Every finding on record at Allure of Knox County

Based on interview and record review, the facility failed to ensure timely assessment, physician notification, and documentation of a significant change in condition for one (R1) of three residents reviewed for notification of changes in the sample list of three. Findings include:The facility's 2025 Notification of Changes policy requires staff to assess residents experiencing a significant change in condition, notify the physician and resident representative, and document the notification.R1's Census Line documents R1 admitted to the facility on [DATE]. This same census line documents R1 readmitted to the facility on [DATE] from a short hospital stay.R1's current care plan documents, R1, is cognitively impaired.R1's Medical Diagnosis list documents R1 has diagnoses including metabolic encephalopathy, lumbar disc degeneration, and severe protein-calorie malnutrition.On 8/3/26 at 9:21 AM, V4 (Hospital Registered Nurse) stated an unknown nurse at the facility reported on 7/13/26 that staff believed R1 may have experienced a stroke approximately one week earlier but had not been sent to the hospital sooner for evaluation. V4 stated this was concerning and felt this should have been reported sooner.On 8/3/26 at 11:30 AM, V5 (Licensed Practical Nurse) stated when V5 arrived for her shift on 7/13/26, V6 (Agency Nurse) expressed concern that R1 had not been acting right and was having stroke-like symptoms so V6 asked V5 to assist in transferring R1 to the local emergency room. V5 further stated R1 was lethargic, not acting right, and was transferred to the emergency department on 7/13/26 due to concerns of a stroke. V5 stated she documented the transfer note and sent paperwork with the paramedics. R1's Electronic Medical record did not contain a documented nursing assessment, vital signs, or progress note describing R1's condition change on or prior to transfer on 7/13/26.On 8/4/26 at 9:53 AM, V6 (Agency Nurse) stated R1 exhibited slurred speech, confusion, refusal of medications, and difficulty eating following return from the hospital on 7/9/26. V6 stated she had taken care of R1 a couple of times since returning to the facility and had been noticing something was not right. V6 stated she was concerned R1 had experienced a stroke and did not see his symptoms were improving so V5 arranged R1 to be transferred on 7/13/26 to the local emergency room, but acknowledged V6 did not complete an assessment, obtain vital signs, or document the condition change because she believed the oncoming nurse (V5) would complete the documentation. V6 stated she had not contacted R1's physician prior to 7/13/26 to report condition change.On 8/3/26 at 1:30 PM, V2 (Director of Nursing) confirmed a nursing assessment, and vital signs should have been completed and documented prior to transfer on 7/13/26 but were not. V2 further stated R1's Physician should have been notified when staff first observed a condition change. V2 confirmed R1s electronic medical chart did not contain documentation of R1's stroke like symptoms or a condition change.

Based on interview and record review, the facility failed to ensure blood glucose monitoring supplies were available and failed to ensure timely administration of sliding scale insulin as ordered for one (R2) of three residents reviewed for medication management in the sample list of three. Findings include:The facility's Timely Administration of insulin policy dated 2025 documents the facility's expectation that insulin is administered timely, according to physician orders, and coordinated with mealtimes and bedtime snacks unless otherwise specified.On 8/3/26 at 8:56 AM, V8 (Agency Nurse) stated she worked the 9:00 AM to 2:00 PM shift at the facility on 7/11/26. V8 stated upon arrival she was responsible for residents located on the back and middle halls. V8 stated she was reviewing scheduled blood glucose checks and preparing supplies for the 11:00 AM blood glucose checks and sliding scale insulin administration when V8 discovered the facility did not have blood glucose strips available. V8 stated she asked another nurse where the blood glucose strips were located and was informed the facility had not had blood glucose strips for several days. V8 stated she asked how staff obtained blood glucose readings for residents receiving sliding scale insulin and the nurse responded, we guess. V8 stated she was not comfortable administering insulin without obtaining a blood glucose reading, so V8 contacted V2 (Director of Nursing). V8 stated V2 informed her there were no blood glucose strips available and that the only box of strips in the facility was locked in V1's (Administrators') office. V8 stated V1 was on vacation and staff did not have access to the office. V8 stated V2 arrived at approximately 1:45 PM with blood glucose strips, at which time she obtained blood glucose readings and administered the 11:00 AM insulin. R2's July 2026 Medication Administration Record (MAR) documents an order for sliding scale insulin Lispro scheduled at 11:00 AM and 4:00 PM daily. R2's MAR documented R2 received two units of insulin Lispro at 2:19 PM for the scheduled 11:00 AM dose which was signed off by V8 and an additional two units at 3:37 PM for the scheduled 4:00 PM dose on 7/11/26.R2's Nurse Progress Notes did not contain documentation of physician notification regarding the inability to obtain the ordered blood glucose level prior to insulin administration, the delay in administration of scheduled insulin, or the rationale for administering insulin outside the ordered timeframe.On 8/3/26 at 10:15 AM, V7 (Registered Nurse) stated the facility frequently runs out of blood glucose supplies and other necessary supplies. V7 stated she previously had to purchase blood glucose strips from a local store because the facility did not have any available.On 8/3/26 at 10:30 AM, V2 (Director of Nursing) stated V2 recalled receiving a call from V8 on 7/11/26 regarding the facility not having blood glucose strips. V2 stated the facility seldom runs out of supplies but acknowledged the facility had run out of blood glucose strips at that time. V2 stated the only available box of strips was locked in V1's office and V2 did not have a key to access the office. V2 stated he instructed V8 to notify the physician but did not follow up to verify notification occurred. V2 stated he was not aware the 11:00 AM sliding scale insulin was administered at approximately 2:00 PM and stated the nurse should not have administered the insulin at that time without physician approval.

Based on interview, and record review the facility failed to ensure the services of a full-time Director of Nursing who is a Registered Nurse, as identified in the facility's staffing plan. This failure affects all 59 residents who reside at the facility.Findings include: The Facility Assessment revised 4/13/26 documents under the facility's staffing plan that the facility will have a Director of Nursing who is a Registered Nurse full time on dayshift. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/8/26 and signed by V10 (Director of Operations), documents 59 residents reside within the facility.On 5/8/26 at 9:30 AM, V3 (ADON/Infection Preventionist) stated that V2, Director of Nursing, was not at the facility because V2 was completing a contract with another employer. V3 stated that V2 began employment with the facility in April 2026 but was not consistently present due to obligations associated with an outside contract. V3 further stated that she attempted to cover responsibilities when V2 was absent but acknowledged she is a Licensed Practical Nurse and not a Registered Nurse.On 5/9/26 at 9:15 AM, V2 (Director of Nursing) stated V2 accepted the Director of Nursing position on April 1, 2026, but continued to fulfill a contractual obligation with a local hospital. V2 stated he was present at the facility approximately three days per week and, at times, worked direct care assignments on the nursing unit, limiting V2's ability to perform Director of Nursing responsibilities.On 5/10/26 at 9:00 AM, V18 (Regional Nurse Consultant) stated that V2 and V3 were responsible for oversight of the facility and that V3 assumed Director of Nursing responsibilities when V2 was unavailable. V18 stated Regional Nurse Consultants were not present in the facility on a daily basis.

Based on observation, interview, and record review the facility failed to ensure the quaternary sanitation buckets contained an adequate level of chemical to sanitize kitchen surfaces and ensure all foods located within the refrigerator were labeled with the date opened or prepared. These failures have the potential to affect all 59 residents residing in the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/8/26 and signed by V10 (Director of Operations), documents 59 residents reside within the facility. The facility's Date Marking for Food Safety, undated, documents, The facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperatures control for safety food. The individual opening or preparing food shall be responsible for date marking the food at the time the food is opened or prepared. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded.The facility's Wiping Cloths policy, undated, documents, All dietary department employees are responsible for complying with this policy. Supervisords and managers are responsible for monitoring compliance and providing correction action and retraining when necessary. All sanitizer rags used in the dietary department shall be stored in an approved sanitizing solution when not in use. Sanitizer rags shall be maintained in a manner that prevents contamination of food, food-contact surfaces, equipment, utensils, linens, and single-service items. 2.Storage Requirements. a. Between uses, all damp sanitizer rags shall be completely submerged in a labeled container of approved sanitizing solution. b. Sanitizer buckets shall be maintained at the proper concentration according to manufacturer instructions and verified with appropriate test strips. The Sanitizing Manufacturer's Directions dated 2021 documents, Testing solution should be at room temperature. Dip paper for 10 seconds. Compare colors immediately with colors on the test strip package to determine ppm (parts per million). Always compare against package scale. Testing solutions should be between 200-400 ppm.On 6/8/26 at 9:10 AM, a kitchen tour was conducted with V4 (Cook). Observation of the two-door refrigerator revealed multiple opened food items, including a protein shake, chocolate syrup, grape jelly, lemon juice, a partially used onion, and a partially used tomato, that were not labeled with the date opened. Additionally, five bowls of ham salad lacked preparation date labels. Five sanitizer buckets containing water and washcloths were observed in the kitchen. V4 identified the buckets as sanitizer solutions used for cleaning food preparation surfaces. V4 tested all five buckets with sanitizer test strips which revealed all five buckets sanitizer concentrations at zero ppm , indicating no detectable sanitizer was present. V4 confirmed that opened and prepared food items should be covered and dated, and that sanitizer buckets should maintain a sanitizer concentration of 200 ppm.

Based on observation, interview, and record review the facility failed to establish and maintain an effective infection prevention and control program by failing to perform surveillance to track and monitor resident and staff illnesses and failed to implement appropriate PPE (Personal Protective Equipment) while handling soiled linens. These failures have the potential to affect all 59 residents residing in the facility. Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/8/26 and signed by V10 (Director of Operations), documents 59 residents reside within the facility.The Infection Prevention and Control Program policy, undated, documents, This facility has established and maintains 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 as per accepted national standards and guidelines. The designated Infection Preventionist is responsible for oversight of the program and services as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposes, surveillance, and epidemiological investigations of exposures of infectious diseases. All staff are responsible for following all policies and procedures related to the program. Surveillance: A system of surveillance is utilized for prevention, identifying, reporting, investigation, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. Linens: Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.The facility's Handling Soiled Linens, undated, documents, It is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection. The policy pertains to soiled linen. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants. Transmission of pathogens can occur through direct contact with linens or aerosols generated from sorting and handling contaminated linen. All used linen should be handled using standard precautions and treated as potentially contaminated. Other protective equipment may be required. Examples of linen that may require special handling include but are not limited to: Visibly soiled with blood or large amounts of body fluids. Residents with infection transmitted by contact.The Environmental Services Laundry Worker Job Description dated 2023 documents, The facility's infection control surveillance logs were all reviewed from 1/1/26 through 6/9/26 and do not contain a tracking log of resident illnesses (that did not require antibiotic use) or employee illnesses.The facility's Infection Control Contact Isolation List documents R62 is currently placed in contact isolation due to ESBL (Extended-Spectrum Beta-Lactamase) of a surgical wound.On 6/8/26 at 9:20 AM V6 (Laundry Aide) was handling and putting soiled linen in the washer. V6 was not wearing a gown while handling the linen. V6 stated soiled linens that are transported to laundry from contact isolation rooms are not in any different containers or bags and V6 stated she never wears a gown or goggles when handling any soiled linens, including linen brought from contact isolation rooms.On 6/9/26 at 1:30 PM V3 (Infection Preventionist) stated she has not been tracking employee illness since she has started the position. V3 stated, I was told to no longer track employee illnesses because we (the facility) are not allowed to ask why the staff called in. We (the facility) do not use special bags or special barrels for isolation linens. Laundry staff should be using a gown and gloves when handling all linens. V3 verified antibiotic tracking logs are maintained for each residents every month, however these do not include a comprehensive record of all resident illnesses other than infections that are being treated with an antibiotic.

Based on Observation, Interview and Record Review, the facility failed to ensure residents had an appropriate diagnosis, timely and accurate consent and targeted behaviors to warrant the use of antipsychotic medications and for four of four residents (R4, R7, R17, R53) reviewed for antipsychotic medications in the sample of 33.Findings include: The facility's Use of Psychotropic Medications policy, dated 2026, documents It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Chemical restraint refers to any drug used for discipline or that makes it more convenient (example; less effort) for staff to care for a resident and not required to treat medical symptoms. This includes when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The indications for initiating, maintaining, or discontinuing medication(s) as well as the use of non-pharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. The facility will document that the resident or residents representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (example; written consent form, narrative note, etcetera.) 1. On 6/8/26 at 11:40 AM, R4 was observed sitting in a wheelchair near the facility's dining room. R4 was not displaying any behaviors. R4's Medication Administration Record, dated 6/10/26, documents R4 was started on Risperidone 0.25 milligrams (mg) (antipsychotic medication) two times daily for Dementia with Psychosis on 1/20/26. R4's Care Plan, dated 3/30/26, documents R4 was admitted to the facility on [DATE] and has diagnoses including Dementia without Behavioral Disturbance, Alzheimer's Disease with Late Onset, Depression, Cognitive Communication Deficit and Dementia with Psychotic Disturbance (added 1/28/26). This same care plan documents a plan of care for Behaviors: (R4) has potential for behaviors. Monitor behavior symptoms, at risk for elopement. This care plan also documents I use psychotropic medications with diagnosis of Dementia with Psychosis. I receive Risperdal (risperidone) 0.25 mg two times a day. R4's care plan does not address targeted behaviors for the use of an antipsychotic or what psych behaviors to monitor R4 for. R4's current electronic medical record does not document behaviors of psychosis for R4. On 6/9/26 at 2:30 PM V16 (Registered Nurse) stated (R4's) only behavior is that she will get anxious or want attention right now. She will want things addressed if she needs something. (R4) has never been aggressive though. 6/10/26 at 10:35 AM V2 (Director of Nursing) stated (R4) doesn't ambulate much. She gets depressed and will be down in her mood. We planned to have her see Psychiatry when they come in. V2 confirmed R4 is not a harm to herself or others and does not display behaviors that are psychotic in nature. V2 stated (R4) is on the list for psych consult due to depression but she is not aggressive towards others. R4's Psychotropic Medication Consent for Risperidone is dated 4/14/26 and does not document the reason for use, a diagnosis for the use, or any non-pharmacological interventions that were attempted prior to initiating the medication. On 6/10/26 at 11:00 AM, V18 (Regional Nurse Consultant) confirmed R4's Risperidone consent was not filled out completely and was not obtained prior to initiating the medication. V18 stated The risperidone was started in January, and we did not get a consent until 4/14/26. I am not sure why, but it should be filled out completely and it is not correct. Several areas were left blank. 2. On 6/8/26 at 11:30 AM, R53 was seated in the facility's dining room being assisted with eating lunch by facility staff. R53 was positioned in a high-back wheelchair with her feet resting on pedals. R53 did not display any behaviors. On 6/8/26 at 11:50 AM, R53 was reclined in a high-back wheelchair with her feet on pedals and was wheeled to her room by facility staff. R53 was quiet, confused with conversation and was not displaying any behaviors. On 6/9/26 at 2:30 PM, R53 was laying in bed in her room with her eyes closed. R53 was quiet and not displaying any behaviors. R53's current Care Plan, dated 4/6/26, documents R53 was admitted to the facility on [DATE] and has diagnoses including Alzheimer's Disease with late onset, Dementia without behavioral disturbance, Depression, Cognitive Communication Deficit, and Major Depressive Disorder without psychotic features. This same care plan documents R53 experienced falls on 1/3/26, 1/11/26, 1/13/26, 1/22/26, 1/24/26, 1/25/26, and 3/9/26 and a plan of care documenting I receive ABH (Ativan (antianxiety medication), Benadryl (antihistamine medication), and Haldol (antipsychotic medication) topical) cream for restlessness. Original start date 2/23/26. R53's Physician Order Sheet, dated 6/9/26, documents ABH cream, apply one milliliter to wrist or other hairless area three times a day for frequent restlessness and agitation. R53's Consent for Psychotropic Medications, dated 6/4/26, documents consent was obtained on 6/4/26 for ABH cream and is categorized as antianxiety medication. On 6/9/26 at 2:30 PM, V16 (Registered Nurse) and V17 (Certified Nursing Assistant) confirmed R53 has behaviors that are consistent with Dementia and Sundowners (confusion worsening in the evening). V16 stated (R53) has increased agitation and restlessness in the evenings. (R53) can get up and tries but she isn't strong enough to hold herself so she would fall. She just has a lot of confusion when she's anxious too. V16 verified that R53 did have several falls in the winter and now is in a high-back wheelchair with foot pedals when she's not in bed. V16 sated We recline her and that helps calm her down. V17 then stated (R53) is typically fine all day and sleeps late at night. It is the usual Sundowners symptoms, and she becomes more agitated and anxious in the evenings for second shift. (R53) is not aggressive towards other residents. On 6/10/26 at 10:35 AM, V2 (Director of Nursing) confirmed that R53 had several falls in January and stated (R53) gets restless and tries to stand up but she is not safe to stand. She has ABH cream now three times a day, I think just because of her being more restless. V2 then confirmed that behaviors of agitation and restlessness in a resident with dementia are normal for the disease process and are not psychotic in nature. 3. On 4/8/26 at 9:45 AM, R7 was sitting in a high back wheelchair asleep in the hallway. R7's Face sheet documents R7 admitted to the facility on [DATE]. R7's Physician Orders documents R7 received Aripiprazole 5 mg (milligrams) daily for Schizophrenia beginning 4/25/26, Seroquel 200 mg, two tablets at bedtime for Schizophrenia beginning 4/24/26, and Seroquel 50 mg daily for Schizophrenia. R7's Target Behaviors for use of Psychotropic medications include repetitive and anxious behaviors and complaints in R7s behavioral monitoring records. On 6/9/26 at 9:15 AM, V14 (Certified Nursing Assistant) stated that R7 does not have behaviors that affect himself or others and occasionally repeats things but does not exhibit other behaviors. On 6/9/26 at 9:25 AM, V3 (Assistant Director of Nursing/Infection Preventionist) stated that R7 does not have behaviors that she has observed. On 6/10/26 at 11:00 AM, V18 (Regional Nurse Consultant) stated that R7's documented target behaviors were not appropriate indicators to support the identified interventions or the use of psychotropic medications to treat a diagnosis of Schizophrenia for R7. V18 stated this should have been identified on R7's admission to the facility on 4/24/26. 4. R17's census line documents R7 admitted to the facility on [DATE]. R17's clinical record documents diagnoses Dementia without behavioral disturbance, Psychotic Disturbance, Mood disorder, Anxiety, and Depression. R7's Physician orders included Clonazepam 0.5 mg (Milligrams), two tablets three times daily for anxiety (ordered 10/6/25), and Quetiapine (Seroquel) 50 mg three times daily for dementia (ordered 1/26/26). Prior documentation also referenced use of Celexa and Trazodone for anxiety and depression per PASRR Level I completed 3/28/25. R7's Behavior Tracking records from 5/24/26 through 6/8/26 revealed no documented behavioral episodes. Target behaviors included increased anxiety, resistance to care, and wandering; however, no behaviors were observed or recorded during this period. On 6/9/26 at 10:00 AM, V14 (Certified Nursing Assistant) stated V14 had not observed any behaviors in R17 that were harmful to self or others. V14 reported the only behavior observed with R17 was talking to self. On 6/10/26 at 11:00 AM, V18 (Regional Nurse Consultant) stated the diagnosis of Dementia for a psychotropic medication is not an appropriate diagnosis and R17's targeted behaviors are not appropriate for the use of psychotropic medications.

Based on Interview and Record Review, the facility failed to ensure residents with a new psychiatric diagnosis or significant change in psychiatric status were reevaluated for a level two PASRR (Preadmission Screening and Resident Review) screening, for four of four residents reviewed for PASARR in the sample of 33.Findings include: The facility's Resident Assessment-Coordination with PASARR Program policy revised in 2025 documents The Social Services Director shall be responsible for keeping track of each resident's PASARR (Preadmission screening and resident review) screening status and referring to the appropriate authority. A resident who demonstrates increased behavioral, Psychiatric, or mood-related symptoms or any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level two resident review. Examples include A. a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where Dementia is not the primary diagnosis). B. a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. 1.R4 PASARR level screening, dated 8/11/24, documents at the time of R4's screening her diagnoses of mental health disorders was limited to Anxiety Disorder and the only medication R4 was taking for mental health was Aricept (Alzheimer's medication). This screening documents R4 did not require a level two evaluation at the time of screening and also documents If changes occur or new information refutes these findings, a new screen must be submitted. R4's current electronic medical record Diagnosis Summary documents R4 was diagnosed with Unspecified Dementia with severe Psychotic Disturbance on 1/28/26. R4's Medication Administration Record, dated 6/10/26, documents R4 was started on Risperidone 0.25 milligrams (antipsychotic medication) two times daily for Dementia with Psychosis on 1/20/26. On 6/10/26 at 11:00 AM, V18 (Regional Nurse Consultant) confirmed that R4 does not have a level two PASARR screening and was given a diagnosis that includes Psychosis in January 2026 when Risperidone was also initiated. V18 confirmed this change signifies a change in R4's psych status and a new PASARR screen should have been conducted. 2. R57's PASARR level one screening, dated 1/21/24, documents at the time of screening R57's only mental health diagnosis was Anxiety Disorder and the only medication R57 took for mental health was Lorazepam (anti-anxiety medication). This screening documents R57 did not require a level two evaluation at the time of screening and also documents If changes occur or new information refutes these findings, a new screen must be submitted. R57's current electronic medical record Diagnosis Summary documents R57 was diagnosed with Delusional Disorder on 2/21/24. R57's Consent for Psychotropic Medications, dated 11/3/25, documents that's R57 was started on Abilify 10 milligrams (Antipsychotic medication) on 11/3/25. On 6/9/26 at 2:30 PM, V16 (Registered Nurse) and V17 (Certified Nursing Assistant) confirmed R57 has had changes in her mental health since living in the facility. V17 stated (R57) does have hallucinations. She sees things not there. (R57's) increased in behaviors since moving her room in the facility. On 6/10/26 at 10:35 AM V2 (Director of Nursing) confirmed R57 had a new psych diagnosis and antipsychotic medication added after admission and stated she should have had a new PASARR screening completed at that time. 3. R7's Face sheet documents R7 admitted to the facility on [DATE]. R7's PASARR documentation revealed a Level I PASARR screening completed on 3/6/23 identified a diagnosis of schizophrenia and documented the use of Ativan for anxiety. A Level II PASARR evaluation was completed on 3/8/23. R7's Physician Orders documents R7 received Aripiprazole 5 mg (milligrams) daily for Schizophrenia beginning 4/25/26, Seroquel 200 mg, two tablets at bedtime for Schizophrenia beginning 4/24/26, and Seroquel 50 mg daily for Schizophrenia. R7's diagnosis list documents a diagnosis of Psychosis dated 1/12/24. R7's Behavioral monitoring records identified target behaviors that included episodes of repetitive and anxious behaviors and complaints. R7's Clinical record did not contain documentation of targeted behaviors for Schizophrenia. R7's clinical record failed to identify evidence that a new PASARR screening or referral for PASARR review was completed following R7's admission on [DATE] or following the identification and treatment of ongoing serious mental illness diagnoses and symptoms. The facility was unable to provide documentation of any PASARR evaluation completed after the Level II PASARR dated 3/8/23. On 6/9/26 at 9:15 AM, V14 (Certified Nursing Assistant) stated that R7 does not have any behaviors that affects himself or others. V14 stated sometimes R7 repeats things but he does not have other behaviors. On 6/8/26 at 9:45 AM, V19 (Social Services Director) confirmed V19 did not initiate a new level two PASARR when R7 admitted to the facility and did not know she needed too. On 6/10/26 at 10:30 AM, V1 (Administrator) confirmed that the facility should have initiated a Level two PASARR upon R7's admission to the facility because R7's last PASARR did not capture medications being used to treat Schizophrenia and did not contain the diagnosis of Psychosis. On 6/10/26 at 11:00 AM, V18 (Regional Nurse Consultant) stated that R7's target behaviors for the use of Seroquel were not appropriate behaviors for the use of this medication. V18 further stated the facility should have initiated a new PASARR on R7's admission to the facility. 4. R17's Census record documented admission to the facility on 4/2/26. R17's Medical Diagnosis List documented diagnoses including dementia with psychotic disturbance, mood disturbance, anxiety, and depression. Review of R17's PASRR Level I screening, completed on 3/28/25, documented the resident was receiving Celexa for anxiety and depression and Trazodone for anxiety and depression. R17's Physician Orders revealed an order dated 10/6/25 for Clonazepam 0.5 mg, two tablets by mouth three times daily for anxiety. R17's Physician Orders also revealed an order dated 1/26/26 for Seroquel 50 mg by mouth three times daily for dementia. On 6/10/26 at 11:00 AM, V18 (Regional Nurse Consultant) stated that R17's target behaviors for the use of Seroquel were not appropriate behaviors for the use of this medication. V18 further stated the facility should have initiated a new PASARR on R17's admission to the facility.

Based on Observation, Interview and Record Review, the facility failed to ensure residents with indwelling urinary catheters were provided drainage privacy bags for three of three residents (R1, R51, R52) reviewed for dignity in the sample of 33.Findings include: The facility's Catheter Care policy, dated 2025, documents It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Privacy bags will be changed out when soiled, with a catheter change or as needed.1. On 6/8/26 at 10:56 AM, R1 was sitting in his room in wheelchair directly in line with the entry to his room. R1's urinary catheter drainage bag was hanging below the wheelchair with copper-tinged urine draining into bag. R1's wheelchair did not have a privacy bag for the urine to be covered or hidden. R1 stated he has had a urinary catheter for several years and confirmed he eats his meals in the dining room typically.2. On 6/8/26 at 11:30 AM, R52 was eating lunch in the facility's dining room. R52's urinary catheter drainage bag was hanging below his wheelchair and contained a large amount of amber colored urine without any dignity covering or privacy bag.3. On 6/8/26 at 11:46 AM, R51 was self-propelling his wheelchair in the hallway. R5's urinary catheter bag was dangling below his wheelchair. An empty dignity bag was also under the wheelchair but R51's catheter bag was draining yellow urine and was not in a covered dignity bag.On 6/10/26 at 10:35 AM, V2 (Director of Nursing) confirmed that residents who have an indwelling urinary catheter should have their drainage collection bags covered with a privacy/dignity bag. V2 stated It should always be in place, for their own dignity and for other residents who likely do not want to see someone else's urine.

Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with facility policy and that residents only self-administer medications when a documented assessment and care plan approval were in place for one (R15) of one resident reviewed for self-medication administration in a sample of 33. Findings Include:The facility's Medication Administration policy, not dated, documents. Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines, 19. Observe resident consumption of medication.On 6/8/2026 at 9:00 AM, R15 was in bed, dressed, and awake, having just had staff assist her with her morning cares. R15 had her bedside table over her lap with her morning medications sitting in a clear medication lid on R15's bedside table.On 6/8/2026 at 9:30 AM, V8 (Licensed Practical Nurse) confirmed R15's medications in the clear medication lid was a cranberry tablet, Lyrica (anticonvulsant), Hydrocodone/Acetaminophen (pain medication), Duloxetine (antidepressant/nerve pain medication), Lasix (loop diuretic), Losartan (blood pressure medication), Tizanidine (skeletal muscle relaxant and a central alpha-2 adrenergic agonist), and Spironolactone (potassium sparing diuretic). R15's Medication Administration Record dated 6/10/26 documented that R6 was administered medications that morning. Cranberry 450 mEq (milliequivalent), Lyrica 75 mg (milligrams), Hydrocodone/Acetaminophen 5/325 mg, Duloxetine 30mg, Lasix 40 mg, Losartan 100 mg, Tizanidine 2mg, and Spironolactone 25mg.On 6/8/2026 at 10:00 AM, V1 (Administrator) stated these medications are not to be left in the resident's room, all medications are to be administered by a nurse, and the nurse is responsible for making sure the residents take the medications by watching them take the medications.R15's Electronic Medical Record does not contain documentation of a medication self-administration assessment, and the current care plan did not include documentation indicating R15 was approved to self-administer medications at bedside.

Based on interview and record review, the facility failed to ensure a written Bed Hold Notice was provided to the resident representative and documented in the medical record at the time of hospitalization for one (R59) of one residents reviewed for transfer and discharge requirements in a sample of 33 residents.Findings include: The facility's Bed Hold Notice policy revised in 2025 documents it is the policy of this facility to provide written information to the resident/resident representative regarding bed hold practices both well in advance, and at the time of a transfer for a hospitalization or a therapeutic leave. R59's Census line documents R59 transferred out of the facility to a local hospital on 5/5/26. On 6/10/26 at 9:45 AM, V1 (Administrator) stated V1 was unable to locate a Bed Hold Notice that had been sent with R59 to the hospital and was unable to find documentation indicating the Bed Hold Notice had been reviewed with the resident's Power of Attorney. During the same interview, the Regional Nurse Consultant (V18) confirmed that a Bed Hold Notice should have been provided and documented in the resident's electronic medical record. On 6/10/26 at 10:30 AM, V19 (Social Services Director) stated V19 does not handle bed hold notifications and did not communicate with R59's Power of Attorney regarding a Bed Hold Notice.

Based on Interview and Record review, the facility failed to ensure a resident with significant weight loss had a plan of care with measurable outcomes and interventions to address and prevent further weight loss for one of one resident (R4) reviewed for weight loss in the sample of 33.Findings include:The facility's Weight Monitoring policy, dated 2025, documents Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: identified causes of impaired nutritional status; reflect the residents personal goals and preferences, identify resident-specific interventions; time frame parameters for monitoring; updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new cause of nutritional-related problems are identified.R4's current electronic record Weight Summary documents on 3/10/26 R4's weight was 137.2 pounds and on 6/6/26, R4's weight was 123.4 pounds (a 10 percent weight loss in three months).R4's Nutritional Dietary progress note, dated 5/26/26 at 4:09 PM, documents R4's weight on 5/26/26 was 126 pounds. This note documents Noted diagnosis Dementia, Alzheimer's Disease. Will refer to psyche. Recommendation Medication Pass (supplement) 120 milliliters two times a day. Meal intake 51-100 percent. Continue weekly weights.R4's current Care Plan, dated 4/7/26, does not document that R4 has experienced significant weight loss, interventions or measurable goals to address the weight loss or R4's medication pass supplement initiation. On 6/10/26 at 10:35 AM V2 (Director of Nursing) confirmed R4 has suffered a significant weight loss and that her care plan does not reflect interventions or a plan of care to address the weight loss and stated the care plan should include R4's weight loss.

Based on observation, interview, and record review, the facility failed to ensure restorative services were provided for one (R9) of one resident reviewed for range of motion in a sample of 33. Findings Include:The facility's Restorative Nursing Programs policy, not dated, documents, It is the policy of this facility to provide maintenance and restorative services designated to maintain or improve a resident's abilities to the highest practicable level. Definition: Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. Policy Explanation and Compliance Guidelines: 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include a. Passive or active range of motion. 9. The restorative nurse is responsible for maintaining a current list of residents who require restorative nursing services, and for ensuring that all elements of each resident's program are implemented.On 6/8/2025 at 9:15 AM, R9 was in bed, dressed, with an indwelling catheter attached to the right side of the bed. R9 had bilateral contractures in his upper extremities and in his bilateral lower extremities. R9 was not interviewable.R9's Care Plan dated 6/10/2026 documents, Restorative: R9 has a diagnosis of Cerebral Palsy and has contractures to his bilateral upper extremities and bilateral lower extremities. R9 is at risk for further declines in range of motion, discomfort, and skin breakdown. Passive range of motion program initiated to maintain or improve range of motion to bilateral upper extremities and bilateral lower extremities, prevent skin breakdown, and reduce discomfort.R9's MDS (Medical Data Set) section GG dated 4/30/2026 documents R9 has an impairment on bilateral upper extremities and bilateral lower extremities, this same document states R9 is dependent on all cares.On 6/10/2026 at 11:00 AM, V13 (Restorative Nurse) stated R9 had not received passive range of motion (PROM) services since April 29, 2026. V13 indicated that R9 was scheduled to receive PROM services daily; however, these services had not been performed as required.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated, changed weekly, failed to provide a care for plan oxygen use, and failed to correctly identify oxygen use on MDS (medical data set) for one (R2) of one resident observed with oxygen therapy in the sample list of 33. Findings Include: The facility's Oxygen Administration policy, not dated, documents, Policy, oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and residents' goals and preferences. Policy explanation and compliance guidelines, 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the residents' assessment and orders, such as, but not limited to: a. The type of oxygen delivery system, b. When to administer, such as continuous or intermittent and/or when to discontinue, c. Equipment setting for prescribed flow rates, d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered e. Monitoring for complications associated with the use of oxygen. 5. b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.On 6/9/2026 at 11:16 AM, R2 was dressed in her high back wheelchair in the dining room. R2 had a nasal cannula with 3 liters of oxygen flowing. Tubing was not dated.R2's Physician's Orders dated 6/10/2026 documents, O2 (oxygen) 2-6 liters via nasal cannula continuously for SOB (shortness of breath).R2's Care Plan dated 6/10/2026 does not document a care plan for oxygen use.R2's MDS (medical data set) section O (Special Treatments, Procedures, and Programs) dated 4/17/2026 does not document the use of oxygen therapy.On 6/9/2026 at 11:20 AM, V1 (Administrator) confirmed there was no date on R2's oxygen tubing. V1 confirmed oxygen tubing should always be dated.

Based on interview and record review the facility failed to provide documentation of communication and collaboration with the dialysis facility regarding dialysis care and services for one (R8) of one resident reviewed for dialysis care in a sample of 33. Findings Include:The facility's Hemodialysis policy, not dated, documents, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. Purpose, the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Compliance Guidelines, 5. The licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility, b. Physician/treatment orders, laboratory values, and vital signs;, c. Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; d. Nutritional/ fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and identification of systems that may interfere with treatments; f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; g. Changes and/or declines in condition related to dialysis; h. The occurrence or risk of falls and any concerns related to transportation to and from dialysis facility.R8's Physician's Order sheet dated 6/10/2026 documents R8 has a diagnosis of End Stage Renal Disease.R8's Care Plan dated 6/10/2026 documents, I have need for hemodialysis related to renal failure at a renal dialysis facility on Monday, Wednesday, and FridayOn 6/10/2026 at 10:05 AM, V1 (Administrator) confirmed R8 does not have any written communication from the hemodialysis facility to communicate and report to facility nurse.

Based on observation, interview, and record review the facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for two of 15 residents (R5 and R56) reviewed for storage and labeling of medications in a sample of 33.Findings include:The facility's Labeling of Medications and Biologicals policy, undated, documents, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed.On 6/8/26 at 9:30 AM V7 (LPN/Licensed Practical Nurse) was standing at the Back Hallway medication cart. V7 opened the top drawer of the medication cart where multi-dose insulin injector pens were stored. This drawer contained R5's opened 1/3 full Lispro Insulin100 u/ml (units/milliliter) injector pen that was not labeled with the date when opened. V7 stated, All insulin pens should be labeled with the date opened. V7 verified R5's insulin pen was not labeled with the date opened.On 6/8/26 at 9:35 AM V8 (LPN) was standing at the Middle Hallway medication cart. V8 opened the top drawer of the medication cart where multi-dose insulin injector pens were stored. This drawer contained R56's opened 1/2 full Basaglar Insulin100 u/ml injector pen that was not labeled with the date when opened. V8 verified R56's insulin pen was not labeled with the date opened.

Based on observation, interview, and record review the facility failed to ensure the State Agency survey results were kept in a location readily accessible to residents and visitors and post a notice that survey results are available for review. This failure has the potential to affect all 59 residents residing in the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/8/26 and signed by V10 (Director of Operations), documents 59 residents reside within the facility.The Ombudsman Resident Rights for People in Long Term Care Facilities booklet, dated 11/2018, documents You have the right to see reports of all inspections by the Illinois Department of Public health from the last five years and the most recent review of your facility along with any plan that your facility gave to the surveyors saying how your facility plans to correct the problem.On 6/9/26 at 10:10 AM, during a resident group meeting, R34, R44, and R51 all denied being aware of a (state agency) survey binder or the availability to review those results. R34 confirmed she is the resident council president and stated she would like to know where the state agency survey binder is so that she can review the state inspection results.On 6/9/26 at 10:15 AM V12 (Activity Director) stated, I usually go over rights with the residents in resident council and I am not even aware of where the state survey inspection binder is located.On 6/9/26 at 10:25 AM, the facility's state agency survey inspection's binder was located on top of a four-drawer filing cabinet behind the receptionist desk and not freely accessible for residents to access. The facility's lobby area and hallways do not contain a posting about the state agency survey results being available for review.On 6/9/2026 at 10:30 AM, V12 confirmed the state survey binder was located behind the receptionist desk and stated she was not aware of any signage about the survey results binder location. V12 verified that residents would not be able to reach the state agency survey binder.

Based on observation, interview, and record review the facility failed to ensure the daily resident census and direct care staff posting was posted in an area accessible to residents and visitors. This failure has the potential to affect all 59 residents residing in the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 6/8/26 and signed by V10 (Director of Operations), documents 59 residents reside within the facility.The facility's Nurse Staff Posting Information policy, undated, documents, It is the policy of this facility to make nurse staffing information readily available in a readable format to residents, staff, and visitors at any given time. 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name. b. the current date. C. Facility's current resident census. d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. i. Registered Nurses. ii. Licenses Practical Nurses/Licenses Vocational Nurses. iii. Certified Nursing Aides. 2.The facility will post the Nursing Staffing Sheet at the beginning of each shift.On 6/8/26 at 9:40 AM a tour was done of the facility. During this tour the direct care staffing and census for 6/8/26 was not posted within the facility.On 6/8/26 at 9:45 AM V5 (Receptionist) verified the direct care staffing for 6/8/26 was not posted within the facility. V5 stated, (V1/Administrator) normally posts the staffing and has not gotten around to it yet.

Based on record review and interview, the facility failed to notify R2's Power of Attorney of R2's transfer to the hospital. This failure affects 1 of 1 resident reviewed for transfers. The facility policy, Notification of Changes, document: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. R2's EMR document R2's diagnosis included: Chronic Obstructive Pulmonary Disease, Chronic Bronchitis, Aphasia, Diabetes Mellitus Type II, Chronic Kidney Disease, Neurologic Neglect Syndrome, Hemiplegia Right Dominant Side, Atherosclerotic Heart Disease, Dependance on Supplemental Oxygen, Gastro-Esophageal Reflux Disease, Major Depressive Disorder, Anxiety Disorder, ST Elevation Myocardial Infarction, Hypertension, Hypercholesterolemia, Dysphagia, and Nicotine Dependence. R2's Progress noted document: [DATE] 9:28 p.m., Aide notified this nurse resident was unresponsive upon walking into room. This nurse assessed resident and began sternal rub with no response. VS/vital signs were taken; Manual BP/blood pressure 200/120, P/pulse 70, R/respirations 22, T/temperature 97.9, o2/oxygen 95, BS/blood sugar 138. Awaiting EMT [emergency medical technician]; [DATE] 1:17 a.m., Note Text: The nurse was informed via phone call that the patient has an intracranial hemorrhage (brain bleed) and is intubated for airway protection. He is awaiting transfer by air to Hospital (in adjacent town) for a higher level of care; and [DATE] 1:45 a.m., Note Text: This nurse answered phone and it was POA [power of attorney] of resident. She stated that she had a call from the [doctor] at [local hospital]and was told resident would be going into surgery due to a brain bleed'. She asked if I knew when resident was sent out because no one had informed her. I explained to her that I am unaware of the time this incident occurred, however I will go speak to the nurse who is on that floor. I spoke to the nurse and asked her to call residents POA to inform her of the incident.R2's Death Certificate document R2 died [DATE] From a Massive Intraventricular Hemorrhage due to Cerebrovascular Accident.On [DATE], at 2:40 p.m., V4 confirmed V4 failed to notify R2's POA that R2 was sent to the hospital. V4 stated, It was the end of the shift; I didn't call-it slipped my mind and it was an honest mistake because there was a lot going on.

Based on observation, interview, and record review the facility failed to provide immediate and adequate supervision after a resident's family member notified facility staff of a resident voicing R1 was going to escape out of his window and implement 15-minute visual checks as directed by the plan of care, for a cognitively impaired resident at risk for elopement for one (R1) of three residents reviewed for elopement in a sample of three. These failures resulted in (R1) a cognitively impaired resident with a previous elopement attempt from the facility, exiting the facility through his room window without staff knowledge or supervision on 9/3/25. (R1) was found across the road from the facility, a block away and close to active railroad tracks. These failures resulted in an Immediate Jeopardy.While the immediacy was removed on 9-11-25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring.Findings include:The facility's Elopements and Wandering Residents Policy, dated 2025, documents Policy: The facility ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Wandering: is random or repetitive locomotion that may be goal-directed (example: the person appears to be searching for something such as an exit) or not-goal directed or aimless. Elopement: Occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: A. Resident will be assessed for risk of elopement and unsafe wandering upon admission throughout their stay by the interdisciplinary care plan team. B. The interdisciplinary Team will evaluation the unique factors contributing to risk in order to develop a person-centered care plan. C. Interventions to increase staff awareness of the resident's risk, modify the residents' behaviors, or to minimize risk associated with hazards will be added to the resident's care plan and communicated to appropriate staff. D. Adequate supervision will be provided to help prevent accidents or elopements. E. Charge Nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.R1's current Face Sheet documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Alzheimer's Disease, Restlessness and Agitation, Essential Hypertension, Congestive Heart Failure, Peripheral Vascular Diseases, Acute Respiratory Failure with Hypoxia, Muscle Wasting/Atrophy, and Other Abnormalities of Gait and Mobility.R1's MDS (Minimum Data Set), dated 6/30/25, documents R1 is severely cognitively impaired.R1's Care Plan, dated 6/27/25 documents, Cognition/Disorientation: (R1) experiences disorientation to place, time. My memory is similarly impaired. I have problems with decision making, insight, logic, reasoning, social skills, judgment. This problem is related to my cognitive deficits.R1's Progress Notes, dated 8/22/25 and signed by V7/RN (Registered Nurse) documents, (V7) called (V11/R1's Physician Assistant) and reported that (R1) is not being cooperative to reenter the facility.R1's BIMS (Brief Interview of Mental Status) Assessments dated 8/22/25 and 9/4/25 documents R1 is cognitively impaired.R1's Elopement Evaluation, dated 8/22/25, documents R1 is at risk of Elopement. This same evaluation documents Focus: Risk for Wandering/Elopement Identified. Goal: (R1) will not leave facility unattended. Goal: (R1's) safety will be maintained.R1's Community Survival Skills, dated 8/22/25, documents, The resident sufficiently alert, oriented, and knowledgeable allowing him/her to be considered for independent outside pass privileges? No. This same form documents R1 requires supervision to be out in the community.R1's Care Plan, dated 9/3/25, documents Focus: Risk for Wandering/Elopement Identified (Date initiated 8/22/25). Interventions: 8/22/25 Wander guard to right ankle. 8/22/25 15-minute checks initiated, 9/3/24 (R1) was moved to memory care unit, 9/3/25 Engage (R1) in purposeful activity, 9/3/25 Provide clear, simple instructions, Provide reorientation to surroundings, environment.R1's 15-Minute Checks, dated 8/22/25 through 9/4/25, does not document any safety concerns under safety concerns located on the top right corner of the 15-minute checks.R1's Illinois Department of Public health First and Final Report, dated 9/4/25, documents on 9/3/25 R1 left the building through his room window. A phone call was made to the facility at 7:34 PM by Local Police Department. Staff located R1 at 7:41 PM.R1's Police Report, dated 9/3/25, documents at 7:28 PM V4/R1's Family Member notified the police department advising that R1 had taken off from the local nursing facility. At 7:34 PM the police department attempted to call the facility with no answer. At 7:38 PM the police department spoke with V7/RN. V7 advised they would look for R1. In the background while V7 had set the phone down the police officer could hear employees stating they could not locate R1. On 9/3/25 at 7:55 PM the police department called the facility and spoke with V7. V7 advised the police department they (facility staff) had located R1 a block away from the facility.R1's Progress Note, dated 9/3/25 and signed by V7/RN, documents, (V7) received a call from (Local Police Department) at 7:33 PM to report that (R1) may have left facility through (R1's) window. Per Local Police Officer, (R1) is on the phone with (V4/R1's Family Member). (V7) and another CNA (Certified Nursing Assistant) identified as (V5), went to (R1's) room and observed that (R1) was not in the room or personal bathroom. (V7) did observed window opened about 14 inches and screen was missing. (V5) went through window to search for (R1) and this nurse informed the other staff on the floor to begin a search in the building. This nurse called (V12/Sister Facility Administrator) at 7:38 PM to report that (R1) had possibly left from facility exiting through windows. (V7) went out the back door and searched in the parking lot. (V7) met up with (V5) and got into (V7's) car and began to search for (R1). (V7) went around the corner and one-half block from facility and observed (R1) walking with a steady gait carrying a plastic bag with a small number of belongings at 7:41 PM. (V7) parked vehicle and approached (R1). (R1) was observed by (V7) that (R1) was on the phone with (V4) when (V7) approached (R1). (R1) agreed to get into vehicle and (R1) was returned to the facility.On 9/8/25 at 10:32 AM R1 was on the memory care unit lying in his bed. R1 was unable to answer questions appropriately but did state he was able to continually work on sliding his window over little by little and hit the window stopper until it would move. R1 stated he would do it a little every day until he knew it was wide enough to get through. R1 denies knowing where he went when he got out the window, speaking to V4/R1's Family Member, or how he got back to the facility on 9/3/25.On 9/8/25 at 3:05 PM this surveyor and V1/Administrator watched the video surveillance on the hallway R1 resided the night R1 left the facility unattended through his window on 9/3/25. At 7:04 PM a male with a meal tray cart (identified as V10/Cook) was observed slightly opening R1's room and grabbing R1's meal tray. At 7:36 PM two females (identified as V5/CNA and V6/CNA) were observed running down the hallway towards R1's room. Once they arrived to R1's room, they both look into (R1's) room and immediately started running back up the hallway. At 7:46 PM two females (identified as V5 and V7) were observed walking (R1) back into the facility's back door. (R1) was observed to have pants, shoes, and a t-shirt on. V1/Administrator confirmed at this time that R1 was on 15-minute checks and that no staff was observed on the camera going in R1's room and checking on R1 every 15 minutes. V1 stated staff should have been implementing R1's 15-minute checks and staff should have physically gone into R1's room and checked on R1 when performing the 15-minute checks. On 9/9/25 at 1:50 PM this surveyor, V1/Administrator, V2/Interim Director of Nursing, and V20/Regional Director of operations watched the video surveillance on the hallway R1 resided the night R1 left the facility unattended on 9/3/25 between 6:00 PM and 7:00 PM. From 6:00 PM to 6:28 PM R1's door is slightly cracked open. At 6:29 PM R1 is observed opening his door and standing slightly in the doorway. At that time V6/CNA is observed walking down the hallway and goes into a different resident's room, next to R1's room. At 6:31 PM V5/CNA is observed going into R1's room to deliver R1's meal tray and then immediately leaves R1's room. From 6:32 PM to 7:00 PM no other staff is observed checking on R1. During this time V1/Administrator and V2/Interim Director of Nursing both verify that R1 was not physically being checked on every 15-minutes as implemented and should have been.On 9/9/25 at 6:38 PM V17/Prior Administrator-in-Training stated she was the administrator in the building when R1 attempted to elope from the facility on 8/22/25. V17 stated, After (R1) attempted to elope, (R1) was determined to be a risk for elopement, so I placed a wander guard on (R1) and implemented 15-minute checks. (R1) was ambulatory and when he attempted to elope on 8/22/25, staff could not get him to come back into the facility. (R1) walked at least five blocks across main roads and railroad tracks (with staff present) and then finally agreed to get back into the facility van and come back to the facility with us. (R1) is not safe to be out in the community by himself. On 9/8/25 at 11:59 AM V7/RN (Registered Nurse) stated, The past two weeks prior to (R1) getting out of the facility on 9/3/25, he was verbalizing that he wanted to go home, or he wanted to get out. (R1) never stated how he was going to get out and rarely ever left his room. I didn't start work on the night of 9/3/25 until around 6:00 PM. While I was getting report between 6:00 PM and 6:15 PM, (V4/R1's Family Member) had called the facility and told me (R1) was wanting to leave and said he was going to get out through his window. I then told (V5/CNA and V6/CNA) to keep an eye on him and check on him periodically through the night. I didn't go down and look at the window myself to see if he could get out at that point. The windows never open very far so I didn't figure there was any way he could get out through his window. Around 7:30 PM the police department called the facility. I was doing my medication pass and had gone to answer the phone. The police department told me that (V4) had called them and stated (R1) had left the building. I then yelled to (V5) and (V6) to go check on him. (V5) ran down to (R1's) room and noticed (R1) was not in the room. (V5) jumped out the window to go look for (R1) and I told staff to start looking for (R1), and then I went outside to look for (R1). I was in the back parking lot looking for (R1) when I saw (V5). We both jumped in my car to go look for (R1). There are railroad tracks, and he was half a block from the tracks when we found (R1). We found (R1) approximately a block away from the facility. (R1) agreed to get in the car and allowed me to drive him back to the facility. We arrived back to the facility around 7:45 PM. On 9/10/25 at 12:25 PM V22/LPN (Licensed Practical Nurse) stated, (V4/R1's Family Member) called on 9/3/25 while I was giving report to (V7/RN). It would have been approximately between 6:00 PM and 6:15 PM. (V4/R1's Family Member) told me (R1) and (V4) had been arguing and that (R1) had told (V4) he was going to escape out of his window tonight. I assured (V4) that we would keep an eye on (R1), I then reported what (V4) had stated to (V7). I did not go down to (R1's) room and assess (R1) or his window. I would have never thought (R1) would have been able to get through his window. The windows usually only open four inches. On 9/8/25 at 1:33 PM V4/R1's Family Member stated, (R1) had called me between 5:00 PM and 6:00 PM the night of 9/3/25 and told me he wanted to leave the facility and that he was almost able to get through his window. I got off the phone and called the facility and spoke to some nurse and told them what (R1) had stated. They told me they would check on (R1). Later, that night around 7:30 PM (R1) had called me and stated he had got out his window and was walking down the street. We then got disconnected so I attempted to call the facility and could not get anyone to answer so I called the local police department and let them know. I was told by the facility (R1) was found around a block away. On 9/8/25 at 11:01 AM V5/CNA stated she was working on the unit where R1 resided when R1 got out of the building on 9/3/25. V5 stated, I do remember (V7/RN) stating (V4/R1's Family Member) had called and told (V7) (R1) was saying he was going to escape out his window and to check on (R1) periodically. It was around 6:15 PM. I did not go down there immediately to check on (R1) but do know I had checked on (R1) at some time, I just don't remember the time. I did not frequently check on (R1) because his room is at the end of the hallway, and I didn't figure there was any way for (R1) to escape since (R1) would have to walk past the nurse's station or try to go through an exit (which he had a wander guard on). I did not look at (R1's) window though to see if he could get through it and should have. I worked with (V6/CNA) that night on that hallway. I was the one in charge of the 15-minute checks. I was not sure why (R1) was on the 15-minute checks. It does not say anywhere. If I had known, I would have kept a better eye on him. I do physically go down and check on (R1) when I am completing the 15-minute checks, but I may not get down there every 15 minutes. I did not know (R1) had attempted to get out of the facility prior to 9/3/25 or that he was a high-risk wanderer. I have never been trained on how to access a resident's care plan or if I even have access. V5 stated the night R1 got out his window on 9/3/25 V5 was sitting at the nurse's station charting. V7 had told V5 she received a phone call that R1 had escaped from the building. V5 reported she immediately ran down to R1's room, noticed R1's window was wide open and R1 was not in his room. V5 stated she immediately told V7 and V5 jumped through the window in an attempt to locate R1. V5 reported she did not notice anything broken on the window. V5 noticed V7 out in the parking lot and got in the car with V7 to go locate R1. V5 stated, I got in (V7's) car in the back parking lot. We took a right out of the parking lot. Then at the stop sign we took another right, then a left at the following stop sign. (R1) was observed to be right at the corner of that block by the stop sign about a half block from the railroad tracks. (R1) was cooperative and did get back in the car with us. On 9/8/25 12:30 PM V6/CNA stated she had no means to check on R1 that night and that she did not know anything about him. V6 denies V7/RN telling her to keep an eye on R1 or that R1 was wanting to escape on 9/3/25. V6 stated, I don't remember the last time I saw (R1) that night. I honestly didn't even know who (R1) was. On 9/8/25 at 2:05 PM V10/Cook stated, I didn't witness anything on 9/3/25 regarding (R1). They just said he was out of the building, and they were looking for him. I don't recall how (R1) got out his window. I would have picked up (R1's) room tray after 7:00 PM, but I don't even know if (R1) was in there. (R1) leaves his door cracked open and I just grabbed (R1's) tray. I didn't put my eyes on (R1). V10 stated no one interviewed him the night of 9/3/25 to ask if he had observed R1 that night or not.On 9/8/25 at 11:26 AM V3/Maintenance Director reports when he came into work on 9/4/25, V3 was told about R1 escaping out his window without staff knowledge. V3 stated, I went down to (R1's) room to observe his window. There are locks located on the bottom of the window seals, they only allow the windows to be open four inches. When I got down to his room, a visible scratch was observed along the bottom of the window seal, and the lock was observed to be next to the other four-inch lock. It looked like (R1) had been working on moving the bottom lock over for a while. I had to physically loosen the set screws and slide it back down to the original position and then set the screws again. I did put a new lock on it with the pointed screws. V3 stated it would have taken R1 a while to get the bottom lock to slide over, R1 would have had to use excessive force, and it was not something that could have happened quickly. V3 reported the only other way to get the bottom window locks to move is by utilizing a special tool to undo the locks. On 9/8/25 at 2:54 PM V1/Administrator stated she would have expected someone (a staff member) to immediately go down and assess R1's window at that time and then move R1 closer to the nurse's station to be monitored closely, after receiving a phone call that R1 was wanting to leave the facility and escape through his window. V1 stated, (R1) most definitely should have been checked on more than 15 minutes at that time if staff were aware he was voicing he was going to get out the window. The immediate jeopardy started on 9/3/25 when V7/RN and V22/LPN were made aware byV4/R1's Family Member of R1 voicing he was going to escape out his window and failed to immediately assess R1's window or immediately provide additional supervision. V1/Administrator and V20/Regional Director of Operations were notified of the Immediate Jeopardy on 9/10/25 at 11:35 AM. On 9/13/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: R1's care plan was reviewed and update to reflect current wandering and elopement risk by V23/MDS Coordinator on 9/4/25.V20/Director of Operations reviewed all resident's MDS sections E and associated CAA (Care Area Assessment) on 9/4/25 and all concerns identified were addressed or updated on 9/4/25.V24/Social Service re-evaluated residents at risk for wandering/elopement, including R1, using the elopement risk assessment tool in PCC (Point Click Care) on 9/4/25.V1/Administrator in serviced all nursing staff on wandering, elopement, and resident safety on 9/4/25 and continued in-serving staff on leave by their next shift. R1 assessed for Memory Care Unit and moved to a room on Memory Care for safety. R1's window faces an interior courtyard. V1/Administrator, V2/Interim Director of Nursing, V20/Director of Operations, V24/Social Service Director, V20/Regional Director of Operations assessed all residents to determine if other residents should be placed in the memory care unit on 9/4/25.R1's room with the damaged window was repaired on 9/4/25 by V3/Maintenance Director.V7/RN completed a head-to-toe assessment on R1 upon his retorn to his room on 9/3/25.On 9/4/25 V25/Chief Nursing Officer audited all residents care plans and diagnosis to determine if any other resident needed to be placed in the locked dementia unit, needed a wander guard, or needed more frequent checks. On 9/4/24 V3/Maintenance director verified all window safety measure in place to ensure that window cannot be opened to a measurement where a resident can climb out the window. V3/Maintenance Director was in serviced by V20/Regional Director of Operation regarding the placement of these window safety measures, and to perform daily checks that the window safety measures are still in place and working properly. On 9/4/25 V1/Administrator in-serviced all staff regarding window safety measures and to alert maintenance or management if they identify a window safety component to be broken, out of place or missing. On 9/4/25 V1/Administrator in-serviced regarding safety and supervision policies and procedures, including but not limited to following resident care plan interventions pertaining to Wandering and Elopement (example: more frequent checks). On 9/4/25 V1/Administrator in-serviced all staff regarding the facility's Elopement Policies and Procedures. On 9/4/25 all staff involved regarding if a resident should be placed in the locked memory care unit, have a wander guard, or need more frequent checks, were in serviced by V20/Regional Director of Operation regarding the assessing the resident collaboratively to make the determination, and relaying to the staff why the determination was made.V20/Regional Director of Operations reviewed the Elopement and Wandering Residents Policy and Procedure with Interdisciplinary Team and V26/Medical Director on 9/4/25.V24/Social Service Director audited new admissions for elopement risk and ensure appropriate interventions were in place on 9/11/25.On 9/4/25 V23/MDS Coordinator audited all completed MDS's to ensure the care plan reflects needs/concerns identified in the CAA's.On 9/4/25 V20/Director of Operations updated all new hire packets with education regarding wandering, elopement, resident safety, and window safety. There have been no new hires since 9/4/25.On 9/4/25 V20/Regional Director of Operations held a QAPI meeting to review and interpret all audit findings, review all procedures, review investigation, review root cause analysis and all facts surrounding the incident IDT team and V26/Medical Director.On 9/4/25 V1/Administrator in-serviced all staff regarding following resident care plan pertaining to resident safety and supervision (Example: conducting 15-minute checks and looking for Elopement and Wandering behaviors). V1/Administrator and V20/Regional Director of Operations conducted an Audit on 9/5/25 and 9/12/25 regarding all policies and procedures pertaining to wandering and elopement, including resident care plans pertaining to wandering and elopement, weekly. Will continue weekly for weeks and then monthly for three months. On 9/11/25 V1 in-serviced all clinical staff on where to find/access the resident care plans. (Staff will not be allowed to return to work until education is completed. On 9/11/25 V1 provided education to clinical staff on the PCC dashboard identifying residents at risk, the intervention, and the reason for the intervention. (Staff will not be allowed to return to work until education is completed. On 9/11/25 V1 provided education to clinical staff on the need for safety interventions (Such as 15-minute checks-requiring actual visualization of resident identified with need for additional safety measures in place). Staff will not be allowed to return to work until education is completed. On 9/4/24 V20/Director of Operations reviewed/modified current policies to ensure appropriate procedures are in place to prevent harm/potential harm with IDT team and V26/Medical Director.

Based on observation, interview and record review the facility failed to ensure one resident (R4) was free of significant medication error of three residents reviewed for medications. This failure caused R4 to be visibly uncomfortable and anxious. The Facility's undated Medication Errors policy documents Medications errors, once identified will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. Resident's condition: if the resident's condition requires rigid control, such as strict intake and out put measurement, daily weights, or monitoring of lab values. b. Drug category: if the medication is from a category that usually requires the resident to be titrated to a specific blood levels such as a medications with a narrow therapeutic index. c. Frequency of Error: if an error is occurring repeatedly such as an omission of a resident's medication several times. The Facility's undated Medication Errors policy documents the facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. medication administered not in accordance with the prescriber's order. Examples include but not limited to: 1. Incorrect dose, route of administration, dosage form, time of administration. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. b. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. c. Document actions taken in the medical record. d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. R4's Medical Record documents that she was admitted to the facility on [DATE] with diagnosis to include but not limited to left below the knee amputation, spinal stenosis, anxiety and depression.On 8/27/25 at 10:50 AM R4 was alert and answered questions appropriately. R4 was lying bed, appeared pale, her hairline was damp and she seemed to be breathing rapidly. R4 stated she was in pain, stated The nurse knows, she hasn't brought my morning medicine yet. Sometimes it takes these agency nurses longer. On 8/27/25 at 10:55 AM V13 (Registered Nurse) confirmed that R4 had not gotten her scheduled 8:00 AM morning medications. V13 stated I'm agency when asked if there was a reasoning or incident causing R4's medications to be late. R4's Medication Administration Record dated August 2025 documents that on 8/27/25, R4's scheduled 8:00 AM medications were administered at 11:22 AM by V13 (Registered Nurse).R4's Medication Administration Record dated August 2025 documents R4's scheduled 8:00 AM medications were: Cranberry (vitamin) 450 mg (milligrams), Duloxetine 30 mg for depression, Lasix (diuretic) 40 mg, Hydrocodone (narcotic) 5-325 mg, Losartan Potassium (anti-hypertensive) 100 mg, Miralax ((laxative)17 Grams, multivitamin 1 tablet, oxybutynin (anticholinergic) 10 mg, Pregabalin (for pain) 75 mg, Spironolactone (diuretic) 25 mg, Tizanidine (muscle relaxer) 2 mg. R4's Medication Administration Record dated August 2025 documents that R4 has a scheduled 12:00 PM dose of Pregabalin (for pain) 75 mg also. R4's noon dose of Pregabalin was not signed out at all. R4's Medication Administration Record dated August 2025 documents that on 8/19/25 R4's scheduled 5:00 PM medications were given at 9:20 PM by V15 (Licensed Practical Nurse).R4's Medication Administration Record dated August 2025 documents R4's scheduled 5:00 PM medications were: Pregabalin (for pain) 75 mg and Tizanidine (muscle relaxer) 2 mg. R4's Medical Record did not contain any documentation regarding why R4's medications were not given at the scheduled time or what R4's condition was on 8/19/25. V15 (Licensed Practical Nurse) was not reachable during the survey to answer questions. R4's Medication Administration Record dated August 2025 documents that on 8/11/25 R4's scheduled 8:00 AM medications were given by V5 (Registered Nurse) at 10:34 AM. R4's Medication Administration Record documents that on 8/18/25 R4's scheduled 8:00 AM medications were given by V5 (RN) at 10:44 AM. Neither date (8/11/25 or 8/18/25) document R4's scheduled 12:00 PM dose of Pregabalin as given. R4's Medical Record did not contain any documentation regarding why R4's medications were not given at the scheduled time or what R4's conditions was on 8/11/25 or 8/18/25.On 8/29/25 at 9:40 AM V5 (RN) stated One of two things happened, either (R4) slept in and I gave the medications late, or I gave (R4)'s medications on time but just did not sign them out until later. V5 stated she did not remember specifically. V5 confirmed that there was no documentation as to which possible reason was what occurred on either date. V5 stated that she did not notify the doctor or any other staff member of what occurred. I might have passed it on verbally to the next shift, I'm not sure. V5 (RN) stated that if she gave R4's Pregabalin late for the 8:00 AM dose she would have waited on giving the scheduled 12:00 PM dose until 1:30 PM or 2:00 PM she wasn't sure. V5 confirmed there is no way of telling based on the documentation in R4's medical record what happened on either day.On 8/29/25 at 10:15 AM Dr. [NAME] did acknowledge that she had chronic pain and that it was usually controlled with her scheduled medications as far as he knew.

Based on observation, interview and record review the facility failed to ensure one resident (R4) was free of significant medication error of three residents reviewed for medications. This failure caused R4 to be visibly uncomfortable and anxious. The Facility's undated Medication Errors policy documents Medications errors, once identified will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: a. Resident's condition: if the resident's condition requires rigid control, such as strict intake and out put measurement, daily weights, or monitoring of lab values. b. Drug category: if the medication is from a category that usually requires the resident to be titrated to a specific blood levels such as a medications with a narrow therapeutic index. c. Frequency of Error: if an error is occurring repeatedly such as an omission of a resident's medication several times. The Facility's undated Medication Errors policy documents the facility will consider factors indicating errors in medication administration, including, but not limited to, the following: a. medication administered not in accordance with the prescriber's order. Examples include but not limited to: 1. Incorrect dose, route of administration, dosage form, time of administration. If a medication error occurs, the following procedure will be initiated: a. The nurse assesses and examines the resident's condition and notifies the physician or health care practitioner as soon as possible. b. Monitor and document the resident's condition, including response to medical treatment or nursing interventions. c. Document actions taken in the medical record. d. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident or occurrence report. R4's Medical Record documents that she was admitted to the facility on [DATE] with diagnosis to include but not limited to left below the knee amputation, spinal stenosis, anxiety and depression.On 8/27/25 at 10:50 AM R4 was alert and answered questions appropriately. R4 was lying bed, appeared pale, her hairline was damp and she seemed to be breathing rapidly. R4 stated she was in pain, stated The nurse knows, she hasn't brought my morning medicine yet. Sometimes it takes these agency nurses longer. On 8/27/25 at 10:55 AM V13 (Registered Nurse) confirmed that R4 had not gotten her scheduled 8:00 AM morning medications. V13 stated I'm agency when asked if there was a reasoning or incident causing R4's medications to be late. R4's Medication Administration Record dated August 2025 documents that on 8/27/25, R4's scheduled 8:00 AM medications were administered at 11:22 AM by V13 (Registered Nurse).R4's Medication Administration Record dated August 2025 documents R4's scheduled 8:00 AM medications were: Cranberry (vitamin) 450 mg (milligrams), Duloxetine 30 mg for depression, Lasix (diuretic) 40 mg, Hydrocodone (narcotic) 5-325 mg, Losartan Potassium (anti-hypertensive) 100 mg, Miralax ((laxative)17 Grams, multivitamin 1 tablet, oxybutynin (anticholinergic) 10 mg, Pregabalin (for pain) 75 mg, Spironolactone (diuretic) 25 mg, Tizanidine (muscle relaxer) 2 mg. R4's Medication Administration Record dated August 2025 documents that R4 has a scheduled 12:00 PM dose of Pregabalin (for pain) 75 mg also. R4's noon dose of Pregabalin was not signed out at all. R4's Medication Administration Record dated August 2025 documents that on 8/19/25 R4's scheduled 5:00 PM medications were given at 9:20 PM by V15 (Licensed Practical Nurse).R4's Medication Administration Record dated August 2025 documents R4's scheduled 5:00 PM medications were: Pregabalin (for pain) 75 mg and Tizanidine (muscle relaxer) 2 mg. R4's Medical Record did not contain any documentation regarding why R4's medications were not given at the scheduled time or what R4's condition was on 8/19/25. V15 (Licensed Practical Nurse) was not reachable during the survey to answer questions. R4's Medication Administration Record dated August 2025 documents that on 8/11/25 R4's scheduled 8:00 AM medications were given by V5 (Registered Nurse) at 10:34 AM. R4's Medication Administration Record documents that on 8/18/25 R4's scheduled 8:00 AM medications were given by V5 (RN) at 10:44 AM. Neither date (8/11/25 or 8/18/25) document R4's scheduled 12:00 PM dose of Pregabalin as given. R4's Medical Record did not contain any documentation regarding why R4's medications were not given at the scheduled time or what R4's conditions was on 8/11/25 or 8/18/25.On 8/29/25 at 9:40 AM V5 (RN) stated One of two things happened, either (R4) slept in and I gave the medications late, or I gave (R4)'s medications on time but just did not sign them out until later. V5 stated she did not remember specifically. V5 confirmed that there was no documentation as to which possible reason was what occurred on either date. V5 stated that she did not notify the doctor or any other staff member of what occurred. I might have passed it on verbally to the next shift, I'm not sure. V5 (RN) stated that if she gave R4's Pregabalin late for the 8:00 AM dose she would have waited on giving the scheduled 12:00 PM dose until 1:30 PM or 2:00 PM she wasn't sure. V5 confirmed there is no way of telling based on the documentation in R4's medical record what happened on either day.On 8/29/25 at 10:15 AM Dr. [NAME] did acknowledge that she had chronic pain and that it was usually controlled with her scheduled medications as far as he knew.

Based on observation, interview, and record review the facility failed to prevent resident physical abuse after (R1) displayed increased agitation and aggression and no interventions were implemented to prevent potential resident abuse for one (R3) of 23 residents reviewed for abuse in the sample of 26. These failures resulted in R1 physically shoving a trash can in R3's face and R3 sustaining a bleeding laceration to upper and lower lips. These failures have the potential to affect all 19 residents (R2, R3, R9 through R25) residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy that began on 4/13/25. While the Immediate Jeopardy was removed on 5/13/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings include: The Facility Abuse, Neglect and Exploitation Policy, reviewed/revised 2/1/25, documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. The facility will develop and implement written policies and procedures that: prohibit ad prevent abuse, neglect, bribery, and exploitation of residents and misappropriation of resident property; Establish policies and procedures to investigate any such allegation; include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and establish coordination with the QAPI (Quality Assurance and Performance Improvement) program. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state agency and other officials in accordance with state law. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, bribery, misappropriation of resident property, and exploitation that achieves: The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which lead to conflict or neglect. The facility will make an effort to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; and revision of resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. The Facility Behavioral Health Services Policy, not dated, documents, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being. The facility will ensure that a resident who, upon admission was not assessed or diagnosed with a mental or psychosocial adjustment difficulty or a documented history of trauma and/or PTSD (Post Traumatic Stress Disorder) does not develop patterns of decreased social interaction and/or increased withdraw, angry, or depressive behaviors while residing in the facility. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Staff will: obtain history from medical records, the resident, and as appropriate the resident's family and friends, regarding mental, psychosocial, and emotional health; monitor closely for expressions or indications of distress; evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable; utilize MDS (Minimum Data Set) and care area assessments; assess and develop a person-centered care plan for concerns identified in the resident's assessment; share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis; accurately document the changes, including the frequency of occurrences and potential triggers in the resident's record; ensure appropriate follow-up assessment, if needed; discuss potential modifications to the care plan; evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident. The resident, and as appropriate the resident's family, are included in comprehensive assessment process along with the interdisciplinary team and outside sources, as indicated. The care plan shall: have interventions that person-centered, evidenced-based, culturally competent, trauma-informed, and in accordance with professional standards of practice; provide for meaningful activities which promote engagement and positive, meaningful relationships; be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. R1's Admission record documents R1's date of admission to the facility was 2/22/25 and his diagnoses included: Cerebral Infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety, Depression, unspecified and Gastro-Esophageal Reflux Disease without Esophagitis. R1's Minimum Data Set (MDS) assessment, dated 2/28/25, documents R1 has a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment and documents R1's transfers/ambulation as supervision or touching assistance. R1's progress notes dated 3/30/25, 3/31/25, 4/1/25, 4/2/25, 4/7/25, 4/12/25, 4/13/25 and 4/15/25 document behaviors of increased wandering, suspicion, agitation, and combativeness. R1's abuse investigation, Final Five-Day Report, dated 4/13/25, documents that R1 became agitated when staff attempted to redirect R1 from another resident room. V22 (Certified Nursing Assistant/CNA) was walking R1 to his room when R1 grabbed a handheld radio from nurse's station desk. V22 (CNA) asked R1 to give her the radio and R1 refused continuing to walk down the hall. V22 (CNA) noted R2 sitting in the hallway and moved her out of R1's way for safety. V22 (CNA) continued to redirect R1 at which time he threw the handheld radio in the hallway striking R2 in the back of the head. R2 assessed for injury with none sustained. Report also stated that R1 was sent to emergency room for a psychiatric evaluation. R1 returned to the facility later that evening with no new orders and facility initiated frequent checks with increase in agitation. No documentation of frequent checks noted in R1's medical record. On 5/7/25, V9 (LPN), V11 (LPN), and V8, V23, and V25 all Certified Nursing Assistants (CNA) stated that they were not educated on increasing supervision on R1 after altercation with R2. On 5/7/25 at 2:12pm, V8 (Certified Nursing Assistant/CNA) stated, I saw that R1 was agitated and (R1) grabbed a walkie talkie (handheld radio) off the nurse's station desk. We (V8, V9, V22) tried to get it from R1, but he got more agitated and kept walking down the hall, so we let him be. Next thing I (V8) know I heard Ow and saw the walkie talkie (handheld radio) hit R2 in the back of the head. R2 was sitting in her wheelchair by room [ROOM NUMBER] with her back to R1 who had just gotten by room [ROOM NUMBER]. I (V8) went and got the nurse (V9/Licensed Practical Nurse) and V9 took over after I told her what I saw. I (V8) had separated R1 from R2 by taking R1 to his room and then I left because my shift was over. On 5/7/25 at 2:15pm, V9 (Licensed Practical Nurse/LPN) stated, I was working when R1 grabbed the walkie (handheld radio) off my cart by the nurse's station. R1 was agitated that day. I (V9) did not know what had happened until V8 (CNA) told me R1 had threw the walkie (handheld radio) and it hit R2. I went and assessed R2 and R2 had no visible injuries. R1 was redirected away from R2. I don't think R1 threw the walkie (handheld radio) at R2 on purpose, I think R1 threw the walkie (handheld radio) to just get rid of it. On 5/8/25 at 3:30pm, V22 (Certified Nursing Assistant/CNA) stated, R1 was agitated prior to the incident with R2. R1 grabbed a walkie talkie (handheld radio) off the nurse's station, and I (V22) tried to get it from him, but he just got more agitated, so the nurse (V9/Licensed Practical Nurse) told me to leave R1 alone. I (V22) followed R1 down the hallway to redirect him and noted R2 was sitting in her wheelchair in the way, I moved R2 so R1 could get past to go to his (R1) room. As R1 went around the corner R1 tossed the walkie talkie (handheld radio) and it hit R2 in the back of the head. I don't think he (R1) was aiming at R2; I think R1 threw the walkie (handheld radio) to get rid of it. R1's Health Status note dated 4/17/25, documents, R1 very agitated before supper. R1 was walking down the hall when this nurse (V9/Licensed Practical Nurse) heard what sounded like trash can being thrown down the hallway. This nurse went to investigate where noise came from and R1 was standing in hallway and trash can was sitting on the floor in front of R1. Another resident (R3) was sitting in his doorway. R1 then came running at this nurse (V9) trying to hit nurse. R1 then turned around and tried to run after resident (R3) sitting in his doorway. The nurse (V9) then looked at the other resident (R3) and he (R3) had a bloody lip. The other resident (R3) states that resident (R1) hit him. Resident (R1) was trying to speak with nurse (V9), but his words were making no sense. This nurse (V9) tried to get resident (R1) to go into his room to try and calm him (R1) down but very resistive and combative. Not able to redirect. MD (doctor) notified. Nurse Manager notified and administrator notified. Resident (R1) then sent to (local hospital emergency department) to eval and treat. R1's abuse investigation, Final Five-Day Report, dated 4/17/25, documents that R1 and R3 were involved in a physical altercation in the hallway. V9 (Licensed Practical Nurse/LPN) heard a waste basket tumble across the floor. V9 (LPN) noted R3 sitting in the doorway to his room and R1 standing a few feet away. R3 had a laceration to his lip and stated R1 hit him. R1 and R3 were separated. R3 was given first aid and R1 was sent to emergency department for further evaluation. Report also documents R3 was identified by a witness (V17/R26's spouse) as the initiator. V17's witness statement documents that R3 yelled at R1 and threw the trash can at R1 when he was walking toward R3. R1 threw trash can back at R3 and R3 threw it back at R1 again. R1 then picked up trash can and pushed it into R3's face, open side up, causing injury. Report also documents facility took the following action: Power of Attorney and Physician notified, R1 sent to emergency department for evaluation and then transferred to psychiatric hospital for further evaluation and treatment. R1's care plan will be updated per physician recommendations. R3's care plan updated, and staff educated on communication needs, redirection strategies and monitoring for signs of agitation. On 5/7/25 V9 (LPN), V11 (LPN), and V8, V23, and V25 all Certified Nursing Assistants (CNA) stated that they were not educated on communication, redirection strategies or monitoring for signs of agitation after altercation with R3. On 5/7/25 at 3:00pm, V9 (Licensed Practical Nurse/LPN) stated R1 became increasingly agitated during a conversation with V9. In R1's agitated state and without staff member supervision, R1 walked down the hallway out of V9's or any other staff members' view. V9 then reported hearing what sounded like a trash can hitting the floor and went to investigate. V9 reports seeing R1 standing in the hallway directly facing R3, who was in the doorway of his (R3) room. A trash can was noted on the hallway floor. V9 noted bleeding to R3's mouth. R3 reported to V9 that R1 had hit him with the trash can. V9 stated she felt the altercation was intentional because R1 and R3 do not seem to like each other, they make rude comments to each other all the time. On 5/8/25 at 3:20pm, V11 (Licensed Practical Nurse/LPN) stated, R1 and R3 do not like each other, they make rude comments to each other and I'm surprised that their (R1, R3) rooms are still next to each other after their altercation. On 5/6/25, 5/7/25, and 5/8/25 tour of the facility conducted. R1 and R3's rooms observed to be next to each other, R1 in room [ROOM NUMBER] and R3 in room [ROOM NUMBER]. On 5/7/25 at 1:30pm, V11 stated that there are no specific individualized interventions to use for any of the residents on the dementia unit, we try what we can and utilize our dementia training but that's about it. R1's current care plan documents a behavior care plan for aggression initiated on 4/29/25, no previous behavior care plan for aggression in medical record. R3's current plan of care documents, Behaviors: I (R3) demonstrate verbally abusive behavior when agitated such as use of profanity/demeaning statements; racial, ethnic, religious, gender slurs; physically abusive behavior when agitated; attempting to push, shove, scratch, hit, slap, kick, grab, or otherwise harm another person related to ineffective coping skills, poor verbal skills and inability to express self, and dementia. Interventions include Ask (R3) to calmly explain what is causing this upsetting behavior; If talking to (R3) is not successful in stopping the behavior, try to take (R3) to a quiet area, away from other individuals, and intervene by speaking calmly and professionally in a soft tone of voice. Staff should avoid raising own voice, since this tends to make a resident more upset and may cause the situation to escalate. R3's current care plan also includes: Behaviors: I (R3) display behavioral symptoms such as verbal and physical aggression due to dementia diagnosis. 4/17/25: (R3) became physically aggressive with another resident throwing a trash can at him. Interventions include: 4/17/25: Staff education provided to monitor for signs of agitation and re-direct away from others if agitation is noted; conduct an evaluation of the behavioral symptoms to determine what strengths or abilities and needs are communicated via behavior; use interventions that address the abilities and needs reflected in the specific symptom: (i.e. rummaging may be an indicator that s/he needs to be busy and work with their hands). On 5/7/25 at 1:41pm, V19 stated she is responsible for aggression assessments when residents are admitted to facility and then initiates the care plans from that assessment. V19 verified that R1's behavior care plan was not initiated until 4/29/25 when he returned from inpatient psychiatric stay. On 5/8/25 at 8:30am, V1 (Administrator in Training/AIT) stated that the facilities dementia unit just opened mid-April and verified that there are system failures regarding care plans, documentation, and communication on interventions with the floor staff. On 5/8/25 at 11:00am, V21 (Chief Nursing Officer/CNO) stated that V16 (Registered Nurse/RN/Former Director of Nursing) was told to educate the floor staff and initiate increased supervision of R1 with documentation of the supervision after R1's incident involving R2 but verified it was not done. R2's Admission Record documents R2's date of admission to the facility was 4/2/25 and her diagnoses included: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Anemia, Diabetes, Depression, Anxiety Disorder, Hypertension, and Insomnia. R2's Minimum Data Set (MDS) assessment, dated 4/8/25, documents R2 has a Brief Interview for Mental Status (BIMS) score of 8/15, indicating severe cognitive impairment. On 5/8/25 at 11:00am, R2 stated she does not remember being hit and feels safe. R2 also stated, If anyone was mean to me, I'd, (R2 shook her fist) then laughed. R3's Admission Record documents R3's date of admission to the facility was 3/3/25 and his diagnoses included: Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Unspecified Dementia, unspecified severity, with agitation, Iron deficiency and Hypertension. R3's Minimum Data Set (MDS) assessment, dated 3/10/25, documents R3 has a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment. R3's progress notes dated 4/13/25, 4/17/25, 4/23/25, 4/30/25, and 5/3/25 document behaviors of yelling, cussing, hitting, kicking, and biting during cares by staff. On 5/9/25 at 10:00am, R3 stated he does not remember the altercation with R1. R3 shook his head no and propelled wheelchair away from surveyor and down the hall. V1 (Administrator in Training/AIT) and V7 (Regional Director of Operations/Administrator) were notified of the Immediate Jeopardy on 5/13/23 at 12:55pm. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 5/13/25 the DON/Director of Nursing, Social Services Director and designee assessed all residents in memory care to determine their level of risk with the Abuse assessments and Aggressive behavior assessment. 2. On 5/08/25 15-minute checks for R1 changed to 1:1 supervision 3. R1 was evaluated by V13's team with inpatient hospital evaluation/treatment and review of medications from 4/17/25 through 4/28/25. 4. On 5/13/25 R1's care plan updated with individualized interventions for aggressive behaviors. 5. On 5/13/25 R1 is not to be seated by other residents with activities, dining etc. when agitated 6. On 5/13/25 Social Services Director, DON and Administrator re-educated staff on Abuse/Neglect & Exploitation policy and Abuse Prevention. 7. All Agency staff being in-serviced on Abuse/Neglect & Exploitation policy and Abuse Prevention prior to start of next shift. 8. On 5/13/25 R1's abuse and aggression assessments completed/updated. 9. On 5/13/25 R1's care plan reviewed and revised by facility interdisciplinary team and revisions and interventions communicated to front line staff caring for R1. 10. On 5/13/25 abuse policies reviewed/revised to include resident to resident altercations. 11. On 5/13/25 abuse investigation procedures and documentation process reviewed/revised, and Education provided to all staff. 12. DON and designee educated Nurse Aids and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director/MDS/Minimum Data Set Coordinator or designee and care plans to be updated as indicated. Staff will be educated on new interventions either verbally or in writing by Care Plan Coordinator or designee. 13. On 5/13/25 an emergency QAPI (Quality Assessment Performance Improvement) meeting was held to develop and implement plans to prevent further resident abuse.

Based on observation, interview, and record review the facility failed to perform pressure ulcer risk assessments as directed by the facility's policy, failed to develop and implement pressure relieving interventions, failed to develop pressure ulcer care plans, and failed to assess a pressure ulcer weekly or obtain a treatment once a pressure ulcer was identified for three of three residents (R1, R2, and R3) reviewed for pressure ulcer development in the sample of four. These failures resulted in R1's left hip stage one pressure ulcer being left untreated and deteriorating from a stage one pressure ulcer to a stage four pressure ulcer that required surgical debridement and R2 developing an unstageable facility-acquired necrotic (dead tissue) pressure ulcer to the right heel. Findings include: The facility's Pressure Injury Prevention and Management policy dated 02/2023 documents, The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Pressure Ulcer Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment using the designated tool, on all residents upon admission/re-admission, weekly times for weeks, then quarterly or whenever the resident's condition changes significantly. b. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Example of risk factors include, but are not limited to: Impaired/decreased mobility and decreased functional ability; co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus; drugs such as steroids that may affect healing; impaired diffuse or localized blood flow; resident refusal of some aspects of care and treatment; cognitive impairment; exposure of skin to urinary and fecal incontinence; under nutrition, malnutrition, and hydration deficits; the presence of a previously healed pressure injury. d. Assessments of pressure injuries will be performed by a licensed nurse and documented on the designated form. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS (Minimum Data Set). 4. Interventions for prevention and to promote healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. c. Evidence-based interventions for preventions will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to redistribute pressure (such as repositioning, protecting, and offloading heels), provide appropriate pressure-redistributing, support surfaces, provide non-irritating surfaces, and maintain or improve nutrition and hydration status. d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with interventions will be documented in the weekly summary charting. 5. Monitoring b. The attending physician will be notified of the presence of a new pressure injury upon identification, the progression towards healing, or lack of healing, of any pressure injuries weekly, and any complications as needed. 6. Modification of interventions a. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include changes in resident's degree of risk for developing a pressure injury, new onset or recurrent pressure injury development, lack of progression towards healing, resident non-compliance, and changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 was a [AGE] year-old with severely impaired cognition that required moderate assistance for rolling left and right and was completely dependent on staff for transfers. This same MDS documents R1 did not have any pressure ulcers on admission and was not on a turning and re-positioning program. R1's Progress Notes document R1 passed away on 3-26-24. R1's Medical Record dated 3-8-24 (admission to the facility) through 3-26-24 (date of R1's death) does not include an assessment of R1's pressure ulcer risk. R1's Progress Notes dated 3-20-24 and signed by V6 (RN/Registered Nurse) documents, Assessed (R1's) left hip for wound. (R1) admitted to facility with a stage one pressure injury to left hip. Stage three wound noted to left hip measures 1.5 cm (centimeters) length by 1.8 cm width by 2.0 cm depth. Undermining around inside wound bed full diameter of wound 2.1 cm. (R1) noted to have moderate amount of yellow purulent drainage on dressing. At twelve o'clock there is a stage two pressure injury 3.0 cm length by 3.0 cm width by 0.1 cm depth. Erythema around wounds 5.6 cm and blanchable. New order to pack wound with lodoform gauze strip and cover with six-by-six optifoam dressing daily and PRN (as needed). R1's Medical Record dated 3-8-24 through 3-26-24 does not include documentation, weekly assessments, or a treatment of R1's pressure wound of the left hip pressure ulcer prior to 3-20-24. R1's Care Plan dated 3-8-24 through 3-26-24 does not include a plan of care to address R1's pressure ulcer to the left hip, or a plan of care with pressure relieving interventions or goals. R1's Initial Wound Evaluation and Management Summary dated 3-21-24 and signed by V9 (Wound Physician) documents, Chief complaint: (R1) present with a wound on his left hip. Stage four pressure wound of the left hip full thickness. Etiology: Pressure. MDS stage four. Duration: Over 21 days. Wound size 1.5 cm length by 1.2 cm width by 1.1 cm depth. Slough (dead inflammatory tissue) 20 percent. Other visible tissue: 80 percent (hardware, tendon, muscle, and subcutaneous tissue). Dressing Treatment Plan: Alginate calcium with silver once daily and cover with foam with border once daily. Off-load wound. Reposition per facility protocol. Turn side to side in bed every one to two hours if able. On 6-27-24 at 1:35 PM V18 (Assistant Director of Nursing) stated, (V19/Prior MDS Coordinator) was responsible for the Braden Scale Pressure Risk Assessments (Pressure Risk Assessment) and Care Plans during the time (R1) resided within the facility. (R1) did not have any Braden Scales Pressure Risk Assessment completed at all when (R1) resided here, did not have a pressure ulcer prevention care plan developed with pressure relieving interventions prior to (R1s) pressure ulcer development, and did not have pressure ulcer care plan development once (R1) developed a pressure ulcer. (R1's) wound to the left hip was caused by pressure. I did not know (R1) had a stage one pressure ulcer to his left hip when he was admitted here. I only knew about (R1's) pressure ulcer to the left hip when (V6/RN) found it was opened up (on 3-21-24). I know (R1) preferred to lay on his left hip and the staff had a hard time getting him to turn off of his left hip. We (the facility) did not address or develop a plan of care/interventions to address (R1's) refusal to turn off of the left hip, or to provide pressure relief to (R1's) left hip. On 6-27-24 at 1:55 PM V6 (RN) stated, When (R1) was admitted to the facility (3-8-24) with a stage one pressure ulcer to the left hip that measured around three centimeters by two centimeters and was red in color, we (the facility staff) did not get a treatment order or measure the area weekly. We just tried to keep (R1) off of his left hip as much as possible. I found the left hip wound on 3-21-24 and it had opened up and was worse. I referred (R1) to the wound physician for assessment and treatment. 2. R2's MDS assessment dated [DATE] documents R2 is a [AGE] year-old with severely impaired cognition that is completely dependent on staff for rolling left and right and transfers. This same MDS documents R2 is at risk of development of pressure ulcers and is not on a turning and re-positioning program. R2's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents R2 was at risk for pressure ulcer development. R2's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents R2 is at moderate risk for pressure ulcer development. R2's Progress Notes dated 6-17-24 document R2 had a significant weight loss within the last month of six percent. R2's Progress Notes dated 6-20-24 document R2 started to experience a change in condition and started to become more lethargic, have a dry cough, had some green phlegm, was experiencing confusion, and was having a decreased appetite. R2's Progress Notes dated 6-21-24 at 3:29 PM and signed by V2 (Director of Nursing) document, Skin Issue. Deep tissue injury. Right heel length 3.0 cm (centimeters) by 2.0 depth. [NAME] cover. R2's Medical Record does not include a completion of a quarterly Braden Scale for Predicting Pressure Ulcer Risk Assessment between 12-6-23 through 6-21-24, or before the development of R2's pressure ulcer development to the right heel on 6-21-24. R2's Emergency Department Notes dated 6-21-24 at 5:21 PM document, (R2) presents to emergency room via EMS (Emergency Medical Services) for complaints of lethargy by house staff. Per EMS, (R2) has been weaker than normal and family recently visited (R2), noticing this change on condition, (R2) does have a right lower extremity treatment in place which has a pressure ulcer. R2's Emergency Department Notes dated 6-22-24 at 1:46 AM document, (V10/R2's Family Member) reports that (R2) resides at skilled nursing facility where she frequently visits her and states that since Monday (R2) has been far more lethargic that normal. Skilled nurse (at) facility reports that (R2) has not been eating all of her meals, and states (R2) has been sleeping more than usual. (V10) reports (R2) has a wound on her right heel that she is concerns is making (R2) septic. Skin: Right heel ulcer with overlying eschar (dead tissue) present. R2's Hospital Wound/Ostomy notes dated 6-24-24 document, Wound history: Right heel pressure injury-unstageable pressure injury. Measurements: 4.0 cm by 4.0 cm with no measurable depth-full thickness. Notes: Continue with air mattress, disposable pads, and heel boots. R2's Care Plan dated 8-2-22 (Admission) documents, (R2) is at risk for alteration in skin integrity related to Diabetes, Peripheral Vascular Disease, impaired mobility, and normal disease progression. Goal: Encourage to re-position as needed. Use pillows/positioning devices as needed. R2's Care Plan dated 6-21-24 documents, (R2) has an alteration in skin integrity-Right heel has a brown scab area. Goal: To heal thru next review date. Interventions: Heel protector to right heel. R2's Initial Wound Evaluation and Management Summary dated 6-26-24 and signed by V9 (Wound Physician) documents, Chief complaint: Present with a wound on her right heel and a rash. Focused Wound Exam: Unstageable due to necrosis of the right heel full thickness. Etiology: Pressure: Duration: Over six days. Wound Size 2.5 cm length by 2.4 cm width by 0.1 cm depth. Exudate: Moderate serosanguinous (bloody-clear drainage). 90 percent thick adherent black necrotic tissue. 10 percent thick adherent devitalized necrotic tissue. (R2) is still very deconditioned and high risk for further pressure injury. I do not think PAD (Peripheral Artery Disease) caused the wound (is not severe enough to cause tissue loss). Utilized the (pressure relieving boots) at all times. May be removed during transfers. Leptospermum honey apply three times per week, cover with abdominal pad, and gauze roll. Off-load wound. Re-position per facility protocol. This same Wound Evaluation documents V9 performed a surgical excisional debridement to R2's right heel wound to remove the necrotic tissue, eschar, and devitalized tissue. On 6-26-24 at 11:45 AM R2 was sitting in a wheelchair in her room with slipper socks on both of her feet. R2 did not have pressure relieving boots on during this time. Both of R2's feet/heels were sitting directly on the floor and R2's pressure relieving boots were sitting on top of R2's bed. V6 performed a treatment to R2's right heel wound. R2's right heel wound was a round quarter-sized area that was beefy red in color and had a moderate amount of serosanguinous drainage. After V6 performed the treatment to R2's right heel wound, V6 did not apply pressure relieving boots to R2's feet. V6 then left the room, leaving R2 sitting in her wheelchair with her feet/heels sitting directly on the floor without pressure relieving boots. On 6-26-24 from 1:15 PM through 2:30 PM R2 was sitting in a wheelchair in her room. R2 had slipper socks on both of her feet. R2 did not have pressure relieving boots on during this time. Both of R2's feet/heels were sitting directly on the floor and R2's pressure relieving boots were sitting on top of R2's bed. On 6-26-24 at 11:30 AM V12 (CNA/Certified Nursing Assistant) stated, (R2) was not feeling well for about three days prior to going to the hospital (on 6-21-24). (R2) was not eating well and not getting out of bed much. We (facility) staff would have to turn (R2) while she was in bed. We never put foot protector boots on (R2) and never lifted (R2's) feet off of the bed with pillows or anything. On 6-26-24 at 2:05 PM V14 (CNA) stated, (R2) started not to feel well before going to the hospital. I know the Thursday before (R2) went to the hospital (6-20-24), (R2) did not get out of bed at all. (R2) did not have heel protecting boots or offloading to her heels prior to hospitalization (6-21-24). On 6-26-24 at 2:10 PM V15 (CNA) stated, (R2) has never had heel protecting boots and I have never lifted her heels off of the bed. I still don't think she has heel protectors. On 6-27-24 at 10:30 AM V10 (R2's Family Member) stated, I saw her on 6-19-24 (Wednesday) and saw a bandage on her right heel. I only saw a bandage. The staff told me there was a blister that had broken open and they put a bandage on it. On Friday (6-21-24) the right heel wound was blackish/brown and did not look good. (R2) had been deteriorating since last Wednesday (6-20-24). I had never saw heel protectors on her or her heels elevated off of the bed prior to (R2) getting the right heel wound. (R2) did not get out of bed at all last Thursday (6-20-24) or Friday (6-21-24). On 6-27-24 at 1:35 PM V18 (Assistant Director of Nursing) stated, I did wound rounds with (V9) yesterday (6-26-24) but did not get time to process (R2's) orders to wear pressure relieving boots before I left yesterday. (R2) was supposed to have pressure relieving boots on at all times. On 6-27-24 at 1:45 PM V2 (Director of Nursing) stated, (R2) did not have a quarterly Braden Scale for Predicting Pressure Ulcers Risk Assessment done quarterly between 12-6-23 through 6-21-24, and one should have been completed around 3-6-24. I did (R2's) Braden Score on 6-21-24 and it was not coded correctly. (R2) was coded as a moderate risk and should have been coded as a high risk. I am not sure what we (facility staff) do once we determine a resident's Braden scale risks to be low, medium, or high. (R2) was not getting her heels off-loaded and did not have pressure relieving boots on prior to (R2) developing the pressure ulcer to the right heel. I found the pressure ulcer to (R2's) right heel on 6-21-24. When I found (R2's) area to the right heel it was covered with clear brown eschar and was unstageable. (R2's) right heel wound was caused by pressure. 3. R3's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents R3 was a high risk of development of pressure ulcers, was bedfast, was very limited in mobility, and has a problem with friction and shearing that requires moderate to maximum assistance when moving. R3's current Care Plan does not include a plan of care with pressure relieving interventions to address R3 being at high risk for pressure ulcer development. On 6-26-24 at 11:35 AM R3 was lying in bed with a pillow under her feet. Both of R3's heels were laying on top of the pillow. On 6-26-24 at 11:40 AM V6 verified R3's heels were sitting directly on top of pillows. V6 stated, (R3's) heels should be off-loaded. (R3's) pillows should not be under her heels. On 6-27-24 at 1:35 PM V18 (Assistant Director of Nursing) stated, (R3) does not have a care plan with pressure relieving interventions to address (R3) being at high risk of developing a pressure ulcer. On 6-27-24 at 1:45 PM V2 (Director of Nursing) stated, (R3's) heels should be off-loaded when she is in bed. Pillows should be placed under (R3's) ankles and calves to keep (R3's) heels off of the bed. The pillows should not be placed under (R3's) heels as that does no good to relieve pressure. On 6-27-24 at 2:15 PM V15 (CNA) stated, I do not elevate (R3's) heels off of the bed.

Based on observation, interview, and record review, the facility failed to ensure a resident was free of injury from electrical devices for one of three residents (R40) reviewed for accidents and supervision in the sample of 25. This failure resulted in R40 sustaining a burn injury to R40's left leg/buttock region after R40 was positioned with a cellular phone charging cube that was plugged into an electrical outlet with use of an extension cord directly under R40's upper leg. After R40 was incontinent of urine, R40's cellular charging cube came into direct contact with liquid, causing the electrical appliance to spark and smoke, resulting in the burning of R40's skin. R40's burn injury has required multiple surgical debridements. Findings include: The facility's Electrical Safety for Residents Policy revised [DATE] states, Policy Statement: The resident will be protected from injury associated with the use of electrical devices, including electrocution, burns, and fire. The facility's Risk Management Incident Report Log documents R40 with a burn on [DATE] at midnight hours. R40's Admission Record documents R40 admitted to the facility on [DATE] with diagnoses to include but not limited to: Type 2 Diabetes Mellitus with Diabetic Neuropathy; Critical Illness Polyneuropathy; Neuromuscular Dysfunction of the Bladder; Anemia; and Protein-Calorie Malnutrition. R40's Minimum Data Set/MDS Assessment, dated [DATE] and [DATE], documents the following: R40 is cognitively intact and R40 is dependent on staff to roll left and right in bed. Dependent is described as Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity. R40's Risk Management Report created by V18/Agency Licensed Practical Nurse/LPN, states, Burn and is dated [DATE]. This same report states, (R40) had cell phone power cord underneath (R40's) left buttock, cord got wet from urine, and created a burn. The facility's Initial and Final Report to the local State Agency, dated [DATE], documents that on [DATE], R40 requested to be repositioned and reported feeling a burning sensation to buttocks. This same report documents that R40 had a cell phone charging block underneath him across the bed and plugged into an extension cord. R40 reported that when R40 was incontinent of urine, the urine entered the charging port thus causing a burn to R40's buttocks. R40's COMS-Skin Only Evaluation dated [DATE], [DATE], and [DATE] documents R40 with current skin issues of a burn to R40's left buttocks. R40's Wound-Weekly Observation Tool dated [DATE] documents R40 acquired a burn to R40's left buttock on [DATE]. The facility's Professional/General Liability Insurance Report Form documents R40 was involved in a resident injury or incident on [DATE]. This same report documents incident and injury description as (R40) obtained an electrical burn after lying on a phone charger plugged into an extension cord after urinating thus causing the electrical burn. V20's (R40's Nurse Practitioner) visit note, dated [DATE], states, Chief Complaint: I (R40) received a burn from my charger being in bed. This same note states, (R40) is being seen today as he suffered a burn to his (left) buttock. (R40) was in his room this morning lying in bed propped up on his side as he reports he has a burn on his (left) buttock as he was laying on his phone which was on the charger. Due to (R40) being incontinent he reports that it caused this (burn) to occur. (R40) did report that his charger was plugged into an extension cord he had from home as he wanted to be able to be on his phone while in bed as it was charging. V1's (Administrator) Incident Follow-Up Note dated [DATE] states, Spoke with (R40) regarding the incident that occurred on [DATE]. (R40) stated he had his cell phone charging block plugged into an extension cord. It was not the extension cord, but the cell phone block that was inadvertently underneath him. When (R40) was incontinent, the urine ran into the cell phone charger and caused the issue. R40's Health Status Note signed and dated by V18/Agency LPN on [DATE] at 2:22 AM, states, (V15/R40's Spouse) removed (R40's) dressing to take pictures of wounds. Dressing reapplied. Open wound continues. Wound edges are now raised and hardened. Several small blisters appearing toward distal end of wound. R40's Health Status Note signed and dated by V18 on [DATE] at 11:44 PM, states, During rounds (R40) requesting to be repositioned and reported burning to buttocks. Staff observed (R40) laying on top of extension cord that then began to smoke and spark due to (R40's) urinary incontinence. Extension cord removed from wall and then from under (R40). Upon Assessment, 3.5 cm/centimeter x (by) 5 cm open area noted to (left) lower buttocks. 3 cm x 2 cm blistered area noted just above open area to (left) buttock. Skin surrounding both wounds red and thin. (R40) does report stinging and discomfort to both areas. Sites cleansed. TAO (Triple Antibiotic Ointment) applied, and then open area covered with bordered foam. R40's Order Summary Report dated [DATE]-[DATE] documents an order for Santyl Ointment 250 Unit/GM (per Gram). Apply to left upper thigh topically every day shift for wound treatment-cleanse with 0.25% (percent) Dakins Solution-apply Santyl then Calcium Alginate-Cover with (foam) border dressing qd (every day). V21's (R40's Wound Physician) Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock Full Thickness. Etiology: Burn. Further Etiology Detail: From shorted out charging station. Wound Size (L x W x D/Length by Width by Depth) 5 cm x 6 cm x 1 cm. Surface Area: 30 cm squared. Exudate: Light Serous. Thick Adherent Black Necrotic Tissue (Eschar): 75 % (percent). Thick Adherent Devitalized Necrotic Tissue: 10 %. Granulation Tissue: 15 %. This same note documents a Surgical Excisional Debridement Procedure was performed on R40's wound on [DATE] to remove necrotic tissue and establish margins of viable tissue, remove thick adherent Eschar and devitalized tissue. This note is documented as an initial evaluation. V21's Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock-Improved Evidenced by Decreased Necrotic Tissue, deceased Surface Area, Full Thickness. R40's wound size measured 4.1 cm x 5.1 cm x 0.1 cm. This same note documents a Surgical Excisional Debridement Procedure to R40's wound was performed on [DATE]. V21's Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock Full Thickness and documents a Surgical Excisional Debridement Procedure was performed on [DATE] to remove necrotic tissue and establish the margins of viable tissue. V21's Wound Evaluation and Management Summary dated [DATE] states, Burn Wound of the Left Buttock Full Thickness and documents a Surgical Excisional Debridement Procedure was performed on [DATE] to remove necrotic tissue and establish the margins of viable tissue. On [DATE] at 9:42 AM, R40 was observed sitting up in bed watching R40's cellular phone which was positioned on a bedside table in front of R40. R40 stated at the end of [DATE], R40's phone was plugged into an extension cord and in the bed with R40. R40 stated R40 was positioned on top of the block that was charging R40's phone. R40 stated when R40 urinated, the urine ran right into that charging port. I got third degree burns because of it. R40 stated R40 has decreased sensation, couldn't feel the cord under R40, and that R40 wasn't able to reposition off the charging cord/cube himself. R40 stated, I was calling for help because I couldn't get off it (phone charging device). I felt a tingling sensation initially, then it started burning really bad. My roommate at the time (R51) turned on his call light for me and got the girls to help me. He said, 'he needs help right now.' I take Norco to help with the pain and they do wound treatments every day. It is getting better. The treatments used to be every shift. R40 stated he had been using his phone cord and extension cord for months and denied that anyone ever said anything to him about their use. On [DATE] at 9:57 AM, V4 (Licensed Practical Nurse) entered R40's room to change R40's wound dressing. R40's soiled dressing was removed, and an approximate golf-ball sized open wound was noted. R40's open wound was noted with a straight edge, resembling a partial square shape on the proximal edge. R40's wound tissue was pinkish red with slight serous drainage noted. While V4 was cleansing and dressing R40's wound, R40 was observed grimacing, moaning, and tensing up/pulling away from V4's touch. On [DATE] at 10:51 AM, V3 (Assistant Director of Nursing) stated V3 had received a phone call in the early morning on [DATE] due to being the on-call nurse. V3 stated V3 could not remember who called V3, but V3 was called to be informed that R40's family was in the facility taking pictures of R40's newly acquired wound. On [DATE] at 10:25 AM, V15 (R40's Spouse) stated R40 had called V15 and told V15 that R40 was burned from his phone cord being under him. V15 stated, I came in and took pics (pictures). (R40) said the lady (V17/Certified Nursing Assistant) who took care of him rolled him over onto his phone cord after she changed him. Nothing should be in his bed or under him, they should make sure he is clear before they leave the room. V15 stated R40 admitted with the extension cord and phone charger back in [DATE]. It (Phone Charger and Extension Cord) had been there for months, and no one ever said anything to me or (R40) about it. We didn't know what we could or couldn't have. On [DATE] at 10:41 AM, V13 (Certified Nursing Assistant/CNA) stated that V13 was aware that R40 used a phone cord charger and cord that plugged into the wall in R40's room. On [DATE] at 12:03 PM, V16 (CNA) stated, I was walking up the hall and (V17/CNA) stepped out and asked me to help pull (R40) up in bed. She said she had just changed him. After, (R40) had his light on and asked for a snack. He said his left leg was 'cramping.' I tried helping him, but then said I would let his nurse know because there wasn't much more I could do for cramps. I left to answer another light. Maybe five minutes or so later, (R40) had his light on again, and his roommate (R51) was yelling, 'Can you help him?' When I went into the room (R40) was yelling, 'it burns, it burns.' I said, 'where is it burning at?' and (R40) said under his bottom. That's when I noticed his phone cord was sparking and smoking. I ripped it out of the wall and then pulled it out from under him. (R40's) phone was connected to a dual head charging cube and that is where the smoke and sparks were coming from. I could smell the smoke. I couldn't see his skin until I rolled him over with the nurse. There was an inch and a half-sized blister. When we looked at it again later in the night it was more open and looked worse. I don't usually work with (R40). (V17) had just changed him. I was at the nurse's station and went back again when (R51) turned the call light on for (R40). I wrote out two handwritten reports. I gave one to my nurse (V22/Licensed Practical Nurse) and I gave the other one to (V4/LPN). I was able to pull out the cord from under (R40) easily. It shouldn't have been under him; I didn't notice it at first when I went in to pull him up the first time. On [DATE] at 9:41 AM, V17 (CNA) stated on [DATE], V17 had repositioned (R40) in bed. V17 stated R40 had wanted to turn on R40's side. I believe he was lying on his back and wanted to turn on his side. A little bit after, (R40) had his light on again, another CNA (V16) I was working with answered the light that time. V17 stated, I didn't see it (the wound or burning cord), but I asked what happened and (V16) said it was smoking. V17 stated V17 recalled R40 having a charger that was in bed with R40 because V17 had to move it to reposition R40 initially. On [DATE] at 12:30 PM, V1 (Administrator) stated that R40 should not have been using an extension cord in R40's room. V1 stated, We are a team, so we should have noticed it too. V1 also stated R40 was burned when R40's urine went into the port where R40's cellular phone cord was plugged into the extension cord. V1 verified R40's cellular phone cord had been positioned under R40 inadvertently. Attempts to speak with V18 (LPN) and V22 (LPN) on [DATE] and [DATE] were unsuccessful. No callbacks were received.

Based on interview and record review the Facility failed to respond to Resident call lights in a timely manner and comply with Resident requests for assistance, for four of four Residents (R1, R2, R3 and R4) reviewed for call light response in a sample of four. This failure resulted in urinary bladder pain, worsening skin conditions, resident request for discharge and embarrassment. Findings include: Facility Call Light Accessibility and Timely Response Policy, dated 2023, documents: the purpose of the Policy is to assure the Facility is adequately equipped with a call light at each Resident's bedside and toilet to allow Residents to call for assistance; call lights will directly relay to a staff member or centralized location to ensure appropriate response; listen to the Resident's request and respond accordingly; and do not promise something you cannot deliver. Facility Resident Rights for People in Long-Term Care Facilities, revised 11/18, documents: the Facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; Facility must provide services to keep your physical and mental health, at their highest practical levels; and you should receive the services included in your plan of care. Facility Certified Nursing Assistant/CNA Job Description, revised 10/2022, documents: assist Residents in accordance to their needs ranging from minimal assistance to total dependent care on activities of daily living/ADL's; contribute to the development and implementation of interventions in accordance with the Resident's needs for care/goals for care preferences and recognize standards of practice that address the identified limitations in ability to perform ADL's; assist the Resident with bowel and bladder functions (take to bathroom); assist with lifting, turning, moving, positioning and transporting Residents into and out of beds and chairs; and perform all assigned tasks in accordance with established Facility policies and procedures and as instructed by your supervisors. Facility Incontinence Policy, dated 2023, documents: all Residents that are incontinent will receive appropriate treatment and services; the Facility must ensure that Residents who are continent of bladder and bowel upon admission receive appropriate services and assistance to maintain continence unless his/her clinical condition is/becomes such that continence is not possible to maintain; and Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. Resident Council Minutes, dated 9/26/23, documents concerns with call lights, cell phone usage and CNA's taking breaks at same time. Resident Council Minutes, dated 10/26/23, documents concerns with call lights taking too long, being shut off without assisting, staff on cell phones in hallways and rooms, do not always get fresh water, taking breaks while meal trays are being passed out. Resident Council Minutes, dated 11/30/23, documents concerns with short staff and concern of staff burnout. 1) R1's Physician Order Sheet/POS, dated 12/27/23, documents that R1 admitted to the facility on [DATE], with diagnoses including: Fracture of Body of Sternum, Closed Fracture; Multiple Rib Fractures, Traumatic Pneumothorax, Sequel, Respiratory Failure with Hypoxia, Localized Edema, Chronic Diastolic Heart Failure/CHF, Vertebrae Fracture, Osteoporosis and Right Clavicle Fracture. R1's Nursing Note, dated 11/24/23, documents: coccyx red/blanchable, no open areas; antiembolic treatment (TED hose); continent of bowel and bladder; bruising to right upper/lower extremities and left lower extremity; and discoloration to coccyx. R1's Nursing Note, dated 12/3/23, documents, Resident has excoriation to gluteal crevice/vaginal area/labia, open areas to Coccyx. R1's Nursing Note also documents that a Treatment was initiated. R1's POS, dated 12/3/23, documents a Treatment Order to cleanse R1's open area to coccyx with normal saline, pat dry, apply medicated ointment/hydrogel and cover with a foam dressing until healed every night shift for pressure ulcers; and apply skin protectant (peri guard) to buttocks, vaginal area/labia every shift. On 12/27/23 at 9:50 am, R1 stated, I went to that Facility for a few weeks just to get therapy and then discharged to home on 12/8/23. On 12/7/23, at 6:00 pm, I put my call light on because I had to go to the bathroom. Someone came in and shut off my call light and left the room and told me that they would be back, and they never came back, until someone came back to help me, for two hours, at about 8:00 pm. Someone even came to help my roommate back and did not even look at me, let alone help me. I know they were all busy with supper time and breaks. All I wanted to do was to get up and use the bathroom, but I could not, I was not allowed to get out of the bed by myself, so I had to pee in a diaper. I had to wait for long periods of time, frequently, and eventually my whole butt was sore. They were supposed to put stuff on my butt, but most times they would not, and it hurt bad because it got a sore on it. I know I got that sore because I always had to wait a long time to get help to the bathroom and I had to sit in urine, when I was fully capable of using the toilet. On 12/28/23 at 9:07 am, V4 (Certified Nursing Assistant/CNA) stated, I remember this night (12/7/23) because (R1) was so mad and wanted to pack up (R1's) stuff and go home. I was assigned to (R1) on 12/7/23 and we were short staffed, with only three of us (CNA's) working. (R1) usually would get up and use the bathroom, but (R1) needed help. Since we were short staffed, I believe she had her call light on for a long time. It was right after dinner time, and we were trying to get other Residents laid down. Around 7:00 pm, a co-worker of mine (V7/CNA) told me that (V7) went in to R1's room to the help R1's roommate and (R1) told (V7) that (R1's) call light had been on for over an hour at that point. According to (V7), (R1) was being rude to (V7) and (V7) told (R1) not to be rude. (V7) told (R1) at that time, that someone will come back to help because (R1) should not be rude. Finally, I got to (R1's) room at about 8:30 pm or 9:00 pm, to help (R1) and (R1) was so upset, (R1) was trying to discharge from the Facility. (V8/Licensed Practical Nurse/LPN) was (R1's) nurse and (V8) even went in earlier to apply a cream to (R1's) bottom and never told any of us that (R1) had a soiled incontinence brief or needed help to the bathroom, it took me going in, finally, around 8:30 pm or 9:00 pm to get (R1) changed and toileted. (R1) usually uses the toilet but had to go to the bathroom in her incontinence brief. I apologized to (R1) because (R1) was so upset and mad. (R1) talked to the nurses, but I am not sure that anything was done because she left the next day. 2) On 12/27/23 at 10:44 am, R2 stated, There is an issue with the timely response to call lights. There are long wait times early in the morning and around shift change between 1:30 PM and 2:00 PM. The CNAs (Certified Nursing Assistant) congregate around the desk just before shift change and do not answer lights. There are times I've waited and waited and waited. R2 was asked if she has ever been incontinent due to long response times. R2 stated, Oh, Lord, yes. R2 stated she sometimes has to use her incontinence brief because she cannot wait any longer for assistance which happens approximately four to five times per week. R2 stated, It's embarrassing to be incontinent just because I need help. R2 was asked if R1 had experienced long wait times when they were roommates. R2 stated, Oh, [NAME] yes. I don't know why she had to wait so long. She had a sore on her butt, maybe that's why they didn't want to help her. R2 also reported that R1 could not place or remove her own bedpan or even turn because she had a bad shoulder. On 12/27/23 at 12:10 pm, V2 (Director of Nursing/DON) stated, We have had to use a lot of Agency CNAs, but starting in January (2024), we will have only our own. Staffing is difficult and has changed drastically, for the worse, over my nursing career, people just do not want to work and have no work ethic. Residents should not be waiting 2 hours for a call light to be answered, or even having to resort to going to the bathroom in an incontinence brief, especially when they are capable of using the toilet. 3) On 12/27/23 at 12:30 PM R4 stated there is an issue with response time to call lights which mostly occurs on second shift. R4 stated, Staff sometimes comes into my room and turns my call light off but does not help me. There are times I am incontinent when I knew I had to go because staff doesn't answer my call light. We discussed this issue yesterday at Resident Council. 4) On 12/27/23 at 12:38 pm, R3 confirmed R3 needs the assistance of staff using a sit to stand for toileting. R3 stated R3 is the Resident Council President and response time to call lights is an issue. R3 stated she has waited up to 25 minutes for someone to assist her after she pushes her call light. R3 stated, I've waited so long, it's painful. R3 stated that she has reported this to the head nurse in the past who 'talks with the aides', but I'm not sure how much good it does. This is an ongoing issue. On 12/27/23 at 1:54 pm, V1 (Administrator/ADM) stated, I have only been employed here for a week, but I just had an inservice on Friday (12/22/23) with all the staff, and actually call lights were one of the issues I spoke about. I am trying to address the major issues first and noticed that the Resident Council is complaining about the call lights and nothing was getting done. I am hoping to get these problems resolved. We have a lot of new staff here and I am hoping that things are going to change.

Based on interview and record review, the facility failed to notify the Physician of cloudy urine (symptoms of a urinary tract infection) and a significant decline in a resident's mental and physical condition for one of three residents (R1) reviewed for change in condition in the sample of five. These failures resulted in R1 experiencing a change in condition which required hospitalization and subsequently being diagnosed with [CONDITION(S)] (a life-threatening condition which occurs when the body's response to an infection damages its own tissues). R1 expired on [DATE] and a cause of death was identified as [CONDITION(S)]. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at Severity Level 2. The facility continues to educate staff and conduct audits on residents for changes in resident condition, reporting of changes in condition, signs and symptoms of a Urinary Tract Infection, and ensuring the facility's policies and procedures for change in condition are being followed. The facility also continues to conduct audits and ensure catheter orders are complete. Findings include: The Facility's Change in Condition policy dated ,d+[DATE], states, Purpose: To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications. Note: (The Centers for Medicare and Medicaid Services) requires, 'A facility must immediately inform the resident, consult with the resident's Physician; and notify, consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial in either life-threatening conditions or clinical complications); According to the American Medical Directors Association (AMDA) Clinical Practice Guidelines-Acute Changes in Condition in the Long-Term Care Setting: Immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. R1's Care Plan dated [DATE], states, Report to Physician signs of [CONDITION(S)] (Urinary Tract Infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, complaints of pain/burning, acute change in mental status, functional decline in ADLs (activities of daily living). Report any changes in amount and color, or odor of urine. R1's Nursing Progress Notes dated [DATE] (Admission) at 8:29 p.m., states, (R1) is continent of stool and has an indwelling (urinary catheter) present. It is draining adequate amounts of yellow urine. R1's Nursing Progress Notes dated [DATE] at 5:29 a.m., states, (R1's Indwelling catheter) is patent and draining cloudy yellow urine. R1's Nursing Progress Notes dated [DATE] at 4:27 a.m., states, (R1's Indwelling catheter) is patent and draining cloudy yellow urine. R1's medical record does not document R1's Physician was notified of R1's cloudy urine on [DATE] and [DATE]. R1's Progress Notes dated [DATE] at 9:40 p.m., V5 (Licensed Practical Nurse/LPN) document, (R1) has seemed more lethargic than normal this shift. Appetite has been poor and (R1) not communicating as much this shift. Reddened area to buttocks noted. (R1) repositioned and turned (every) 2 hours. Fax out to Physician. Will continue to monitor. R1's medical record does not document any further notification of V13 (R1's Physician) regarding R1's significant change in mental and physical status. R1's medical record does not document V13's response to the fax sent by V5 on [DATE]. R1's Progress Note dated [DATE] at 1:50 p.m., documents that R1 had a significant change in condition and was sent to the local emergency department for evaluation. R1's Hospital Emergency Medicine Physician note dated [DATE] at 2:27 p.m., states, (R1) has a chronic indwelling catheter at this time. (R1) is nonverbal appears ill and septic. Apparently had a fever of 102 this morning. Smells of foul urine at this time with very dark cloudy urine with sediment in her catheter. (R1) is toxic appearing. (R1) is lethargic and disoriented. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [CONDITION(S)], Shock, Dehydration and [CONDITION(S)]. R1's Hospital Laboratory Urine Culture dated [DATE] at 5:45 p.m., documents R1 had a Urinary Tract Infection with Escherichia Coli (bacteria). R1's Death Certificate dated [DATE], documents R1's cause of death as [CONDITION(S)] with Multi Organ Failure. On [DATE] at 1:43 p.m., V4 (Agency Registered Nurse) stated, I did take care of (R1) on [DATE] day shift. I do remember therapy reporting some changes with (R1) and I took her blood pressure and thought it wasn't that low or concerning. I do remember the therapists reporting that she was lethargic. I didn't feel that Physician notification was needed at that time. I don't remember if I charted anything or not. On [DATE] at 11:55 a.m., V5 (LPN) stated, On [DATE], therapy (staff) had noticed and reported that (R1) had a change in condition and that (R1) was more lethargic. (R1) went in and out. I didn't know if (R1) was just having an episode or what. (R1) didn't speak to me like she normally did. (R1) is usually more talkative. (I sent a) fax to (R1's) physician. (R1's physician) did not return the call on my shift. I don't know what the guideline is for faxing versus calling the Physician. The fax was just a notice that (R1) had a change. I noticed there was something off with (R1). (R1's physician) wouldn't have received the fax that late at night (9:40 p.m.) and it would have been the next day before anyone would have given the fax to him. On [DATE] at 9:23 a.m., V11 (Speech Therapist/Director of Rehab) stated V11 worked with R1 during lunch on [DATE] and noticed a change in her condition. V11 stated that R1 is normally able to converse but on [DATE], R1 might answer yes or no on occasion but nothing like she normally did. V11 stated that R1 did not eat or drink for V11 that day. V11 stated R1's change in condition was reported to the nursing staff. On [DATE] at 12:55 p.m., V7 (Hospital Registered Nurse) stated that she was R1's nurse when R1 was brought into the Emergency Department on [DATE]. V7 stated that R1 was very ill and critical upon admission. V7 stated R1 was mottling (blotchy, red-purplish marbling of the skin) from her feet to above her knees, hands, chest, shoulders, and even at the tip of her nose had a purplish color to it. V7 stated R1 was pale and unresponsive to anything but sternal rubbing. V7 stated R1's urine in the catheter bag was brown and yellow and had thick mucous like substance or pus moving through the urine. V7 stated, Before I even took (R1's) catheter out I could smell the odor of the urine. It was horrible and made me nauseous. When I removed the catheter there was mucous clogging the insertions site. I put a new catheter in. We did a bladder scan to make sure she wasn't holding large amount of urine, but it was empty. Her kidneys were already shutting down at that point. After inserting the new catheter, she only had about 35 milliliters of urine output in ,d+[DATE] hours. We did everything we could for (R1), but she was so severely septic that her organs were already failing. On [DATE] at 11:40 a.m., V13 (R1's Physician) stated nursing staff should have intervened and notified V13 when R1's urine was first noted to be cloudy. V13 stated V13 would have had them do a urinalysis to see if there was any infection in R1's urine. V13 stated V13 or the on-call physician should have also been called on [DATE] when R1 had a change in her condition. V13 stated, I wouldn't even have seen the fax (sent by V5) until at least the next business day. By the time I saw the fax that was sent to me on [DATE] at 9:40 p.m., (R1) was already in the hospital ([DATE]). I had no indication from the facility that (R1) continued to present with a decline in her condition. I was shocked to say the least. V13 stated that a quicker response from the nursing staff to notify V13 of (R1's) cloudy urine could have potentially prevented R1's decline in status, hospitalization and even death. V13 stated V13 had no knowledge that there was ever an issue with R1's urine. On [DATE] at 3:33 p.m., V2 (Director of Nursing) stated the nurses should have notified V13 when R1's urine first became cloudy on [DATE] and [DATE], according to their policy and R1's care plan. V2 stated that V13 or the on-call physician should have been called on [DATE] as soon as staff observed R1 was having a significant change in condition. An Immediate Jeopardy was identified on [DATE] at 9:13 a.m. The Immediate Jeopardy began on [DATE] when R1's medical record first documented R1 had cloudy urine and R1's Physician was not notified. This Immediate Jeopardy also includes the facility's failure to notify R1's Physician of a documented significant decline in a R1's mental and physical condition on [DATE] and [DATE]. On [DATE] at 11:00 a.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. On [DATE] at 3:45 p.m. the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The Quality Assurance Consultant educated the Director of Nursing on signs and symptoms of a Urinary Tract Infection, change in condition, reporting of a change in condition on [DATE]. The Director of Nursing educated nursing staff on signs and symptoms of a Urinary Tract Infection, change in condition, reporting of a change in condition on [DATE] and [DATE] and ongoing. 2. Quality Assurance Consultant educated the Director of Nursing and Unit Manager's on review of urinary catheter guidelines on [DATE]. The Director of Nursing and Unit Managers educated nursing staff on urinary catheter guidelines, completed on [DATE] and [DATE] and ongoing. 3. The facility has current policies and procedures that address catheter care and services, including but not limited to: ongoing assessment and documentation for a resident with a catheter, including the identification of the resident's need for the catheter, the removal of the catheter when the resident's clinical condition demonstrates the catheter is no longer needed, obtaining Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Quality Assurance Consultant educated the Director of Nursing and Unit Managers on policies and procedures noted above on [DATE] and ongoing. The Director of Nursing and Unit Managers educated nursing staff on the policies noted above, completed on [DATE] and [DATE] and ongoing. 4. R3 is the only like resident identified with a urinary catheter. R3 has been reviewed to ensure Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 has been reviewed for any changes in condition. Completed on [DATE] and ongoing. 5. Progress Notes reviewed for all residents for any changes in condition. Completed on [DATE] and ongoing. 6. (The facility's Medical Director) has been notified on [DATE] and will be notified and updated again on [DATE]. 7. A Quality Assurance meeting was held on [DATE] and [DATE] to review findings of the (Immediate Jeopardy) and to review the abatement plan.

Based on observation, interview and record review, the facility failed identify and assess the medical justification for R1's catheter use, identify and monitor R1's signs and symptoms of a urinary tract infection, and failed to implement appropriate interventions when R1's urine became cloudy and R1 experienced increased lethargy, decreased communication and changes in skin integrity (R1). The facility also failed to obtain Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 experiencing a change in physical and mental status consisting of unresponsiveness, abnormal vital signs, abnormal breathing and being sent to the local hospital where R1 was diagnosed with [CONDITION(S)] (a life-threatening condition which occurs when the body's response to an infection damages its own tissues) which was the result of R1's urinary tract infection. R1 subsequently expired on [DATE] due to R1's urinary tract infection that led to [CONDITION(S)]. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remained out of compliance at Severity level 2. The facility continues to educate staff and conduct audits on residents for indwelling catheter use, signs and symptoms of a urinary tract infection, changes in resident condition, and ensuring the facility's catheter policies and procedures are being followed. Findings include: On [DATE] at 12:05 p.m., V2 (Director of Nursing) stated, We don't really have a policy for Catheter Use, Catheter Assessment or on Urinary Tract Infections ([CONDITION(S)]) but we follow the standards of practice and refer to the Mayo Clinic [CONDITION(S)] symptoms and causes. The Mayo Clinic [CONDITION(S)] Symptoms and Causes material dated [DATE], provided by V2, states, A [CONDITION(S)] is an infection in any part of your urinary system-your kidneys, Ureter, bladder and urethra. Most infections involve the lower urinary tract-the bladder and the urethra. ([CONDITION(S)]'s) don't always cause signs and symptoms, but when they do they may include: A strong, persistent urge to urinate, a burning sensation when urinating, passing frequent small amounts of urine, urine that appears cloudy, strong smelling urine, pelvic pain, in women. Contact your doctor if you have signs and symptoms of a [CONDITION(S)]. Other risk factors for UTIs include: Catheter Use, People who can't urinate on their own and use a tube (catheter) to urinate have an increased risk of UTIs. When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, a urinary tract infection can have serious consequences. Complications of a [CONDITION(S)] may include: [CONDITION(S)], a potentially life-threatening complication of an infection, especially if the infection works its way up your urinary tract to your kidneys. The facility's Catheter Care: Indwelling Catheter policy dated ,d+[DATE], states, Catheter bags should be covered with a catheter dignity bag to preserve the dignity of the patient. Secure the catheter to the patient's leg using a securement device or leg strap to prevent traction on the urethra. Catheter securement device must be changed every 7 days. 1. R1's Admission assessment dated [DATE], documents R1 was admitted from the hospital after sustaining a [CONDITION(S)] from a fall at home. On [DATE] at 4:44 p.m., V8 (R1's daughter) stated that R1 fell at home on [DATE] and sustained a hairline [CONDITION(S)] that did not require surgical repair. V8 stated that R1 was sent from the local hospital's emergency department to the facility on [DATE], for a short term stay to receive skilled therapy and return home as soon as possible. V8 stated prior to R1's fall at home on [DATE], R1 lived alone and was able to care for all of her needs independently, with no care givers. V8 stated R1 had never had a catheter prior to R1's emergency room visit on [DATE]. V8 stated the catheter was inserted so R1 did not have to get out of bed to urinate at the hospital. R1's Care Plan dated [DATE], states, Use of indwelling urinary catheter needed due to urinary retention. Report to Physician signs of [CONDITION(S)] (Urinary Tract Infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, complaints of pain/burning, acute change in mental status, functional decline in activities of daily living. Report any changes in amount and color, or odor of urine. R1's computerized medical record, including Physician orders, progress notes, assessments, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's computerized medical record does not document a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Nursing Progress Notes dated [DATE] (Admission) at 8:29 p.m., states, (R1) is continent of stool and has an indwelling (urinary catheter) present (16 french/10 cubic centimeter) bulb. It is draining adequate amounts of yellow urine. R1's medical record does not document any further assessment of R1's catheter or urine characteristics after [DATE] at 8:29 p.m. until [DATE]. R1's Nursing Progress Notes dated [DATE] at 5:29 a.m., states, (R1's Indwelling urinary catheter) is patent and draining cloudy yellow urine. R1's Nursing Progress Notes dated [DATE] at 4:27 a.m., states, (R1's Indwelling urinary catheter) is patent and draining cloudy yellow urine. R1's medical record does not document any further assessment of R1's catheter or urine characteristics after [DATE] through [DATE] when R1 was transferred to the hospital for a significant change in condition. R1's Occupational Therapy Treatment Encounter Note(s) dated [DATE], documents, (R1) Required additional cueing to stay on task and focused. (R1) not quite herself today. Lethargic, presents with increased tremors, and drooling/running nose. Nurse notified. (Blood Pressure) ,d+[DATE] manually. (R1's) therapy session decreased. R1's Speech Therapy Treatment Encounter Notes dated [DATE], documents, Decline in (R1's) status since last session (on [DATE]). Decline in (R1's) ability to attend to and participate in tasks and respond appropriately to communication. R1's Nursing Progress Notes dated [DATE] at 9:40 p.m., states, (R1) has seemed more lethargic than normal this shift. Appetite has been poor and (R1) not communicating as much this shift. Fax out to Physician. R1's medical record did not include any further documentation of R1's condition until [DATE] at 1:50 p.m. (over 16 hours later). R1's Progress Note dated [DATE] at 1:50 p.m., V6 (Registered Nurse) documents, (Certified Nurse Aide) came and got (V6) to look at (R1's) bottom. Both buttocks are red and slightly purple in color and blanchable. (R1's) mid spine is red (with) purple hue. Did apply (foam) dressing for protection and it is blanchable as well. (R1) would not open eyes and noted to be diaphoretic. Respirations 50, very labored (abdominal) breathing. (Temperature 99.0 degrees Fahrenheit, Heart Rate 86 and irregular.) V6 documented V6 called and gave report to (local hospital), called 911, and ambulance arrived at 1:45 p.m. to transport R1 to the local Emergency Department. R1's Ambulance Report dated [DATE] at 1:46 p.m., documents, (Ambulance) was dispatched to (the facility) for a [AGE] year-old female with possible [CONDITION(S)]. On arrival, the nursing staff states (R1) has been sick since yesterday. The nursing staff stated (R1) became unresponsive in the morning and has been getting worse. The nursing staff state (R1) usually (Alert and oriented). Upon (R1) contact, (R1) was lying in bed and was only responsive to pain. (R1) was hot to touch, (R1's) respiration was rapid, pulse was rapid and weak, (R1's) (urine in the catheter drainage bag) was dark brown and cloudy. R1's Hospital Laboratory Urine Culture dated [DATE] at 5:45 p.m., documents R1 had a Urinary Tract Infection with Escherichia Coli (bacteria). R1's Hospital Emergency Medicine Physician note dated [DATE] at 2:27 p.m., documents, (R1) has a chronic indwelling catheter at this time. (R1) is nonverbal appears ill and septic. Apparently had a fever of 102 this morning. Smells of foul urine at this time with very dark cloudy urine with sediment in her catheter. (R1) is toxic appearing. (R1) is lethargic and disoriented. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: [CONDITION(S)], Shock, Dehydration and [CONDITION(S)]. R1's Hospital Nephrology Physician consult dated [DATE] at 5:30 p.m., documents Septic Shock, likely source is urine. Altered mental status likely in the setting of [CONDITION(S)]/[CONDITION(S)]. Prognosis quite guarded at this point. R1's Hospital Pulmonary Disease Physician consult dated [DATE] at 6:03 p.m., documents, (R1) is basically severely septic, septic shock with acute [CONDITION(S)]. (R1) currently is being admitted with severe septic shock, [CONDITION(S)], mainly due to septic shock sources. Apparently, urine looked like pus. R1's Hospital Emergency Medicine Physician note dated [DATE] at 9:14 p.m., documents, (R1's) prognosis extremely poor. Source likely (urine) as catheter was changed and (there) was pus in it. (Diagnosis): Septic Shock, [CONDITION(S)] (elevated potassium), [CONDITION(S)] with multi-organ dysfunction. R1's Hospital Nurses Note date [DATE] at 1:53 a.m., documents, Preparing for intubation when (R1's) blood pressure began to decrease, (R1) declined in mental status, with no response to pain, gasping breaths, no palpable pulse. Time of Death called at (1:40 a.m.). R1's Death Certificate dated [DATE], documents R1's cause of death as [CONDITION(S)] with Multi Organ Failure. On [DATE] at 10:42 a.m., V9 (Certified Nurse Aide) stated, I didn't work on [DATE] or [DATE] when (R1) was discharged but I (took care of R1) several days prior to those dates. I do remember that her urine had a terrible odor. I can't recall exactly what (R1's) urine looked like at that time. On [DATE] at 11:09 a.m., V15 (Certified Nurse Aide) stated V15 was R1's Certified Nurse Aide on [DATE]. V15 stated she had taken care of R1 a lot since R1 was admitted and knew a lot about R1's normal required care. V15 stated when R1 was first admitted her urine was clear yellow. V15 stated, I do remember (R1's) urine turning cloudy and reminded me of pale milk with things floating in it. I can't remember the date that her urine started getting cloudy. I would say approximately one week prior to [DATE]. I know the nurses were aware of it. V15 stated when V15 came to work on [DATE] at 6:00 a.m., the night certified nurse aide (unknown) reported that V15 had not been herself and was extremely lethargic and the staff had decided to leave her in bed to rest instead of getting R1 up for breakfast as usual. V15 stated the other (Certified Nurse Aide) that was working with V15 was also very concerned about R1 and had taken care of R1 the day before ([DATE]) and R1 was sick then also. V15 stated when V15 went to check on R1 on [DATE] at approximately 6:45 a.m., R1 could not open her eyes or talk like usual. V15 stated R1 is usually up and talking by the time V15 gets to her room in the morning. V15 stated this was a huge change for R1. V15 stated R1's temperature was 102.3 degrees (Fahrenheit). V15 stated, I felt like that was really high. I reported this temperature to (V14-Licensed Practical Nurse) and she did not seem very concerned and told me (R1) had been warm and to recheck it in a while. (R1's) urine was very dark. When we were changing (R1) there was a brown liquid that had absorbed in the incontinence brief. I don't think it was bowel (movement). I think it was drainage from around the catheter that leaked out, but I truly don't know. I was really worried about the lack of response to (R1's) change in condition so I went and told (V6-Registered Nurse). (V6) immediately came to assess (R1) and got her sent to the hospital. On [DATE] at 10:07 a.m., V14 (Licensed Practical Nurse) stated, I did notice (R1) starting to decline around lunchtime on [DATE]. V14 stated R1 was in bed at the time and didn't remember getting any information at shift change about R1's condition. V14 stated she did not recall assessing R1's urine on [DATE]. V14 stated she helped V6 get R1 ready to send to the hospital. On [DATE] at 2:52 p.m., V6 (Registered Nurse) stated that V15 came to get V6 and asked her to come and look at R1. V6 stated, I did look at her skin that (V15) stated was new redness on her buttocks and spine. (R1) was warm to the touch. I checked (R1's) temperature and it was 99.2. As I continued to assess (R1) and put some protective dressings on her spinal area, she took a further decline. (R1's) fever spiked higher and her respirations jumped up to 50. I literally ran to the nurse's station to call (R1's physician). In less than 15 minutes (R1) was transferred to the hospital. If a resident has cloudy urine, a urinalysis should be collected to check for infection. When a resident has a change in condition, the sooner it is acted upon the sooner we can get the resident help. A part of the nurse's daily assessment should be to assess the urine of a resident with a catheter. On [DATE] at 12:55 p.m., V7 (Hospital Registered Nurse) stated that she was R1's nurse when R1 was brought into the Emergency Department on [DATE]. V7 stated R1 was very ill and critical upon admission. V7 stated R1 was mottling (blotchy, red-purplish marbling of the skin) from her feet to above her knees, hands, chest, shoulders, and even at the tip of her nose had a purplish color to it. V7 stated that R1 was pale and unresponsive to anything but sternal rubbing. V7 stated R1's urine in the catheter bag was brown and yellow and had thick [MEDICATION(S)] like substance or pus moving through the urine. V7 stated, Before I even took (R1's) catheter out I could smell the odor of the urine. It was horrible and made me nauseous. When I removed the catheter, there was mucous clogging the insertions site. I put a new catheter in. We did a bladder scan to make sure she wasn't holding large amount of urine, but it was empty. Her kidneys were already shutting down at that point. After inserting the new catheter, she only had about 35 milliliters of urine output in ,d+[DATE] hours. We did everything we could for (R1), but she was so severely septic that her organs were already failing. On [DATE] at 11:40 a.m., V13 (R1's Physician) stated nursing staff should have intervened when R1's urine was first noted to be cloudy. V13 stated that V13 would have had them do a urinalysis to see if there was any infection in R1's urine. V13 stated, I've known (R1) for years and she has never had a catheter prior to this [CONDITION(S)]. V13 stated she had no known diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V13 stated V13 would expect to be called after hours if a resident has a change in condition rather than a fax be sent. V13 stated, I wouldn't even seen the fax until at least the next business day. By the time I saw the fax that was sent to me on [DATE] at 9:40 p.m., (R1) was already in the hospital ([DATE]). I had no indication from the facility that (R1) continued to present with a decline in her condition. I was shocked to say the least. V13 stated a quicker response from the nursing staff to (R1's) cloudy urine could have potentially prevented R1's decline in status, hospitalization and even death. V13 stated that V13 had no knowledge that there was ever an issue with R1's urine. 2. On [DATE] at 11:10 a.m., R2 was lying in bed with an indwelling urinary catheter drainage bag hanging from the frame of R2's bed without being covered in a dignity bag. On [DATE] at 11:32 a.m., V9 (Certified Nursing Assistant) stated, I'm not sure if we have any dignity bags. I'll check into that. R2's current computerized medical record did not include documentation that a catheter assessment was completed to document justification for the use of R2's catheter. 3. On [DATE] at 10:50 a.m., R3 was lying in bed with an indwelling catheter drainage bag hanging from R3's bed frame. R3's catheter drainage bag was not covered or in a bag for dignity. R3's catheter was not secured to her leg and was taunt while she moved in bed and received catheter care. R3 was complaining of burning. R3's catheter drainage bag had a smear of brown substance on the back of the bag. On [DATE] at 10:57 a.m., V11 (Certified Nurse Aide) stated, I'm not sure what that is (on the back of R1's drainage bag). It looks like (Bowel Movement). On [DATE] at 11:30 a.m., R3's catheter drainage bag continued to have the brown substance on the back of the bag. R3's catheter was not anchored to her leg and continued pulling on the catheter every time R3 moved in bed. R3's computerized medical record, including Physician orders, progress notes, assessments, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:33 p.m., V2 (Director of Nursing) stated the nurses should have acted when R1's urine first became cloudy on [DATE] and [DATE]. V2 stated continued monitoring of R1's urine should have been done every shift. V2 stated V13 or the on-call physician should have been called on [DATE] when staff noticed R1 was having a significant change in condition and then continued to monitor her at least once a shift. V2 stated there is a lack of documentation regarding R1's catheter, urine and change in condition. V2 stated R1's catheter was not assessed for medical justification on admission like it should have been. V2 stated she was unsure whether R1 needed to have an indwelling catheter. V2 stated R1's care plan documents R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated, I'm not sure why that was put on (R1's) care plan. V2 stated there is no policy or guidance for the nurses on calling versus faxing a doctor. V2 stated a significant change in condition should be called to the Physician and not faxed, especially after office hours. V2 stated R1 and R3 did not have Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated the facility does not have a catheter assessment. V2 stated R2 and R3 also do not have catheter assessments in their medical record and R3 does not have a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated a soiled catheter drainage bag should be replaced immediately when observed. V2 stated all indwelling catheters should be secured to the resident's leg to prevent tension on the catheter possibly causing damage. V2 stated all urinary catheter drainage bags should be placed in a bag/cover to maintain the resident's dignity. V2 stated she was unsure if the facility had any dignity bags at this time. An Immediate Jeopardy was identified on [DATE] at 9:13 a.m. The Immediate Jeopardy began on [DATE] when R1 was admitted to the facility and a catheter assessment was not completed to ensure R1 had medical justification for the use of an indwelling catheter. This Immediate Jeopardy also includes the facility's failure to identify and monitor R1's signs and symptoms of a urinary tract infection, and failure to implement appropriate interventions when R1's urine became cloudy resulting in R1 experiencing increased lethargy, decreased communication and changes in skin integrity. On [DATE] at 11:00 a.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. On [DATE] at 3:45 p.m., the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The Quality Assurance Consultant educated the Director of Nursing on signs and symptoms of a Urinary Tract Infection, change in condition, reporting of a change in condition on [DATE]. The Director of Nursing educated nursing staff on signs and symptoms of a Urinary Tract Infection, change in condition, reporting of a change in condition on [DATE] and [DATE] and ongoing. 2. The Quality Assurance Consultant educated the Director of Nursing and Unit Manager's on review of urinary catheter guidelines on [DATE]. The Director of Nursing and Unit Managers educated nursing staff on urinary catheter guidelines, completed on [DATE] and [DATE] and ongoing. 3. The facility has current policies and procedures that address catheter care and services, including but not limited to: ongoing assessment and documentation for a resident with a catheter, including the identification of the resident's need for the catheter, the removal of the catheter when the resident's clinical condition demonstrates the catheter is no longer needed, obtaining Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quality Assurance Consultant educated the Director of Nursing and Unit Managers on policies and procedures noted above on [DATE] and ongoing. The Director of Nursing and Unit Managers educated nursing staff on the policies noted above, completed on [DATE] and [DATE] and ongoing. 4. R3 is the only like resident identified with a urinary catheter. R2 no longer resided at the facility, R3 has been reviewed to ensure Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 has been reviewed for any changes in condition. Completed on [DATE] and ongoing. 5. Progress Notes reviewed for all residents for any changes in condition. Completed on [DATE] and ongoing. 6. (The facility's Medical Director) has been notified on [DATE] and will be notified and updated again on [DATE]. 7. A Quality Assurance meeting was held on [DATE] and [DATE] to review findings of the (Immediate Jeopardy) and to review the abatement plan.

Based on observation, interview and record review the facility failed to ensure a scoop mattress, an identified fall intervention, was in place for one resident (R1) of three residents reviewed for falls. This failure resulted in R1 falling out of bed and sustaining a wrist fracture. Findings include: Current Physician Order Report indicates R1 was admitted to the facility 7/7/21 with diagnoses that include Intracranial Injury/Skull Fracture (result of Motor Vehicle Accident), Cognitive Communication Deficit and Anxiety Disorder. Incident Investigation Report dated 9/27/21 indicates R1 was found on that date lying on her back on the floor next to her bed. Report indicates R1 is moderately cognitively impaired and was not in her normal bed due to being in respiratory isolation as a result of COVID-19 exposure. Report indicates R1 was transferred to the hospital after complaining of hip and head pain. Report indicates R1 was transferred back to the facility the same day with diagnosis of closed non-displaced fracture of the left wrist. Hospital Record dated 9/27/21 at 3:48pm indicates R1 only complained of left wrist pain, X-Rays were done which showed a closed nondisplaced fracture (of scaphoid) of left wrist Will splint. Nurse Note dated 9/27/21 at 7:02pm indicates R1 returned to the facility with a small left wrist brace. R1 was observed in bed - on a scoop mattress, in a low bed - multiple times throughout the day on 10/5/21. On 10/5/21 at 9:53am V3, LPN (Licensed Practical Nurse) stated she was the nurse that responded when R1 fell out of bed. V3 stated that R1's bed is supposed to be in the low position and The bed was low but R1's head of the bed was raised higher than usual. On 10/5/21 at 1pm V5, Nurse Unit Manager stated that R1 was not in her usual room when she fell on [DATE]. V5 stated that R1 had a scoop mattress on her bed, but when she transferred to the quarantine room - the scoop mattress was not put on R1's bed. V5 acknowledged that a scoop mattress was previously identified as an intervention to prevent R1 from falling out of bed. Care Plan (date initiated 7/8/21) indicates R1 is at risk for falls due to history of falls, impaired balance/poor coordination and unsteady gait. Care Plan interventions include Scoop/perimeter mattress (dated initiated 8/14/21) and Bed in low position (date initiated 7/16/21). Facility Policy/Falls Practice Guide dated 2011 documents: Individualized interventions are developed and initiated for fall reduction and injury prevention.

Based on observation, record review and interview, the facility failed to ensure adequate staff were present while conducting a mechanical lift transfer for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 sustaining a fall while in the mechanical lift and dislocating R1's left hip subsequently requiring transport to the local hospital and moderate sedation to reduce R1's left hip. Findings include: The facility's Mechanical Lift policy (4/2019) documents the following: To move immobile or obese patients for whom transfer poses potential for staff or patient injury. Verify transfer assist needed per Kardex. Obtain additional assistance and needed equipment as indicated. Use of a mechanical lift requires a second caregiver. Using the hand control, slowly raise the patient to a standing position. If at any time the patient is unable to assist with the transfer and bear weight on lower extremities, return the patient to the sitting position on the chair or bed. The facility's Mechanical Lift Manufacturer Guide (7/2016) documents the following: Intended use: (Mechanical Lift) is a standing and raising aid for short transfers e.g. raising from bed and transfer to wheelchair, or from wheelchair to toilet. (Mechanical Lift) is also suitable for walking training when the footboard and kneepad are removed. (Mechanical Lift) is intended to be used in hospitals, nursing homes or other health care facilities for the different category of residents/patients. Category C, where the resident/patient: Sits in a wheelchair; Is able to bear weight on at least one leg; Has some trunk stability; Is dependent on the caregiver in most situations; And needs mobility-maintaining standing exercise. If possible, the patient should then hold on to the Patient Support arms with one or both hands. The patient is then ready to be lifted. If the patient is able to offer some assistance when standing this may be beneficial to patient confidence and muscular exercise. Patients who can only hold on with one hand, (those who have suffered a 'stroke', for example) may still be lifted by using the (Mechanical Lift). The patient may just rest the unusable arm on the Arc- Rest or hold it across their chest, and rest their elbow on the end of the Arc- Rest, while their usable hand holds the handgrip in the normal way. R1's current electronic Medical [DIAGNOSES REDACTED]. R1's Admission/Readmission Screen (4/25/19) documents R1 was admitted to the facility on [DATE] from an acute care hospital following surgery for [REDACTED]. R1's Patient Transfer Screening Worksheet (4/25/19) documents R1 is to utilize a Sit to stand mechanical transfer device with appropriate weight capacity. R1's Incident Report (4/26/19) documents the following: (R1) was being transferred from her wheelchair with (mechanical lift) to the bathroom and fell to the floor, on her buttocks. (R1) was assessed, range of motion was normal. (R1) complaining of discomfort to the left hip but no more than usual. (R1) then was lifted up by four staff members and gait belt, then (R1) stated, 'It's really starting to hurt.' Pain medication was given and (V6, R1's Physician) called to send to (local hospital). On 4/26/19 at 3:00 PM, V3 (Certified Nursing Assistant/CNA) went to answer (R1)'s call light. (R1) told (V3) she had to use the bathroom so (V3) hooked (R1) up to the mechanical lift to assist (R1) to the bathroom. As (V3) was lifting the patient, the patient let go of the lift handles and knees buckled causing (R1) to fall to the ground on her buttocks. R1's local Emergency Department report (4/26/19) documents R1's admitting [DIAGNOSES REDACTED]. This report also documents the following: (R1) had a dislocation of her left hip. Moderate sedation and closed reduction of (the) left hip was performed and (R1) tolerated well. R1's Statement (4/30/19) regarding the 4/26/19 fall incident documents the following: (V3, CNA) came in to help me to the bathroom. (V3) was getting me ready. I (R1) said, 'Do you need two aides?' (V3) said, 'No we will make it with one.' We started to go and my hands came off the lift and I went straight down (to the floor) on my bottom. The sling was still on me but loose. V3's Statement (4/29/19) regarding the 4/26/19 fall incident documents the following: I (V3) went to answer (R1)'s call light. (R1) stated she needed to use the bathroom. I went to get the (Mechanical sit to stand lift) to transfer (R1) from her wheelchair. I put the sling around her for the lift. I couldn't/didn't look for assist(ance) because I was trying to just get (R1) in the bathroom so she didn't have to wait. I had transferred her the day before with the lift and assist and (R1) did not hold on to it very well but I don't remember if I told my nurse. I started to lift (R1) with the lift and as I kept going up with the lift, (R1) started to slide down out of the sling and I couldn't get the wheelchair under her. (R1) was half way up with the (mechanical lift). I was unable to get the wheelchair under (R1) and (R1) was still in the sling with Velcro strapped around her when her bottom hit the ground with her legs out in front of her with her feet on the machine. On 5/6/19 at 1:00 PM, R1 was sitting in R1's wheelchair watching television. R1 stated, They dropped me over there (pointing to a nearby area in R1's room). (V3) did not have me fastened in well enough and I fell . It just happened so fast. R1 stated that prior to that fall, there had been two Certified Nursing Assistants transferring R1 utilizing the mechanical lift and that it was only V3 transferring R1 when R1 fell . On 5/7/19 at 1:10 PM, V7 (Certified Nursing Assistant) and V8 (Certified Nursing Assistant) transferred R1 from R1's wheelchair to R1's bed with a seated mechanical lift. R1 followed commands for R1's hand placement during the transfer. On 5/6/19 at 2:00 PM, V3 (Certified Nursing Assistant) stated that on 4/26/19 V3 attempted to transfer R1 from R1's wheelchair to the bathroom. V3 verified that V3 did not request assistance while utilizing the mechanical lift to transfer R1. V3 stated that V3 should have obtained a second staff member to assist during the mechanical lift transfer. V3 stated that as V3 lifted R1 using the mechanical lift, R1 started to slip out of the sling and lower towards the floor. V3 stated that V3 tried to get the wheelchair under R1 but R1 continued to lower to the ground and landed on R1's buttocks. V3 stated that V3 was utilizing an extra large sling and V3 thinks that the sling may have been too large for R1. On 5/7/19 at 9:30 AM, V5 (Unit Manager) stated that R1 was a two person stand pivot assist before coming to the facility. V5 stated that R1 was deemed to utilize the sit to stand mechanical lift since R1 was able to sit on the edge of the bed, bear some weight and hold on to the handle bars. V5 verified that V3 should have had a second staff member present when transferring R1 from R1's wheelchair to the bathroom. V5 verified that the mechanical lift's manufacturer guidelines document that if a resident is able to hold on to the handles with one or both handles, then the resident should hold on to the handles. V5 verified that as a result of R1 falling while transferring in the mechanical lift, R1 was sent to the local hospital and found to have a dislocated left hip. On 5/7/19 at 10:45 AM, V2 (Director of Nursing) stated that on 4/26/19, V3 (CNA) attempted to transfer R1 with a mechanical lift from the wheelchair to the bathroom. V2 verified that V3 tried to implement this transfer alone and should have asked for assistance from a second staff member for the transfer. V2 stated that as R1 went up in the mechanical lift, the sling slid up R1's back, R1's arms went inside the sling and R1 began to slide down. V2 stated that R1 was found with the sling still around R1 with R1's arms tucked inside the sling and R1's feet on the foot rest. V2 verified that R1's arms should have remained outside of the sling while being transferred. V2 stated that when R1 returned to the facility, the facility obtained orders to make R1 a total seated mechanical lift instead of the sit to stand mechanical lift.

Based on observation, record review and interviews the facility failed to supervise and prevent a fall for one of three residents (R1) reviewed for falls in a sample of three. While unsupervised and wheelchair unsecured R1 rolled backwards in the facility van. This failure resulted in R1 rolling backwards and tipping over causing R1 to fall out of the wheelchair and hit R1's head, and resulted in a C5 vertebral fracture. Findings include: Facility investigation report for R1's fall on 8/20/18 reads, (R1) is alert and oriented. He is here as a long term patient until V4 (family member) feels she can take care of (R1) at home. (R1) is very impulsive and has poor safety awareness. On 8/20/18 Maintenance Director (V3) left facility with resident in our van to take (R1) to (local hospital) for a scheduled follow-up CT scan of his head from previous fall with a head injury on 8/2/18. Once they arrived at the hospital our staff member (V3) parked the van and went to the back and released the restraints from the wheelchair and the safety belt, (V3) then placed the resident (R1) in front of the lift door and applied his wheelchair brakes and told (R1) to stay put so (V3) could open the lift doors. As (V3) was getting off the van, (V3) heard (R1) yell and (V3) looked back in the van and noted (R1's) feet in the air. (V3) went back on the van and (R1) stated to (V3) at that time that (R1) had released his wheelchair brakes to move the wheelchair because he thought the bar from the ramp was in the way and once (R1) unlocked the brakes the wheelchair rolled back and tipped causing (R1) to fall out of the wheelchair and hit his head. On 8/28/18 at 10:15 A.M., V1 (Administrator) stated that it has been the facility practice to undo the securement straps from residents wheelchairs and rolling the residents in front of the ramp door prior to the ramp being lowered and ready for use. V1 stated that since this incident facility van drivers have been educated that the securement straps will not be released until the ramp is in place and the resident is ready to be rolled onto the ramp by the driver. On 8/28/18 at 1:10 P.M., R1 was lying in the hospital bed with a neck collar on. R1 stated at the time of the fall on 8/20/18 that the driver (V3) was outside the van when R1 unlocked the wheelchair brakes. R1 stated that the van was obviously not flat because as soon as he released the breaks the wheelchair rolled quickly backwards and tipped over. On 8/28/18 at 1:15 P.M., V4 stated that V4 has tried to tell the facility staff that R1 has some confusion at times and does not make safe decisions. V4 stated that she does not understand why V3 would have taken the safety straps off R1 before he was ready to get R1 onto the ramp. V4 stated that R1 has had a rough time in the hospital and has been in a lot of pain with his fractured neck. R1's hospital radiology imaging dated 8/20/18 reads, [MEDICAL CONDITION] body at the level of C5 extending to the level of the vertebral foramen.

Based on record review and interview, the facility failed to ensure all staff had knowledge of the conditions that require initiation of CPR (cardiopulmonary resuscitation) for one of three residents (R1) reviewed for advanced directives/CPR in a sample of three. This failure resulted in R1's advance directives not being honored in that R1 did not receive CPR when R1 suffered respiratory arrest. The failure also has the potential to affect one of three residents (R3) reviewed for advanced directives/CPR in a sample of three and 28 residents (R4-R31) in the supplemental sample. This failure resulted in an immediate jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at severity level two as the facility continues to monitor the effectiveness of training regarding staff knowledge of when to initiate CPR. Findings Include: The facility policy, entitled Cardio-Pulmonary Resuscitation (CPR): Adult, revised ,[DATE], documents, CPR is initiated unless one of three following conditions is present: 1) a valid DNR (Do Not Resuscitate) is in place; 2) initiating CPR could cause injury or peril to the rescuer; or 3) in the presence of obvious signs of clinical death (e.g. (that is), rigor mortis, dependent lividity, decapitation, transection, or decomposition) .Procedure: upon discovering unresponsive patient with no breathing or no normal breathing, call for help .initiate compressions .attach and use AED (automated external defibrillator) .continue CPR until relieved, spontaneous breathing and, or heart rate resumes or emergency medical personnel arrive and assume control of the situation. R1's Routine Physician Orders/MARs (Medication Administration Record), dated [DATE], document, Advanced Directives: Full-Code . R1's medical chart has a full-sized, light purple, sheet of paper the documents RESIDENT IS A FULL CODE . R1's Admission Record Report, dated [DATE], documents, Current admitted -[DATE]. R1's (Facility initials/city) Progress Notes, dated [DATE], charted by E3 (Licensed Practical Nurse), document, 1745 (5:45 p.m.) this nurse reentered room to check on the resident and there were 0 respirations, skin cool no VS (vital signs) or heart tones. R1's medical records do not document CPR was ever initiated, or the 911 was ever notified. On [DATE], at 12:25 p.m., E5 (Registered Nurse/Nurse Manager) confirmed: being the first nurse to find R1 unresponsive, on [DATE] at 5:45 p.m., in R1's bed; R1 was a full code status per R1's chart; CPR should have been started right away; and CPR was not done at any time. On [DATE], at 12:50 p.m., E5 confirmed R1 did not have any of the clinical signs of death according to the aforementioned facility policy. On [DATE], at 12:00 p.m., E2 (Director of Nursing), confirmed: R1 was admitted on [DATE] from a local hospital; R1 was to be a short-term stay and then be discharged to R1's home; R1 was a full-code status upon admission;R1's code status was on the kardex at the nurse's station, and in R1's room for staff to see; E5 (Registered Nurse) should have started CPR immediately upon finding R1 unresponsive; and E5 should have called for help and notified 911 services. On [DATE], at 12:44 p.m., E3 confirmed: E3's aforementioned nursing progress notes; R1 was a full code; CPR was not performed on R1; CPR should have been performed on R1; and 911 was not notified. The facility document, entitled Record of Death, documents R1's date of death : [DATE] and Hour: 5:45 p.m. On [DATE] at 4:25 p.m., E2 confirmed: E5, being an RN, would respond to any codes in the facility; and there are 29 residents (R3-R31), residing in the facility that have a code status of Full (requiring all life support measures). The Immediate Jeopardy was identified on [DATE] at 2:45 PM. The Immediate Jeopardy began on [DATE] at 5:45PM when the facility failed to identify when CPR is to be initiated. E1 (Administrator) and E2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 12PM. The surveyor confirmed through observation and interview that the facility took the following actions to remove the Immediate Jeopardy: 1) The DON/designee provided education for licensed staff licensed staff on F-tag 155; that licensed staff provide basic life support, including CPR to a resident requiring such immediate care prior to the arrival of emergency services & subject to the related MD orders and the patient's advance directives; Review of CPR; Adult guideline; Emergency Management Guideline to include documentation of emergency services provided and mock drills; and AED use. Inservice sheets were signed by staff. (Started [DATE] and finished [DATE]) 2) E3 and E5 received 1:1 re-education on the aforementioned training (item 1)). (Completed On [DATE]) 3) Human Resource Department reviewed nursing staff files and composed a list of CPR certification dates, identified staff needing recertified, and has scheduled CPR instruction for those in need. There will be a verified CPR-trained member of staff on each shift. (Completed On [DATE]) 4) Director of Nursing completed an audit of residents' code status and ensured the appropriate color-coded identifiers and Physician Order's for Life-Sustaining Treatment (POLST) forms are on the resident charts. (Completed On [DATE]) 5) E2 Director of Nursing and E6 Unit Manager reassessed like residents to identify current CPR status including proper orders. (Completed On [DATE])

Based on record review and interview, the facility neglected to follow their policy regarding Cardio-pulmonary Resuscitation (CPR) initiation, for one of three residents (R1) reviewed for advanced directives/cardiopulmonary resuscitation in a total sample of three. This failure resulted in R1 having no opportunity for resuscitation after experiencing cardiac and respiratory arrest. Findings Include: Facility policy, entitled, Patient Protection:Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention, copyright date 2016, documents, Neglect is the failure of the facility, its employees or service providers to provide goods or services to a resident . The facility policy, entitled Cardio-Pulmonary Resuscitation (CPR): Adult, revised ,[DATE], documents, CPR is initiated unless one of three following conditions is present: 1) a valid DNR (Do Not Resuscitate) is in place; 2) initiating CPR could cause injury or peril to the rescuer; or 3) in the presence of obvious signs of clinical death (e.g. (that is), rigor mortis, dependent lividity, decapitation, transaction, or decomposition) .Procedure: upon discovering unresponsive patient with no breathing or no normal breathing, call for help .initiate compressions .attach and use AED (automated external defibrillator) .continue CPR until relieved, spontaneous breathing and, or heart rate resumes or emergency medical personnel arrive and assume control of the situation. Facility document, entitled (R1's name), dated [DATE], documents R1 is a full code. Per E2 (Director of Nursing), on [DATE], at 12:00 p.m., this document was taped in R1's closet, and located at the nurse's station, and is used as a quick reference to R1 Activities for Daily Living, Safety, Skin Care, and Special Needs Care. R1's Routine Physician Orders/MARs (Medication Administration Record), dated [DATE], documents, Advanced Directives: Full-Code. R1's Admission Record Report, dated [DATE], documents, Current admitted -[DATE]. R1's (Facility initials/city) Progress Notes, dated [DATE], charted by E3 (Licensed Practical Nurse), document, 1745 (5:45 p.m.) this nurse reentered room to check on the resident and there were 0 respirations, skin cool no VS or heart tones. R1's medical records do not document CPR was ever initiated, or that 911 was ever notified. On [DATE], at 12:00 p.m., E2 (Director of Nursing), confirmed: R1 was a full-code status; E5 (Registered Nurse) did not initiate CPR upon finding R1 unresponsive; E5 should have called for help, started CPR, and notified 911 services. On [DATE], at 12:25 p.m., E5 (Registered Nurse/Nurse Manager) confirmed: being the first nurse to find R1 unresponsive in R1's bed; R1 was a full code status per R1's chart; CPR should have been started right away; and CPR was not done. The facility document, entitled Record of Death, documents R1's date of death : [DATE] and Hour: 5:45 p.m.

Based on record review and interview, the facility failed to ensure staff provided change in status assessments for one of three residents (R1) reviewed for assessments, in a sample of three. This failure resulted in R1 being found not breathing and without a pulse after a 25 minute period of time between status checks. Findings Include: physician's orders [REDACTED]. Discharge Summary from the local hospital, dated 12-26-16, documents that R1 had oxygen saturation levels from 92-96% on room air. Skilled Nursing Progress Note, dated 12-27-16 at 10:13 PM, state, resident is alert and able to make needs known . Skilled Nursing Progress Note, dated 12-29-16 at 3 AM, document that R1 is alert and oriented x3 (to person, place and time). The facility policy, entitled Change in Condition, dated 11/2016, documents, immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and is a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. R1's: Routine Physician Orders/MARs (Medication Administration Record), dated 1/1/2017, documents, Advanced Directives: Full-Code; Admission Record Report, dated 1/1/2017, documents, Current admitted [DATE]; Radiology Report, dated 1/1/2017, documents, Patchy perihilar infiltrates and subsegmental atelectasis with minimal right pleural effusion; and physician's orders [REDACTED]. R1's vital signs are documented in the electronic medical record as blood pressure-115/26, heart rate-89 and respiratory rate-20 on 1-2-17 at 10:55 AM. R1's vital signs are documented in the electronic medical record as blood pressure-143/67, heart rate-83 and respiratory rate-24 on 1-2-17 at 8:30 PM. R1's (Facility initials/city) Progress Notes, dated 1/3/2017, at 11:17 a.m., document, Cont(inues) to have increased SOB (shortness of breath), at rest and esp(ecially) with any exertions. O2 (oxygen) is running at 3 L (liters) per nasal cannula, and sat(uration) is just at 89%. Up to 4L with no improvement. Remains on (levofloxicin) for pneumonia . R1's medical record does not document R1's physician was notified, nor any new orders prescribed. R1's medical record does not provide any further documentation until 1/3/2017 at 5:20 p.m. R1's (Facility initials/city) Progress Notes, dated 1/3/2017, charted by E3 (Licensed Practical Nurse), document: 1) 1720 (5:20 p.m.) VS (vital signs) were taken MD (medical doctor) was called for new order for nebs (breathing treatments). BP (blood pressure) 98/42, P (pulse) 96, R (respirations) 22, T (temperature) 98.6. Resident was alert and responding could not tell me what was wrong with her she kept saying I don't know; 2) 1745 (5:45 p.m.) this nurse reentered room to check on the resident and there were 0 respirations, skin cool no VS or heart tones; R1's medical records do not provide documentation that vitals, or status checks, were done on R1, from 5:20 p.m. to 5:45 p.m. on 1/3/2017. On 1/5/2017, at 12:44 p.m., E3 confirmed: E3's nursing progress notes; and confirmed no resident status checks were done from 5:20 p.m. to 5:45 p.m. on 1/3/2017. On 1/5/2017, at 12:00 p.m., E2(Director of Nursing) confirmed: R1 was admitted on [DATE] from a local hospital; R1 was to be a short-term stay and then be discharged to R1's home; R1 was a full-code status upon admission; and no resident status checks were done from 5:20 p.m. to 5:45 p.m. on 1/3/2017. On 1/5/2017, at 3:30 p.m., R2 (R1's roommate on 1/3/2017), stated, in between R1's vitals being taken (at 5:20 p.m.) and staff coming back in the room (at 5:45 p.m.), all R2 heard was noises and I knew she needed help. R2 was unable to give a timeframe for when R2 last heard any noise from R1's side of the room. The facility document, entitled Record of Death, documents R1's date of death : 1/3/2017 and Hour: 5:45 p.m.

Based on record review and interview, the facility failed to analyze fall history, determine root cause for falls, and develop and implement individualized care plan interventions for fall prevention for two residents (R5 and R6) of 13 evaluated for fall histories in a total sample of 15. R5 and R6 sustained hip fractures. Findings include: 1. The facility's Monthly Safety Tracking Logs for January through December 2011 indicated that R6 had experienced falls on 1/1, 1/6, 3/20, 6/2, and 10/8/11. The logs indicated that R6 sustained a laceration during the fall on 3/20/11 and a fracture on 10/8/11. R6's care plan dated 12/28/11 instructed staff in the Intervention section for R6's fall risk problem,"Do not leave unattended in room when in wheelchair." This intervention was noted as having been added to the care plan on 3/20/11. An incident report dated 10/8/11 indicated that R6 was found lying on her left side on the floor of her room in front of the sink at 10 AM on that date. The facility's investigation report dated 10/8/11 for this incident indicated that after complaints of pain in the left hip, an x-ray of R6's left hip showed a left femoral neck fracture. The report also stated that R6 was then transferred to the hospital for fracture treatment. A written account of an interview done with E4 (Licensed Practical Nurse) on 10/8/11, as part of the facility's investigation, indicated that E4 found R6 earlier that morning lying on her left side on the floor of her room next to R6's wheelchair. E4 stated on 1/9/12 at 2:45 PM that R6's incident of 10/8/11 occurred during a period when R6 was alone in her room, so the fall was not witnessed. E4 said that R6 was found in front of the room sink, and R6 frequently used the sink for brushing her teeth. 2. R5 has had three admissions and discharges to the hospital from 1/7/1 1 through 11/1/11 with at least 18 documented falls since his initial admission of 1/7/11 at the facility. R5's Minimum Data Set of 10/17/11 for a significant change noted R5 is "total dependence- requiring full staff performance every time during the entire 7-day period" with "one person physical assist." Section J1800 is not addressed for a fall history on admission. Fall investigation-incident report for 1/28/11 fall for R5 states under #12: "Results of investigation: resident has cognitive impairment-dementia. Resident stood up and missed the chair when trying to sit back down. No injuries noted. Will continue with current plan of care. Care plan was in place at time of the incident." No new approach was evidenced. Interview with the Director of Nurses, E2, on 1/10/12 at 10:00 am verified that the falls of 1/28, 4/11 and 8/11 were not addressed with new careplan interventions. The three falls were not specifically identified with careplan up-dates for each of the individual falls, rather summarized together without dates to identify the related fall to the new intervention. On 1/11/12 at 9:20 am the Director of Nurse, E2, verified that the care plan staff were not aware that the care plans did not include all the interventions for falls individually addressed. The facility's documentation on the Comprehensive Assessment does not show any entries under the "history of falling" to analyze the findings. Past history of falls at the facility with conclusions about the root causes with contributing factors related to previous falls were not identified and summarized to prevent further incidents. The hospital physical and history of admission of 10/5/11 states " fell about a week ago. Apparently an xray was negative or not done. Had an xray done at nursing home and showed a femoral neck fracture. (R5) is bedridden with assistance so the pain in the hip wasn't identified by weight bearing." Incident report of 10/3/11 entry entered by E5, Registered Nurse, Director of Care Delivery, "The hipster's were not applied after incident report due to increased pain. The physician was contacted on three or more different occasions requesting x-rays and scheduled pain medication. Resident was admitted to hospital for a fractured left neck femur and repair. This was five days after 2 falls (9/29 at 9:15 PM and 9/27/12 at 11:00 AM.) had occurred. Hipsters were never attempted or assessed by therapy as stated for intervention. This intervention was deemed not appropriate due to increased pain issues resulting in a fracture after two x-rays completed."