femoral, superficial, and popliteal veins show deep venous thrombosis. Start Apixaban 10mg (milligrams) twice a day for 1 week then 5mg twice a day. On 5/6/25 at 11:58am, surveyor requested R2's (2/15/25) SBAR (Situation Background Assessment Recommendation) Communication Form V4 (Assistant Director of Nursing) stated There's no SBAR for (R2) in February. Surveyor inquired about staff requirements for R2's change in condition V4 responded Report it to the doctor, there should have been an SBAR an e (electronic) interact change in condition that should have been filled out. This is (R2's) progress note from 2/18/25, it says writer (V13 Agency Registered Nurse) relayed orders to the provider, no new orders were given. I think they (V13) were trying to say labs. Surveyor inquired what orders were relayed to the provider V4 replied I'm (V4) not sure, it just says radiology note. Surveyor inquired if R2 was sent to the hospital on 2/15/25 (to rule out DVT) V4 stated She (R2) wasn't sent out in February, there were no orders to send her out and the Primary (V14/Physician) seen her (R2) 4 days later [4 days after DVT was identified on venous duplex scan]. Surveyor inquired about staff requirements for diagnostic orders V4 responded When they (staff) receive orders for diagnostics, the expectation is that they carry them out and should put in a progress note. Once they are performed, they should be relaying them to the doctor. Surveyor inquired about staff requirements for following up on diagnostic results V4 replied They (Nurses) use a communication board in report. When there's stuff on the communication board, we have stand up meeting daily and discuss whatever is on there. [Surveyor requested the (2/15/25) facility communication board documentation at this time]. On 5/6/25 at 12:38pm, V4 stated We (facility) don't have the communication for that day (referring to 2/15/25) it's not in there they (staff) didn't put in a communication for that day. I (V4) also just checked the report book and it's not in there either. On 5/7/25 at 11:06am, surveyor inquired about requirements for suspected DVT V14 (Physician) stated We order venous doppler if somebody has swelling. Surveyor inquired if R2's arterial and venous dopplers were ordered stat (on 2/15/25) V14 responded I (V14) don't remember but I give order for venous not arterial doppler, I don't know if she (Nurse) misunderstood me. Surveyor inquired if R2 waiting 3 days for arterial/venous dopplers was acceptable considering abnormal presentation and pain rated 7/10 (on 2/17/25) V14 replied I don't remember all the details. Usually with the DVT you don't have a lot of pain, we see more swelling in the legs. When I saw the patient (R2) she said I have severe swelling, I have severe pain. The patient diverted us, I thought she had infection, so we start her on Antibiotic and ordered venous doppler. Surveyor inquired about staff requirements for abnormal diagnostic results V14 stated They (staff) have to report the results to us (Providers) especially when its positive or abnormal. Surveyor inquired if V14 was notified of R2's increased pain and/or (2/18/25) abnormal venous duplex scan V14 responded I remember I was on the floor and the nurse ask me (V14) to see the patient, I start ATB (Antibiotic) and ordered labs (referring to 2/15/25). I came the following week to see all the results I was told was negative, but I check it myself and see it was positive, so I start Apixaban. I was told the venous doppler was negative and when I came on the floor (referring to 2/22/25), I found it was positive. Surveyor inquired if R2's right leg was twice the size of the left V14 replied It was, the swelling was quite impressive it was double the size. Surveyor inquired about potential harm to a resident with an untreated DVT V14 stated To have PE (Pulmonary Embolism). If I have concern for DVT or PE I have to start anticoagulation right away. The (09/20) facility change in condition policy states the attending physician on call/NP (Nurse Practitioner) will be notified of all changes in condition. Document time of call, physician, nurse practitioner or other person spoken to; reason for call, and result or orders received. Follow suggested guidelines for reporting clinical problems based on AMDA (American Medical Directors Association) Guidelines. Immediate Notification: any symptom, sign, or apparent discomfort that is acute or sudden in onset and a marked change (ie: more severe) in relation to usual symptoms, or unrelieved by measures already prescribed. Signs/Symptoms for Immediate Notification include abrupt onset of unilateral leg edema, with tenderness or redness and new severe pain or marked increase in chronic pain.

Based on interviews and record review, the facility failed to ensure that one resident (R2), who is diagnosed with cancer received two scheduled chemo therapy treatments. This failure has caused R2 to stress and worry about the cancer progressing due to missed chemotherapy. Findings include: R2 is a [AGE] year old with diagnosis including but not limited to: Malignant neoplasm of unspecified lung, quadriplegia, secondary malignant neoplasm of other specified sites, acquired absence of left leg above the knee, and unsteadiness on feet. R2 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. Surveyor inquired about what happened with R2's appointments. On 2/10/25 at 11:52 AM, V15 (LPN/ Licensed Practical Nurse) said, I work with R2 often. He (R2) missed two chemo appointments that I am aware of. The 1st appointment that he (R2) missed was because transportation was not set up. The second missed appointment was because the transportation picked him (R2) up at 6:30 AM and he got to his appointment early. Since there was no escort with R2, he had to be brought back to the facility. We had a hard time rescheduling his (R2) appointment, but the DON (V2) was able to secure an appointment for R2 today. On 12/10/25 at 12:05 PM, V16 (Nurse Practitioner) said that R2's recently missed chemo appointment was because he (R2) was picked up too early by transportation and since he had no escort, was sent back to the facility. Surveyor inquired about the importance of the chemo therapy treatment. At that time V16 said, Since the chemo therapy is only once monthly, it is important to not miss any appointments. The mass could possibly get bigger and the chemo can be less effective if there are missed appointments. Delayed chemo treatments in this early stage is not good. Surveyor inquired about what happened with R2's appointments. On 2/10/25 at 1:10 PM, V21 (Transportation personnel) said, I did not know about R2's first appointment because it did not show up under the order listing report when I ran a report. If the nurse does not enter an end date for the order, it will not show up on the listing report for me to schedule transportation. For the second appointment, R2 got to the appointment too early and he had to be brought back to the facility because there was no one to wait with him. R2 is transported via ambulance and stretcher. I am not sure if I would have been able to get another ambulance out to pick him up on the same day. Typically, we are to schedule the transportation prior and not the day of. Surveyor asked is R2 required an escort for appointments. On 2/10/25 at 1:10 PM, V21 (Transportation personnel) said that since R2 was transported via stretcher, he should have had an escort. On 2/10/25 at 2:10 PM, R2 said, I have missed two chemo appointments. The first time, I don't think that I had transportation set up. The second time, I was taken too early for my appointment and was brought back to the facility because I didn't have an escort. The transportation could not leave me alone because I use a stretcher to transport. The transportation could have transferred me to a bed, but I would need someone to sit with me. I am supposed to go for chemo treatments every six weeks. I'm worried that my cancer has worsened and I can't have this happen again. On 2/18/25 at 2:00 PM, V29 (R2's family) said, My main focus is to make sure that my brother's cancer treatments are consistent and as scheduled. The facility seemed passive about his missed appointments and did not seemed concerned about rescheduling them. These are serious appointments that he (R2) needs and I am concerned for him. R2's Care Plan documents, R2 has a diagnosis of Lung cancer; R2 has an ADL (Activities of Daily Living) self-care performance deficiency due to generalized weakness and impaired mobility secondary to diagnosis of quadriplegia. R2's order report documents, Appointment on 1/20/25 at 10:00 AM cancer center. R2's order report documents, Appointment on 2/3/25 at 7:00 AM cancer center; need a stretcher with escort. R2's progress note dated 1/21/25 and authored by V32 (LPN/ Licensed Practical Nurse) documents, writer spoke with representative at cancer center whom stated that R2 missed three appointments. R2's progress noted dated 2/3/25 and authored by V15 (LPN) documents, R2 went out today for his scheduled appointment with the cancer center. When R2 arrived by ambulance, the medics were told that R2 was too early for his appointment. Writer was advised to arrange for R2 to be transported back to the nursing facility. Facility policy titled Transportation documents, the facility will assist residents in arranging for transportation as needed.

Based on observation, interview, and record review the facility failed to provide prescribe wound care as ordered by the physician for 4 residents (R1, R5, R6, and R7); failed to set the low air mattress at the appropriate setting for one resident (R10); failed to ensure heel protectors were in place for one resident (R1); and failed to properly assess R1's right heel wound. These failures have affected 5 out of 5 residents reviewed for pressure ulcer prevention; and resulted in R1's heel wound worsening and R1 being hospitalized for sepsis on 2/11/25. Findings include: On 02/10/25 at 11:20 am, R7 was observed in bed awake, alert, and unable to communicate. Surveyor observed R7 with a dressing to R7's right foot undated. When Surveyor brought this observation to V6 (Wound Care Nurse), V6 stated, We (referring to staff) don't date dressing here (referring to the facility). It's the facility protocol. When V6 was asked regarding how staff is made aware of when the last time the dressing has been changed for a resident V6 stated, I (V6) asked that same question when I started. We change the dressings every day. We know by the appearance of the dressing. If the dressing doesn't look fresh then the dressing was not changed. On 02/11/25 at 9:20 am, Surveyor questioned V2 (Director of Nursing, DON) regarding wound care dressings being dated, V2 stated that it is the facility's policy to not date wound care dressings. Surveyor requested V2 to provide the facility's policy for not dating dressings, V2 stated that the facility does not have a policy for not dating wound care dressings. On 02/11/25 at 12:20 pm, Surveyor questioned V12 (Wound Care Coordinator) regarding wound care dressings being dated, V12 stated, We are told that it is the policy of the facility to not date the residents wound care dressings. Surveyor requested V12 to provide the facility's policy for not dating dressings, V12 stated that the facility does not have a policy for not dating wound care dressings. V12 stated, This is the first place (referring to the facility) that I (V12) was told not to date the wound care dressings. I don't know why we are not allowed to date the wound care dressings. I am just following the facility's policy. On 02/11/25 at 12:35 pm, Surveyor and V12 reviewed the Treatment Administration Record (TAR) for R5, R6 and R7's TAR's and observed the following: Review of R7's TAR showed that R7 did not receive wound care on 02/08/25 Review of R6's TAR showed that R6 did not receive wound care on 02/03/25 Review of R5's TAR showed that R5 did not receive wound care on 02/01/25, 02/02/25, 02/03/25, 02/04/25, 02/06/25, 02/08/25 or 02/09/25. On 02/11/25 at 12:40 pm, Surveyor questioned V12 regarding the missing signatures on R5, R6, and R7's TAR and V12 stated that after a treatment (wound care dressing change) is performed it should be signed out immediately on the residents TAR when the dressing change has been completed. V12 stated that if treatments are not signed out on the TAR the treatment has not been performed. V12 then stated, Not documented not done. V12 explained that the purpose of the documentation on the TAR is to verify that the treatment has been performed for the resident. When V12 was asked regarding what could happen if a resident goes without getting ordered wound care by the physician and V12 stated that the resident's wound could worsening and increase chances of a wound infection. V12 stated, We should be following the physicians orders for scheduled changes for wound care to prevent worsening wound and an increased risk of infection. R5's face sheet shows that R5 has a diagnosis which includes but not limited to end stage renal disease, dependence on renal dialysis, hypertensive heart disease with heart failure, chronic systolic (congestive) heart failure, type 2 diabetes mellitus without complications, asthma, anemia in chronic kidney disease, pancreas transplant status, kidney transplant rejection, complete loss of teeth due to periodontal disease, depressive episodes, opioid dependence, atelectasis, personal history of nicotine dependence. R5's Brief Interview for Mental Status (BIMS) dated 12/26/24 shows that R5 has a BIMS score of 15 which indicates that R5 is cognitively intact. R5's Physician Order Sheet (POS) dated active orders as of 02/10/25 shows that R5 has orders for Optifoam Ag (Silver) Adhesive 4 x 4 External apply to left ischium topically every day shift for skin condition apply Xeroform. R5's TAR dated 02/10/25- 02/28/25 shows no signature for R5's orders to receive wound care with Optifoam Ag (Silver) Adhesive 4 x 4 External apply to left ischium topically everyday shift for skin condition apply Xeroform on 02/01/25, 02/02/25, 02/03/25, 02/04/25, 02/06/25, 02/08/25 or 02/09/25. R6's face sheet shows that R5 has a diagnosis which includes but not limited anoxic brain damage, peripheral vascular disease, and type 2 diabetes mellitus with ketoacidosis without coma. R6's Brief Interview for Mental Status (BIMS) dated 12/10/24 does not show a BIMS score for R6 and indicates that R6 has memory impairment. R6's POS dated active orders as of 02/10/25 shows that R5 has orders for Medi honey wound/burn dressing past (wound dressings) apply to right anterior lower leg topically as needed for skin condition cleanse area W/NS (with normal saline), apply Medi honey/hydrogel sheet and cover with dry dressing . Skintegrity (skin integrity) Hydrogel Gel (Wound Dressing) apply to right anterior lower leg topically as needed for skin condition cleanse area W/NS, apply Medi honey/hydrogel sheet and cover with dry dressing. R6's TAR dated 02/10/25- 02/28/25 shows no signature for R6 to receive wound care with for Medi honey wound/burn dressing past (wound dressings) apply to right anterior lower leg topically as needed for skin condition cleanse area W/NS (with normal saline), apply Medi honey/hydrogel sheet and cover with dry dressing . Skintegrity (skin integrity) Hydrogel Gel (Wound Dressing) apply to right anterior lower leg topically as needed for skin condition cleanse area W/NS, apply Medi honey/hydrogel sheet and cover with dry dressing on 02/03/25. R7's face sheet shows that R5 has a diagnosis which includes but not limited to anoxic brain damage, non-pressure chronic ulcer of other part of foot with unspecified severity, and encephalopathy. R7's Brief Interview for Mental Status (BIMS) dated 12/31/24 does not show a BIMS score for R7 and indicates that R7 has memory impairment. R7's POS dated active orders as of 02/10/25 shows that R7 has orders for Puracol Plus External Pad (Microscaffold Collagen) apply to R (right) lateral foot topically everyday shift for skin condition clean with N/S (normal saline) apply puracol /4x4/ ABD (abdominal)/ kerlix and offload. R7's TAR dated 02/10/25- 02/28/25 shows no signature for R7 to receive wound with Puracol Plus External Pad (Microscaffold Collagen) apply to R (right) lateral foot topically every day shift for skin condition clean with N/S (normal saline) apply puracol /4x4/ ABD (abdominal)/ kerlix and offload on 02/08/25. The facility's document dated 03/02/21 and titled Prevention and Treatment of Pressure Injury and other Skin Alterations documents, in part: Policy: . 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. The facility's job description document dated 11/2021 and titled Wound Care Coordinator documents, in part: Essential Functions: A. Must ensure that all nursing procedures and protocols are followed in accordance with established policies. B. Directly supervise the nurses, CNA's and other members of the IDT (interdisciplinary team) that would care treatments and protocols are followed accordingly. D. Responsible/overseas for assessing and documenting women status in skin care. E. Administer or assist with wound treatments as ordered by physician. F. Review treatment orders for completeness of information and accuracy of transcription of the physicians orders. G. Review home assessments for completeness and accuracy. 47303 R1 is [AGE] year old with diagnosis including but not limited to: pressure ulcer of sacral region, pressure ulcer of left heel, pressure ulcer of right heel, severe sepsis with septic shock, hemiplegia and hemiparesis following cerebral infarction affecting left side. On 2/10/25 at 10:43 AM, R1 observed was lying flat on his back. At that time, no heel protectors were observed on R1's feet and no pillow was observed under R1's legs. On 2/10/25 at 10:47 AM, V6 (Wound care nurse) said that R1 had DTIs (Deep tissue injuries) on both heels. Surveyor asked who was responsible for applying resident's pressure relieving heel protectors. On 2/10/25 at 10:47 AM, V6 said that the assigned Nurses, CNAs (Certified Nurse Assistants), and wound treatment team worked together to ensure that all pressure-relieving interventions are in place. Surveyor inquired about expectations regarding wound assessments and wound prevention. On 2/18/25 at 12:30 PM, V12 (Wound Care Coordinator) said, Upon the initial wound assessment, we capture the size of all wounds in order to monitor the progress of each wound. For wound prevention, we offload boney areas of the resident and the floor staff reposition every two hours. Surveyor inquired about expectations regarding new wound orders. On 2/18/25 at 12:30 PM, V12 (Wound Care Coordinator) said that whoever rounds with V13 (Wound Care Doctor) takes the order recommendations and enters them into the Medical chart within 24 hours. Surveyor inquired about R1's recent hospitalization . On 2/18/25 at 12:30 PM, V12 (WCC) said that R1 had been hospitalized on [DATE] for sepsis. Surveyor inquired about weekly assessments and new orders. On 2/19/25 at 12:46 PM, V13 (Wound Doctor) said, I round weekly and give verbal orders as we round. At the end of my rounds, I also give them (treatment team) a printout of my progress notes with the orders. Surveyor inquired about the expectations regarding entering and following new wound care orders. On 2/19/25 at 12:46 PM, V13 (Wound Doctor) said, I would expect for the orders to be put in within the next day. Some orders may be for the next day or the following day. The orders are expected to be followed to have a goal of wound healing and prevention of infection. Surveyor asked if an infected wound causes sepsis. On 2/19/25 at 12:46 PM, V13 (Wound Doctor) said, Yes, an infected wound can cause sepsis. Surveyor asked what the treatment expected date meant. On 2/19/25 at 12:50 PM, V13 (Wound Doctor) said, The treatment expected date is the date treatment will end. Some treatments may continue past the end date if I (V13) don't make any changes. Surveyor asked what could happen if heel protectors are not used as ordered. On 2/19/25 at 12:50 PM, V13 (Wound Doctor) said, If there are no heel protectors or pillows, that can cause pressure and worsening of a wound. R1's Care Plan documents, R1 has an actual alteration in skin integrity related to pressure ulcers; Treatment as ordered. R1's Section M- Skin Conditions assessment dated [DATE] documents, R1 is at risk for developing pressure ulcers. R1's Wound Assessment performed by V13 (Wound Doctor) on 12/24/24 documents no measurements for R1's right heel wound. R1's Wound Assessment performed by V13 on 2/11/25 documents a measurement of 1x1x0 (Length x Width x Depth) for R1's right heel wound. R1's Wound Assessment performed by V13 on 12/24/24 documents the following intervention in the plan of care: offload heels with heel protectors or pillow. R1's Wound Assessment performed by V13 on 12/24/24 documents the following new orders: 1. Sacral wound cleansed daily and PRN (as needed) with normal saline and dressed with Medihoney and Adaptic for thirty days, through 1/23/25. 2. Left heel cleansed three times per week with normal saline and dressed with betadine paint and Xeroform for thirty days, through 1/23/25. 3. Right heel cleansed three times per week with normal saline and dressed with betadine paint and Xeroform for thirty days, through 1/23/25. 4. Right ankle cleansed three times three times per week with normal saline and dressed with betadine paint and Xeroform for thirty days, through 1/23/25. 5. Right lateral lower leg cleansed three times per week with normal saline and dressed with betadine paint. R1's Wound Assessment performed by V13 on 2/11/24 documents the following new orders: 1. Sacral wound cleansed daily and PRN (as needed) with normal saline and dressed with Medihoney and Adaptic for thirty days, through 2/27/25. 2. Left heel cleansed three times per week with normal saline and dressed with betadine paint and Xeroform for thirty days, through 2/27/25. 3. Right heel cleansed three times per week with normal saline and dressed with betadine paint and Xeroforn for thirty days, through 2/27/25. 4. Right ankle cleansed three times three times per week with normal saline and dressed with betadine paint and Xeroform for thirty days, through 2/27/25. 5. Right lateral lower leg cleansed three times per week with normal saline and dressed with Medihoney and Adaptic. R1's Order Summary Report with active orders as of 2/10/25 excludes new wound care orders given by V13 (Wound Doctor) on 12/24/24 and 2/11/24. R1's Order Recap Report documents all orders entered between 1/1/25- 2/28/25 and excludes any wound care orders given by V13 on 12/24/24 and 2/11/24. 43351 Findings include: On 02/10/2025 at 11:29am, with V4 (Assistant Director of Nursing) inside R10's room. R10 was lying on a low air loss mattress set at 280lbs alternating every 10 minutes. This observation was pointed out to V4. V4 stated setting is at 280lbs alternating every 10 minutes. This surveyor inquired about R10's weight. V19 (R10's family member) stated she weighs about 180lbs. Review of R10's 02/3/2025 weight indicated that R10 weighed 161.2lbs. On 02/11/2025 at 12:42pm, V12 (Wound Care Coordinator) stated if a resident weighs 160lbs, the setting of her low air loss mattress should be at 180lbs. The setting should not be at 280lbs because there will be too much air and it will constrict the flow of the low air loss mattress which makes the mattress harder defeating the purpose of the low air loss mattress and the resident will have a chance of acquiring pressure wound. On 02/19/2025 at 12:46pm, V13 (Wound Doctor) stated if the setting of a low air low mattress are too high, the mattress will be too hard and does not work well to prevent pressure ulcers. R10's (Active Order as Of 02/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) anoxic brain damage, essential primary hypertension and Type 2 Diabetes Mellitus. Order Summary: low air loss mattress. R10's (01/09/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: no entry. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. M0150. Risk of Pressure Ulcers/Injuries: 1- Yes. M1200. Skin and Ulcer Injury Treatments. B - Pressure reducing device for bed. R10's (04/10/2024) care plan documented, in part has potential for alteration in skin integrity. Skin will remain intact. Pressure redistribution support (low air or alternating air) in bed. The (undated) Protekt Aire medical products operation Manual documented, in part General: Protekt pump and mattress is high quality and affordable air mattress system suitable for medium and high-ris pressure ulcer treatment. They have been specifically designed for prevention of bedsores and offer an affordable solution to 24-hour pressure area care. Pressure Set-Up. Note. It is recommended to press auto firm on the panel when the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort.

Based on interview and record review, the facility failed to ensure R1 was free from neglect by failing to ensure R1 received needed antibiotics to treat R1's infections. This failure contributed to R1 being sent to the hospital for management of sepsis. This failure affected 1 resident (R1) reviewed for neglect. Findings include: R1's discharge paperwork from the hospital (dated 1/8/2025) documents, .Instructions from your doctor: Finish antibiotics --> vancomycin 1.25 g every 12 hours, metronidazole 500 mg every 8 hours, and cefepime 2 g every 8 hours for 6 more days until 1/12/2025 . R1's medication administration record documents that R1 received cefipeme on 1/9/2025 and 1/10/2025. No documentation was provided that R1 received vancomycin or metronidazole. R1's physician orders do not indicate that R1 received vancomycin or metronidazole or that the orders were transcribed to the facility's physician orders. R1's progress notes by V20 (Agency Registered Nurse) affirm that medications were reviewed and reconciled with R1's attending physician's nurse practitioner and that there were no changes to R1's medications. On 1/24/2025 at 11:38 AM, V2 (Director of Nursing) reviewed R1's discharge documentation from the hospital and confirmed R1 was supposed to receive vancomycin 1.5 grams every 2 hours, metronidazole 500 mg every 8 hours, and cefepime 2 grams every 8 hours until 1/12/2025. V2 reviewed R1's electronic health record and confirmed there was no documentation that the orders for metronidazole/vancomycin were transcribed to the facility's records or that the metronidazole/vancomycin was administered. V2 was not made aware of the medication error. V2 explained that the admitting nurse is supposed to transcribe the orders into the facility's system upon readmission and then the clinical support nurse is supposed to complete an audit of the chart to ensure all orders were transcribed. V2 could not give a reason why the metronidazole and vancomycin were not given. V2 stated that if antibiotics are not given, a resident's health status could get worse or develop a serious infection. V2 affirmed that it is the facility's expectation that all orders are transcribed accurately and are carried out. On 1/24/2025 at 2:39 PM, V5 (Consultant Pharmacist) affirmed that V5 is the consultant pharmacist for the facility. V5 reviewed R1's hospital records and affirmed that R1 should have been administered vancomycin, metronidazole and cefepime. V5 reviewed the cultures provided in the hospital paperwork and stated, Cefepime would not have had enough coverage to effectively treat all of what grew in (R1's) cultures. V5 affirmed that the pharmacy was not made aware of the vancomycin or metronidazole order and stated that the orders were not in the pharmacy's system. V5 confirmed that the vancomycin and metronidazole were not dispensed to the facility for R1. V5 stated that not treating infections with the appropriate antibiotics can cause an infection to a worsen or cause sepsis. On 1/25/2025 at 10:45 AM, V6 (Physician) affirmed that V6 is the attending physician for R1. V6 reviewed R1's vital signs and progress notes from 1/11/2025. V6 stated that R1 met sepsis criteria. V6 stated that V6 was not made aware of the medication error or any changes to V6's medication by V6's nurse practitioner. R1's cultures were reviewed with V6 and V6 affirmed that cefepime was not enough to cover all the bacteria identified within the culture. V6 stated that the lack of antibiotic administration, certainly could have contributed to (R1) developing sepsis, I mean, (R1) clearly needed the medication. On 1/25/2025 at 11:02 AM, V1 (Administrator) affirmed that V1 was the abuse prevention coordinator for the facility. Surveyor inquired the definition of neglect and V1 replied, I would have to google it to give you the definition, I don't want to give you something wrong. V1 explained that medication reconciliation is the responsibility of the admission floor nurse. After, the clinical support nurse (CSN) reviews for accuracy. V1 stated, that is the role of the CSN, (V12) is basically a QA (quality assurance) nurse. V1 stated, I wouldn't say sepsis is a life-threatening condition but that would be more of a question for a clinician. On 1/27/2025 at 9:41 AM, V12 (Clinical Support Nurse, Licensed Practical Nurse) affirmed that V12 completes quality assurance audits on all new admissions or readmissions to the facility. V12 stated that V12 completed an audit on R1's chart when R1 was readmitted to the facility. V12 reviewed R1's discharge records and affirmed that R1 had orders for vancomycin, metronidazole and cefepime. V12 reviewed R1's orders and affirmed that the orders were not transcribed to R1's medical record. V12 stated that V12 did not catch (the medication errors). I must have missed it. On 1/27/2025 at 1:29 PM, V20 (Agency Registered Nurse) stated that V20 has picked up shifts on 2 occasions at the facility but couldn't recall if V20 had worked on 1/8/2025 when R1 was readmitted . V20 stated, go look in the chart, and see if I worked. You see my notes? Then clearly I worked. V20 stated that V20 recalled getting an admission on one of the shifts. V20 explained that V20 transcribed the orders and called the nurse practitioner, and no orders were changed from the discharge paperwork. Surveyor reviewed the discharge paperwork with V20 and V20 affirmed that those orders for metronidazole and vancomycin should have been transcribed. Surveyor asked where V20 transcribed the orders to and V20 replied the physician orders in (electronic health record). Surveyor reviewed the orders with V20 that were transcribed and no orders for vancomycin and metronidazole were noted. Surveyor inquired why V20 did not transcribe the orders into the system and V20 stated, check the miscellaneous tab, they discontinued them (INCONGRUENT STATEMENT). Surveyor asked who discontinued the orders and V20 could not say, and stated, the facility must have gotten rid of my fax. V20 could not give any more information about the incident. The miscellaneous tab was reviewed and no relevant information was noted. On 1/27/2025 at 1:38 PM, surveyor requested documentation of the fax from V20 from V2 and V4 (Nurse Consultant). V2 stated, there is no fax and V4 stated, no (V20's) story isn't right. (R1) should have gotten the meds and didn't. It's a medication error and we are working on fixing it. Record review of R1's progress notes documents in part that R1 was stabilized and transferred back to the faility on 1/8/2025. On 1/11/2025 at 1:05 AM, a telehealth visit was completed by V19 (Physician). R1's vital signs were: temperature 100.4, heart rate 135 beats per minute, respiratory rate 22 breaths per minute, blood pressure 87/55, oxygen saturation 55% on trach collar. V19 documented in part R1 is a patient with hypotension and sepsis and the facility will (transfer) to the emergency department for rapid evaluation and management of sepsis with low blood pressure. R1 was transferred to the hospital at 2:30 AM and was subsequently admitted . On 1/29/2025 at 5:02 AM, V24 (Licensed Practical Nurse) affirmed V24 was caring for R1 on 1/11/2025. V24 explained that R1 was having difficulty breathing and V24 obtained R1's vital signs. R1 had increased respirations, heart rate, a fever which were signs of sepsis. V24 called the telehealth physician and completed a telehealth appointment with V19 (Physician). V19 told V24 that V19 was concerned with septic shock so V24 called EMS and R1 was sent to the hospital. V19 stated that V19 was unaware of any antibiotics that were missed during admission. V19 stated that sepsis is a life-threatening condition. On 1/29/2025 at 11:59 AM, V19 (Physician) reviewed V19's charting and affirmed V19 was the physician that treated R1 on 1/11/2025 via telehealth. V19 stated that R1's vital signs were indicative of sepsis because R1 was being treated for an infection. V19 recalled being concerned with the low blood pressure as that is a sign of septic shock. V19 ordered R1 to be sent to the hospital for evaluation and management of sepsis. V19 was unaware that R1 was ordered vancomycin and metronidazole and did not receive them. V19 stated if the antibiotics were ordered, they were ordered for a reason; people should get the medication that a physician orders. V19 affirmed that sepsis and septic shock is life-threating. Facility policy titled, ABUSE POLICY (For Illinois Facilities) (Dated 9/20) documents in part, .This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion . This facility therefore prohibits mistreatment, neglect or abuse of its residents .the facility is committed to protecting our residents from abuse by anyone including by not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or other individuals . Neglect is the failure of the facility, its employees or service providers to provide goods and services needed to avoid physical harm, pain, mental anguish or emotional distress .

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors. This failure contributed to R1 developing sepsis and requiring hospitalization . These failures affected 2 residents (R1, R3) reviewed for medication errors. Findings include: 1) R1's discharge paperwork from the hospital (dated 1/8/2025) documents, .Instructions from your doctor: Finish antibiotics --> vancomycin 1.25 g every 12 hours, metronidazole 500 mg every 8 hours, and cefepime 2 g every 8 hours for 6 more days until 1/12/2025 . R1's medication administration record documents that R1 received cefipeme on 1/9/2025 and 1/10/2025. No documentation was provided that R1 received vancomycin or metronidazole. R1's physician orders do not indicate that R1 received vancomycin or metronidazole or that the orders were transcribed to the facility's physician orders. R1's progress notes by V20 (Agency Registered Nurse) affirm that medications were reviewed and reconciled with R1's attending physician's nurse practitioner and that there were no changes to R1's medications. On 1/24/2025 at 11:38 AM, V2 (Director of Nursing) reviewed R1's discharge documentation from the hospital and confirmed R1 was supposed to receive vancomycin 1.5 grams every 2 hours, metronidazole 500 mg every 8 hours, and cefepime 2 grams every 8 hours until 1/12/2025. V2 reviewed R1's electronic health record and confirmed there was no documentation that the orders for metronidazole/vancomycin were transcribed to the facility's records or that the metronidazole/vancomycin was administered. V2 was not made aware of the medication error. V2 explained that the admitting nurse is supposed to transcribe the orders into the facility's system upon readmission and then the clinical support nurse is supposed to complete an audit of the chart to ensure all orders were transcribed. V2 could not give a reason why the metronidazole and vancomycin were not given. V2 stated that if antibiotics are not given, a resident's health status could get worse or develop a serious infection. V2 affirmed that it is the facility's expectation that all orders are transcribed accurately and are carried out. On 1/24/2025 at 2:39 PM, V5 (Consultant Pharmacist) affirmed that V5 is the consultant pharmacist for the facility. V5 reviewed R1's hospital records and affirmed that R1 should have been administered vancomycin, metronidazole and cefepime. V5 reviewed the cultures provided in the hospital paperwork and stated, Cefepime would not have had enough coverage to effectively treat all of what grew in (R1's) cultures. V5 affirmed that the pharmacy was not made aware of the vancomycin or metronidazole order and stated that the orders were not in the pharmacy's system. V5 confirmed that the vancomycin and metronidazole were not dispensed to the facility for R1. V5 stated that not treating infections with the appropriate antibiotics can cause an infection to worsen or cause sepsis. On 1/25/2025 at 10:45 AM, V6 (Physician) affirmed that V6 is the attending physician for R1. V6 reviewed R1's vital signs and progress notes from 1/11/2025. V6 stated that R1 met sepsis criteria. V6 stated that V6 was not made aware of the medication error or any changes to V6's medication by V6's nurse practitioner. R1's cultures were reviewed with V6 and V6 affirmed that cefepime was not enough to cover all the bacteria identified within the culture. V6 stated that the lack of antibiotic administration, certainly could have contributed to (R1) developing sepsis, I mean, (R1) clearly needed the medication. On 1/27/2025 at 9:41 AM, V12 (Clinical Support Nurse, Licensed Practical Nurse) affirmed that V12 completes quality assurance audits on all new admissions or readmissions to the facility. V12 stated that V12 completed an audit on R1's chart when R1 was readmitted to the facility. V12 reviewed R1's discharge records and affirmed that R1 had orders for vancomycin, metronidazole and cefepime. V12 reviewed R1's orders and affirmed that the orders were not transcribed to R1's medical record. V12 stated that V12 did not catch (the medication errors). I must have missed it. On 1/27/2025 at 1:29 PM, V20 (Agency Registered Nurse) stated that V20 has picked up shifts on 2 occasions at the facility but couldn't recall if V20 had worked on 1/8/2025 when R1 was readmitted . V20 stated, go look in the chart, and see if I worked. You see my notes? Then clearly I worked. V20 stated that V20 recalled getting an admission on one of the shifts. V20 explained that V20 transcribed the orders and called the nurse practitioner, and no orders were changed from the discharge paperwork. Surveyor reviewed the discharge paperwork with V20 and V20 affirmed that those orders for metronidazole and vancomycin should have been transcribed. Surveyor asked where V20 transcribed the orders to and V20 replied the physician orders in (electronic health record). Surveyor reviewed the orders with V20 that were transcribed and no orders for vancomycin and metronidazole were noted. Surveyor inquired why V20 did not transcribe the orders into the system and V20 stated, check the miscellaneous tab, they discontinued them (INCONGRUENT STATEMENT). Surveyor asked who discontinued the orders and V20 could not say, and stated, the facility must have gotten rid of my fax. V20 could not give any more information about the incident. The miscellaneous tab was reviewed and no relevant information was noted. On 1/27/2025 at 1:38 PM, surveyor requested documentation of the fax from V20 from V2 and V4 (Nurse Consultant). V2 stated, there is no fax and V4 stated, no (V20's) story isn't right. (R1) should have gotten the meds and didn't. It's a medication error and we are working on fixing it. No fax was provided before the end of the survey related to medication errors. Record review of R1's progress notes documents in part that R1 was stabilized and transferred back to the hospital on 1/8/2025. On 1/11/2025 at 1:05 AM, a telehealth visit was completed by V19 (Physician). R1's vital signs were: temperature 100.4, heart rate 135 beats per minute, respiratory rate 22 breaths per minute, blood pressure 87/55, oxygen saturation 55% on trach collar. V19 documented in part R1 is a patient with hypotension and sepsis and the facility will (transfer) to the emergency department for rapid evaluation and management of sepsis with low blood pressure. R1 was transferred to the hospital at 2:30 AM and was subsequently admitted . On 1/29/2025 at 5:02 AM, V24 (Licensed Practical Nurse) affirmed V24 was caring for R1 on 1/11/2025. V24 explained that R1 was having difficulty breathing and V24 obtained R1's vital signs. R1 had increased respirations, heart rate, a fever which were signs of sepsis. V24 called the telehealth physician and completed a telehealth appointment with V19 (Physician). V19 told V24 that V19 was concerned with septic shock so V24 called EMS and R1 was sent to the hospital. V19 stated that V19 was unaware of any antibiotics that were missed during admission. V19 stated that sepsis is a life-threatening condition. On 1/29/2025 at 11:59 AM, V19 (Physician) reviewed V19's charting and affirmed V19 was the physician that treated R1 on 1/11/2025 via telehealth. V19 stated that R1's vital signs were indicative of sepsis because R1 was being treated for an infection. V19 recalled being concerned with the low blood pressure as that is a sign of septic shock. V19 ordered R1 to be sent to the hospital for evaluation and management of sepsis. V19 was unaware that R1 was ordered vancomycin and metronidazole and did not receive them. V19 stated if the antibiotics were ordered, they were ordered for a reason; people should get the medication that a physician orders. V19 affirmed that sepsis and septic shock is life-threating. 2) Record review of R3's patient transfer summary signed by R3's hospital physician documents in part an order for micafungin 100 mg every 24 hours via IV. R3's hospital records Instructions from your doctor documents in part instructions to administer micafungin 100 mg every 24 hours until 1/5/2025 for candidiasis (yeast infection). Record review of R3's physician orders and medication administration record, documents in part that R3 had an order for and received micafungin 50 mg IV every 24 hours until 1/5/2025. Record review of R3's progress notes does not indicate that medication reconciliation occurred with R3's physician. No documentation was received by the end of the survey that indicates that the order for micafungin was changed by a provider. On 1/25/25 at 10:52 AM, V2 (Director of Nursing) reviewed R3's medical record, including but not limited to physician orders, progress notes, medication administration record and hospital discharge paperwork. V2 affirmed that R3 received 50 mg of micafungin. V2 stated that R3 should have received 100 mg. V2 affirmed that the incorrect dose of micafungin was administered and could not give a reason for the medication error. On 1/27/2025 at 9:41 AM, V12 (Clinical Support Nurse, Licensed Practical Nurse) affirmed that V12 completes quality assurance audits on all new admissions or readmissions to the facility. V12 stated that V12 completed an audit on R3's chart when R3 was readmitted to the facility. V12 reviewed R3's discharge records and affirmed that R10 had orders for micafungin 100 mg. V12 reviewed R3's orders and affirmed that R3 had 50 mg transcribed instead of 100 mg. V12 reviewed R3's medical record and could not find documentation to warrant a different dose. V12 stated, I guess I missed this (medication) during my audit too. Facility policy titled Re-admissions dated 6/2022, documents in part, Policy/Purpose: Medications for residents readmitted to the facility are verified and initiated on a timely basis . 2. The facility nurse will clarify and confirm all admission orders (or any changes, additions or deletions from previous POS (Physician Order Sheet)) with the attending physician .4. If the resident was discharged for longer than 24 hours, or other time as determined by facility policy, a new set of physician orders are prepared at readmission .

Failures at this level require two deficient practice statements. 1) Based on interview and record review the facility failed to ensure that a resident (R2) who has a community pass with supervision did not leave the facility unsupervised. As a result, R2 left the facility unsupervised on 08/05/24, boarded a bus and ended up over 35 miles away. R2 was unable to return without assistance from emergency services. R2 did not return to the facility until 08/06/24. This failure put R2 at risk for serious harm. This was identified as an immediate jeopardy which began on 08/05/24 at 3:30pm when V9 LPN (Licensed Practical Nurse) gave R2 a pass without supervision. V1 was notified of the immediate jeopardy on 08/28/24 at 1:50pm. The immediacy was removed on 08/29/24 at 07:40pm. An on-site investigation was conducted on 09/04/24 to confirm the implementation of facility's removal plan. Although the immediacy was removed, the deficiency remains at a level two until the facility can determine the effectiveness of the implementation of removal. Findings include: R2 is a [AGE] year-old resident with diagnosis that includes Acute respiratory failure with hypoxia, Asthma, Type 2 diabetes mellitus without complications, abnormalities of gait and mobility, weakness, major depressive disorder, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease, and long-term use of anticoagulants. On 08/20/24 at 12:24pm, R2 stated that. I (R2) am very intelligent, and I don't think I should have any problem in going out. I (R2) explained to the nurse that I (R2) want to walk out to (local store) few blocks away (from the facility) to buy some things from there. As I (R2) was walking, I became tired and weak, so I decided to get into a bus. Mind you I have not gone in a bus in 34 to [AGE] years. So, I thought the bus will stop at the (local store), the next thing I knew the bus was in downtown heading south. I tried calling the facility and my phone was having problem in connecting. I asked for help no one was willing to help me. I was told to change my bus because the bus was not going to turn back and take me back north to (Local store). I tried calling here (referring to the facility), no one was picking up that understand what I was saying. I (R2) have a delayed speech. I (R2) started having headache from all this stress and anxious. When I (R2) got into the next bus, the next thing I (R2) know, I was on 95th street among thugs. Sorry for my language. but I (R2) was scared. I (R2) saw the police already at the bus station and when I asked for help to get back to the facility, they told me they are not a (public transportation company) don't take people and drop them off everywhere, so they called the ambulance, and I (R2) found myself at a (Local Hospital). By the time we got to the hospital my phone started working and I (R2) was able to call the (facility). The hospital arranged for the ambulance to drive me (R2) home (Facility). R2's medical record showed physician order with order date 04/15/24 and revised date of 04/16/24 that documented that R2 may go out on pass with meds (medication) and instruction PRN (As needed) accompanied. This order was not followed. R2 has an order for oxygen per nasal cannula @ 3 liters per minute continuous every shift with order date 04/15/24 and starting date of 04/06/24. R2's medical record and pass record did not have any documentation that any medication including oxygen was made available for R2 when out on pass. R2's medical record MDS (Minimum Data Set) used in assessing facility resident dated 06/05/24 scored R2 BIMS (Brief Interview for Mental Status) at 14 indicating that R2 is not cognitively impaired. R2's medical record Social Service Quarterly assessment dated [DATE] documented under progress note that R2 displays some periods of forgetfulness during which time, cues /guidance, or reorientation beneficial. On 08/20/24 at 1:03pm, V11 (Social Services Designee) stated that in his professional opinion R2 should have oxygen supplement when leaving the facility. R2 should not go out without supervision because of R2's health being not stable. On 08/20/24 at 2:17pm, V5 RN (Registered Nurse) stated that she did not know R2 that well. R2 asked for a pass to go out to shop, I (V5) asked V3 ADON (Assistant director of Nurse's), and he (V3) asked me to check the doctors order and when I (V5) checked there was a pass order that R2 can go out, so I gave R2 a pass for two hours to go to the store to shop without knowing R2's baseline. I (V5) took the vital signs, and they were normal. Later when R2 did not return in two hours to the (facility), I (V5) called V4 (Resident care manager/ADON) to let her know that R2 did not return in two hours. When surveyor asked about the facility protocol on pass, V5 stated to check the orders to make sure of the pass order, assess the resident and notify the management, the DON (Director of Nurse's), ADON, and the supervisor. V5 stated to be honest with you, I (V5) did not see the order that R2 should go out accompanied. The surveyor then asked V5 whether in her own professional opinion it is appropriate for R2 to go out to the community on pass without supervision (alone). V5 stated, I (V5) did not know R2 well and thinking about it, R2 should not go out without supervision because of other health issues like having respiratory issues and use of oxygen. 08/20/24 at 3:20pm, interview with V3 ADON (Assistant Director of Nurses), V3 stated that R2 is not able to go out on pass without supervision/ by herself because R2 uses oxygen and has anxiety problem. The nurses issue the passes, but they must check the order to make sure the order documents whether the resident should go out on accompanied or unaccompanied pass. V3 was asked should R2 should go out without supervision, V3 stated, R2 is alert to make some decisions but R2 tends to have anxiety. With this issue of anxiety, I would think (R2) would be at risk to be by herself in the community without supervision. On 08/28/24 at 9:43am, V16 NP (Nurse Practitioner) stated that R2 is not allowed to go out alone. R2 should either be accompanied by staff or family member for R2's safety. V16 stated R2 is on oxygen and when (R2) gets anxious R2 needs the oxygen. I'm worried about R2 being anxious but when she is accompanied there is someone to help. Physical limitations and being anxious is why I (V16) rarely give passes for residents to go out without supervision. On 08/28/24 at 11:38am, V2 DON (Director of Nurse's) stated that R2's plan of care was not reviewed or changed because R2 did not have an order to go out on pass alone. V2 stated the only thing the resident must do when going out on pass is to give the receptionist the pass paper signed by the Nurse who must have verified the order making sure the order was written and followed as written. R2's pass documentation titled Release of Responsibility for Leave of Absence showed person signing resident out was said resident, R2. V2 (DON) stated because I was not here (Facility) at the time it happened. I could not tell you who signed it, but I think the nurse signed it. On 08/28/24 between 1:31 to 1:35pm, interview conducted with V18 (Business office Manager). V18 stated that she was the staff covering as the receptionist on (08/05/24). R2 came to me around 3:30pm gave me a pass and said she will be right back, and the pass says to return at 5:30pm. V18 stated that at about 7pm, V11(Social Service Designee) asked me (V18) whether R2 has returned to the facility. V11 was informed that R2 has not returned. The surveyor then asked V18 before a resident leaves the facility when on pass how do you verify the pass order. V18 stated that I should have checked the order in PCC (Point Click Care) and that's something I did not do. I was thinking the Nurse has signed the pass, so I did not check PCC. R2's hospital ED (emergency department) report documented date and time of admission as 08/06/24 4:56am and means of arrival as local fire department. R2 was discharged via local ambulance to the facility on [DATE] at 5:33am. R2's diagnosis listed as wellness examination. The facility Pass procedure presented as the facility policy documented under procedure that the resident or responsible party is to sign the form indicating the date and time the resident is leaving the facility and the date and time resident is expected to return. This procedure was not followed. The facility Medication Administration policy presented dated 09/2020 documented that medications will be administered in accordance with the established policies and procedures. Procedure listed includes but not limited to drugs must be administered in accordance with the written orders of the attending physician. On 09/04/24 the surveyor made observations, conducted interviews, and received documents to confirm the following removal plan was initiated. 1. R2 is no longer residing in the facility. 2. R2 went home AMA (Against Medical Advice). 3. Eight out of 150 residents residing in the facility R6, R11, R12, R13, R14, R15, R16, and R17 are listed as having independent pass privilege (alone pass) with care plan reviewed. 4. All eight residents identified name are placed at the receptionist area and on the narcotic book binder on each floor. R6, R11, R12, R13, R14, R15, R16, and R17. 5. All nursing staff are educated on the followings: pass policy and guideline, incident /Accident policy, physician order policy. V15, V17, V18, V19, V21, V23, V26, V29, V30, and V31 were interviewed. V18, V19, V25, and V30 were also interviewed. 6. Documentation showed that eight residents attended council meeting held on 08/21/24. R9, R16, R18, R19, R20, R21, R22, and R26. Conducted by V30 (Activity Director). 7. The other residents are being educated by V1 (Administrator), V2 DON (Director of Nurse's), nurses, the receptionist, and other delegated staff. 8. Quality Assurance Audit tool initiated for pass privileges. 2) Failed to ensure that the residents' environment remains free from accidental hazards by not leaving medication in a medication cup and a disposable razor on the bed side table for two residents (R4 and R9); failed to ensure that the treatment cart was locked when not in use and not in the proximity of the nurse to prevent tampering and accidental hazard. This failure affected R4 whose medication was left in a medication cup on the bed side table, visible from the hallway, and R9 who has a disposable razor blade stored on the bed side table. This failure also has the potential to affect all residents on the 3rd floor. Findings include: On 08/20/24 at 10:53am, treatment cart observed in the hallway unlocked and not in view of the nurse. When this was shown to V9 LPN (Licensed Practical Nurse). V9 stated that it is the treatment cart, and it should be locked when not in use and that because the treatment is done by the wound care nurses, she (V9) did not pay any attention to the cart being unlocked. On 08/20/24 at 11:39am, R9 was noted in the room on the bed with two disposable razors on the bed side table uncontained. R9 stated the disposable razor belongs to (R9) and they are kept on the table. At 11:45am this observation was shown to V6 RN (Registered Nurse). V6 was asked about the facility policy / protocol on sharp objects that includes disposable Razor blades. V6 stated that sharp objects are not allowed to be kept in the rooms by residents. V6 stated when not in use they are to be kept in the locked clean utility room. V7 CNA (Certified Nurse Assistant) assigned to R9 stated that R9 is not supposed to have the razor in the room. V7 stated the family probably brought it for R9. On 08/20/24 at 11:50 am, R4 was observed in bed with eyes closed and from the hallway, a medication cup was noted on the bed side table. Upon entering the room, R4 appeared to be asleep, and the medication cup contained three pills. At 11:53am when this was shown to V6 RN (Registered Nurse), V6 identified the pills as R4's medication that R4 was supposed to have taken at 9:00am. Metformin, Meclizine and Florastor capsule. V6 stated I forgot to go back to make sure R4 has taken the medicine. When asked about the facility policy/protocol on medication administration and professional standards of medication administration, V6 stated never leave medication at the bedside, medication should be given as ordered because it can be a medication error if not taken at the right time. Anyone, the staff, or visitors can go in the room and take it. V6 stated professional standards about medication administration, I should have watched R4 take the medication before leaving the room. On 08/21/24 at 12:10pm, one can of a disinfectant was noted in R2's room beside the bed. R2 stated the disinfectant was for (R2) and uses it to eliminate the bad odor in the room. R2's admission diagnosis includes but not limited to, Acute respiratory failure with hypoxia and Asthma. At 12:15pm. V15 (LPN) was made aware of this observation. V15 was asked about the facility policy on hazard and supervision on use of disinfectant. V15 stated that I don't know the policy and don't know whether R2 should be allowed to keep it in the room. V15 stated all I know is R2 is a germophobe. At 12:27pm, V7 (CNA) assigned to R2 stated I was in the room this morning and I did not see the disinfectant can. V7 stated the residents are not allowed to keep the spray in their rooms. At 12:30pm, V12 (Housekeeping Manager) stated the facility do not allow residents to have disinfectant in their possession. The facility Medication Administration policy dated 09/2020 documented that medications will be administered in accordance with the established policies and procedures. Procedure listed includes but not limited to, drugs must be administered in accordance with the written orders of the attending physician. The facility Housekeeping Policy and Procedure presented with revision date 1/23 documented listed procedures that includes but not limited to all chemicals will be kept inaccessible to residents at all times. Chemicals will be stored in locked carts, cabinets, or rooms. During use chemicals will be under constant supervision of staff. The facility Pharmacy Standard Operation policies and procedure on Medication Administration general guidelines documented that the policy is to ensure that medication is administered safely as prescribed. Residents are permitted to self -administer medications when specifically authorized by the physician and if determined able in accordance with policies and procedures for self-administration of medication. Listed procedure includes but not limited to medications are prepared and administered by the same authorized staff, administration should occur at the time of preparation. The facility Pharmacy Standard Operation policies and procedure on Medication Pass Guidelines dated 09/2022 documented under Locking Carts/ key that do not leave cart(s) unlocked when unattended, lock cart when not in direct view. This guideline was not followed.

Based on interview and record review the facility failed to identify a change in condition for one resident (R5), failed to follow the facility's Head Injuries policy and failed to call 911 after a fall with head injury that resulted in resident (R5) expiring due to intracranial hemorrhage with midline shift related to the fall. This failure affected one resident (R5) of four residents reviewed for change in condition after a fall. This was identified as an Immediate Jeopardy that began on 4/08/24. On 6/06/2024 at 3:26pm V1 (Administrator) and V2 (Director of Nursing) were notified of the immediate jeopardy. The facility presented an abatement removal plan on 6/07/2024 at 12:00pm to remove the immediacy and it was not approved. The abatement plan was submitted again on 6/07/2024 at 6:25pm to remove immediacy. The Abatement plan was approved on 6/10/2024 at 1:51pm. Findings include: R5's Physician Order Summary (POS) with active orders as of 4/08/2024 documents, in part, send to (local) Hospital for evaluation post fall. POS also documents Metoprolol Tartrate Oral Tablet 25 mg (milligrams) every 12 hours. R5's Medication Administration Audit Record (MAAR) documents that R5's ordered Metoprolol Tartrate Oral Tablet 25mg was given on 4/08/2024 at 8:06pm. R5 has a diagnosis of, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction, Visuospatial Deficit and Spatial Neglect, Acute Respiratory Failure with Hypercapnia, Acute on Chronic Diastolic Heart Failure, Tracheostomy, Dysphagia, Hypertensive Heart Disease with Heart Failure. R5's Brief Interview of Mental Status (BIMS) dated 4/8/2024 documents, BIMS score not assessed. On 5/29/2024 at 1:13pm V3 (Licensed Practical Nurse-LPN) stated at about 5:30pm on 4/08/2024 R5 fell face forward from the bed and V10 (Certified Nursing Assistant-CNA) made her aware that R5 fell out of the bed) by yelling out at the time R5 was falling. On 5/29/2024 at 3:30pm V10 (CNA) stated on 4/08/2024 at around 5:00pm I (V10) was bringing R5 her dinner tray and as I stepped one foot into the room I (V10) observed R5 sitting at foot of the bed, at the top of the fold (foot of bed was elevated), as R5 was literally falling forward from the bed onto the floor. R5 was wearing her glasses and hit her face on the floor with a very hard with a loud thud and her glasses remained in place but were broken (right arm flew off). V10 stated R5 hit her face and head (right side) onto the floor with a very loud thud, the loudest thud I had ever heard from a fall. R5's progress notes dated 4/08/2024 at 6:28pm by V12 (Assistant Director of Nursing-ADON) documents, in part, R5 was witnessed losing balance and falling forward on the floor striking her head above her right eye, R5 was wearing glasses at the time causing an abrasion to her temple with scant bleeding. A 2cm (centimeter) hematoma was noted on R5's right temple with a 1cm abrasion, VS (vital signs) taken and WNL (within normal limits). NP (Nurse Practitioner-V22) notified via phone to send out for evaluation and ambulance called with ETA (estimated time of arrival) of 60 minutes. R5's Blood Pressure on 4/08/2024 at 5:38pm and 5:40pm was 167/109. R5's Neurological Flow Sheet dated 4/08/2024 at 5:46pm documents, in part, LOC (Level of Consciousness) responds to name, and touch, Hand Grasps: right/left weak, Vital Signs: 97.5, 85, 20, 166/100. At 6:17pm documents, in part, LOC: responds to name and touch, hand grasps weak bilaterally, blood pressure 181/102. At 6:31pm documents, in part, LOC: responds to name and touch, hand grasps weak bilaterally, blood pressure 154/94. 7:01pm documents, in part, LOC: responds to name and touch, hand grasps: right weak, left strong, blood pressure 177/98. At 7:30pm documents, in part, LOC: responds to name, touch, light pain, deep pain, hand grasps: right weak, left strong, blood pressure 161/90. R5's Admission initial assessment on 4/02/2024 documents, Blood pressure of 138/85, Right and left pupil size to be normal (size and shape) hand grasps (upper extremities and hand grasps) to be left strong and right weak. R5's Vitals from (Electronic Health Record System) documents a blood pressure of 134/87 at 10:15am on 4/08/2024, 155/89 on 4/07/2024 at 9:41am, and 129/85 on 4/07/2024 at 8:51am. All other blood pressure were below 132/82 from 4/03/2024-4/06/2024. Ambulance run sheet dated 4/08/2024 documents, in part, dispatch notified at 5:51pm for Advance Life Support services. Progress note dated 4/08/2024 at 8:30pm documents, in part, Ambulance (company) contacted to follow up on resident's transportation, ambulance is on the way and will be here shortly per dispatch. On 5/29/2024 at 1:13pm V3 (LPN) stated R5's orientation status was a 1-2 and we called the ambulance service and not 911 because R5 was stable, verbally responsive, vitals were within normal range and R5 did not appear to be in any distress. On 5/30/2024 at 9:14am V17 (Physician) stated the nurse should do a mental and body assessment and call 911 and that a nursing home could not manage a fall with head trauma. V17 also stated a change in mental can be immediate or delayed and the reason why we would send them out 911 for further testing so that the hospital handle and manage. The hospital is capable of doing tests to determine if there is internal bleeding. On 5/30/2024 at 3:00pm V12 (ADON) stated R5's orientation status was that she was awake and oriented 1-2 (to self and place) and based on the nurse's assessment we would have called the regular ambulance service to send R5 out for evaluation. V12 also stated irregular vital signs, pupil irregularity, pain or signs of head injury would been a reason to call 911. On 5/31/2024 at 12:21pm via phone V22 (Nurse Practitioner-NP) stated any resident who has a head injury (or hit that is above the neck i.e., head, face, neck) witnessed or witnessed should be sent to the hospital via 911. At 3:33pm V22 (NP) stated he was told that R5 fell on R5's face and she should have been sent out via 911 and in his V22's (NP) professional opinion I (V22) don't want to single this situation out but all falls with a head injury should be sent out 911 because I (V22) can't see internal bleeding and I (911) would rather error on the side of caution and send them out via 911. On 5/31/2024 at 1:40pm via phone V13 (LPN) stated she did not speak to V22 (NP), V12 (Assistant Director of Nursing-ADON) called V22 (NP), but she (V13-LPN) does not recall being told to call 911. V13 (LPN) stated she took R5 neuro checks every 15 minutes, then every 30 minutes and there were no changes in LOC (level of consciousness) in speech, swelling (hematoma) and vital signs. On 5/31/2024 at 3:07pm V20 (RN) stated R5 had swelling on the right side of the head and R5's vitals were within normal range. V20 stated abnormal blood pressure is above 140's but R5's trended a little bit higher. V20 also state I would call 911 if there is a change of condition. On 6/05/2024 at 10:11am V23 (Lead Paramedic) stated facility staff did not know how critical R5 was when we (V23 and the partner) arrived. V23 stated he (V23) noticed R5's blood pressure read 226/110 on the facility's vitals monitor, legs twitching and the big (size of baseball) hematoma (a solid swelling of clotted blood within the tissues) that was very prominent on R5's head; R5 was unstable, unresponsive and breathing fast. V23 stated that when they arrived R5 was connected to the facility's vitals monitor and her blood pressure read high, so we confirmed R5's blood pressure with our own equipment. V23 stated that they (V23 and his partner) were not made aware of anything (R5's status). V23 stated that the call came in as a BLS (Basic Life Support) call because it was reported as a fall, but after his assessment he had to call his superiors to get the call updated to ALS (Advance Life Support) due to R5 being unstable, hypertensive with a big hematoma on the head and having altered Consciousness-unresponsive. V23 stated that facility staff wanted them (paramedic staff) to take R5 to local hospital (hospital, doctor is affiliated with) and that the nurse (V20-RN) told him (V23) that the resident was awake about 15 minutes prior to them arriving and she was able to give the resident her medication. V23 stated when he (V23) saw how high R5's blood pressure was I started to question what was really going on and felt that the medications were given to cover the facility. V23 stated that he tried to advocate for R5 to be transferred to a hospital that had trauma center due to her symptoms but was told to take her to the closest hospital. R5 was taken to the closest hospital but later transferred to the hospital he was advocating for due to her symptoms and that hospital being a trauma center. On 6/05/2024 at 3:58pm V12 (Assistant Director of Nursing-ADON) stated R5's vitals (blood pressure 167/109) indicated that she was hypertensive after the fall and R5's baseline is 130-140 over 90 from previous blood pressure that was taken on 4/07/2024. R5 had a hematoma that was about 2 cm and circular in size. V12 stated that a blood pressure of 170/100 would warrant a call to 911 for R5 to be sent out. V12 also said, yes, the elevated blood pressure of 181/102 would have warranted a phone call to the doctor and yes, this is considered a change in condition. V12 also stated a hematoma could be an indicator of internal bleeding along with an increase in size of the hematoma and R5's blood pressure, hematoma and hand grasps did not warrant a call to 911 because the ambulance was already scheduled to pick her up. R5's Ambulance run sheet documents, in part, on scene at 8:54pm with Altered Consciousness Unresponsive and at 9:05pm R5's blood pressure was 226/110, respirations 22. Right and left pupils' size was 6mm and non-reactive. Upon arrival on scene patient was found laying in bed, [AGE] year-old female, only alert to painful stimuli by attempting to open her eyes and localizing to pain. Ambulance run sheet also documents R5 has a 3-inch diameter hematoma to her right eyebrow and temple and upon assessment patient was found hypertensive and AMS (Altered Mental Status). Crew repositioned the patient and suctioned due to patient started having gurgled respiration. R5's Death Certificate dated 4/15/2024 documents cause of death complications from subdural hemorrhage and fall. The facility's policy, dated September 2020, titled Head Injuries, documents, Policy: Residents who exhibit signs and symptoms of head injury will be assessed and treated immediately. Procedure: 3. Determine baseline condition of the resident. e-Measure blood pressure, pulse, respirations. 5- Call paramedics (911) and transfer to hospital if indicated. Job Description titled for Staff Nurse (Registered Nurse/License Practical Nurse) with a date of 1/2015 documents, in part, responsible to provide direct nursing care to the customer, objective is to ensure the highest degree of quality care is maintained at all time, assume all nursing procedures and protocols are followed in accordance with established policies and notify the customer's attending physician and family when there is a change in the customer's condition. The surveyor confirmed, by reviewing the nursing staff in-service list that included in the approved Abatement Plan, and by interviewing V6, V27, V28, V3 and V29 after the in-service was performed, that the immediacy was removed on 06/10/2024. The immediate Jeopardy that began on 4/8/2024 was removed on 6/10/2024 when the facility took the following actions to remove the immediacy: On 5/30/24 and 05/31/24 education listed below was started by the Director of Nursing, with all nursing staff that were working and those that were scheduled to work upcoming shifts. Education will continue to be conducted prior to the start of the next shift for each licensed nursing staff including agency nurses (RN, LPNs) and on an ongoing basis until all nurses scheduled to work have been educated and demonstrate understanding of the education through written quizzes and/or return demonstration of competency. Education will focus on all licensed nursing staff including agency nurses (RNs, LPNs) with the potential to be impacted by the non-compliance and not limited to staff involved in the actual incident. Education will be completed by 6/10/24. All residents were reviewed for fall risk, and the care plans were updated as indicated by restorative nurse. All licensed nursing staff including agency nurses (RNs, LPNs) were educated by the Director of Nursing, Nurse Consultant or designee regarding: All licensed nursing staff including agency nurses (RNs, LPNs) were educated on the risk of internal bleeding (brain damage) after a fall with head trauma All licensed nursing staff including agency nurses (RNs, LPNs) staff were educated by the Director of Nursing, Nurse Consultant, or designee regarding the Fall Prevention Program All licensed nursing staff including agency nurses (RNs, LPNs) were educated by the Director of Nursing, Nurse Consultant, or designee to ensure the nurses are knowledgeable about interventions and assessing changes in conditions based on post falls with head injuries and ensuring timely transport to hospital is arranged All licensed nursing staff including agency nurses (RNs, LPNs) were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's Change in Condition Policy. All licensed nursing staff including agency nurses (RNs, LPNs) were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's Change in Conditions and Signs and Symptoms from AMDA Clinical Practice Guidelines/Interact 4.0 report immediately. All licensed nursing staff including agency nurses (RNs, LPNs) were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's Head Injury Policy & Procedure. All licensed nursing staff including agency nurses (RNs, LPNs) were educated by the Director of Nursing, Nurse Consultant or designee on ensuring interventions were established to prevent further falls based on root cause analysis/assessment and to ensure resident's safety. Systems, Policies and Procedure: On 05/30/24, 05/31/24 and 06/06/24 the facility DON, Administrator and Nurse Consultant reviewed policies and procedures on falls and comprehensive care plans with the medical director. This review included but is not limited to staffing, environment, preadmission history of falls, addressing risk factors, root cause analysis post fall, implementation of interventions post fall based on root cause analysis in the resident comprehensive care plan. The following policies were reviewed with no changes made. Management of Fall Change of Condition Change in Conditions and Signs and Symptoms from AMDA Clinical Practice Guidelines/Interact 4.0 Head injury Policy The Administrator and DON conducted a review of compliance using Quality Assurance Audit tool for falls, and root cause analysis post fall. Interventions were established and included in the comprehensive plan of care based on the root cause analysis/assessment to prevent further falls. The audit started on 5/30/24. The Audits will be done three times a week for four weeks, then weekly for four weeks, then monthly x 3 months, and then randomly by Administrator, Director of Nursing, Assistant Director of Nursing/designee until compliance is maintained. The results of the QA Audits shall be reviewed monthly by the Facility QAPI team to determine any necessary changes. The QA meeting is held at least quarterly and PRN. An emergency QA meeting was held on 06/06/24 by the Administrator with the Interdisciplinary Care Team and Medical Director. The meeting included discussion of a fall resulting in change in condition, root cause analysis post fall, and implementation of a comprehensive care plan with intervention reflective of root cause analysis. The Medical Director and Interdisciplinary Care Team approved this Removal Plan. This will be monitored by the Administrator, DON, ADON, and Restorative Nurse.

Based on interviews and records review, the facility failed to provide and monitor for safe and quality care to one (R6) resident reviewed in a sample of three. The deficiency resulted in R6 sustaining a fracture of the left femur. Findings include: R6 is a [AGE] year-old individual with medical diagnosis that include but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other sequelae of other cerebrovascular disease, Acute displaced proximal left femoral shaft fracture. R6's MDS (Minimum Data Set) dated 9/20/2023 document R6's Cognitive Skills for Daily Decision Making is severely impaired, and R6's Functional Abilities document R6 is dependent on staff for all ADL (Activities of Daily Living) care. On 10/10/2023 at 2:06pm, V9(R6's daughter) said her mother R6 has a femoral fracture. V9 said the last time she visited R6 was on 8/13/2023 and she was with a friend, and she did not try to move or exercise R6. V9 said she was not notified R6 has any leg/hip issues until September 1st or 2nd, 2023, when a nurse called and left a voice mail message that R6 was experiencing pain. V9 said she returned the facility's message and was told that R6 was sent out to the hospital and at the hospital, R6 was found to have a femoral fracture. V9 said the facility tried to blame her for R6's fracture, saying that V9 has tried to perform range of motion exercises on R6. V9 stated she had not been to the facility to visit R6 since 8/13/2023. V9 added that R6 can make her needs understood if someone takes the time to listen and understand her. On 10/11/2023 at 9:58am, V2(Director of Nursing/DON) said R6 is dependent on staff for all Activities of Daily living (ADLs) and R6 is severely contracted. V2 further said that the fracture could have happened during R6'S ADL (Activities of Daily Living) care, repositioning, from falls, or from R6's daughter performing Range of Motion (ROM) exercises to R6, or the fracture can be pathological. V2 said he does not know what happened to R6, but residents should be kept safe at the facility. On 10/11/2023 at 11:31am, V13(Nurse consultant) said on 08/31/2023, she interviewed staff as she was conducting investigations after R6 was found to have a fracture of the femur. V13 said staff stated R6 was observed to be grimacing during perineal care and R6 said she was experiencing pain on her left lower/upper leg. V13 said there was no definitive answer as to what caused the fracture and R6 did not have any bruising during body assessment. V13 said when R6 was admitted to the facility she was contracted, and this could have caused the fracture. On 10/11/2023 at 12:28pm, V14 (Physician) said R6 is not able to move by herself, she depends on staff for all ADL care. V14 said she received a call from the facility stating R6 had pain to the left hip/lower extremity. V14 stated she gave orders for R6 to be sent to the hospital for further evaluation. V14 said R6 was found to have a femoral fracture of the left leg. V14 said the fracture could be insidious or traumatic and it could have happened during ADL care or during lifting and repositioning because R6 is severely contracted and cannot move herself. On 10/12/2023 at 11:52am, V21(Registered Nurse-RN) said she worked on the day shift on 8/31/2023, and while in R6's room attending to another resident, V21 saw CNA (No name provided) struggling to clean R6 up because R6 was resisting care and did not want to be cleaned up. V21 told the CNA (unknown) to wait for V21 to finish attending to the other resident, then she would help her perform ADL (Activity of daily Living) Care to R6. V21 said while helping the CNA (no name provided) with cleaning R6, she noticed R6 was having facial grimacing and some discomfort whenever V21 and the CNA moved R6's left leg. V21 said she asked R6 if she was having any pain, and R6 nodded yes. V21 said she assessed R6's left leg, and she noticed it was cool to touch, and there was some bruising on the leg and on the abdomen. V21 said R6 is on anticoagulant medication, therefore she did not know if that is what was causing the bruising and skin discoloration. V21 said she repositioned R6 for comfort and called V14(Physician) to report what she had observed. V21 said that at approximately 7:30pm, V14 ordered an x-ray of the affected extremity of R6 as she(V21) was leaving at the end of the shift. V21 stated she saw the X-ray technician go into R6's room. V21 said when she came to work the following day, she looked for the x-ray results and there was none. V21 said she called V14 to notify her that there were no X-ray results for R6's leg. V14 gave orders for R6 to be sent to the hospital for X-ray and further evaluation. V21 said the night nurse (No name provided) confirmed from the hospital that R6 has a femoral fracture on the left leg. V6 said R6 can mouth words, nod, or shake her head to communicate and R6 is able to communicate when in pain by nodding or mouthing words. V21 said R6 is a total care resident and cannot take care of herself independently. V21 further said R6 cannot physically move her lower extremities because she is contracted. Nursing progress notes dated 8/31/2023 2:06pm, Documents: -V14(Physician) was notified that R6 was having pain on the left hip/left lower extremity. V14 ordered an Xray for R6's Left hip and lower extremity. Hospital records dated 09/02/2023 document R6 was admitted to the hospital for left leg pain. CAT Scan was performed and R6 was found to have: -Acute Displaced Proximal Left Femoral Shaft Fracture. This would be very difficult fracture to fix due to patient's contracture. Likely this is a nonoperative fracture, for this reason if pain can be controlled. R6 is not ambulatory. Difficult to assess R6's pain level due to R6's no responsiveness.

Based on interview and record review, the facility failed to ensure that one resident (R1) was free from a significant medication error in which insulin was administered instead of heparin to a non-diabetic resident (R1). This failure resulted in R1 needing hospitalization for blood sugar monitoring and administration of intravenous dextrose for a severely low blood sugar reading of 34 mg/dL (milligrams/deciliter) recorded in the emergency department. Findings include: R1's Admission Record documents diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic pain syndrome, peripheral vascular disease, and long term (current) use of anticoagulants. R1's 5/16/23 BIMS (Brief Interview for Mental Status) determined a score of 15, indicating that R1's cognition is intact. On 5/30/23 at 12:25 PM, R1 stated that on May 9th, 2023, around 4 pm, after V9 (Agency LPN/Licensed Practical Nurse) gave R1 an injection, Like a half hour later she (V9) came back and said, 'I (V9) made a mistake. I (V9) gave you insulin instead of heparin.' I (R1) said I'm not a diabetic. R1 stated that his (R1) blood sugar dropped to 51 mg/dL, and he (R1) was sent out to the hospital. R1 added, I (R1) was scared, and knowing I (R1) got all that insulin, I (R1) didn't know what would happen. R1 stated that since then, he (R1) is very skeptical and requires the nurse to show him (R1) the heparin vial with his (R1) label on it as well as draw up the syringe in front of him (R1). On 5/30/23 at 3:16 PM, V9 stated that after administering R1's injection, she (V9) walked back to her (V9) medication cart and noticed a vial of insulin sitting on top of the cart. V9 stated, I don't know if I put the heparin vial back in the cart. All these thoughts start going through my mind. It's too great of a risk to not say anything if he (R1) was given that (insulin). V9 asserted that she (V9) did have the eMAR (electronic Medication Administration Record) open and verified the medication at the time she (V9) was preparing R1's injection. V9 added that R1's initial blood sugar was 60 mg/dL upon assessment after the alleged medication error and physician orders were received to send R1 to the hospital. V9 described using a TB (Tuberculin needle) to inject 1 ml (milliliter) of medication into R1's arm. On 5/30/23 at 2:47 PM, V3 (ADON/Assistant Director of Nursing) affirmed that V9 notified him (V3) that she (V9) may have given insulin instead of heparin because when she (V9) came back to her (V9) cart, she (V9) saw the insulin bottle, so she (V9) wasn't sure if she had drawn insulin lispro (fast-acting insulin). On 5/31/23 at 1:41 PM, V2 (Interim DON/Director of Nursing) stated that the expectation with medication administration is to administer medications as prescribed by the physician. V2 added that the process for medication administration is to confirm the order, make sure it's the right medication, right patient, right time, and right dose. V2 stated there is a risk of a medication error occurring if this process is not followed. V2 stated that the risks of a medication error involving insulin include but are not limited to, Hypoglycemia (low blood sugar), altered mental status, or change in condition. On 5/31/23 at 3:18 PM, V18 (Medical Doctor/R1's Primary Care Physician) confirmed that she (V18) was notified of the potential medication error. V18 also confirmed that R1 is not diabetic and was supposed to receive heparin. V18 stated, I knew his (R1) sugar was going to drop. I (V18) told them to send him (R1) to the hospital immediately. R1's 5/9/23 at 8:42 PM ED (Emergency Department) Note Nursing documents, in part, Accucheck (blood sugar monitoring) 34. ER (emergency room ) MD (Medical Doctor) notified. Amp (ampule) D50 (50% Dextrose injection) administered per order. Pt (patient) provided with Dr. Pepper and brownie. R1's Hospital Discharge Summary authored by V18 documents, in part, Chief Complaint and History of Present Illness .Patient was injected accidentally 100 units of insulin by nursing staff at SNF (Skilled Nursing Facility), called EMS (Emergency Medical Services) and who injected glucagon (emergency medication used to treat very low blood sugar). Patient became mildly altered, blood pressure went down to 60 (systolic)/30 (diastolic) and became better after glucagon injection. Patient was brought to ED (Emergency Department), was started on D10W (intravenous fluids containing dextrose), admitted for close observation of hypoglycemia (low blood sugar) and further treatment . R1's Order Summary Report lists a physician order for Heparin Sodium (Porcine) Injection Solution 5000 unit/ml (milliliter). Inject 1 ml subcutaneously every 8 hours for DVT (Deep Vein Thrombosis) prophylaxis related to peripheral vascular disease. R1 does not have a physician order for insulin. The facility Medication Correction Form filled out by V9 (Agency LPN) documents, in part, Describe the error: Administration of wrong medication. Insulin given. 1. State medication and dosage (if any) should have been given: Heparin 5000 unit/ml 2. What medication was given: insulin lispro . 2. What act contributed most to giving a wrong medication? Insulin and heparin stored in close proximeter (proximity). The facility 3/2021 Medication Administration: General Guidelines documents, in part, Policy: To ensure that medications are administered safely as prescribed . Procedure: . 3. Medications are prepared and administered by the same authorized staff. Administration should occur at the time of preparation. 4. Prior to administration, the authorized staff must verify medications and orders by comparing the medication label with the physician's order on the MAR/eMAR. Any discrepancies must be followed up by checking the original physician's order . 7. Medications prescribed for one resident shall not be administered to another resident. The CDC (Centers for Disease Control and Prevention) online article titled Low Blood Sugar (Hypoglycemia) documents, in part, Blood sugar levels change often during the day. When they drop below 70 mg/dL, this is called having low blood sugar. At this level, you need to take action to bring it back up .Causes of low blood sugar: There are many reasons why you may have low blood sugar, including: Taking too much insulin . Severe low blood sugar: As your low blood sugar gets worse, you may experience more serious symptoms, including: Feeling weak, having difficulty walking or seeing clearly, acting strange or feeling confused, having seizures. Severe low blood sugar is below 54 mg/dL. Blood sugar this low may make you faint (pass out). Often, you'll need someone to help you treat severe low blood sugar. (https://www.cdc.gov/diabetes/basics/low-blood-sugar.html)

Based on interview and record review the facility failed to follow doctor's orders and failed to follow the facility's Hypoglycemic Policy for one resident (R2) in a sample of 3. This failure affected one resident (R2) and resulted in R2 being sent to the local hospital with diagnosis of Hypoglycemia with a blood sugar of 29. Findings include: R2 was reviewed as a closed record. R2 expired on [DATE]. R2's face sheet dated [DATE] documents, in part: R2 was admitted on [DATE]. R2 is a [AGE] year-old man with a diagnosis of but not limited to: End Stage Renal Disease, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease, Type 2 Diabetes Mellitus with Severe Nonproliferative Diabetic Retinopathy without Macular Edema, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. R2's BIMS (Brief Interview of Mental Status) dated [DATE] documents score of 15 (cognitively intact). Local Fire Department Patient Care Report dated [DATE] documents in part: Unit Notified by [DATE], Dispatch: 05:14:00 (5:14am) Scene: Complaint Reported: Person (R2) Unconscious Breathing. Vital Signs: 05:25am (5:25am) heart rate 84, blood pressure ,d+[DATE], blood glucose of 29, respiration of 20 with no eye movement when assessed, no verbal/vocal response and no motor response. Patient Care Report Narrative documents, Upon arrival patient lying supine in the hospital bed at the nursing home with staff and the scene. Upon exam patient is unresponsive in a very diaphoretic, staff states that the patient is a known diabetic and has a blood sugar of 29 (obtained by EMS). ALS (Advance Life Support) care established patient given D10 (Dextrose) IV (Intravenously). And become alert and oriented X 3. Local Hospital notified on telemetry, patient. Transported through the emergency room . R2's Local Fire Department Patient Care Report documents that R2 was transferred to local hospital at 5:51am on [DATE]. R2's Local Hospital Report dated [DATE] states, in part, R2 brought in by Local Fire Department from facility with a complaint of hypoglycemia 29 mg/dl and unresponsiveness. Patient able to answer questions upon arriving ED (Emergency Department). Progress note dated [DATE] at 10:15am by V25 (LPN) states Local Hospital ER, provided information that R2 is admitted for abnormal blood glucose and ESRD (End Stage Renal Disease). Local Hospital's History and Physical Reports dated [DATE] at 12:30pm documents under Assessment/Plan R2 was admitted to local hospital because of insulin induced hypoglycemia and R2 was transferred from the facility after his random blood glucose level was 29 mg/dl and unresponsiveness after he received insulin this morning. Progress note dated [DATE] at 6:42am states that writer (V26) observed resident diaphoretic hypertensive, around 5:30am. Resident was responding to stimuli, but was not verbalizing. Hypoglycemic at the time. 911 called. Paramedics came quickly to facility. On [DATE] at 7:46am V26 (LPN) stated, Between 4:30am and 5:00am on [DATE] (V26) entered R2's room to give R2 his scheduled 6:00am morning meds. R2 was unresponsive to me calling his name, but he responded to painful stimuli. V26 stated, I checked his blood glucose and his blood pressure right away and R2's blood pressure was extremely high (,d+[DATE]) and his blood glucose extremely low. V26 stated, I (V26) did not recall what the blood glucose level was but that the blood glucose was under 50. V26 stated, I (V26) do not remember what his actual numbers (referring to blood glucose and blood pressure) were. V26 stated, There was no order for glucagon and there was no glucagon in the medication cart on the second floor. V26 stated, One of the CNA's (Certified Nursing Assistant) had to run to the third floor to get the glucagon from the nurse, who had to get it from the drug dispensing cabinet. V26 stated, I (V26) do not know who the CNA was that went to get the glucagon. V26 stated, I (V26) only checked R2's blood glucose once and that is when I (V26) determined he was hypoglycemic. V26 stated, I called 911, from my cell phone and had one of the CNA's (Certified Nursing Assistant) to get V1 (Administrator) who was on the fourth floor to assist her. V26 stated, EMT got their quickly, in about 10 minutes and started an IV and gave R2 glucagon, I believe. Once EMT got there I was at the door out of the way observing. V26 further stated, V1 called the doctor and R2's family. V26 stated that she did not administer R2's scheduled 6:00am medicine. Surveyor asked V26 where should R2's vital signs and blood sugar be documented. V26 stated, The vitals and the blood glucose level would have been documented in PCC (Electronic Medical Record) in the vitals section and in the progress notes. On [DATE] at 5:02pm V1 (Administrator) stated, V26 had administered glucagon and called 911 due to R2's low blood sugar. V1 also stated, I think V26 notified the doctor and the family. V1 stated that she expects the nurse, in case of an emergency, to call 911 first than notify the doctor. Surveyor asked the expectation of the nurse if a resident's blood glucose drops below normal. V1 stated, It depends on the blood glucose level. V26 made the decision to administer glucagon due to the blood glucose being low. Surveyor asked, in this situation, did you expect the nurse to obtain vital signs and blood glucose, and would you expect the nurse to document the residents' vital signs and blood sugar results? V1 stated, I expect the nurse to document everything that is done for the patient. If the blood sugar is low, I would expect them to administer glucagon. Vitals should be documented in the vitals section, in progress note or the assessment. V1 stated, For diabetes management it would include the nurse checking the blood glucose, and that the blood glucose should be checked before administering insulin. Surveyor asked V1 if there was an order for glucagon. V1 said, I do not see an order for glucagon. Surveyor asked if vitals were in PCC (electronic medical record). V1 said, Not that I can identify in the computer. V1 further stated, Diabetic residents do get evening snacks, but I don't know if R2 had one on [DATE]. On [DATE] at 4:45pm V1 confirmed that V26 was the nurse on the second floor and that V28 (CNA) and V29 (CNA) were the CNA's on [DATE] that worked on the second floor. On [DATE] at 7:27am V28 (CNA) stated, It was early in the morning about 4:30am or 5:00am. V28 stated, When I (V28) saw him he (R2) was real sweaty and he was not moving. V28 stated that V26 was calling his (R2) name and touching him. She (V26) was taking his vitals and checking his blood glucose. V28 stated, V26 called 911 and there was something that she needed that she could not find. V28 stated, V26 had me go to the third floor to get a dose of glucagon from the nurse. V28 stated, the nurse gave me (V28) the glucagon. I (V28) went back to the second floor and gave her (V26) the glucagon. I (V28) don't know who (referring to the nurse or the paramedics) gave it (glucagon) to R2. V28 stated, V29 (CNA) went downstairs to open the door for the paramedics. On [DATE] at 7:48am surveyor called and left a message for V29 (CNA) to return my call. On [DATE] at 8:15am V26 stated, No, I did not give him (R2) glucagon before the paramedics got there. The CNA had to run upstairs to get the glucagon from the nurse on the third floor. V26 stated, R2 did not have a roommate. On [DATE] at 8:29am V30 (Physician) stated, It is expected that the nurse follows the hypoglycemic protocol which is to give an amp of glucagon or start an IV of dextrose. Blood sugars should be rechecked 30 minutes later and notify the doctor. V30 said, Yes, the blood glucose level should be checked 3 times a day with meals and at bedtime for someone on insulin. V30 stated, If insulin is given and the blood glucose is not checked the blood glucose could drop below normal causing the person to become hypoglycemic. Surveyor asked what the blood glucose level was the morning of [DATE]. V30 said, There was a blood sugar [DATE] at 10:29pm and it (referring to blood sugar) was 207 and nothing recorded for [DATE]. The progress notes for [DATE] does not indicate many characteristics of the patient (R2), no vital signs and no blood sugar. On [DATE] at 11:03am surveyor called and left a message for V29 (CNA) to return my call. As of [DATE] at 5:30pm V29 had not returned surveyor's call. On [DATE] at 3:29pm Surveyor confirmed with V1 there was no blood glucose level documented for [DATE] for R2 and the progress note dated [DATE] at 6:42am by V26 does not include any vitals or blood glucose levels. The last blood glucose level documented by V26 for R2 was on [DATE] and R2's blood glucose level was 207 at 10:28pm. On [DATE] at 4:08pm V2 (DON) stated for a Hypoglycemic episode the nurse should act right away, call the doctor, and follow the order of the doctor. Make sure they follow the orders for the prescribed insulin about checking the blood glucose levels and if it is not within the parameters than they would have to call the physician. V2 said, All results of vitals and blood sugars should be documented in the weights and vitals tab and characteristics and other pertinent information should be documented in the progress note. Vitals and blood glucose levels should be in one of those places' vitals or progress note. If it was not written anywhere than I would not assume that it was done. On [DATE] at 6:00pm V34 (CFD Paramedic) stated, the narrative that was written is correct. We (Paramedics) were told R2 had a decreased level of glucose. I (V34) checked R2's glucose and it was 29. The facility did not make us aware of R2's blood sugar. We (paramedics) did not give glucagon. We checked R2's blood sugar and it was 29, we took a set of vitals, and we started an IV and gave R2 D10. We rechecked the blood sugar and got another set of vitals. V34 stated, there was problems with how the nursing staff was answering our questions. The facility (nurse) did not give us any blood sugar level or vitals for R2. V26 told us she (V26) did not give glucagon to R2. If we were unable to give D10 via IV, we would have given glucagon IM. I do not recall the nurse saying what happened to R2. R2 was unresponsive when we got there and did not respond to painful stimuli when the IV was inserted. Surveyor reviewed R2's progress notes dated [DATE] and there was no documentation from the physician (facility unable to provide name of physician) on call regarding R2's change of condition. Progress note dated [DATE] by V26 does not include any documentation of vital signs, blood glucose level. Nursing assessment of R2 was limited when R2 had a change in condition. The last blood glucose level documented by V26 for R2 was on [DATE] which showed R2's blood glucose level was 207 at 10:28pm. Resident Council Meeting minutes dated [DATE] concern documented Nursing: don't take blood glucose from residents before giving medication or food. Policy titled Hypoglycemia Management dated ,d+[DATE] states, in part, caring for a resident with low blood sugar, when an abnormally low finger stick for glucose is obtained with or without symptoms the test should be repeated and if resident cannot drink, confused, unconscious, unable to follow directions, resists help, extreme lethargy or coma or has a seizure: a. give glucagon IM or SQ (available in Emergency C box) or Cubex, b. call 911 (if applicable), if resident is not responding to glucagon and c. document results. Policy title Diabetes Management dated ,d+[DATE] states, in part, restore carbohydrate utilization, correct electrolyte imbalance and prevent and recognize, treat or prevent complications commonly associated with diabetes. Job description title Staff Nurse (Registered Nurse and License Practical Nurse) dated ,d+[DATE] states, in part, Responsible to provide direct nursing care to the customer and the objective is to ensure the highest degree of quality care is maintained at all times. It also states, in part, assume all Nursing procedures and protocols are followed in accordance with established policies, Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the customer, as well as the customer's response to the care, complete required assessments upon the customer's transfer and take and record TPR's, blood pressures, accuchecks, etc., as necessary.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision and failed to follow a residents fall intervention for one resident (R1) in a sample of 3. This failure resulted in R1 falling and sustaining an acute nondisplaced fracture of the left lamina of cervical (C)1 extending to the margins of the left transverse foramen and a left frontal laceration requiring four sutures. Findings Include: R1's Face sheet documents that R1 has a diagnosis which include but not limited to a displaced fracture of first cervical vertebra subsequent encounter for fracture with routine healing, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, and dysarthria following unspecified [CONDITION(S)] disease. R1's Brief Mental Status Interview (BIMS) dated 07/20/22 documents that R1 is severely impaired with memory problems. R1 was not interview able for this investigation. Facility's document dated 07/12/22 and titled Incident/Accident Notification Initial Report documents, in part: R1 found lying in prone position on the floor next to R1's bed by staff . Laceration noted to R1's forehead above R1's left eye with some bleeding . Orders given to send to the emergency room for evaluation. R1 admitted and was taken to local hospital via ambulance then transferred to another local hospital. R1 was admitted to the local hospital for laceration to the forehead requiring sutures and acute nondisplaced fracture of the left lamina and C1 extending to the margins of the left transverse foramen. R1's progress notes authored by V9 (Registered Nurse, RN) dated 07/12/22 at 6:15 am, documents, in part that V6 (Certified Nursing Assistant, CNA) informed V9 that R1 was on the floor next to R1's bed . R1 landed on R1's forehead . Pressure dressing applied to R1's forehead. R1 with 1 centimeter (cm) laceration. R1's hospital records dated 07/12/22 documents, in part that R1 was admitted to local hospital at 08:26 am, R1 came from skilled nursing facility with active bleeding from laceration; EMS (Emergency Medical Service) stated CNA (Certified Nursing Assistant) at skilled nursing facility was cleaning R1 and R1 fell off the bed and hit R1's forehead. At 11:00 pm, Cervical Collar (C)- collar put on R1, x-ray shows fracture at C-1. R1 being transferred to another local hospital. On 08/08/22 at 11:39 am, Surveyor observed R1 in bed awake and alert unable to answer questions appropriately with R1's legs hanging off the side of R1's bed, no floor mat in place with a cup of water spilled on the floor next to R1's bed. On 08/08/22 at 11:54 am, V3 (Staffing Coordinator\Certified Nursing Assistant, CNA) was asked regarding R1's legs hanging off the side of R1's bed, and the cup of water spilled on the floor next to R1's bed. V3 stated, V3 had 2 CNA's that did not show up to work that were assigned to the 4th floor unit and no CNA was assigned to R1's room until 12:00 pm. V3 stated, I (V3) was now assigned to R1's room at 12:00 noon and had not had a chance to round to provide care to R1 for the shift. V3 was asked regarding the cup of spilled water next to R1's bed. V3 stated, That is water spilled. Someone left it (referring to the water next to R1's bed), and someone can fall if it stays there. On 08/08/22 at 12:00 pm V5 (Registered Nurse, RN) was interviewed regarding R1's care. V5 stated, The CNA just came in. We (referring to the 4th floor staff) had 2 CNAs to call off today. V5 was asked regarding R1 hanging off R1's bed. V5 stated, He (R1) does that. Surveyor asked V5 regarding the spilled water on R1's floor. V5 stated, If someone walks into to this, they (referring to if someone walked into the spilled water on the floor next to R1's bed) can fall. On 08/09/22 at 1:23 pm, V2 (DON) was interviewed regarding R1's care. V2 stated, R1 recently fell out of R1's bed, was injured and went to the local hospital. V2 was asked when was the last time staff rounded on R1 on 07/12/22 prior to R1's fall. V2 stated, I (V2) did not know. V2 also stated that residents should be rounded on every hour and a minimum of every 2 hours to prevent falls with injury. V2 was asked the importance of rounding on residents. V2 stated, if a resident goes unmonitored from staff that increases that resident's risk of falling. V2 stated that all residents including residents who do not score as a fall risk should have fall interventions in place such as frequent monitoring and rounding at all times to prevent the resident from falling. V2 was questioned regarding a resident who was falling out of the bed being left unsupervised. V2 stated, That should not happen. If a resident is falling out of the bed the staff should not leave the resident and should call out for help or pull the call light. V2 was asked what could happen if a residents fall care plan intervention is not in place or not followed. V2 stated, the resident could get a very serious injury. 08/09/22 at 2:19 pm, Surveyor attempted to interview V6 (Certified Nursing Assistant, CNA) regarding R1's fall on 07/12/22 and V1 (Administrator) stated, V6 no longer was employed by the facility. V1 provided a phone number to reach V6. Surveyor attempted to reach V6 and was unable to reach V6 with phone number provided by V1. On 08/09/22 at 2:28 pm, V9 (Registered Nurse, RN) was interviewed regarding R1's fall on 07/12/22. V9 stated, on 07/12/22 V9 was on the 4th floor unit hallway at V9's medication cart. V6 Resident Assistant, (RA) informed V9 that V6 observed R1 hanging off the side of R1's bed and needed to be repositioned in bed. V9 stated, by the time V9 and V6 went back to R1's room to reposition R1 in R1's bed, R1 was lying near the window, face down on the bare floor, with blood coming from R1's forehead. V9 stated, I (V9) was not sure of the exact timeframe in which V9 had saw R1 prior to V6 informing V9 that R1 was hanging off the bed. On 08/10/22 at 2:39 pm, V8 (Nurse Practitioner, NP) was interviewed regarding R1's care. V8 stated, residents who are known to hang off the side of the bed and climb out of the bed left unsupervised and do not have fall interventions in place are at high risk for falls with injuries such as head injuries, fractures, and dislocations. V8 also stated that residents who are known to climb out of bed or hang from the side of the bed, beds should be in the lowest position and should have a floor mat to catch the patient if the patient falls. R1's Falls care plan dated initiated 04/10/20 documents, in part: Rounding at a minimum of every 2 hours and prompt or assist for change in position. R1's Fall Risk assessment dated [DATE] documents that R1 has a score of 5 which indicates that R1 is at risk for falls. Facility's document dated 08/2020 and titled Management of Falls documents, in part: Policy: The facility will assess hazards and risk, 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 risk for fall incidents and/or injuries to the resident. Procedure: . 6. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. Facility's undated document titled Job Description documents, in part: Title: Certified Nursing Assistant: 1. Job Summary: Provides residents with daily nursing care in accordance with current federal, state and local standards, guidelines and regulations, facility policies and as may be directed by the Charge Nurse, Supervisor, Assistant Director of Nursing or Administrator to ensure that the highest degree of quality care is maintained at all times . Essential Functions: . F. Make rounds to assure customers are safe and comfortable.

Based on observation, interview and record review, the facility failed to ensure that pressure ulcer prevention interventions were being implemented. This failure resulted in delayed incontinence care and repositioning which along with R6's comorbidities subsequently led to the development of a facility-acquired unstageable pressure injury (Stage IV post debridement) on R6's sacrum. Findings include: R6's Admission Record documents R6's initial date of admission as 03/18/2021. R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's MDS (Minimum Data Set) for Cognitive Patterns dated 05/05/2022 documents, in part, that R6 scored a 15 out of 15 on the BIMS (Brief Interview for Mental Status), indicating R6 is cognitively intact. R6's New Admission Skin/Wound Progress note dated 03/18/21 documents, in part, Hospital records did not indicate any skin alteration. After head-to-toe assessment writer observed that skin is intact, dry, warm and appropriate color for R6's ethnicity. The 4th floor assignment sheet for 06/14/22 for the 7am-3pm shift listed 3 CNAs including V8 who is a RA (Resident Attendant)/CNA (Certified Nursing Assistant) in Training and V18 RA. The facility census as of 6/13/22 lists 66 residents on the 4th floor. On 6/14/22 at 10:03 AM, the surveyor entered R6's room and encountered V10 (Wound Care Nurse) who stated that V10 just finished changing R6's sacral dressing. R6 was observed lying on R6's back on a low air loss mattress with the head of the bed at a 45-degree angle and a wedge underneath R6's left upper back. When the surveyor asked R6 if R6 has been getting out of bed, R6 replied, No, not anymore. I would like to. I presume it's because of lack of staff. When asked if R6 asked staff to get out of bed, R6 stated, I mentioned it a few times, but then I just let it go. When asked if R6 is being repositioned, R6 replied, Yes. A couple times a day, but I have to ask them to do it, and sometimes they complain that they're not strong enough to do it. The surveyor inquired if R6 is being turned or repositioned every two hours. R6 replied, Oh hell no. That's fancy. R6 added that sometimes R6 sees a CNA early in the morning and then not until the afternoon. Regarding call light responsiveness, R6 stated that there have been times when no one has showed up at all. R6 stated that R6 wears a condom catheter due to urinary incontinence, but it falls off frequently leaving R6 wet. When R6 has a bowel movement, R6 stated that R6 will usually wait for a CNA to round, but if R6 has been waiting too long, then will use the call light to get changed. On 06/14/22 at 11:30 AM, According to V16 (CNA/Staffing Coordinator), V18 RA is not in school yet. V16 added that a RA in school can do patient care but transfers have to be done with another certified CNA. If you're a CNA in training, it's the same thing as an RA in school, per V16. On 06/14/22 at 12:08 pm, the surveyor observed R6 still lying in the same position on R6's back with wedge still under the left upper back and head at approximately a 45-degree position, but R6's body was lower down in the bed with R6's left foot pushed up against the bed board. At 12:11 pm, V18 RA brought R6's lunch tray and commented, Why they got you sitting down so low today? V18 assisted R6 with pushing the bed control to lift R6's head of the bed up higher then exited the room. When the surveyor asked R6 if R6 had been repositioned since 10:03 am, R6 replied, No. On 6/14/22 at 2:02 pm, the surveyor observed R6 lying in the same position as was observed at 12:08 pm. When the surveyor asked if anyone had been in to reposition R6, R6 stated, No. No one's been here. I could use somebody to change me. R6 was observed to be wearing an incontinence brief. On 6/14/22 at 2:12 pm, the surveyor asked V8 if V8 had provided incontinence care to R6 today. V8 stated, No, I haven't been in there yet. V8 added that having to pass out breakfast and lunch takes a lot of time so it isn't until after that task is finished that V8 can get back to changing beds and providing incontinence care. V8 stated that when there's only 2 or 3 CNAs working, each will get 13 residents or more. Today there's only 3 (CNAs). V8 added that sometimes residents only get changed once a day due to the workload. When the surveyor asked if R6 has been repositioned since the start of V8's shift, V8 replied, That I don't know because the RA (Resident Attendant) is supposed to go around and do that. On 06/14/22 at 2:16 PM, The surveyor asked V10 (Wound Care Nurse) if R6 appears to be in the same position as was at 10:03 AM when V10 finished with wound care. V10 replied, R6 does. When the surveyor asked R6 if R6 would like to be repositioned, R6 stated, Yes. V10 stated that staff should be repositioning R6 because, I don't think R6 has the mobility to do it R6-self. The surveyor asked V10 what the low air loss mattress settings were set at. V10 stated that the pump was set at 340 pounds with a 20-minute alternating cycle. V10 stated, The settings shouldn't be this, and explained that for a resident with a pressure ulcer, the settings should be based on weight. V10 added that the pump should be set to one step above the resident's weight with a 10-minute alternating cycle to allow for pressure redistribution to prevent further deterioration of the wound. V10 proceeded to change the setting to 280 pounds at a 10-minute alternating cycle. When asked what R6's current weight is, V10 stated, I don't know off the top of my head. V10 added that R6 had voiced a concern that the low air loss mattress has been losing air. As a result, stated V10, Staff thinks by changing the settings, it will get better. V10 stated that there was a technician that came out last week to look at the mattress but could not find a problem so V10 requested a new mattress since they couldn't find another solution, but the mattress hasn't arrived yet. V10 stated that V10 never saw any signs of deflation, and the first time V10 was made aware of the issue was when V10 first assessed R6's wound on 05/03/2022. R6 stated, That's how I got the wound in the first place; because it was deflated and felt like I was sleeping on the frame. R6 added that this is the same mattress that R6 was on when was moved from the 2nd floor to the 4th floor. Per V2 (Assistant Administrator), R6 transferred from the 2nd floor on 10/25/2021. The surveyor inquired about the layering of linens. Per V10, the resident can have a flat sheet as well as one other layer such as an incontinence brief, but no other chucks or lift sheets. R6 was noted to have just a flat sheet and incontinence brief on. On 06/14/22 At 2:29 pm, V8 arrived to R6's room to provide incontinence care. R6 was noted to have a large, brown BM was a baseball sized brown stain to the flat sheet. When the surveyor asked when R6 had the bowel movement (BM), R6 stated that it was before lunch but wasn't sure if R6 was finished with the BM so waited to call and then fell asleep. The surveyor inquired about the risk of lying in urine or feces for an extended period of time. V10 stated that there's a risk of infection and worsening/deepening of the wound as well as a potential for maceration of the skin if not being changed promptly. On 06/14/22 at 3:10 pm, the surveyor asked V18 (RA) if V18 had repositioned any patients on the 4th floor today. V18 stated, No, I didn't. On 06/15/22 at 11:48 am, V11 DON (Director of Nursing) stated that a RA who is not in school is not allowed to use lifts, assist with transfers or toileting, and not allowed to dress or ambulate a resident. When the surveyor asked if an RA not in school can reposition a resident, V11 stated, No. On 06/15/22 at 12:45 PM, during a phone interview with V20 PA (Physician Assistant) the surveyor inquired about the risk factors that may lead to a Stage IV pressure sore? V20 replied, In my expertise, it would have to be incontinence, not being able to move (immobility), and if they have any psychiatric disease where they may not be able to tell when they're wet or in pain. V20 added that a resident should be repositioned at least every two hours. The surveyor asked whether incorrect low air loss mattress setting could lead to further skin alteration. V20 stated, That's a possibility, but ultimately that's not the only reason. All the other comorbidities can make the wound worse. The purpose of the low air loss mattress is to prevent any further pressure ulcer formation by redistributing the pressure on the body so it's not all in one area, according to V20. V20 agreed that residents still need to be repositioned despite the use of a low air loss mattress and that if the resident is incontinent for a long period of time, then that can lead to worsening of the wound. R6's Skin/Wound progress note dated 10/10/2021 documents, in part, Assigned CNA reported skin alteration. Noticed R6 has some redness on R6's sacrum and buttocks area .treatment orders received and completed. Low air loss, turning schedule in place. The wound type/location was documented as MASD (Moisture-Associated [CONDITION(S)]) of the sacrum/buttocks. On 10/22/2021, the site was documented to be resolved. R6's Skin/Wound progress note dated 05/03/2022 documents, in part, R6 was noted with a new skin condition. This morning the writer and Wound Specialist V20 assessed R6. Noticed unstageable pressure wound on R6's sacrum. Educated staff and resident to shift weight frequently, to stay clean and dry at all times to prevent further skin break down. R6 is on low air loss, turning clock and heels offloaded. R6's Skin/Wound progress note dated 05/17/2022 documents, in part, Doctor debrided sacral wound and classified it as stage 4. R6's Skin/Wound progress note dated 05/19/2022 documents, in part, Wound NP (nurse practitioner) saw R6 today. NP debrided sacral wound and noted increase in depth post debridement. The following notes on 05/24/22, 06/02/22, and 06/07/22 all document, noted increase in depth post debridement. The facility Pressure Injury report documents the letter F in the column labeled Where acquired for R6's sacral wound. Per V2 (Assistant Administrator) the F stands for facility acquired. Review of R6's POC (Point of Care) response history from 5/16/22 until 06/14/22 for the task of Turned and Repositioned: at no greater than every 2 hours based on resident need documents the response No for the dates of 05/17 (6:33 pm), 05/19 (10:18 pm), 05/24 (12:07 am), 05/28 (10:20 am), 6/2 (11:42 am), 6/7 (9:36 am) and 6/9 (8:47 pm). R6's Braden Scale for Predicting Pressure Ulcer Risk dated 05/04/22 documents a score of 12 indicating R6 has a High Risk for developing a pressure ulcer. R6's care plan dated 03/18/2021 documents, in part, Focus: R6 has actual alteration in skin integrity - pressure injury to sacrum and MASD to perineum, potential for alteration in skin integrity. R6 is at risk for further alteration in skin integrity r/t (related to) requiring assistance with ADLs (Activities of Daily Living), incontinent, dx (diagnosis) with [CONDITION(S)], [CONDITION(S)] (hypertension), [CONDITION(S)] (Urinary Tract Infection), overactive bladder and vasomotor rhinitis. Interventions/Tasks include but are not limited to Inspect skin daily with care, peri-care after incontinent episodes, pressure reduction foam mattress redistribution support (low air or alternation air) in bed, turn and reposition every two hours as needed. R6's care plan dated 08/06/2021 documents, in part, Focus: R6 requires assistance form staff for bed mobility; unable to turn and reposition self in bed without physical assistance from staff secondary to weakness and [CONDITION(S)]. Interventions/Tasks include but are not limited to, Assist/cue resident into side lying position, reposition using full body sling lift or friction reducing devices. The facility policy titled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Identify residents at risk for developing pressure injuries. 2. Identify the presence of pressure injurie and/or other skin alterations. 3. Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through the Individual Program Plan (IPP). Procedure includes but is not limited to, All implemented measures (preventive and/or therapeutic) will be documented within the IPP and will be revised via Special Staffing as needed; at least daily, staff should remain alert for any skin changes during resident care and communicate these changes to the nurse on duty. The facility policy titled Routine Resident Checks and dated 9/2020 documents, in part, Policy interpretation and implementation: 1. To ensure the safety and wellbeing of our residents, a resident check will be made at least every two (2) hours throughout each 24-hour shift by nursing service personnel. 2. Routine checks involve entering the resident's room to determine if the resident's needs are being met .needs toileting assistance, etc. The facility policy titled Alternating Pressure Air Mattress dated 09/20 documents the purpose: 1. To maintain and promote adequate circulation. 2. To relieve pressure and aid in healing and/or prevention of pressure ulcers. 3. To reduce pain due to pressure. Procedure: 9. Make periodic checks to check for proper inflation of mattress.

Based on interviews and record reviews, this facility failed to ensure 2 person physical assistance was used during care of actiivities of daily living and bed mobility of a total dependent and contracted resident this affected 1 of 3 residents (R1) reviewed for avoidable accidents during care. This failure resulted in R1 being observed by the nurse with abnormal swelling to the lower extremities and sent to the local hospital diagnosed with [REDACTED]. Findings include: Review of the medical record notes R1 with [DIAGNOSES REDACTED]. On 9/21/19, comminuted (bone broken into three or more pieces) fracture of left femur. On 10/9/19 at 12:10pm, V5 CNA (certified nurse aide) stated that R1's legs are contracted. V5 stated that R1 is totally dependent on staff for bed mobility and incontinence care. V5 stated that R1's extremities were stiff. V5 stated that R1 was bedridden and was not gotten out of bed into a reclining wheelchair due to R1's legs were contracted. V5 denied witnessing or being informed of R1 falling. V5 stated that two staff members should be used for turning/repositioning and incontinence care for R1's safety. V5 denied witnessing R1's legs hanging over side of bed. On 10/9/19 at 1:16pm, V7 (orthopedic surgeon) stated that the type of fracture R1 presented to the hospital with typically occurs with falls; this is not a typical fracture for a resident who is bedridden. V7 stated that R1 could have sustained fracture if R1 was forcefully being repositioned or during care. On 10/9/19 at 2:44pm, V8 (restorative nurse) stated that R1 required maximum to total assistance with ADLs. On 10/9/19 at 3:15pm, V9 (restorative nurse) stated that V9 performed quarterly restorative assessments on R1. R1 is totally dependent on staff for all ADLs (activities of daily living). V9 stated that R1 was unable to move extremities without staff assistance. V9 stated that R1 had limited range of motion with all extremities. V9 denied witnessing R1's legs hanging over side of bed. On 10/9/19 at 3:30pm, V10 RN stated that R1 was totally dependent on staff for ADLs. V10 stated that R1 was able to make slight movements with arms, but R1's legs were contracted and R1 did not move legs. V10 stated that V10 always observed R1 lying in a fetal position. V10 denied witnessing R1's legs hanging over side of bed. On 10/10/19 at 7:55am, V2 DON (director of nursing) stated that R1 was able to dangle legs off bed without assistance. V2 stated that this dangling caused pressure on R1's thigh causing left femur fracture. V2 denied any history of falls for R1. On 10/10/19 at 8:00am, V11 RN stated that R1 was able to make slight movements of upper extremities. V11 stated that on 9/21/19 at 3:30am during resident rounding, V11 observed R1's left thigh swollen and R1 grimaced in pain when V11 touched R1's thigh. V11 stated that V11 administered pain medication and notified V15 (attending physician). V11 stated that V11 received order to send R1 to the hospital. On 10/10/19 at 1:52pm, V13 CNA stated that R1 was not able to move extremities, legs were contracted. V13 stated that V13 worked over night 9/20 at 7:00pm to 9/21 at 7:00am. V13 stated that V11 RN assisted her with incontinence care for R1. V13 stated that she and V11 observed swelling to R1's left thigh at that time. V13 stated that R1 should be a two person assist with all care. On 10/10/19 at 11:00am, V15 (attending physician) stated that R1 was able to make slight movements of extremities. V15 denied witnessing R1 with legs over the side of bed. On 10/10/19 at 1:00pm, V1 (administrator) stated that R1 had no history of falls while at this facility. Review of R1's MARs (medication administration records), dated (MONTH) through (MONTH) 2019, notes R1's pain was assessed every shift and was 0 out of 10 except for three occasions in September. On 9/17/19 at 8:23am, R1's pain was assessed at 2 out of 10 due to facial expression and tense body language. On 9/19 at 00:01am, R1's pain was assessed 4 out of 10 due to occassional moans/groans, facial grimacing, and tense body language. On 9/21 at 3:30am, R1's pain assessed at 5 out of 10 due to facial grimacing and tense body language. Review of R1's MDS (minimum data set), dated 9/12/19, notes R1 with total dependence on two staff members for bed mobility, transfers, and toileting/incontinence care. R1 has impairment in range of motion to all extremities. It also notes that R1 is always incontinent of bowel and bladder. All of R1's MDS assessments since admission to this facility on 6/6/2018 were reviewed; admission assessment on 6/13/18, quarterly assessments on 9/13/18, 12/13/18, and 3/14/19 and annual assessment on 6/13/19. All of R1's assessments note the same findings R1 is totally dependent on two staff members for bed mobility, transfers, and toileting/incontinence care. Review of the CNAs task documentation for past 30 days notes R1 with total dependence on staff for bed mobility, transfers, and toileting. It notes 21 opportunities for turning/repositoning in bed were documented; staff repositioned R1 12 times with one staff assist; 9 times R1 was repositioned with two staff assisting. R1 required the use of a mechanical lift device for all transfers. It also notes 17 oportunities for toileting/incontinence care; staff provided incontinence care 9 times with one staff assist and 8 times with two staff assisting. Review of R1's functional limitation in range of motion assessment, dated 9/18/19, notes R1 with limitations in both upper extremities. R1 has weakness, stiffness, unable to move arms past shoulder level with PROM (passive range of motion), unable to follow verbal commands due to impaired cognition and [DIAGNOSES REDACTED]. R1 has limitations in both legs due to weakness, stiffness, unable to move legs from midline, unable to follow verbal commands due to impaired cognition and [DIAGNOSES REDACTED]. PROM recommended for all extremities. Review of R1's functional assessment, dated 9/18/19, notes R1 with total dependence for bed mobility, transfers, dressing, eating, toileting, hygiene, and bathing. Review of R1's progress notes, dated 9/21/19, notes at 3:00am, while making rounds, V11 RN took R1's vital signs and noticed R1's left leg was swollen, warm to touch as compared to the right leg, and was abnormally firm upon palpation, V15 (attending physician) made aware with order to send R1 to the hospital. Ambulance service notified and arrived at facility at 5:15am. R1 admitted to the hospital with [REDACTED]. Review of R1's emergency room physician's report, dated 9/21/19 at 6:40am, unable to fully evaluate range of motion, severe left hip redness, tenderness, and swelling. X-ray of left hip completed at 7:34am; results note R1 with significant left femur fracture with severe surrounding swelling. Attempts at providing traction and repositioning unsuccessful based on significant swelling. Review of R1's hospital medical record, dated 9/21/19, notes R1's x-ray shows comminuted [MEDICAL CONDITION] left femur shaft with possible 90 degree angulation at the fracture site. This facility's investigation into R1's injury of unknown origin, dated 9/21/19, was reviewed. Upon completion of their investigation, this facility noted that the level of contractures that R1 has specifically combined with R1's legs noted to be off the bed at times at knees contributed to pressure on the top of the left femur. R1's left hip and thigh were observed to be swollen at 3:30am.

Based on interview and record review, the facility failed to implement fall prevention monitoring and interventions to prevent a resident at risk for fall from falling multiple times with in a two day period. This applies to one of four residents (R1) reviewed for falls in a sample of six. As a result, R1 sustained repeated falls, skin tear on the right forearm, bilateral nasal bone fracture and subdural hematoma. Findings include: Admit/Transfer/Discharge logs indicate that R1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. R1's initial fall risk assessment dated [DATE] indicates R1 has unsteady gait, predisposing condition of Seizures, impaired memory or judgment, history of falls in past 1-6 months, on drugs that have a diuretic effect, drugs that affect the thought process, drugs that create a hypotensive effect, R1scored at high risk for falls. Admit/Transfer/Discharge logs and census activity of R1 indicates: R1 was admitted to the facility on [DATE] at 12:19pm. R1's nursing notes indicates, R1 had a fall at 2:00pm, and second fall at 7:30pm which resulted in skin tear of four inches long to the right forearm with minimal amount of bleeding. R1 was transferred to a local community hospital (Hospital#1) on 11/04/2016 at 12:15am, came back to the facility at 4:30am, with negative reports of head injury. R1 had a third fall on 11/04/2016 at 6:55am, and R1 was transferred to local community hospital (Hospital#2) at 4:48pm, radiologic studies revealed subdural hematoma and bilateral nasal bone fractures. Nurses progress notes and post occurrence documentation by E2 (Director of Nursing-DON) indicate that R1 fell on [DATE] at 2:00pm and R1 was observed getting up from the wheelchair to transfer to a regular chair in the dining room. R1 lost his balance and fell on his buttocks before staff could get to him. R1 stated, I was just trying to see if I can get up by myself to that chair. Nurses notes and post occurrence documentation dated 11/03/2016 indicate that R1 fell at 7:30pm, R1 was in his wheelchair, R1 got up, started to walk and fell backwards, hitting his head on the floor. With the fall, R1 had a skin tear of four inches long noted on the right forearm with minimal amount of bleeding. On 11/04/2016 at 12:15am, R1 was transferred to a local hospital (Hospital#1) and was transferred back to the facility at 4:30am. Post occurrence documentation dated 11/04/2016, 7:05am reads that E3 (Registered Nurse-RN) saw R1 sleeping in bed, after 30 minutes, E3 went to check on R1 and found him on the floor next to his bed with bleeding from nose. R1 stated He was trying to get his pants. R1 complained of pain in the nose. Neurological checks for every 15 minutes were initiated. R1 was transferred to local hospital (Hospital#2) at 4:48pm. R1's care plan reads R1 is at high risk for falls secondary to history of falls, psychotropic use, [DIAGNOSES REDACTED]. R1 is also care planned for impaired cognitive functioning with interventions of providing orientation/directional cues as needed initiated on 11/03/2016. The interventions were put in place only after the fall occurred, not prior to the fall as preventive measures. On 11/17/2016 at 3:05pm, E4 (Restorative Director) stated He (R1) was transferred to fourth floor because he needed more supervision and I did the restorative assessment. He was very confused, agitated, had unsteady gait and was unsafe to walk. He was at high risk for falls with prior history of falls. Our fall protocol is implemented with interventions based on how the resident fell . If a resident falls from a chair, we put a chair alarm or safety release belt, if the fall is from bed; we put bed alarm in place. For him (R1) after the first fall, we put a safety release belt. After the second fall, I did one on one supervision until he was sent out to the hospital (Hospital#1). After the third fall, we put a bed alarm. After the third fall, the social worker was doing one to one supervision until he was sent out to another local hospital (Hospital#2) . When asked about whether the 1:1 supervision was implemented after R1 came back to the facility from local hospital (Hospital#1), E4 stated, No, the nurses were not doing 1:1 supervision, but they were frequently monitoring him. The nurses should have kept him (R1) on 1:1 supervision. CT scan (special x-ray) of head on 11/03/2016 at 11:48pm at local hospital (Hospital#1) reads: Slightly hyper dense extra-axial collection about much of the right cerebral hemisphere measuring up to 6 millimeters in width may reflect a sub acute subdural hematoma. A short term follow-up exam is recommended to evaluate stability findings. On 11/04/2016, the admitting [DIAGNOSES REDACTED].#2) is subdural hematoma. CT scan of head on 11/04/2016 at local hospital (Hospital#2): Findings: There is a right-sided extra-axial intermediate density collection overlying the entire right cerebral hemisphere. It measures up to 5 millimeters in thickness. Bilateral nasal bone fractures noted. CT scan of the head on 11/05/2016 at local hospital (Hospital#2): Impression: Slight interval increase in right subdural hematoma. Increased density, indicating a more acute component. CT scan of the head on 11/05/2016 at local hospital (Hospital#2): Findings: A right subdural hematoma, measures five to six millimeters in thickness at the level of the inferior frontal lobe. This is stable. On 11/21/16 at 9:53am, Z1 (physician) stated, He (R1) had poor judgment, history of psychiatric illness, I put him on psychiatric consultation, he (R1) was not a suitable resident for this nursing home, If they were doing 1:1 supervision after the second fall, they should have continued with the same intervention to avoid third fall. On 11/21/16 at 10:20am, E2 (DON) stated He (R1) had ataxia was very unsafe to walk, even when I was doing my initial fall risk assessment, he was trying to get out of the bed, So, I called for the help of the nurse aide to help him use the washroom. We didn't put him on 1:1 supervision after he came back from the local hospital (Hospital#2), but we were monitoring him every 15 minutes. The facility policy titled Prevention of Falls dated 06/13 reads: 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. Develop a plan of care to include goals and interventions which address risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses, co morbidities, history of fall incidents, incontinence, medications, and assistance required with activities of daily living, gait/transfer/ balance issues, behaviors and /or cognitive status. This policy was not followed. -