Every finding on record at Allure Of Moline

Based on interview and record review the facility failed to ensure a resident's change of condition was followed through for medical evaluation. This applies to 1 of 6 residents (R2) reviewed for quality of care in the sample of 6. The findings include: R2's face sheet shows she has diagnoses including vascular dementia with agitation, type 2 diabetes, unspecified protein calorie malnutrition, cellulitis of face, and zoster ocular disease. On 7/10/26 at 10:55 AM, V3 (ADON) said on 6/5/26, she was the second shift nurse for R2. V4 (Nurse Practitioner) had rounded on R2 during the day shift. R2 was previously being treated for pink eye, then scratched her face and developed cellulitis. R2 was receiving an oral antibiotic. R2's left eye and facial area did not look good and was progressively getting worse. Her left eye was swollen, reddened with thick drainage. The family expressed concerns regarding her face and demanding that she be sent to the hospital. V3 said she explained to the family they were managing the infection, and she did not feel it was an emergency. The family became upset and aggressive. V3 then called V1 (Administrator) to report the family's concern and she was instructed by V1 to send R2 out. V3 said it was never reported to her there was a discussion on the previous shift between V4 (Nurse Practitioner) and V2 (DON) regarding sending R2 to the hospital. On 7/10/26 at 11:10 AM, V2 (DON) said on 6/5/26 she worked as the day shift nurse for R2. R2's family was visiting and was upset regarding the condition of R2's face. R2 had scabbing where she scratched herself and her eye was matted with green drainage. The left side of her face was swollen from the top of her hairline to down to the left cheek area. V4 rounded that day around 10:30 AM and she discussed with her potentially sending R2 out to the hospital for evaluation. V2 said V4 planned to reach out to V13 (Medical Director) and follow up with any new orders. V2 confirmed she did not follow up or call V4 regarding R2's condition or transfer status, stating, We should have followed up. On 7/10/26 at 11:26 AM, V3 (ADON) said V4 (NP) reported having called V2 (DON) and leaving her a voicemail that day advising R2 to be sent out to the hospital. V3 said she was unaware of this message. V3 said she transferred R2 out to the hospital because the family was upset with R2's eye condition. She was not aware of any prior communication that day regarding R2's condition and it was not reported to her to follow up with V4 regarding R2's status to be sent out for evaluation. On 7/10/26 at 11:44 AM, V4 (NP) said on 6/5/26 she rounded R2. The left side of R2's face from her hairline down toward the nose and into left cheek was reddened and swollen. R2's left eye was matted and completely swollen shut, it looked like possibly shingles. She reported to V2 (DON) that she was going to consult with the V13 and would follow up regarding whether R2 needed to be sent out to the hospital. V13 reported to her that R2's condition could not be treated at the facility and recommended R2 to be sent out to the hospital. V4 said she called V2 (DON) and left her a voicemail instructing her to send R2 out to the hospital, but she never received a return call from V2. V4's Progress note dated 6/5/26 shows (R2) is seen today for a follow up visit. (R2) has developed redness around the left eye that has since spread to the bridge of her nose, the center of the forehead, across the hairline and covers the left area of the forehead as well. The left eye is swollen shut with a large amount of thick yellow drainage. She was initially placed on ofloxacin eye drips for a possible infection to the left eye.and switched to amoxicillin. The provider called and spoke with the medical director regarding her potential infection.it was decided she send out to the emergency room for further evaluation of possible cellulitis versus shingles to eye and face. (V2) was notified that (R2) will need to be sent to the emergency room. R2's nurses note dated 6/5/26 at 4:22 PM, per family's request nurse called 911. Provided education to family that she currently is receiving an antibiotic for eye/cellulitis. R2's family agitated and hostile. V4 made aware. R2's hospital records dated 6/5/26 show she was treated for herpes zoster ophthalmicus and preseptal cellulitis. R2 was admitted for worsening left sided rash despite outpatient antibiotic therapy. Ophthalmology evaluation confirmed herpes zoster and was managed with IV ampicillin (antibiotic) for infection.

Based on observation, interview, and record review, the facility failed to honor residents' request not to use Styrofoam products during meals for 8 of 12 residents (R2, R3, R6, R8, R9, R10, R11 and R12) reviewed for dignity in the sample of 12.The findings include:On 3/6/26 at 12:40 PM during lunch, R2, R9, R10, R11 and R12 were served their lunch using Styrofoam products including Styrofoam plates, Styrofoam cups, and plastic utensils. R2 stated I have told them before I do not like Styrofoam, I prefer my meals served in ceramic dishes or regular dishes. R9 and R11 both said it would be nice to at least be served our meals in regular dishes. R10 and R12 said this was not the first time they were served using Styrofoam products. R10 and R12 said they would prefer non-disposable dishes rather than Styrofoam. R3, R6 and R8 said they have been served their meals using Styrofoam products before. They would like the regular dishes. V1 (Administrator) who was also in the dining room said she was also wondering why Styrofoam products were being used at lunch; it should not be, they need to use regular dishes.On 3/6/26 at 9:15 AM, V5 (Certified Nursing Assistant-CNA) said Styrofoam products were used during meals to residents that eat in their rooms.On 3/6/26 at 12 PM, V6 (CNA) said Styrofoam products were used at times in the dining rooms during meals and room trays. On 3/6/26 at 1:10 PM, V2 (Director of Nursing) said using Styrofoam during meals is a dignity issue, this is the resident's home, they need to use regular dishes at mealtimes.On 3/6/26 at 2PM, V1 said she had ordered regular dishes to replace the use of Styrofoam products. Regular dishes should be used in the dining rooms and room trays (except when residents were in isolation that requires use of plastic wares.)The facility Policy entitled Promoting and Maintaining Resident's Dignity during Mealtimes (undated) states, it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life recognizing its residents individuality and protecting the rights of each residents.

Based on observation, interview and record review the facility failed to securely store medications for two residents (R15 and R21). This failure has the potential to affect all medications being stored in the E Hall cart (R5,R6 and R9 through R42.)The Facility's undated Medication Storage documents It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light and ventilation, moisture control, segregation and security. On 11/25/25 at 8:45 AM V5 (Licensed Practical Nurse) was in the main dining room with two clear medication cups with pills in them in one hand and a glass of tan brownish liquid. V5 handed the glass of liquid to a resident then stopped and handed medications to R15 and then handed another cup to R21. On 11/25/25 at 9:15 AM V5 (LPN) stated that she forgot to give a resident his protein drink, so she dropped that off and then administered R15 and R21's medications. V5 stated that the medication cups contained all of R15 and R21's scheduled 8:00 AM medications. R15's Medication Administration Record dated November 2025 documents R15's scheduled 8:00 AM medications as Gabapentin 100 mg (milligrams), Aspirin 81 mg, Baclofen 10 mg, Multiple Vitamins with Minerals, Pepcid 20 mg, and Senna Tablet 8.5 mg. R21's Medication Administration Record dated November 2025 documents R21's scheduled 8:00 AM medications as Famotidine 20 mg, Lithium Carbonate 150 mg, Ascorbic Acid 500 mg, Aspirin 325 mg, Potassium Chloride 20 meq (milliequivalents), Vitamin D3 2000 Units, Eye-Vites (multivitamins), mucus relief 400 mg. On 11/25/25 at 10:00 AM V1 (Administrator) stated All medications should be kept in the carts and the nurses should only pass one person's medications at a time to avoid possible medication errors.

Based on interview and record review the facility failed to prevent abuse for two residents (R5 and R8) of three residents reviewed for abuse in a total sample of forty-two. The Facility's undated Abuse, Neglect and Exploitation policy 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 prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 1.The Facility's Final Investigative Report dated 11/10/25 documents that R6 pushed R8 into a wall. On 11/25/25 at 2:30 PM R8 confirmed that he was pushed by R6 some time ago. R8 stated I ran into the wall. R8 stated I was relatively new to the place and did not realize once (staff) announce it is time for a smoke break that some of them (other residents) will run for the door. (R6) wanted me out of his way pronto. Throughout the survey R6 refused to speak to this surveyor. V5 (Licensed Practical Nurse) stated (R6) only speaks when he wants to. It is normal for him to not answer questions when he is asked. 2.The Facility's Final Investigative Report dated 11/24/25 documents that R7 struck R5 on the arm. The investigation documents that R5 has a history of mumbling to himself and making noises randomly which then annoyed R7 who struck him on the arm. Throughout the survey R5 did not answer any questions. R5 was noted to be mumbling incoherently and making clicking noises. On 11/25/25 at 2:45 PM R7 confirmed he lightly smacked R5's arm. Those noises are annoying. On 11/26/25 V1 (Administrator) confirmed that the allegation of physical abuse regarding R6 and R8 dated 11/10/25 and the allegation dated 11/24/25 regarding R7 and R5 would be considered substantiated because they did happen.

Based on observation, interview and record review the facility failed to ensure a resident's call light was within reach for 1 of 3 residents (R1) reviewed for accommodation of needs in the sample of 3. The findings include:On 9/12/25 at 10:47 AM, R1 was lying in bed. R1's nightstand was located on the left side of her bed. R1 was unable to move her left arm independently. R1 said that on a date that she does not recall, an aide came into her room at night and took her call light away. R1 said that she threw it and said that she was using it too much. On 9/12/25 at 12:07 PM, V4, Certified Nursing Assistant (CNA) said that R1 does use her call light frequently. V4 said that she uses it every one to two hours throughout the night and typically wants to be repositioned in bed. V4 said that on the date of the incident, she was working nights and day shift. V4 said that typically R1 would call to get up around 7:00 AM and on that day she did not call so she went into her room around 7:30 AM to get her up. V4 said that R1's call light was on her nightstand and not within reach of her. V4 said that R1 is unable to turn herself so she would not have been able to place it on the nightstand nor reach it if she needed something. V4 said that R1 told her that the CNA from night shift came in and took it away from her and told her that she was using it too much. On 9/12/25 at 1:05 PM, V5 (CNA) said that if a resident is in bed, the call light should be clipped on or near them. On 9/12/25 at 1:57 PM, V2 (Director of Nursing) said that R1 came to the facility after having a CVA and is unable to move her left side but is able to move her right side. V2 said that R1 is fairly alert and oriented. V2 said that R1 is able to use her call light and it should be pinned to her chest when she is in bed. V2 said that R1 would not be able to reach her call light if it was on her nightstand. On 9/12/25 at 12:07 PM, V1 (Administrator) said that it was reported to her by V4 that when she went into R1's room, her call light was on her nightstand and not within reach and R1 had told V4 that the night CNA told her that she was using it too much and took it away. V1 said that she started an investigation and R1 told her the same story so V3 was terminated. R1's Minimum Data Set assessment dated [DATE] shows that her cognition is intact, has an impairment to one side of her upper and lower extremities and requires substantial/maximal assistance for bed mobility.R1's Activities of Daily Living Care Plan shows that she has a self-care performance deficit related to CVA with hemiplegia affecting her left side with intervention of: Encourage to use bell to call for assistance. The facility's Call Light: Accessibility and Timely Response Policy shows, Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview and record review the facility failed to ensure a resident with dysphagia (difficulty swallowing) on a puree diet was supervised in the dining room. This failure allowed R1 to move through the dining room and consume solid foods from resident trays, resulting in him choking and expiring. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 4.The Immediate Jeopardy began on 8/9/25 when R1 was unsupervised in the dining room, choked on food and expired. V1 Administrator was notified of the Immediate Jeopardy on 8/19/25 at 8:10 AM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 8/11/25, prior to the start of the survey and was therefore Past Noncompliance. The findings include:R1's admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery, hemiplegia (partial paralysis), unspecified affecting right dominant side, aphasia (difficulty speaking) following cerebral infarction, and dysphagia (difficulty swallowing), oral phase.R1's August order summary report documents a diet order for a general diet with a pureed texture and nectar consistency liquids. Double portions, fortified ice cream twice daily. Up in chair for all intakes. Must be supervised closely in dining room for taking food. Patient with choking and aspiration risks. R1's annual Resident Assessment and Care Screening of 8/6/25 documents him to have moderate cognitive impairment. His functional abilities assessment showed he uses a wheelchair for mobility. The same assessment documented he required supervision for eating.R1's care plan documents a swallow risk related to dysphagia and Cerebrovascular Accident (CVA). At risk for choking due to removing food and eating from other resident's trays that is not on prescribed diet, attempts to eat nonfood items. The interventions include R1 was to only eat with supervision.R1's nursing progress note of 8/9/25 showed he finished his pureed dinner, and he was cleaned up and self-propelled across the dining area towards his room on D hall. At approximately 6:45 PM, V6 Certified Nursing Assistant (CNA) noted R1 sitting at the beginning of the hallway in obvious distress, face pale in color. Two CNAs rushed to assist resident and noted he was choking and started the Heimlich maneuver immediately. V1 Licensed Practical Nurse (LPN) was alerted and intervened. A partial bolus of food was removed from his mouth and the Heimlich was continued. Emergency Medical Technicians (EMTs) arrived on the scene and assumed intervention including suctioning, IV medications, chest compressions, and intubation. These efforts were futile and R1 was pronounced dead at 7:27 PM. On 8/17/25 at 8:15 AM, the dining room was observed to be a large open room. Upon entrance, A wing was directly to the left, then following around the room to the right was B wing, and C wing was located straight from the entryway. Followed by D wing then to the right was E wing. A short pony wall surrounded the dining area with room to move around the room behind the walls. Nurses had their carts behind the walls preparing and passing medications. Staff were serving breakfast.On 8/17/25 at 8:20 AM, V7 LPN said R1 was on a pureed diet, and was able to feed himself. She said he was on a puree diet due to the weak muscles in this throat following a stroke. He was alert but non-verbal. He seemed to understand what was being said to him, and he knew he was not supposed to have solid foods. He would always be grabbing and sneaking food off of trays and hurry and stuff it in his mouth. V7 said R1 could propel the wheelchair himself with his left foot. She said sometimes the staff would take him out of the dining room and he would just go back in, and he would grab at food.On 8/17/25 at 11:00 AM, V5 CNA said R1 was alert and always did his own thing and did not like to listen. He did not speak; he used a lot of hand motions. She said R1 was on a puree diet, and he could feed himself, and he also had thickened liquids. He would try to take food mainly from the snack cart or food left on tables. We reminded the independent residents not to leave food behind. She said R1 was non-complaint with his puree diet and was quick to grab anything and try to eat. She said there was no special rules or procedures to ensure he left the dining room without grabbing food as he was leaving. She said it was just common knowledge among the aides to just keep an eye on him because of his behaviors of grabbing at food.On 8/17/25 at 11:20 AM, V6 CNA said she has witnessed R1 snatching food such as a pork tenderloin sandwich and a burger. She said R1 was able to feed himself and propel himself, and he did need to be watched when he was leaving the dining room. When he would get food he would stuff it in his mouth really fast because he knew he was not supposed to have it. V6 said on 8/9/25 she was in the dining room for the dinner meal and had her back turned while feeding other residents. She did not know where R1 was located at the time. She said call lights were going off on D wing, so her and V3 CNA decided to go check. She said as she was walking towards D wing she noticed R1 and he appeared to be choking. She began doing back thrusts and the Heimlich maneuver. She said it appeared bread and hot dogs were in his mouth. On 8/17/25 at 11:36 AM, V3 said she did see him once trying to take a sandwich off of another resident's tray. If he was leaving the dining room and seen a plate, he would try and take food. He wandered in his wheelchair and able to go wherever he wanted. She said the staff would monitor him but could not watch him 24/7. She said in the dining room there would be 2-3 aides sitting at a table assisting residents to eat. V3 said R1 would sit in the dining room closer to the B wing entrance and would take himself out of the dining room. Sometimes he would go around the short wall of the dining room or through it. There was no set process or procedure. V3 said she was walking with V6 towards D wing when they noted R1 to be choking and she assisted with resuscitation measures, but R1 expired. V3 said she was speaking with V4 LPN and heard her say she had just passed R1 and he had food in his mouth but did not do anything.On 8/17/25 at 12:30 PM, V4 said R1 was on a puree diet and had behaviors of taking food from the dining room tables. She did not see him before the choking incident on 8/9/25. She said R1 was able to move himself through the facility. There was no procedure or protocol in place at that time to ensure he got out of the dining room without stealing food from plates.On 8/17/25 at 2:30 PM, V1 Administrator said she was working as an LPN the night of the incident. She said during the meal service, she recalls R1 was in the dining room at his table near the entrance of B wing. He was eating his pureed diet and able to move himself around. V1 said she was at the nurse's station when she heard staff calling for help. She saw V3 and V6 giving back thrusts and performing the Heimlich maneuver, and it was not helping. She said you could tell his mouth was full of food, and as she was pulling it out, it appeared to be hot dogs and buns. V1 said 911 was called, and she continued efforts to get the food out. When the EMTs arrived, they tried to intubate him, but could not get the tube in, and R1 could not breathe. She said the EMTs tried for 40 minutes, but R1 expired. V1 said R1 was always trying to get food off plates in the dining room. Most of the time residents will yell out at the staff to alert us to him stealing food. She said none of the residents ever said anything. V1 said R1 was sat next to those residents needing fed, but he moved so fast. He must have picked up food while he was moving through the dining room. All of the CNAs are to be in the dining room and passing trays. During that time, R1 needed better supervision. Everyone is supposed to be monitored. Should have been watching (R1) and taking him out of the dining room. We did fail him somewhere, I guess.The facility's revised 8/11/25 policy for meal supervision and assistance documents The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: 1. Identifying hazards and risks 2. Evaluating and analyzing hazards and risks 3. Implementing interventions to reduce hazards and risks 4. Monitoring for effectiveness and modifying interventions when necessary.The immediate jeopardy that began on 8/9/25 was removed on 8/11/25 when the facility: Identified all residents who could potentially be affected by a choking incident from ingesting food not on their recommended diet, have adequate supervision in place during meals and while exiting the dining area. Care plans for residents with pureed and mechanical soft diets were reviewed for accuracy. Revisions were made to reflect all current supervision and safety interventions. The revisions were reviewed with staff involved in the care of each resident and updated on the staff assignment sheet and cheat sheets. The deficient practice was corrected on 8/11/25 after the facility: Audited care plans of all the residents requiring modified diets, and supervision while eating. All care plans have been reviewed and modified for accuracy. Environmental review of the dining room completed on 8/10/25 and table changes made as necessary as well as identified residents at risk, are now escorted from the dining room after meals. Residents on a pureed diet will be seated together for resident dignity and safety/supervision with a staff member assigned to their table. On 8/11/25 all licensed nursing staff were in-serviced on the facility policy for Meal Supervision and Incidents and Accidents. On 8/11/25 an emergency Quality Assurance and Performance Improvement (QAPI) meeting was held with the medical director. Hot Dogs will no longer be served in the building, and an adequate replacement has been implemented. Quality Assurance (QA) tools developed post QAPI to ensure quality and compliance. New staff will receive the education during their onboarding process.

Based on observation, interview, and record review the facility failed to provide privacy for a resident during her shower by not closing the door for 1 of 3 residents (R2) reviewed for privacy in the sample of 8. The findings include: On 7/9/25 at 10:20 AM the C hall shower room door was halfway open, and the shower was on. R2 was naked sitting in shower chair covered in soap. V4 Certified Nursing Assistant (CNA) was washing R2 in the shower. R2 and V4 were asked if they would like the door closed while R2 is in the shower. V4 replied, Yes. R2 stated she wanted the door closed and didn't like that it was open. On 7/9/25 at 12:45 PM, V1 Administrator stated staff are supposed to close the door when giving a resident a shower for the resident's privacy and dignity. On 7/9/25 at 1:38 PM, V5 CNA stated they always shut the door in bathroom and when a resident takes a shower for the privacy of the resident. On 7/9/25 at 1:43 PM, V3 Assistant Director of Nursing (ADON) stated the resident's door should be shut for privacy during care, when on the toilet, and when they are in the shower. The Face Sheet dated 7/9/25 for R2 showed diagnoses including Parkinson's, acute osteomyelitis of left ankle and foot, chronic obstructive pulmonary disease, type 2 diabetes mellitus, severe protein calorie malnutrition, methicillin resistant staphylococcus aureus, bipolar disorder, vertigo, anxiety disorder, hypomagnesemia, nicotine dependence, peripheral vascular angioplasty status with implants and grafts, erysipelas, radiculopathy, hypertension, deep venous thrombosis, Charcot's joint of left ankle and foot. The Minimum Data Set for R2 dated 5/23/25 showed she is alert and oriented with no cognitive impairment. R2 is dependent for toileting and bathing. The facility's Promoting/Maintaining Resident Dignity policy (2024) showed, all staff members are involved in providing care to residents to promote and maintain dignity and respect residents rights. Maintain resident privacy.

Based on interview and record review the Facility failed to provide the services of a Registered Professional Nurse (RN) for eight consecutive hours a day, seven days a week. This failure has the potential to affect all 99 Residents in the Facility. Findings include: The Facility's Long Term Care Facility Application for Medicare and Medicaid, dated 5/18/25, documents 99 Residents residing in the Facility. The Facility Assessment Tool, dated 5/5/25, documents: the purpose is to determine what resources are necessary to care for Residents competently, including staff and staffing plan; and decisions about direct care staff, as well as your capabilities to provide services to the Residents in your Facility; serve as a record for staff and management to understand the reasoning for the decisions made regarding staffing and other resources necessary to carry out Facility function; and identify the type of staff members that are needed to provide support and care for the Residents. The Facility's Daily Staff Posting Sheets, dated 5/3/25 through 5/19/25, does not document an eight hour assignment for a Registered Nurse (RN). The Facility Monthly Nursing Schedule, dated 5/4/25 to 5/21/25, does not document an eight hour assignment for a Registered Nurse (RN) on 5/5/25, 5/6/25, 5/7/25, 5/8/25, 5/9/25, 5/10/25, 5/11/25, 5/13/25, 5/16/25, 5/17/25, 5/18/25, 5/19/25, 5/20/25 and 5/21/25. On 5/21/25 at 11:45 am, V9 (Corporate Nursing Officer) stated, We just cannot find Registered Nurses. We increased our hourly pay and offered incentive bonuses, but we just cannot find them. There are RNs out there but we do not want to hire a lot of them due to their poor former work ethic with our company or reputation within the community. We have a dedicated corporate person now just for hiring nurses.

Based on interview and record review the facility failed to provide a copy of the bed hold policy for residents discharging to the hospital for four of four residents (R14, R19, R34, and R52) reviewed for bed holds in the sample of 35. Findings include: The facility's Bed Hold Notice, undated, documents that it is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. 1. R14's medical record documents that R14 was discharged to the hospital on 1/5/25. R14's medical record does not contain documentation that a written notice of the facility's bed hold policy was given to R14 or R14's resident representative. 2. R52's medical record documents that R52 was discharged to the hospital on 1/27/25. R52's medical record does not contain documentation that a written notice of the facility's bed hold was given to R52 or R52's resident representative. 32061 3. R19's medical record documents that R19 was hospitalized on [DATE], 3/21/2025, 4/19/2025 and 5/16/2025. R19's medical record does not contain documentation of written notice to R19 or R19's resident representative, of the facility bed hold policy. 4. R34's medical record documents that R34 was hospitalized on [DATE] and 3/23/2025 . R34's medical record does not contain documentation of written notice to R34 or R34's resident representative, of the facility bed hold policy. On 5/19/25 at 12:45pm, V1, Administrator, stated that bed holds were not given to the residents at the time of the transfer. V1 verified the facility does not send the Bed Hold Notices as they should and is aware of it being an issue.

Based on interview and record review the facility failed to monitor blood levels of a psychotropic medication (Lithium Carbonate) per physician order for one of five residents (R44) reviewed for unnecessary medications in a sample of 35. Findings Include: The facility's Laboratory Services and Reporting policy, (not dated), documents The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the timeliness of the services. Assist the resident in making transportation arrangements to and from the laboratory if necessary. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. R44's current Physician Orders Sheet documents an order for Lithium Carbonate Oral Capsule 450 MG (milligrams) twice a day. R44's current Physician Orders Sheet documents an order for Lithium levels to be checked every three months. This order has a start date of 2/5/2024. R44's Lab (Laboratory) Results Report, dated 11/5/2024 documents a lithium level was collected. As of 5/20/25, R44's medical record did not contain documentation of R44's Lithium level lab results after 11/5/2024. On 5/20/2025 at 10:00 AM, V2 (DON/Director of Nursing) verified R44 has not had his lithium level checked since 11/5/2024.

Based on Interview and Record Review, the facility failed to ensure the facility's Abuse policy was implemented and followed for two of three residents (R44, R87) reviewed for Abuse in the sample of 35. Findings include: The facility's Abuse, Neglect and Exploitation policy (undated), documents It is the policy of this facility to provide protections for 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. Instances of abuse of all residents, irrespectively of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This same policy documents Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. This policy also documents The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to residents abuse and certain resident to resident altercations. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R87's current Care Plan, dated 4/3/25, documents Behaviors: 11/16/24, Verbal altercation with another resident including threats of physical harm. On 5/20/25 at 12:45 PM, V9 (Corporate Nurse) stated the facility does not have any abuse investigations or allegations in the past year for R87. On 5/20/25 at 1:20 PM, V4 (Social Service Director) confirmed she wrote the care plan for R87's behaviors on 11/16/24. V4 stated I wrote a note in (R87's) care plan because in morning meeting it was reported that he and (R44) had an altercation, more of just a verbal disagreement over the telephone. There was no nursing progress note. I only have my notes from that morning to show it was talked about in morning meeting. V4 confirmed the disagreement happened on a Saturday and V4 was made aware the following Monday morning. V4 stated I wasn't here over the weekend and it was so long ago that I do not know who the nurse was who reported the incident. On 5/21/25 12:15 PM, V1 (Administrator in Training) confirmed she is the facility's Abuse Coordinator and confirmed there was not an abuse investigation or report to the state agency for the 11/16/24 alleged incident. V1 stated I wasn't made aware (of the alleged argument between R44 and R87). I would expect staff to contact me if something happened over the weekend and I would report and investigate that. I wasn't made aware and I do not recall that incident. Nursing did not call me and (V4) did not update me when she made the care plan as well.

Based on Interview and Record review the facility failed to report an allegation of resident to resident abuse to the facility's Abuse Coordinator and the State Agency for two of three residents (R44, R87) reviewed for Abuse in the sample of 35. Findings include: The facility's Abuse, Neglect and Exploitation policy (undated), documents It is the policy of this facility to provide protections for 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. Instances of abuse of all residents, irrespectively of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This same policy documents Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. This policy also documents The facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. R87's current Care Plan, dated 4/3/25, documents Behaviors: 11/16/24, Verbal altercation with another resident including threats of physical harm. On 5/20/25 at 1:20 PM, V4 (Social Service Director) confirmed she wrote the care plan for R87's behaviors on 11/16/24. V4 stated I wrote a note in (R87's) care plan because in morning meeting it was reported that he and (R44) had an altercation, more of just a verbal disagreement over the telephone. V4 stated I wasn't here over the weekend (11/16/24) and it was so long ago that I do not know who the nurse was who reported the incident. On 5/21/25 12:15 PM, V1 (Administrator in Training) confirmed she is the facility's Abuse Coordinator and confirmed there was not an abuse report sent to the state agency for the 11/16/24 alleged incident. V1 stated I wasn't made aware (of the alleged argument between R44 and R87). I would expect staff to contact me if something happened over the weekend and I would report and investigate that. I wasn't made aware and I do not recall that incident. Nursing did not call me and (V4) did not update me when she made the care plan as well.

Based on Interview and Record Review, the facility failed to investigate an alleged incident of resident to resident verbal abuse for two of three residents (R44, R87) reviewed for Abuse in the sample of 35. Findings include: The facility's Abuse, Neglect and Exploitation policy (undated), documents It is the policy of this facility to provide protections for 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. Instances of abuse of all residents, irrespectively of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. This same policy documents Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. This policy also documents An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. R87's current Care Plan, dated 4/3/25, documents Behaviors: I have a history of displaying behavioral symptoms related to severe mental illness; dementia; difficulty adjusting to life in the long-term facility; poor/ineffective coping skills; history of noncompliance with recommendations from health care professionals. Behaviors manifested by verbal aggression and physical aggression directed at peers; socially inappropriate/disruptive behavior. 11/16/24, Verbal altercation with another resident including threats of physical harm. R87's Nursing Progress Notes, dated November 2024, does not document any details related to the care planned 11/16/24 altercation. On 5/20/25 at 12:45 PM, V9 (Corporate Nurse) stated the facility does not have any abuse investigations or allegations in the past year for R87. On 5/20/25 at 1:20 PM, V4 (Social Service Director) confirmed she wrote the care plan for R87's behaviors on 11/16/24. V4 stated I wrote a note in (R87's) care plan because in morning meeting it was reported that he and (R44) had an altercation, more of just a verbal disagreement over the telephone. There was no nursing progress note. I only have my notes from that morning to show it was talked about in morning meeting. V4 confirmed the disagreement happened on a Saturday and V4 was made aware the following Monday morning. V4 stated, I wasn't here over the weekend and it was so long ago that I do not know who the nurse was who reported the incident. I would assume V1 (Administrator in Training) was also at the same morning meeting. On 5/21/25 12:15 PM, V1 (Administrator in Training) confirmed she is the facility's Abuse Coordinator and confirmed there was not an abuse investigation for the 11/16/24 alleged incident. V1 stated, I wasn't made aware (of the argument between R44 and R87). I would expect staff to contact me if something happened over the weekend and I would report and investigate that. I wasn't made aware and I do not recall that incident. Nursing did not call me and (V4) did not update me when she made the care plan.

Based on Observation, Interview and Record Review, the facility failed to ensure a resident requiring dependence on staff for hygiene, was provided a shower weekly, for one of one resident (R79) reviewed for showers in the sample of 35. Findings include: The facility's Resident Showers policy (undated), documents It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. On 5/18/25 at 9:25 AM R79 was sitting in his room in a high-back wheelchair. R79 was pleasantly confused with conversation and his hair was slicked back and shiny with an oily appearance. On 5/19/25 at 9:30 AM V11 (R79's family) stated she is able to visit R79 three to four times a week. V11 stated (R79) is scheduled to get baths or showers twice a week and it is on Tuesday and Saturdays. I don't think his hair is getting washed. If I ask they will wash his hair or a lot of times when I am there I will wash it but it always looks greasy and when I know it's been washed I can see it's dry and not greasy looking. On 5/20/25, V1 (Administrator in Training) provided R79's shower sheets for the month of May. These sheets document R79 received a shower on 5/3, 5/7 and 5/10/25. R79's medical record does not document any showers have been provided to R79 from 5/10/25- 5/20/25. On 5/21/25 at 12:35 PM, V2 (Director of Nursing) stated Showers should be twice a week and as requested if staff are able. CNAs (Certified Nursing Assistants) are expected to do a shower sheet with each shower. V2 confirmed that R79's records do not document any showers have been done since 5/10 and stated R79 should have had two to three showers since then. V2 stated if a resident is refusing multiple times to be bathed it should be documented in the notes and there is nothing documented for R79. V2 stated I don't believe he (R79) ever refuses.

Based on observation, interview, and record review the facility failed to perform indwelling urinary catheter care per facility policy for one of one resident (R45) reviewed for urinary catheters in the sample of of 35. Findings include: The facility's Catheter Care, (not dated), 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. Catheter care will be performed every shift and as needed by nursing personnel. Compliance guidelines, knock and gain permission to enter the resident's room, explain the procedure, provide privacy by closing the door, closing the blinds/curtains, pulling the room dividing curtain, etc. Gather supplies needed, assist resident to a lying position or the most comfortable position for the resident. Drape resident to expose only the perineal area, perform hand hygiene, don gloves. For a male, gently grasp penis, draw foreskin back if applicable, using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). With a new moistened cloth, starting at the urinary meatus moving down, cleans the shaft of the penis, with a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter, dry area with towel. Bag and gather all supplies used, discarding disposable items in the trash can, assist resident to a comfortable, appropriate position, ensure call light is within reach, return room back to the original order, perform hand hygiene. On 05/20/25 at 10:30 AM, V8 (CNA/Certified Nursing Assistant) entered R45's room to perform catheter care. V8 assisted R45 in standing up to complete the catheter care. V8 cleansed R45's perineal area, but did not cleanse R45's meatus and did not cleanse R45's indwelling urinary catheter tube. On 05/20/2025 at 10:45 AM, V8 verified that V8 should have cleaned R45's meatus and cleansed R45's urinary catheter tube. On 5/21/2025 at 10:15 AM, V2 (DON/Director of Nursing) confirmed that during catheter cares for a male, the meatus, perineal area, and catheter tube should be cleansed during catheter cares every time.

Based on interview and record review, the facility failed to ensure a resident receiving hemodialysis was provided dialysis prescribed medication and received physician ordered daily weights for one of two residents (R82) reviewed for dialysis in the sample of 35. Findings include: The facility's Hemodialysis policy (undated), 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 resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. This same policy documents The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; Physician/treatment orders, laboratory values, and vital signs; 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. R82's current Care Plan, dated 10/17/24, documents R82 has diagnoses including, but not limited to End Stage Renal Disease, Dependence on Renal Dialysis, Heart Failure and Hyperkalemia. This care plan documents Hematological Status: I have an alteration in hemological status related to Chronic Kidney Disease, history of Hyperkalemia. Interventions; Administer medications as ordered for Hyperkalemia. Monitor for effectiveness. This Care Plan also documents Dialysis: I need dialysis hemo (hemodialysis) related to End Stage Renal failure. Interventions; Collaborate with dialysis center for best plan of care. Daily weight. Report weight gain of three pounds in one day or five pounds in one week to cardiologist. Lokelma Oral packet 10 grams (sodium zirconium cyclosilicate) give one packet by mouth one time a day every Monday, Wednesday, Friday and Sunday for High potassium, date initiated 4/8/25. R82's current Physician Order Sheet, dated 5/19/25, documents Daily Weight. Report weight gain of three pounds in one day or five pounds in one week to cardiologist. Must be weighed by (mechanical lift) every day shift. Lokelma Oral packet 10 grams (sodium zirconium cyclosilicate) give one packet by mouth one time a day every Monday, Wednesday, Friday and Sunday for High potassium, start date 4/25/25. R82's Nursing Progress notes, dated 4/8/2025 at 9:23 AM, documents Call received from dialysis this AM. Resident (R82) has a high Potassium level of 6.5. New orders received and noted to add low potassium to diet and Lokelma 10 grams on non-dialysis days. Dietary manager and pharmacy updated. R82's Nursing Progress notes, dated 4/30/2025 at 9:57 AM, documents Call placed to (Dialysis Center) to clarify orders. This same note documents Also notified dialysis that we are still having difficulty getting Lokelma. Pharmacy and resident updated. R82's Medication Administration records for April 1-30, 2025 and May 1-20, 2025 documents throughout April and May, R82's Lokelma order was started and stopped multiple times. These records document that a total of four scheduled doses of Lokelma were not administered in April (4/23, 4/25, 4/28, 4/30) and two scheduled doses were not administered in May (5/4, 5/5). R82's Medication Administration records for April 1-30, 2025 and May 1-20, 2025 document R82 was not weighed on 4/9, 4/14 or 4/27/25 and was not weighed on 5/4, 5/12 or 5/18/25. On 5/21/25 at 12:39 PM V2 (Director of Nursing) confirmed there has been multiple missed daily weights and Lokelma medication administrations missed for R82, throughout April and May 2025. V2 stated Lokelma kept saying it wasn't covered by insurance and we couldn't get it from the pharmacy. I am not sure why her weights would not have been not done on certain days. V2 confirmed that R82's Potassium level was significantly high at the beginning of April when the Lokelma was ordered and the medication was prescribed to lower that level. V2 stated (R82) should be weighed daily as ordered and provided the medications needed to promote her health and dialysis needs.

Based on observation, interview, and record review the facility failed to apply gloves during Insulin administration for one of three residents (R148) reviewed for Insulin administration in a sample of 35. Findings include: The facility policy, Infection Control Guidelines for All Nursing Procedures, dated August 2012 directs staff, To provide guidelines for general infection control while caring for residents. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions and excretions regardless of whether or not they contain visible blood. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. R148's current Physician Order Sheet, dated May 2025 includes the following physician orders: Humalog Injection Solution 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale subcutaneously before meals related to Type 2 Diabetes Mellitus. On 5/18/25 at 12:16 P.M.,V6/Licensed Practical Nurse (LPN) prepared to administer insulin for R148. V6/LPN drew up five units of Humalog Insulin and entered R148's room. Without applying gloves, V6/LPN administered the insulin in R148's left arm, exited the room and placed the used syringe in a plastic container. At that time, V6/LPN verified she had administered the insulin without applying gloves.

Based on observation, interview and record review the facility failed to provide hot water at comfortable temperatures for 22 residents (R4-R25) who reside on D-Hall of 22 residents reviewed for water temperatures in the sample of 27. Findings include: On 5/6/25 at 10:15am V5, CNA (Certified Nurse Assistant) stated there is no hot or even warm water in any of the rooms on D-Hall It's been like this for about a month. V5 stated We have to go to the nurses station to get hot water to clean residents that we get up in the morning. On 5/6/25 at 10:25am R4 stated that the CNA's have to get hot water from the nurses station to clean him up. R4 stated there have been times they used the bathroom sink water from his bathroom and it was cold and uncomfortable. R4 stated all the CNA's know about No hot water, its been like this for at least a month. On 5/6/25 at 11:35am V5, Maintenance Director used a digital thermometer to check the hot water temperature in the bathroom sink in R4's room. After approximately three minutes the hot water reached a maximum of 76 degrees F (Fahrenheit). Water temperature was also checked across the hall in a currently occupied resident room/bathroom sink and after approximately three minutes reached a maximum of 76 degrees F. On 5/6/25 at 11:40am V5, Maintenance stated the nurses told me 1-2 weeks ago and said residents were complaining of cold water on D-Hall. V5 stated he does take water temperatures and sometimes the water would warm up after about 5-10 minutes. V5 acknowledged that 5-10 minutes is a long time to wait for hot (warm) water and whether it gets warm has been inconsistent. V5 stated they had new water pipes put in about a month ago and the lack of hot water on D-Hall might have to do with that installation. V5 stated I notified (Corporate Maintenance Director) and checked the equipment he told me to, but we have not called for outside assistance. Water Management Program/Point of Use Water Temperature Logs indicate: Note Hot Water temperature below 105 degrees F or Cold Water above 67 degrees F as outside control limits. 4/3/25 D Hall room Hot water temperature 107.1 degrees F 4/21/25 D Hall (2 rooms) Hot water temperatures 49 degrees F and 58 degrees F 4/28/25 D Hall (2 rooms) Hot water temperatures 50 degrees F and 60 degrees F 5/6/25 D Hall (2 rooms) Hot water temperatures 74 degrees F and 76 degrees F On 5/7/25 at 1:15pm V5, Maintenance stated hot water temperatures should be between 100 and 110 degrees F. The facility provided an undated resident roster that showed R4-R25 resided on the D wing of the facility. Facility Policy/Safe Water Temperatures dated 2025 documents: It is the policy of this facility to maintain appropriate water temperatures in resident care areas.

Based on interview and record review the facility failed to prevent resident to resident physical assault for one resident (R5) of four residents reviewed for abuse in the sample of 27. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2025 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 with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. Final Incident Investigation Report dated 4/21/25 indicates R6 reached out and struck R5; residents separated immediately. R6 placed on 1:1 supervision until transported out of the facility to a behavioral hospital for evaluation. Nurse Note dated 4/15/2025 at 4:34pm indicates R6 argued and attempted to strike R16. Staff removed R16 to de-escalate the situation when he heard resident R5 talking to himself. R6 assumed R5 was talking about him and R6 began to yell and struck R5 on the arm. Staff intervened and separated both residents. On 5/7/25 at 11:00am V9, CNA (Certified Nurse Assistant) stated (on 4/1/5/25) she was sitting down D-Hall when she heard R6 shouting from the dining room. V9 stated as she responded to the dining room, she saw V11, LPN (licensed Practical Nurse) moving R16 away from R6 and then witnessed R6 hit R5 with his fist before she could get to R5 to remove him from proximity to R6. V9 stated because of her angle, she could see R6 strike R5 but could not see exactly where R6 made contact with R5's body. V9 stated somewhere around (R5's) chest or arm. V9 stated that she then pulled R5 away from R6 as R5 was in a wheelchair and R6 was standing. V9 stated R5 did not have any reaction to being struck by R6 and no injuries were found after R5 was assessed. V9 stated R6 continued yelling, shouting and cussing which is (R6's) usual behavior. V9 stated she believes R6's primary language is Spanish and that he gets easily frustrated when he isn't understood. V9 stated she accompanied R6 to the hospital and the hospital physician spoke Spanish to R6 and he seemed happy. On 5/6/25 at 2:15pm R5 was observed in his bed, R5 was unable to answer questions appropriately; speech was garbled and mostly incoherent. On 5/6/25 and 5/7/25 R5 was seen in a wheelchair in the dining room during lunch meals. Abuse/Neglect/Trauma assessment dated [DATE] indicates R5 is at moderate risk for potential future problems related to mistreatment. Comprehensive assessment dated [DATE] indicates R5 has diagnosis of Alzheimer's dementia and is severely cognitively impaired. R5's current Care Plan indicates R5 has a communication deficit related to hearing loss and cognitive impairment. On 5/6/25/25 and 5/7/25 R6 was observed ambulating in the dining room and appeared to be preoccupied. Abuse/Neglect/Trauma assessment dated [DATE] indicates R6 is at moderate risk for potential future problems related to mistreatment. Comprehensive assessment dated [DATE] indicates R6 has diagnosis of Paranoid Schizophrenia and has moderate cognitive impairment. R6's current Care Plan indicates R6 Behaviors Risk with the potential to be verbally aggressive, such as yelling/cursing at staff and residents and has aggressive behavior toward others. Current Care Plan does not include communication/language problem or identify Spanish as R6's Primary language. Nurse Notes indicates that on 4/9/25 and 3/30/25 R6 had to be redirected after yelling and putting up fist at other residents with attempts to strike them. 3/28/2025 17:45 (5:45 pm) Nurse Note dated 3/28/2025 at 5:45pm indicates R6 has had an increase in behaviors. Staff has had to step in between him and other residents multiple times this shift due to aggressive behaviors and attempting to strike at other residents.

Based on observation, interview and record review the facility failed to ensure a resident's medication was administered for 1 of 6 residents (R3) reviewed for medication administration in the sample of 6. The findings include: The 2/28/25 quarterly assessment documents R3 was admitted to the facility on [DATE], and is cognitively intact. The same assessment documents R3 to have multiple diagnoses including hypertension, anxiety, depression and respiratory failure. On 5/2/25 at 10:00 AM, R3 was lying in bed sleeping, and a cup of 5 pills was sitting on the bedside table, along with 3 large chewable tablets. R3 awoke and said she did not know her pills were there. She said the cup had her morning pills, but did not know how long they had been sitting there. R3 attempted to name her medications, but fell back to sleep. The medication cup contained 1 large white pill, 1 white capsule, 1/2 of a large white pill, a green capsule, and 1 small round white pill. The May 2025 Medication Administration Record (MAR) shows R3's morning medications to include duloxetine 20 mg for depression, loratadine 10 mg for allergies, calcium 600 mg for supplement, dronedarone 400 mg (1/2 tablet) for preventative, pregabalin 150 mg for pain, and calcium carbonate 500 mg, 3 tablets for supplement. On 5/2/25 at 10:10 AM, V6 Licensed Practical Nurse (LPN), said she completed the medication pass on E wing. She gave R3 her medications, including 3 large chewable calcium tablets. V6 said she gave R3 the medication cups and told her to take them, but did not stay with her or watch her take the pills. V6 said R3 must have put them down after she left the room, she should have stayed with her to ensure she took them. The medications included her anti-depressant, pain medication and calcium. On 5/2/25 at 11:14 AM, V2 Director of Nursing (DON) said the nurses deliver medication to the residents and observe them taking the pills. The nurses are to stay with them until all of the pills are taken. Medications should not be left on the table. The facility's 2025 policy for Medication Administration documents their policy as 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: 18. Observe resident consumption of medication.

Based on record review and interview, the facility failed to ensure resident funds were not misappropriated from resident account for one resident (R1) of three residents reviewed for resident funds.The facility failed to protect R1, a resident with diagnoses of bipolar disorder and autistic disorder, from theft and exploitation when V5 opened an account in R1's name and withdrew $11,900.00. This failure would result in a reasonable person experiencing anger and anxiety from having a large sum of money removed from their account without their consent. FINDINGS INCLUDE: Facility policy, entitled Abuse, Neglect, and Exploitation, dated 2023, document, Misappropriation of Resident Property. means that deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. R1's Electronic Medical Record document R1's diagnosis to include: Bipolar II Disorder, Epilepsy, Diabetes Mellitus Type II, Autistic Disorder, Unspecified Fall, Dysphagia, Suicidal Ideation, Intermittent Explosive Disorder, Gastro-Esophageal Reflux Disorder, Cleft Palate, and Obstructive Sleep Apnea; and R1's Quarterly Minimum Data Set, dated dated [DATE], document R1's Brief Interview for Mental Status as 15/15, which indicates R1 is cognitively intact. The facility's final report, submitted to the State Agency on 4/3/2024, documents: Investigation ongoing, Family is not willing to cooperate with staff on investigation progress, however, police report was filed. Previous BOM [V5/Former Business Office Manager] helped resident set up an ABLE (Achieving a Better Life Experience) account debit card, and per the resident and family, [V5] had access to the account; and information, from [Bank] document the following amounts were transferred from R1's ABLE account to V5's [personal electronic money account]: 3/4/24-1K [$1000.00]/1K/1K/1K; 3/5/24-2K, 3K; 4/1/24-$100/100/200/500/500/1500. All totaled $11,900.00. On 4/25/24, a written statement, provided by V1/Administrator-in-Training, document, Thursday 3/7/24, [V5] exited her office, across from mine, kind of looked at me sadly. I asked if she was OK, she stated Yes, I am just not feeling too well and am going to leave a little early to get some cold meds and go home. She did not return to work the next day. Made several attempts to reach out without success. -3/11/24, [R1] let us know he was expecting a new debit card. -3/28/24 [R1's] father came to the facility to see me, I was at a conference, so he left and filed a police report because he received a statement from his son's account that only reflected a small amount of money, rather than the almost $12,000.00 that was supposed to be in there. This was reported to [State Agency] 3-28-2024. On 4/25/24, at 1:25 p.m., V4/Regional Nurse confirmed V5 should not have taken R1's funds and V5's employment was terminated.

Based on interview and record review, the facility failed to provide timely radiology services for one resident (R1) of three residents reviewed for falls. This failure resulted in R1 not receiving an X-ray after a noted deformity to the left leg and being diagnosed with a left femur fracture that was not immobilized for over 24 hours with increased pain and decreased range of motion of the left leg. Findings include: Physician's Order Summary Report indicates R1 was readmitted to the facility 1/3/23 with diagnoses that include Left Femur Fracture, Disc Degeneration. Hospice Certification and Plan of Care dated 1/18/23 indicates R1 also has the following diagnoses: Malignant Neoplasm of Lung/Bronchus Malignant Neoplasm of Bone Malignant Neoplasm of Liver and Intrahepatic Bile Duct Dementia (unspecified) Chronic Pain Syndrome Comprehensive assessment dated [DATE] indicates R1 had moderate cognitive impairments. Progress Note dated 12/30/22 at 2:30pm indicates staff reported that R1 was experiencing increased pain when attempting to remove the lift sling. Upon assessment R1 was noted to be lying in the bed with the lift sling under her and R1 did not want staff to remove the sling from under her because it hurt too bad. When asked, R1 stated her whole left leg hurt. Note indicates R1's left leg was assessed with no bruising, warmth or redness noted, however R1's left knee was slightly bowed in. Note indicates that R1 was able to straighten her leg with staff assistance. Note indicates R1 stated that she has an old injury and her left lower extremity often bows inward and outward. Note indicates V2 (Director of Nursing/DON) was notified, and portable X-rays were ordered. Note indicates a narcotic pain medication was given for pain and discomfort. Physician's Orders indicate left hip/unilateral pelvis/left knee X-rays were ordered on 12/30/23 at 2:57pm. Progress Note dated 12/31/22 at 5:38pm indicates mobile X-ray company was called at 1pm (on 12/31/23) to check on the status of R1's X-ray. Note indicates mobile X-ray company confirmed they had an order for R1's X-ray however they did not have a time frame for when the X-ray would be done. Progress Note dated 12/31/22 at 10:20pm indicates staff notified the nurse that R1 was in excruciating pain, R1's leg was assessed by the nurse and found R1's left leg to be rotated inward. Note indicates (R1) was screaming out in pain without any movement or touching. Note indicates new orders were received to transfer R1 to the hospital. Hospital Radiology Report, dated 1/1/23 at 12:26am, indicates left femur fracture - no dislocation. Progress Note dated 1/1/23 at 4:20am indicates R1 was admitted to the hospital with diagnosis of left femur fracture. On 1/31/23 at 2:45pm, V5 stated (on 12/30/23) R1 was fussing more than usual, complaining of pain all over - wasn't just her leg. V5 stated that she told V7 (Licensed Practical Nurse/LPN) that R1 was having pain. R1 prefers to have the sling left under her - doesn't want to be moved around. Always like that. R1 was screaming bloody murder. I know they didn't come to do the Xray when they should have. On 2/1/23 at 10:20am, V7 (LPN) stated that R1 was getting pain medications around the clock to manage her pain. V7 stated when R1 was left alone, she was fine but had a lot more pain than usual when she was touched or moved. V7 stated that R1's left leg was turned inward. V7 stated when she came on shift (12/31/22), she noticed that R1's X-ray had still not been done, and that's when she called the X-ray company to find out when they were coming. V7 stated that she was confused when the X-ray company told her they didn't know when they could get to the facility. V7 stated I really wasn't sure what to do. I thought we had to get the X-ray results before we could send a resident to the hospital - and the X-ray still hadn't even been done. V7 stated that she texted V3 (Assistant Director of Nursing/ADON) but wasn't told to send R1 to the hospital. V7 stated they have had ongoing problems with the mobile X-ray company not showing up and not notifying when they couldn't show up. V7 stated in the past, she's waited 2 or 3 days for them to finally show up to do an X-ray. On 2/1/23 at 1:15pm, V2 (Director of Nursing/DON) stated that she was aware of the problems the nurses have had with the mobile X-ray company and a new company was to start (on 2/1/23). V2 acknowledged that if a resident's leg is turned inward and they are in a lot of pain - whether they fell or not - they should be sent to the hospital rather than waiting on X-rays as they are going to need surgery if there is a fracture. The standard is X-rays should be done within 4 hours if STAT and within 12 hours if routine. On 2/1/23 at 2:30pm, V4 (Certified Nurse Assistant/CNA) stated, I was still on the floor- around 2-2:30 pm (on 12/30/23) waiting for my replacement and heard R1 yelling in pain. R1 told me she was in pain and rubbing her leg. I pulled back the blanket and saw her leg/knee was turned inward and her foot was still straight. I knew not to touch her any further and notified the nurse. MAR (Medication Administration Record) dated 12/2022 indicates R1 received Norco (narcotic) 5-325mg (milligrams) 10 times from 12/26 to 12/31 as needed for pain and only 6 times from 12/1 to 12/25, 2022. X-rays that were ordered on 12/30/22 were not obtained with R1 being transferred to the hospital greater than 24 hours later to obtain X-rays to rule out fracture.

Based on observation, interview and record review, the facility failed to safely secure one resident (R1) during transport in the facility van of three residents reviewed for accidents in the sample of three. This failure resulted in R1 experiencing a fall from R1's wheelchair while being transported in the facility van, striking R1's face and sustaining facial fractures requiring multiple hospitalization s. Findings include: The facility's Final Investigation Report (undated) documents that on 4/14/21, R1 fell in the transport van and was sent to the ED (Emergency Department) for evaluation and treatment. Report indicates R1 fell forward when the van had to suddenly stop to avoid an accident. Report indicates R1 received two cuts above the eyebrow, one small cut on bridge of nose, one above the lip and a fractured nose. The facility's Summary of the van accident signed by V1, Administrator dated 4/20/21 documents the following: V6, Driver, called the facility on 4/14/21 to report an incident in the van with R1 during transport. V6 stated he had to quickly brake the van to prevent a collision with a semi-truck. that had to do the same. in front of him. In the summary, V6 stated that, due to the force of the brakes being engaged, R1's buckle came loose and R1 fell forward hitting his face. R1 was then taken to the nearest hospital (Out of State Local Hospital 1). This summary indicates V6 reported that R1 had buckled himself in and that V6 checked the seatbelt by pulling on the seatbelt several times to check that it was locked in place. V6 stated that he had no idea how R1 could have come out of the belt. This summary report also indicates R1 was interviewed and R1 confirmed that he had buckled himself and that V6 had double checked the belt. In the summary, R1 indicates he was looking at his cell phone when the accident occurred. Nurse Progress Notes indicates: 4/14/21 at 10:20am, Received call from transporter that during transport, an accident on the highway caused him to slam on the breaks and swerve to avoid collision and the seatbelt holding R1 disengaged and R1 fell forward from the wheelchair. striking R1's face on the center console 4/14/21 at 6:15pm, R1 brought back to the facility from (Out of State Local Hospital 1) with staff assistance. Multiple new lacerations to face - four stitches above left eyebrow, three stitches above right eyebrow, three stitches to bridge of nose, three stitches upper lip, bruising to both eyes and swelling present throughout. No breaks present CT (Computerized Tomography) clear. 4/15/21 at 3:55am, R1 sent to (Local Hospital 1) Emergency Department for excessive nose bleed. CT scan done and found fractured nose. 4/15/21 at 10:07am R1 still in hospital, to be transferred to (Local Hospital 2) for ENT (Ear, Nose, Throat) specialist. 4/15/21 at 11:47am R1 admitted to hospital (Local Hospital 2) with ENT services. 4/16/21 at 1:55pm Assessment of resident at facility (post hospital return) (Out of State Local Hospital) ED (Emergency Department) record dated 4/14/21 documents that R1 was on [MEDICATION(S)] (anticoagulant) for blood clot prophylaxis presented at the ED for facial lacerations secondary to MVC (Motor Vehicle Collision). (R1) was traveling on highway when transport vehicle came to an abrupt stop due to traffic jam throwing (R1) from chair and hitting face on dashboard. Emergency Department Assessment documents a 2cm (centimeter) laceration above both left and right eyebrow, 2cm laceration along nasal bridge and 1cm laceration upper lip - all with active oozing. This record indicates R1 is alert and fully oriented. (Local Hospital 1) Hospital Radiology records dated 4/15/21 indicate Reason for Exam: Car accident with facial contusion earlier today, bleeding from nostril; rule out midface fracture, rule out head bleed; there is nasal packing in right nostril. Radiological findings: acute highly comminuted fractures of nasal bones and anterior nasal septum bilaterally. Extensive bilateral facial soft tissue swelling. (Local Hospital 2) Hospital History and Physical Documentation dated 4/15/21 at 12:21pm indicates R1 presented with nose bleed for 3 - 4 hours due to facial trauma earlier. (R1) stated he was traveling in the facility van to a medical appointment (yesterday) when the driver slammed on the brakes and R1 hit the windshield. R1 was taken to (Out of State Local Hospital), CT scan was negative (for fracture) and R1 was released home. Later that evening, R1 started having copious amount of nosebleed and was taken to (Local Hospital 1) where CT scan showed highly communicating acute fracture in the bilateral nasal bones and anterior nasal septum. R1's Minimum Data Set Assessment (3/4/21) BIMS (Brief Interview for Mental Status) indicates R1 is cognitively intact. On 4/21/21, R1 stated that he was in his wheelchair in the facility van going to a medical appointment. R1 stated he had the seat belt on, which he fastened and was looking at his phone when All of a sudden there was all this braking and I flew out of the seat toward the front of the van into the console. R1 stated that V6 began apologizing over and over when he saw his face and that he was bleeding. R1 stated that V6 then helped him get into the passenger seat, seat belted him in and drove to the (Out of State Local Hospital) about 15 minutes away. R1 stated, I couldn't have accidentally unlatched the seatbelt when (V6) hit the brakes. I tried to brace myself, messing with the seatbelt was the last thing I would've done. R1 stated In my opinion, both (V5 and V6/Drivers) follow too close to the car ahead of them. V6 was driving too fast and following too close. R2's Minimum Data Set Assessment/BIMS dated 3/16/21 indicates R2 is cognitively intact. On 4/21/21 at R2 stated he rides in the van two times a week and sometimes he buckles himself and sometimes the driver does. R2 stated that the buckle is off to the side - not in front, not in the lap area. R2 stated, One time I couldn't get the buckle clicked all the way, told (V5, Driver) who said she already reported it, but it doesn't get fixed. I didn't know it wasn't clicked in all the way until we got back. I just moved and the buckle came apart. On 4/21/21 at 12:40pm V3, Driver/CNA (Certified Nurse Assistant) stated she was trained to fasten the seatbelt for the resident , not the resident to fasten himself. V3 stated that she was also told to be careful when braking , not to break suddenly, something with the brakes wasn't right. V3 stated that V5, Driver, did all the training. On 4/22/21 at 10:00am V5, Transport Driver stated that she worked at the facility for approximately three years and did the driver training. V5 stated that V6, Housekeeper/Driver was not properly trained. V5 stated that V3, CNA (Certified Nursing Assistant)/Driver was the last person she trained. V5 stated that she was trained in 2018/2019 and has been the primary driver since then. V5 stated that because V6 was not properly trained , that is why R1 was allowed to fasten the seatbelt himself. V5 stated that the driver is supposed to fasten the seatbelt, not the resident. V5 stated that she has told V2, DON (Director of Nursing) about the issues with the van and the seatbelt, but nothing was done (to correct the van or seatbelt issue). On 4/22/21 at 10:10am V6, Housekeeping/Driver stated that he never had formal training. V6 stated, No in-services or step by step training. Just followed along with V5 on trips sometimes. V6 stated that there was a paper or sticker that he found jammed in the buckle of the seatbelt on the day of the accident or the next day. That might have had something to do with the buckle not locking. V6 stated that when the seatbelt is put through the wheelchair, the buckle is not in front of the residents' lap more off to the side of the resident. V6 stated that he doesn't believe R1 was able to release the buckle of the seatbelt at the time of the accident. V6 stated that he fastened the seatbelt on R1 on the day of the accident But you barely had to touch it and it would come apart. V6 stated that V5 also had trouble with the seatbelt at times and told management. V6 also stated that the brakes were spongy and locked up when he had to slam on the brakes to avoid the collision. On 4/22/21 at 9:45am V4, Auto Shop President stated that the facility brought the van seatbelt on 4/20/21 for inspection. V4 stated that he was the person who physically inspected the seatbelt. V4 stated that the seat belt functioned as it should. V4 stated that the button on the latch has to be fully pushed to disengage the lock. The only other way for the latch to be pulled apart is that it's not fully engaged in the lock to start with. It is possible for the seatbelt to be pushed together, but not fully locked, be tugged on and not fully come out - depending on the angle. On 4/21/21 at 10:15am, the facility's van seatbelt and van were observed. The van seat belt locked and disengaged appropriately. No paper or other debris were noted to be inside of the locking mechanism. At that time, V1, Administrator stated that they were not using the seatbelt due to questions about it's reliability to remain locked and the facility would be purchasing a new seatbelt. V1 stated she had never been told about any problems with the seatbelt prior to the accident with R1. V1 stated she was unaware the Motor Vehicle Safety Program directs the passenger to fasten the seatbelt. Facility Motor Vehicle Safety Program (undated) documents: Seat belts and shoulder harnesses (occupant restraint systems) shall be worn or used whenever the vehicle is in operation. The vehicle may not move until all passengers have fastened their seatbelts. Transportation, Diagnostic services (undated) documents: If a facility is used, the person transporting the resident will ensure that the wheelchair brakes are locked, is properly secured to the floor and that the resident is properly secured in the seat with the seatbelt.

Based on observation, interview and record review, the facility failed to prevent and treat a pressure ulcer for one (R7) of three residents reviewed for pressure ulcers in a sample of nine. This failure resulted in the worsening of a house acquired pressure ulcer from a Stage one to a Stage four and subsequently required antibiotics for a wound infection. Findings include: Facility Pressure Ulcer Prevention Policy, revised 1/15/18, documents the purpose is to prevent and treat pressure sores/pressure injury; inspect the skin several times daily during bathing, hygiene and repositioning; pressure reducing mattresses are used for all residents unless otherwise indicated, specialty mattresses such as low air loss, alternating pressure, etc. may be used for residents who have multiple Stage Two wounds or one or more Stage Three or Stage Four wounds. R7's current Care Plan, documents that width, length, depth, type of tissue and exudate of the skin breakdown will be documented. The Care Plan also documents that R7 is receiving Proheal for wound healing, [MEDICATION NAME] Acid, Multivitamin and Zinc. R7's Physician order [REDACTED]. R7's Skin Condition Report, dated 7/18/20, documents a house acquired pressure ulcer to R7's Coccyx. The Pressure Ulcer description is Two small and one larger open area to the coccyx. No measurements (length, width and depth), type of tissue or exudate were documented. R7's Skin Condition Report, dated 7/20/20, documents that R7's Stage One Pressure Ulcer to the Coccyx measured 4.6 centimeters/cm by 3.3 cm. No depth was documented. The Surface Area was 9.1 cm. R7's Weekly Skin Documentation, dated 8/26/20, documents that R7's Coccyx is a Stage Four. On 8/27/20, at 9:58 am, V2 (Administrator) confirmed that R7's Coccyx pressure ulcer measured 3.9 cm by 3.0 cm by 2.1 cm. On 8/23/20, at 10:25 am, R7 was lying in bed and V4 (Certified Nursing Assistant/CNA) positioned R7 in bed, and R7's Coccyx pressure ulcer did not have a dressing applied. A black, necrotic, eschar area, with a foul odor, that was slightly larger than an approximate size of a half dollar, was on R7's Coccyx. R7 was not on a pressure reducing mattress. On 8/23/20, at 10:25 am, V4 (CNA) stated, This open area started out about the size of a pea, and they only do the dressing as needed (PRN), and now it is the size of about a half dollar, and it is bad. It is black and smells. The Nurses do not do the dressings, the wound nurse usually does the dressings, so often she goes without a dressing on it. I am not a nurse, but I think she needs a scheduled treatment to her coccyx. (R7) also is seen by the Wound Doctor, and I have not seen the Doctor for a couple of weeks. R7's Physician order [REDACTED]. R7's Wound Infection Report, dated 8/26/20, documents a physician's orders [REDACTED]. R7's Treatment Administration Record/TAR, 7/1/20 through 8/23/20, does not document Physician Ordered treatments to R7's Coccyx pressure ulcer on 7/18 through 7/21/20 and 7/23/20 through 7/31/20. R7's TAR, dated 8/5/20 through 8/22/20, documents a treatment to cleanse R7's coccyx pressure ulcer with Normal Saline, apply ointment (Santyl), cover with a four by four gauze and dry dressing (ABD pad in the evening for wound management. Physician ordered treatments were not completed and documented. On 8/23/20, at 10:15 am, V3 (Agency Licensed Practical Nurse/LPN) stated, I am an Agency Nurse and I am not real familiar with (R7). The treatment orders for (R7's) coccyx are Santyl (medicated topical ointment), a four by four (4 X 4) and dry pad. The treatment is not a scheduled treatment, it is ordered as needed (PRN). The Wound Nurse does all the treatments, so I have not seen (R7's) pressure areas. On 8/23/20, at 11:10 am, V6 (Licensed Practical Nurse/LPN/Wound Nurse) stated, Yes, (R7's) coccyx has gotten worse. It was not like that when I measured it last week. The Wound Doctor/Nurse Practitioner has been on vacation for about two weeks and has not been here, but I am going to make a referral for (R7) to be seen by the Wound Doctor. The Nurses on the floors do the treatments and I do the measurements once a week. We just changed the treatment order today (8/23/20), after we noticed it was only getting done as needed (PRN) and made it a scheduled treatment. Somehow we overlooked that. On 8/23/20, at 11:08 am, V2 (Director of Nursing/DON) stated, (R7's) Coccyx treatment was an error and it should have been a scheduled treatment. It has gotten worse because the treatment was only getting done as needed (PRN). We corrected the treatment order and made it a scheduled treatment now. (R7) is not on a pressure reducing mattress and should be on one. We need to get (R7) on one. On 8/25/20, at 10:00 am, V16 (R7's Physician) stated, I would never order Santyl PRN (as needed) for a pressure ulcer. A PRN order is never good for a wound, they will always get worse. They should have been doing treatments daily or the wound can get worse and infected. R7's Skin Condition Report, dated 7/12/20, documents that R7's Left Heel was Red, Beefy looking and bleeding and R7's Right Heel was Black and soft. The Report documents that the Left and Right Heel were House Acquired. A new order for an antiseptic ([MEDICATION NAME]) to the bilateral heels with a dry dressing (ABD pad and Kerlix was ordered. The Left Lateral Foot measured 1.6 cm by 1.0 cm. with a surface area of 1.1 cm. R7's Skin Condition Report, dated 7/12/20, documents that R7's Lateral Right Foot measured 1.6 cm by 1.0 cm, with a surface area of 1.1 cm. R7's Skin Condition Report, dated 8/26/20, documents that R7's Left Heel measured 3.3 cm by 2.3 cm and had a surface area of 5.1 cm. R7's Skin Condition Report, dated 8/26/20 documents that R7's House Acquired Pressure Ulcer to R7's Medial Left Foot measured 2.1 cm by 1.2 cm. R7's Weekly Skin Observations, dated 7/30/20, document Dark peeling areas to right and left heels, open area to right ankle, red areas to bunion on left foot and outside area on left foot. R7's TAR, dated 7/12/20 through 7/31/20, documents a treatment to R7's Left Heel on 7/18/20 through 7/24/20. No other treatments were documented. R7's TAR dated 7/12/20 through 7/31/20, documents a treatment to R7's Left Lateral Foot on 7/23/20 and 7/24/20. No other treatments were documented.

Based on interview and record review the facility failed to assess, document and implement interventions and failed to obtain physician orders to administer treatment for [REDACTED]. This failure resulted in a delay in treatment and a blister developing into a Stage 4 deep tissue injury. Findings include: Facility Policy/Pressure Injury and Skin Condition assessment dated /revised 1/17/18 documents: A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by a licensed nurse. Dressings which are applied to pressure ulcers, skin tears, wounds, [MEDICAL CONDITION] or incisions shall include the date of the licensed nurse who performed the procedure. Dressings will be checked daily for placement, cleanliness and signs and symptoms of infection. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. When used, the licensed nurse will document the observation in the treatment administration record and initial the dressing to verify the treatment was performed. Physician Order Sheet dated 4/2019 indicates R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician Order Sheet indicates R1 was admitted to the facility on [DATE] and discharged home on[DATE]. On 4/24/19 at 8:40am R1 stated that R1 had been telling staff R1 had a blister on R1's foot, and a nurse put a dressing on it after a few days. R1 stated the wound doctor saw R1's heel on Tuesday (4/16/19) and said he should have seen it a long time ago. Nurse Practitioner Wound Plan Note dated 4/16/19 indicates (R1) reports tenderness to R1's right heel, upon assessment wound noted: Diagnosis - Pressure (wound) Stage 4. Note indicates wound appears to be a large blister area - 10% blood filled and 90% clear fluid filled. (R1) unaware of how long wound had been there and is also unaware of when dressing was applied and who applied the dressing. Note indicates moderate peri wound [DIAGNOSES REDACTED] (redness) noted with macerated edges; moderate serous drainage also noted. Note indicates Suspect macerated edges due to inappropriate dressing in place and collection of drainage against peri wound. Note also indicates (Pressure relieving) boot to be worn at all times. On 4/30/19 V4, Wound NP (Nurse Practitioner) stated one day out of nowhere staff ask me to look at R1's foot. V4 stated R1's heel was covered in a foam dressing with no date, time, or initials and that there was enough drainage on the bandage to cause the edges of the wound to be macerated. V4 stated V4 should have been notified sooner to have ordered the appropriate dressing, stating the foam dressing was not appropriate for the wound. V4 stated the wound was 10% filled with blood and 90% filled with clear fluid. V4 stated because there was visible blood in the wound it had to be staged as a Stage 4 DTI (Deep Tissue Injury). V4 stated the wound had probably been there for at least a couple days. V4 stated I didn't know anything about it, I should have been called. I follow (R1) for other wounds. V4 stated he also ordered a pressure relieving boot because the wound wouldn't heal without relieving the pressure and applying the appropriate treatment. Skin/Wound Report dated 4/16/19 at 10:55am indicates Right heel - in house acquired - Pressure Injury/Deep Tissue Injury. Report indicates wound is purple fluid filled blister with moderate serous drainage measuring 4.5cm (centimeter) x 6.2cm. On 4/30/19 at 12:40pm V2, DON (Director of Nursing) stated she completed the assessment after V4, NP made rounds and saw R1's foot. V2 stated that V2 was told the night nurse saw the wound (on 4/15/19) and passed it along to the day shift nurse to have V4 see R1's foot the next day. V2 stated V2 did not know who put the dressing on R1's heel without getting physician orders. V2 stated the night nurse should have assessed and documented about R1's heel wound and notified the physician/NP. No assessment, documentation, or interventions were implemented until R1 was seen by V4, Wound NP on 4/16/19. Physician Order Sheet dated 4/2019 indicated orders for skin prep to right heel, cover with 4 x 4 abdominal pad and secure with conforming wrap daily and as needed were initiated on 4/17/19. No physician orders were found to administer a foam dressing to R1's right heel.

Based on observation, interview, and record review, the facility failed to identify interventions for a resident that was high risk for elopement and failed to have a system for ensuring door alarms are working correctly during the evening and at night. As a result of this failure R1 eloped from the facility. This also had the potential to affect R3, R4, R5, and R6. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 11/6/17 at 4:00 p.m., the facility remains out of compliance at a Severity Level II as the facility reviews all residents at risk for elopement and their care plans and initiates daily every shift door alarm checks. The facility also continues to inservice staff about identifying residents at high risk for elopement, developing interim care plans when a resident is identified as being an elopement risk at admission, missing resident procedures, and door alarm checks and maintenance. Findings include: The facility's Door Alarms policy, no date available, documents, A safe environment for the the residents and staff will be provided to assure resident, staff and visitors safety. This will be accomplished by: Setting door alarms at all times; Re-setting door alarms immediately after use. R1's Electronic Record documents that R1 was admitted to the facility on [DATE], and that R1 has the [DIAGNOSES REDACTED]. R1's Nurse's note, dated 10/25/17 at 5:39 p.m., document that R1 was restless, agitated, and hard to redirect. The Nurse's note also documents, (R1) up pacing hall and attempted to exit C hall door two times. R1's Admission Observation, dated 10/25/17, documents that R1 is oriented to person only, R1 wanders daily, and R1 has behaviors of displaying anger, verbally aggressive, and resistive to cares. R1's Elopement Assessment, dated 10/25/17, documents that R1 scored a 15 determining that R1 was at risk to elope and should be placed on the Elopement Risk Protocol. The assessment also documents that R1 is physically able to leave the facility, that R1 has signs of compromised decisional capacity and substantially impaired judgement and/or physical status limitations that would place R1 at risk in the community, and that R1 becomes agitated, confused and/or disoriented or displays consistently poor judgement (i.e. would not be able to safely care for himself outside of the facility. R1's Nurse's notes, dated 10/25/17 at 8:30 p.m., document, Elopement assessment complete and resident scored high. Therefore, a wander guard was placed on the resident for safety. R1's Brief Interview for Mental status, dated 10/26/17, documents that R1 has a score of eight determining that R1's cognition is moderately impaired. R1's Electronic record has no documentation of an initial care plan put in place regarding R1's risk for elopement. On 10/30/17 at 11:05 a.m., E8 (Licensed Practical Nurse) stated, None of the door alarms went off. (R1) ended up going out D hall exit, and it has two alarms and neither of them went off. If they were going off you would be able to hear them anywhere. I don't know what time we figured out he was missing, but from the video surveillance we found out he left around 5:35 a.m. I would say around 5:15-5:20 a.m., he was sitting in the dining room drinking a soda. E8 also stated, I saw (R1) up and walking around non stop the whole time I was here (during third shift). He was trying to get out the doors. He opened C-Hall door but never got out the door. On 10/30/17 at 1:30 p.m., E9 (Registered Nurse) stated, I called the Code Pink (missing resident) at 6:30 a.m. There were no door alarms going off when they found out (R1) was missing. On 10/30/17 at 3:45 p.m.,. E6 (Certified Nursing Assistant) stated, (R1) was wandering throughout the night (during third shift) and trying to go out the doors. No alarms were going off on the D-hall at the time the facility is saying (R1) left. On 11/1/17 at 5:35 a.m., E5 (Licensed Practical Nurse) stated, (R1) kept wanting to get out that night (during third shift). He was trying all the exits. That night he was wearing a T-shirt and shorts. I did not hear any alarms that's why I said he had to be in the building somewhere. On 11/1/17 at 6:45 a.m., E4 (Certified Nursing Assistant) stated, I did not hear any door alarms going off (10/26/16), and believe me they are loud. On 11/1/17 at 9:45 a.m., E10 (Certified Nursing Assistant) stated, Early in the night (during third shift), (R1) was very confused on why he was in the facility, and then he started getting more and more anxious about an appointment he had in the morning. He was worried he was going to miss it so he was up and down frequently. He attempted to go out the C-Hall exit a couple of times. I took him to the dining room to watch the television. He would still get up and he was walking around on his own real quickly like he was trying to do something. Sometime between 5:30 and 6:00 a.m. he was still sitting in the dining room. Then when I gave report after 6:00 a.m. I realized he wasn't sitting in the same spot. So I went and checked his room. (R1) wasn't there. So I told the nurse and she called Code Pink. Then everyone started looking for (R1). He ambulates independently. No door alarms were going off when he left. (R1) was wearing a T-shirt, shorts, and socks (no shoes) the last time I saw him. On 11/1/17 at 2:30 p.m., E12 (Certified Nursing Assistant) stated, He was really anxious that night (during second shift) rushing around confused. He was confused not knowing where he was. He requires supervision at times for his safety, but the rest of the time he is independent. He is not safe to make decisions on his own. That is why we have to supervise him because he doesn't make safe choices. On 11/1/17 at 2:50 p.m., E9 (Registered Nurse) stated that R1 had poor cognition, he was confused, and not able to make safe decisions on his own. On 11/2/17 at 9:40 a.m., E3 (Assistant Director of Nursing) confirmed that an initial care plan was not put into place when R1 was identified as being an elopement risk. On 10/30/17 at 1:45 p.m., Z3 (Police Station Records Clerk) stated, The facility called the police department at 7:27 a.m. and reported a missing person. At 6:25 a.m. the police department responded to a welfare check. The caller (Z4 Citizen) said he picked (R1) up. (R1) told (Z4) that he wanted a ride home. When (Z4) headed towards the highway, (R1) got extremely confused, and asked (Z4) to be let him out. So (Z4) let him out and called the police. On 10/31/17 at 11:20 a.m., Z2 (Police Officer) stated, (Z4 Citizen) dropped (R1) off at a retail store then called us. We picked (R1) up walking towards the highway. (Z4) picked up (R1) approximately one mile from the facility. (R1) was only wearing gym shorts, a T-shirt, and socks with no shoes. His indwelling urinary catheter was disconnected and he had urine all over him. He was freezing cold. It was 38 degrees Fahrenheit that morning. (R1) was so cold I put him in my police car and drove him to the fire department. They took him to the hospital. (R1) was confused the whole time. The location that Z2 picked R1 up from was a highly trafficked 35 mph road directly off of a four lane 45 mph highly trafficked road. On 11/1/17 at 2:15 p.m., Z4 (citizen) stated, (R1) waved me down at an intersection behind a local elementary school. When he got in the car with me he was confused and having troubles talking. He told me he was cold. He was only wearing a T-shirt, shorts, and no shoes. He smelled like urine also. I did get out of him that he was needing a ride home. We drove around looking for his house for about 20 minutes. He continued to be confused and got anxious about the situation. I offered to take him to the police station, and he told me to just let him out. That is when I took him to the retail store. I dropped him off and called the police. I left before the police arrived. The location that Z4 picked R1 up in was a 20 mph school zone neighbor hood area. In order for R1 to get to this location, R1 would have crossed the high trafficked 30 mph road directly in front of the facility. R1's emergency room Physician notes, dated 10/26/17 at 7:41 a.m., document, (R1) was found wandering the streets this morning by the police department after 'escaping' from a nursing facility. (R1) is slurring words, does not respond appropriately to questions, and unable to provide a reliable history. The Physician's notes also documents in the physical examination that R1 had a low temperature of 97.5 degrees Fahrenheit, and that R1 was disoriented to time and place. A facility investigation, no date available, documents, E1 (Administrator) received notification from E2 (Director of Nursing) on 10/26/17 at approximately 6:50 a.m. that R1 was missing and that a Code Pink (missing resident) had been been initiated at the facility. The investigation also documents, Upon notification of the local police department we were informed that R1 had been picked up by the police and that he was being transported to the hospital. The investigation also documents, A facility wide inspection was conducted of all exit doors and alarms. Upon inspection it was discovered that D-wing door did not alarm properly. On 10/30/17 at 9:45 a.m., Z1 (R1's Brother) stated, (R1) doesn't have his mind. He is not able to make his own decisions. He was up and down constantly not knowing where he was, and the facility knew they needed to watch him. On 11/2/17 at 10:45 a.m., Z5 (R1's Brother) stated, When I picked (R1) up from the hospital that morning (10/26/17) he was very upset and confused. He is not conscious enough to make safe decisions obviously it was 38 degrees Fahrenheit that day and he walked outside in a T-shirt, shorts, and no shoes. That shows he can't make safe decisions for himself. On 11/1/17 at 10:10 a.m., E1 stated, I called the police to report a missing person, and they told me they currently had (R1) in the ambulance. I didn't follow up with the police. I'm not sure where he got picked up at. E1 also stated, When we screened (R1) a few weeks before coming to the facility we noticed they had a one on one with (R1) and he was agitated about being in the hospital. E1 stated, (10/26/17) he exited from the D-hall exit door. The door alarm is supposed to continually alarm until it's reset, but the alarm did not do that. If the door alarm had been working properly this could have alerted staff sooner that (R1) was gone, and they could have caught him before leaving the grounds. (R1) could only have gone to the left out the D-wing exit door because to the right is blocked off. The fence goes for a little ways then it opens to the woods. He could have gone into the woods, but if he went into the woods he would have gotten hurt. Video surveillance showed that R1 left the building at 5:37 a.m. On 11/1/17 at 12:40 p.m., E11 (Medical Director) stated, The facility's doors and alarms should be functioning properly to protect the residents and prevent this from happening. On 10/30/17 at 11:35 a.m., E7 (Maintenance Director) tested the administrative wing exit door alarm by opening the door. The door alarm was not functioning correctly. E7 attempted the door alarm eleven times, and three out of the eleven times the door chirped softly one time and then stopped without being reset with a code. E7 confirmed the alarm was not working correctly. At this time, E7 verified that the only door alarm in the facility that the wanderguards would set off an alarm is the front entrance/exit. On 11/1/17 at 10:10 a.m., E1 verified that R3, R4, R5, and R6 have access to the administrative wing hallway exit, and they independently ambulate. On 10/30/17 E1 provided a list of residents who were elopement risks. The list included R3, R4, R5, and R6. On 11/1/17 at 10:45 a.m., in the presence of E7, the D-hall exit door opens up to a chain link fence with a wooded drop off ravine on the other side of it. If a person turns left out the door the chain link fence lasts approximately 45 feet before its broken down and opens up to the wooden ravine area. The wooden ravine area is approximately 245 feet long with the last 145 feet of the wooded drop off containing large cement blocks and large downed trees. Continuing around the facility, the facility property has about 240 feet of neighboring fencing. After the fencing ends it is about 300 feet to the highly trafficked road with a 30 mph speed limit and multiple cars were passing continuously. The Immediate Jeopardy was identified to begin at 5:35 AM on 10/26/17 when R1 left the facility unattended. E1 and E13 (Care plan Coordinator) were notified of the Immediate Jeopardy on 11/6/17 at 9:00 a.m. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. A facility audit of all high elopement risk residents was done on 10/26/17 by E14 (Social Services Director). 2. The Elopement risk book at the front desk and nurses' stations were audited for accuracy by E14 on 10/26/17. The Elopement risk book will be audited monthly and as needed by E14 or designee for three months and reported in the Quality Assurance meetings 3. The care plans for the high elopement risk residents were audited by nursing department on 10/26/17. 4. A facility wide audit of quarterly Elopement risk assessments was completed on 10/26/17 by the nursing department and Social Services. All high risk elopement residents identified have a wanderguard in place. 5. Daily monitoring of door alarms was initiated 10/30/17, and then increased to daily each shift on 11/6/17. This is to be completed by E7 (Maintenance Director), the manager on duty when E7 is not in the building, and the third shift nurse. If a faulty alarm is detected a door monitor will be put into place until the alarm is functioning properly. All door alarm issues will be reported in Quality Assurance meetings. 6. Door alarm maintenance was completed on 10/26/17 and 10/30/17 by E7. 7. Staff were inserviced on 10/26/17 by E1 (Administrator), E14, and E2 (Director of Nursing) regarding Code Pink (missing person) procedures, door alarms, and who to contact if a faulty alarm is detected. 8. E7 was inserviced on 10/26/17 and 10/30/17 by E1 regarding door alarm checks and maintenance. 9. Elopement risk assessments will be conducted by the nurse on duty immediately upon admission. An Interim Care Plan will be established for residents identified at high risk for elopement with appropriate interventions in place. The resident will be properly fitted for a wanderguard if found to be a high risk. 10. An Elopement Drill tabletop exercise was conducted by the management staff on 10/26/17.

Based on interview and record review the facility failed to initiate Cardiopulmonary resuscitation. (CPR) for R1 in accordance with R1's advance directives. On [DATE] at 8:27 PM, R1 was found unresponsive on the floor, hanging by the ties of R1's nightgown around the foot board of R1's bed. No CPR was initiated until EMS (Emergency Medical Services) arrived over 15 minutes later. These failures contributed to R1 expiring on [DATE] at 9:15 PM. The Immediate Jeopardy began on [DATE] at 8:30 PM when R1 was found unresponsive. On [DATE] at 10:20 AM, E1 (Administrator) was informed of the Immediate Jeopardy. The immediacy was removed on [DATE]. The facility remains out of compliance at severity level two as additional time is needed to complete CPR training, and to monitor and evaluate the effectiveness of staff training of when to initiate CPR, and to determine a resident code status and to ensure all emergency equipment is available on the crash cart. This applies to 1 of 5 residents (R1) reviewed for advanced directives in the sample of 5. The findings include: The facility incident report documents on [DATE], E6 and E9 (Certified Nursing Assistants - CNA) returned from break at 8:27 PM. E4 (Licensed Practical Nurse - LPN) instructed them to put a resident to bed that required a mechanical lift. E6 and E9 proceeded to assist the resident when they observed the call light for R1's room was on. E9 asked E6 to answer the light (while she prepared the resident for transfer). E6 went into the resident room and found R1 on the floor next to R1's bed with R1's face down and R1's hospital gown ties on the foot board. On [DATE] at 2:45 PM, E6 (CNA) stated E6 responded to the call light for R1's room. R4 (R1's roommate) looked at me and told me R1 fell . E6 stated R4 often put R4's call light on when R1 was out of bed without assistance. E6 stated E6 found R1 with the nightgown tie around R1's neck and it was caught on the (decorative) post on R1's footboard of the bed. R1's face was toward the door and the rest of R1's body was lying on the floor. E6 stated it appeared R1 was headed to bed. E6 stated E6 called (R1's) name with no answer. R1's face was turning dark blue and R1's fingertips were blue. E6 untied the string; E6 could see the impression of the night gown ties on both sides of R1's neck. E6 lowered R1's head to the floor and throw up started coming out of (R1's) mouth; It was rolling out of R1's mouth. E6 stated E6 thought R1 took a breath after E6 untied R1, but wasn't sure. E6 ran out of the room to get E9. They returned to the room; E9 stayed with R1 and E6 went to search for a nurse. E6 stated E6 went to C wing station and asked E5 (LPN) where E4 (LPN) was, and E5 did not know. E6 went to A wing station and found E4 down the E wing hall passing medication. E6 stated E6 reported to E4 there was an emergency in R1's room and to come right away. E6 stated when E6 returned to R1's room, E9 was sitting on the floor next to R1. R1 was on R1's side and there was more throw up coming out of R1's mouth. E15 (LPN) was in the room and stated E15 thought R1 was a DNR (do not resuscitate). E5 (LPN) was also in the room and stated they could not do CPR because R1 was vomiting. E6 stated E6 did not observe any breathing from R1 while R1 was lying on R1's side. E6 said that E5 (LPN) said R1 did not have a pulse and E5 questioned R1's code status. E6 stated when they figured out R1 was a full code, the EMS (Emergency Medical Service) personnel had arrived and they started to suction R1 and started compressions. On [DATE] at 3:15 PM, E9 (CNA) stated after they returned from break E9 asked E6 to answer R1's call light. E9 stated E6 came back and told me R1 was On the ground. E9 stated when E9 entered the room R1 was still, no movement; R1 didn't look right. E9 stated they noticed the string of R1's night gown was caught on the bed post and when they untied it R1 started to throw up. E9 stated E9 was CPR trained 3 years ago before E9 started working at this facility. E9 stated, My first thought was to check R1's pulse and there was none. (R1) was throwing up so my instinct was to roll R1 on R1's side. The nurse arrived to the room and I let her take over. On [DATE] at 2:20 PM, E4 (LPN) stated E4 was passing medications on [DATE] and around 8:40 PM, E6 came up to me and told me to come look at R1. E6 told E4 to Hurry up, he's down. E4 stated when E4 entered the room, R1 did not have any verbal response and I thought I saw him breathing. E4 stated E4 left the room to get E5 (LPN) to assess R1 with me. E5 checked for a pulse and said to call 911. E4 stated E4 went to the nurses' station to call and someone handed E4 a POLST (Physician order [REDACTED]. When E4 arrived back to R1's room, E4 realized that E4 had the wrong paper; it was the wrong last name. E4 returned to the nurses' station and got the correct paper and by that time EMS had arrived. E4 stated the crash cart had been brought to R1's room, but none of the equipment was used. E4 stated E4 learned CPR and to keep the airway open. E4 stated no attempts were made to swipe R1's mouth because of the vomit. On [DATE] at 3:45 PM, E4 stated E4 did not know that R1 was hung up on the foot board (by R1's gown ties). E4 stated E4 was only told that R1 was down. E4 stated E4 learned that information after the fact. On [DATE] at 3:20 PM, E5 (LPN) stated E6 approached me and told me they, Needed help ASAP. E5 stated E5 thought she felt a slight carotid pulse, but (R1) was still vomiting and there was no air moving. E5 stated E5 thought R1 was still there. E5 stated E5 did not check for respirations. E5 stated the airway could not be cleared because there was so much vomiting. E5 did not hear R1 take any gasps for breath. E5 stated E5 did not know that R1 was strangulated by the ties of R1's night gown, I just thought R1 had fallen. If I had known that I would have started compressions. And I would have done things differently. E5 stated at first the staff thought R1 was a DNR and then found the right paper and R1 was a full code. E5 reported full code to the EMS personnel and they started compressions. The EMS run sheet dated [DATE] shows the call was received at 8:47 PM and EMS arrived at 8:51 PM and CPR initiated at 8:52 PM. The documentation stated the staff reported resident was found 15 minutes prior to EMS arrival face down with vomit in R1's mouth. The EMS assessment stated, Patient unresponsive, airway obstructed, not breathing, carotid pulse absent. Skin cold to touch, pupils fixed and dilated. No CPR initiated prior to arrival. The progress notes for R1 on [DATE] show R1 was seen by Z1 (Physician) at 4:30 PM. There are no resident assessments documented at 8:45 PM when it was noted R1 was found unresponsive and 911 was called. Time of death was recorded at 9:15 PM. On [DATE] at 3:01 PM, Z1 (physician) stated R1's family designated R1's advance directive wishes when R1 was admitted by the facility staff. They selected R1 to be a full code. Z1 stated in the event of a [MEDICAL CONDITION] and the heart stopping clearing the airway would be the first priority, and then establish breathing and circulation. The physician order [REDACTED]. On [DATE] at E11 (Social Services) stated on admission to the facility, All residents are a full code until a POLST is completed and the physician order [REDACTED]. I ask them, do you want us to attempt CPR and whatever we can to get your heart going in the event it stops? I explain every effort will be made to keep you healthy. I further explain life sustaining measures like a ventilator and feeding tube. E11 stated the copy is placed in a code status book at the nursing station for staff reference. On [DATE] at 1:25 PM, E13 (Licensed Practical Nurse - LPN) stated there is 1 crash cart for the facility. Inside the locked cart, suction connecting tubing was found and in a separate drawer a [MEDICATION NAME] suction tip catheter was found. There was no connector in the cart to connect the suction catheter to the connecting tubing. Without the connector the suction equipment is not operational to remove oral secreations from a resident's mouth. The undated facility procedure for Cardiopulmonary Resuscitation states (CPR) will be initiated on all patients, employees or visitors for whom this intervention is indicated. The procedure states: To check for absent pulse, absent respiration or gasping respirations, dilated or constricted pupils or skin color change, to initiate the arrest and call 911. To open the airway, assess for obstruction and insert an airway. To ventilate the patient by mouth to mouth or ambu bag method and to provide external cardiac compressions. On [DATE] at 3:15 PM, E9 (Certified Nursing Assistant - CNA) stated E9 started working at the facility in [DATE]. E9 stated E9 responded to R1's fall on [DATE]. E9 stated, I reported to the nurse (when she arrived in R1's room) there was no pulse or breathing; R1 was throwing up so my instinct was to turn R1 on R1's side. E9 stated E9 could not recall airway training in E9's CPR certification. E9 stated E9 was not sure if being CPR certified was a requirement to work here, E9 was not aware of any scheduled training. She was CPR trained 3 years ago when E9 worked at a different facility. The CNA schedule for [DATE] shows 3 of 16 CNA staff on night shift, 1 of 21 CNA staff on evening shift and 3 of 23 on the day shift are certified. E9 (CNA) is listed as the only CNA on the evening shift as being CPR certified. A copy of E9's CPR certification card was not available. The nursing schedule for [DATE], shows 2 of 3 nurses on the night shift are CPR certified, 3 of 3 are certified on evening shift and 5 of 6 are certified on day shift. On [DATE] at 12:15 PM, E8 (CNA) stated, I left here 1 year ago and they said then we needed to get CPR certified. I just returned (to work here) and nothing has been said about getting certified until now. On [DATE] at 9:50 AM, E3 (Assistant Director of Nursing - ADON) stated when a resident is found without a pulse, the first response would be to initiate CPR. E3 stated as far as E3 knew the CNA staff are not required to be CPR certified. E3 thought however, it would be highly likely the CNA staff would be the first to find a resident down. E3 stated there has not been any staff training on emergency procedures in the past year. The facility undated policy for Cardiopulmonary Resuscitation stated all nursing and hostess staff must be CPR certified within 90 days of employment and re-certified in CPR yearly. The surveyor confirmed through interview and record review that the facility took the following action to remove the immediacy of the Immediate Jeopardy: All beds were checked for same type of footboard immediately. All beds identified as a risk had the footboards and headboards removed immediately. Completed on [DATE]. Emergency cart was audited and suction machine verified as complete and working on [DATE] and [DATE]. Another audit was conducted. Completed on [DATE] Training was completed on Advance Directives, Code blue procedures, CPR policy, call light response, suctioning and proper placement of Code status orders in electronic health record. Completed on [DATE] A code binder with all current advanced directives was placed on each nursing unit for prompt access and verification. Completed on [DATE] The following policies were in-serviced:CPR, call light, Code blue, suctioning Completed on [DATE] and [DATE]. Staff was trained to respond to emergency situations with the entire binder and two staff will confirm code status. Completed on [DATE] Emergency care drills were conducted. Completed on [DATE] and [DATE] CPR tracking binder implemented and organized by date of expiration. CPR classes have been scheduled. All nurses have been CPR certified. Monthly CPR classes will be held until all nursing staff are certified. All remaining nursing staff will be attending CPR classes over the next two months. 2 CPR classes were completed on [DATE].

Based on interview and record review the facility failed to ensure resident call lights were answered to respond to a resident fall, failed to ensure emergency equipment supplies were available for use on the crash cart, and failed to ensure all staff are trained in CPR within 90 days of hire per policy. This failure resulted on [DATE], when R1's call light was not answered for 20 minutes after falling, and R1 not immediately receiving CPR when he was found unresponsive and hanging by the neck ties of his night gown. This applies to 1 of 5 residents (R1) reviewed for advance directives and safety in a sample of 5. The findings include: 1. The facility incident report documents on [DATE], E6 and E9 (Certified Nursing Assistants - CNA) returned from break at 8:27 PM. E4 (Licensed Practical Nurse - LPN) instructed them to put a resident to bed that required a mechanical lift. E6 and E9 proceeded to assist the resident when they observed the call light for R1's room was on. E9 asked E6 to answer the light (while E9 prepared the resident for transfer). E6 went into the resident room and found R1 on the floor next to R1's bed with R1's face down and R1's hospital gown ties on the foot board. On [DATE] at 2:45 PM, E6 (CNA) stated E6 responded to the call light for R1's room. R4 (R1's roommate) looked at me and told me R1 was out of bed and fell so R4 put on R4's call light to get R1 some help. E6 stated R4 often put R4's call light on when R1 was out of bed without assistance. E6 stated E6 found R1 with the nightgown tie around R1's neck and it was caught on the (decorative) post on R1's footboard of the bed. R1's face was toward the door and the rest of R1's body was lying on the floor. E6 stated it appeared R1 was headed to bed. R1's face was turning dark blue and R1's fingertips were blue. E6 untied the string; E6 could see the impression of the night gown ties on both sides of R1's neck. On [DATE] at 3:15 PM, E9 (CNA) stated after they returned from break, they were walking down the hall and noticed R4's call light was on. R4 always puts on R4's call light when R1 is up. We always need to answer R4's light real quick. E9 stated when E9 entered the room R1 was still, had no movement; R1 didn't look right. E9 stated they noticed the string of R1's night gown was caught on the bed post and when they untied it R1 started to throw up. On [DATE] at 10:25 AM, R4 lying in R4's bed stated R4 recalled the incident when R4's roommate (R1) fell . R4 stated that night R1 got up after the girls put R1 to bed. I told R1 to go back to bed. R1 walked over to the closet and grabbed a coat. R1 came by my bed and I again told R1 to go back to bed. I pressed my call light to get R1 help. The next thing I know R1 was on the floor. It took 15 - 20 minutes before anyone came to help. I was just guessing at the time, but it took a really long time. I heard R1 at first, then the next thing R1 wasn't breathing. I always leave my light on above my bed so we can see. On [DATE] at 8:45 AM, E15 (Licensed Practical Nurse - LPN) stated, Sometimes call lights take longer to answer than they should. You never know what going on and R1's fall is a good example. On [DATE] at 12:15 PM, E8 (CNA) stated, I was working that night ([DATE]) on another wing. I heard the call light, but there were 2 CNA and 1 nurse assigned to the wing, so I figured they would get it. I did not know they (CNA) were on break. The resident council minutes of [DATE] and [DATE] include resident concerns, Call lights could be answered faster. Concerns about answering resident call lights was again identified in the [DATE] council meeting minutes. On [DATE] at 3:20 PM, E15 (Licensed Practical Nurse - LPN) stated when the CNA staff take a break, the CNA staff from the other halls are to cover the lights. E15 stated, I get a lot of complaints (from residents) that it takes a long time to get their lights answered. E15 stated the minimum wait time is around 10 minutes, but I think 10 minutes is too long. 2. On [DATE] at 3:15 PM, E9 (Certified Nursing Assistant - CNA) stated E9 started working at the facility in [DATE]. E9 did not know if it was a requirement to be CPR trained at this facility. E9 stated E9 responded to R1's fall on [DATE]. E9 stated E9 could not recall airway training in E9's CPR training. E9 stated E9 was not sure if being CPR certified was a requirement to work here, E9 was not aware of any scheduled training. E9 was CPR trained 3 years ago when E9 worked at a different facility. The CNA schedule for [DATE] shows 3 of 16 CNA staff on night shift, 1 of 21 CNA staff on evening shift and 3 of 23 on the day shift are certified. E9 (CNA) is listed as the only CNA on the evening shift as being CPR certified. A copy of E9's CPR certification card was not available. The nursing schedule for [DATE], shows 2 of 3 nurses on the night shift are CPR certified, 3of 3 are certified on evening shift and 5 of 6 are certified on day shift. On [DATE] at 12:15 PM, E8 (CNA) stated, I left here 1 year ago and they said we needed to get CPR certified. I just returned (to work here) and nothing has been said about getting certified until now. On [DATE] at 9:50 AM, E3 (Assistant Director of Nursing - ADON) stated as far as E3 knew the CNA staff are not required to be CPR certified. E3 thought however, it would be highly likely the CNA staff would be the first to find a resident down. E3 stated there has not been any staff training on emergency procedures in the past year. The facility undated policy for Cardiopulmonary Resuscitation stated all nursing and hostess staff must be CPR certified within 90 days of employment and re-certified in CPR yearly. 3. On [DATE] at 1:25 PM, E13 (Licensed Practical Nurse - LPN) stated there is 1 crash cart for the facility. Inside the locked cart, suction connecting tubing was found and in a separate drawer a yankauer suction tip catheter was found. There was no connector in the cart to connect the yankauer suction tip catheter to the connecting tubing . Without the connector the suction equipment would not be functional to remove oral secreations from a resident's mouth. In the top drawer of the crash cart, 2 white plastic oral airways were found un-bagged and unlabeled lying in the drawer among the other supplies. The airways appeared to be the same size. There were no clean, packaged and labeled airways available for use in the emergency cart. E13 stated, These airways would be used to open the airway in CPR. I'm not sure what size they are. E13 stated additional emergency supplies would be in the locked store room if needed. An IV (intravenous) start kit was found in the emergency cart, but no IV connecting tubing or IV needle cap in the cart. There was no IV solution in the cart. Without the IV tubing or cap, the intravenous access would not be functional. E13 stated each shift the nurses verify the emergency cart is locked and weekly the supplies are checked. Among the supplies listed on the cart checklist, the connector for suction is not listed and the number and sizes of oral airways are not identified. The IV start kit is listed, but no IV tubing, IV needle cap or type of IV solution is listed. On [DATE] at 9:50 AM, E3 (Assistant Director of Nursing - ADON) stated E3 stated in the event of CPR, the suction machine could be used (to clear the airway) or attempt to put an oral airway in place. E3 stated E3 was unsure of the oral airway storage procedures. E3 stated more oral airways are on order, the ones in the crash cart is all that is currently available at the facility. On [DATE] at 3:01 PM, Z1 (Physician) stated, In the event of a cardiac arrest the first priority should be to clear the airway, use suction and insert an oral airway, then establish breathing and circulation.

Based on record review and interview the facility failed to have medication ([MEDICATION NAME] and Rifaximin) available and administered an anticoagulant in error for five days for one of three residents (R2) reviewed for medication in a sample of 16. This failure resulted in R2 being hospitalized and required R2 to receive a blood transfusion. FINDINGS INCLUDE: 1. A Pharmacy Recommendation Form dated 06/01/17 states Resident currently receiving an antibiotic, insurance does not cover it. We recommend [MEDICATION NAME] 5mg (milligrams) daily. The Pharmacy Recommendation Form was marked Yes and signed by Z1 ( R2's Physician). The Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The Progress Notes for R2 dated 06/05/17 at 12:00 P.M. documents Z1 was notified of (blood thinner) order error. New order for Vitamin K 10 mg one time. R2's lab results show on 06/06/17 R1 had an INR (Internation Normalized Ratio) of 13.9, the normal range is 08.-3.0 seconds. R2's Progress Notes show when Z1 was notified of INR of 13.9 seconds a new order of give Vitamin K 5 mg one time was written. R2's lab results dated 06/07/18 show an INR( International Normalized Ratio ) of 16.9 seconds, the normal range is 0.9-1.1 seconds. The Progress Notes for R1 document that Z1 was notified of INR of 16.9 seconds and new order to Give Vitamin K 10 mg one time was written. R2's Progress Notes dated 06/08/17 show a INR of 10 seconds, no normal range was documented. R2's Progress Notes for 06/08/17 show that and R2 was sent to the hospital for elevated clotting time. R2's Progress Notes dated 06/08/17 show due to a report from the hospital stating that the resident was being admitted to the hospital for a Supratherapeutic INR and the resident will be receiving a blood transfusion. The After Visit Summary states: You were admitted on [DATE] and discharged [DATE]. The next documented INR ( International Normalized Ratio) in R2's Progress Notes was on 06/12/17 was 3.8, normal range 0.9-1.1 seconds. R1's Progress Notes dated 06/12/17 show that Z1 was notified of the INR and was sent to the hospital for evaluation and treatment. On 06/12/17 R2's Progress Notes show that R2 was admitted to the hospital for a Supratherapeutic INR. A Medication Related Incident Report for R2 from the facility's pharmacy dated 06/07/17 documents Wrong alternative recommend by pharmacy. The Response to error was documented as High INR. The form shows Action taken was Pharmacist inform DON (Director of Nursing) that there is a suitable alternative but MD (Medical Doctor) ordered wrong alternative due to error on the Pharmacist's part. On 06/30/17 at 11:00 A.M. E2 (Director of Nursing) stated I don't know why the nurses did not catch that an antibiotic was being changed to an anticouglant. 2. A review of R2's Medication Administration Records for May and June showed multiple codings of 9. On 06/30/17 at 9:30 A.M. E 12 (Careplan Coordinator) confirmed that if a 9 is marked that the medication was not available for administration. R'2 May Physician order [REDACTED]. R2's May Medication Administration Record [REDACTED].M. 9;05/22/27 8:00 A.M. 9;05/30/17 8:00 A.M. 9; 05/30/17 4:00 P.M. 9;05/31/17 8:00 A.M. 9; 05/31/17 12:00 A.M. 9;05/31/17 8:00 A.M. 9 and 05/31/17 4:00 P.M. 9. R2's May Physician order [REDACTED]. R2's Medication Administration shows the following: Rifaximin 550 mg (milligrams) 05/21/17 8:00 P.M. 9, 05/22/17 8:00 A.M. 9, 05/22/17 8:00 P.M. 9; 05/23/17 8:00 A.M. 9, 05/23/17 8:00 P.M. 9;05/24/17 8:00 A.M. 9, 05/24/17 8:00 P.M. 9; 05/28/17 8:00 P.M. 9; 05/29/17 and 8:00 A.M. 9. R2's June Physician order [REDACTED]. R2's June Medication Administration Record [REDACTED].M. 9, 06/08/17 8:00 A.M. 9, 06/08/17 12:00 A.M. 9; 06/09/17 12:00 A.M. 9, 06/09/17 8:00 A.M. 9, 06/09/17 4:00 P.M. 9; 06/10/17 8:00 A.M. 9, 4:00 P.M. 9; 06/11/17 8:00 A.M. 8:00 A.M. 9 and 06/11/12/17 12:00 A.M. 9. On 06/30/17 at 9:00 A.M. E2 (Director of Nursing) stated we had troubles getting some of (R2's) medications approved by the insurance, we should have just asked for something different or we (the facility) should have just ate the cost.

Based on interview and record review, facility staff failed to correctly use a mechanical lift for one of three residents (R4) reviewed for falls in the sample of 8. R4 was dropped while being transferred by two staff persons, resulting in fractures of the left proximal femur and femoral neck. Findings include: The Facility's Incident Report of R4's fall, which is not dated, documents (E7, and E8 Certified Nursing Assistants, CNA's) were getting the resident out of bed. (E7 CNA) was on the other side while they swung the resident to the left side. The strap came unhooked. (R4) slid out of sling and fell to floor. Resident stated that she hit the back of her head, Resident landed on her back with (mechanical) lift pedal under her. Resident slid completely out of sling to floor. (E7 CNA) stated she and (E8, CNA) were getting (R4) up and the sling "unhooked" from the (mechanical lift). Resident fell on floor. All slings were examined. No faulty slings were found in facility. (Mechanical lift) was examined and hooks intact. All CNA's were in-serviced on proper use of (mechanical lifts). (E7& E8 CNA's) were in-serviced prior to being allowed back on the floor. E9's Nurse's Notes dated 01/12/2013 (sic 2014) state, "When I got to the room resident was noticed on floor with head on (mechanical) lift and on left side of body...sling still intact three side hooks one unhooked. Resident stated she slid out of (lift)...Resident screamed out in pain when I tried to roll her to her right side screamed out 'My leg, My leg'...Notified Doc (doctor)...send to ER (emergency room ) to be evaluated." Radiology Report dated 01/12/14 documents "Findings There is an intertrochanteric fracture of the left hip." On 02/18/2014 at 11:34 AM, E7, CNA, stated "I wasn't touching the lift...I was guiding the resident off the bed. I had hooked the sling to the lift...we were talking about anything. As soon as we were off the bed I took hold of the back of the lift pad to help guide her...I saw her fall. I don't know what went wrong." On 02/18/2014 at 11:38 AM E8, CNA stated "We had hooked her up in the bed and swung her around. Then one of the straps came off the lift, the one toward the head of the lift. She fell and there was nothing we could do about it." On 02/18/2014 at 11:41 AM, E9, Licensed Practical Nurse stated "I went down to her room and found her lying on the floor. There was a strap undone from the lift. The girls (CNA's) were very upset. I secured the resident and called 911. The resident was sent out." On 02/18/2014 at 11:30 AM E1, Administrator stated "There was nothing wrong with the lift or the sling. The straps were put on wrong. Both of the staff was in-serviced on proper transfers/use of the lift, before they could work the floor again."

Based on interview, observation and record review, the facility failed to immediately identify and stop a situation of occurring sexual assault for one of six residents (R2) reviewed for sexual assault in the sample of six. R2 was sexually assaulted by R1. R2 suffered physical trauma to her vaginal and rectal areas. This failure had the potential to affect nineteen other confused, female residents in the supplemental sample (R5, R7, R8 through R24). Findings include: E5, Certified Nurses Aide (CNA), on 08/11/11 at 2:35 P.M., stated that she entered R2's room between 9:30 P.M. to 9:45 P.M. and saw an unidentified man (later identified as R1) laying on top of R2. E5 related that both the unidentified man and R2 had their pants "Half way down." E5 stated she was uncertain if R2 had some sort of conjugal privileges and R2 was "Laughing, sort of, and said (to E5) to close the door." E5 stated that she closed R2's room door and went to tell two other CNAs, E6 and E7. All three CNAs then went back to R2's room and found R1 laying in bed next to R2 with his pants up. E5 stated E7 directed R1 out of R2's room and the incident was reported to E29, Registered Nurse (RN). R2's Resident Admission Information dated 06/02/11 indicates that R2 is widowed. E5 stated on 08/11/11 at 2:35 P.M. she was not aware that R2 was widowed. E5 verbally related she was also not aware that there were no facility consensual sexual activity contracts in place on 08/08/11. E13's, Licensed Practical Nurse (LPN), police interview dated 08/08/11, was provided by Z1, Detective with the local police municipality. E13 stated E7, CNA, reported that R1 had been found "On top of (R2) and moving up and down. The top of (R2's) head was banging against the head of the bed." E29's, Registered Nurse (RN), police interview dated 08/08/11, documents that E5, E6, and E7 (All CNA's) informed E29 that (R1) and (R2) were "Actively engaging in the act of intercourse." This document also indicates that E29 stated that R1 was witnessed "By all three CNAs (E5, E6, and E7)...(R1) in (R2's) room...on top of (R2) on her bed...(R1's) penis was noted to be protruding out of the opening of his pajamas and that (R1) was laying on top of (R2) whose pants and (incontinence) briefs were pulled down to her knees...observed (R1) in thrusting motion while on top of (R2)." E7, CNA, stated on 08/16/11 at 2:37 P.M. that E29 was informed "Within a minute after (E5) told us about (R2)." E7 stated that when she saw R1 in R2's room, "I knew he wasn't supposed to be there. I told (R1) to leave." E7 stated that R1 went to his room which was across the hallway from R2's room and that she stood outside R1's doorway until "The police arrived before the ambulances did." The local police Incident/Investigation indicates that the police arrived at the facility on 08/08/11 at 10:57 P.M. Both E6 and E7, CNAs, on 08/15/11 at 2:30 P.M. and 08/16/11 at 2:37 P.M., respectively, stated that upon being informed by E5 on 08/08/11 of what she had just witnessed, they realized that was not right. Both E6 and E7 stated that within a minute of being informed, all three (E5, E6, and E7) went to R2's room. On 08/15/11 at 2:30 P.M. E6, CNA, stated that upon arriving at R2's room and opening the door, R1 was laying beside R2 with his pants fully on and up but R2 's pants were "Half way down." E6 stated "(R1) wasn't supposed to be there...(R1) was told to leave and he walked out of the room." E6 stated that E7 informed E29, RN, of this incident. E8, the nurse manager, on 08/11/11 at 12:30 P.M., stated that she had been called "Around 10 P.M.," on 08/08/11 about the incident between R1 and R2. E8 stated she had spoken to E19, Medical Director, and received orders for R1 to be sent out for a psychiatric evaluation and R2 for an emergency, physical evaluation. E8 stated she had also notified E1, Administrator, E2, Director of Nurses (DON), E18, Assistant Administrator, and "the nurse consultant," all around that time. E8 stated that E13, Licensed Practical Nurse (LPN), had called the local ambulance dispatch to arrange transport for R1 and R2. R2's Patient Transfer and Medical Record completed by E13 on 08/08/11, indicates that R2 was transported to a local emergency roiagnom on [DATE] with "Complaints of backside/bottom hurting after sexual assault by other resident...(R2) witnessed being sexually abused by a male resident." R2's emergency room (ER) record of 08/08/11-08/09/11, indicates that Z6, a local hospital's emergency room physician, completed a physical exam on R2 on 08/09/11 at 2:07 A.M. This physical exam indicates that in a sexual trauma kit report that R2 had "Evidence of perianal (around the anus) and vulva (vagina) trauma (injury) with petechia (Small red dots often arising on skin or other tissue after frictional rubbing) and skin excoriation (abrasions)." The ER report of the same date indicates, "Vulva and perineum (area between the vulva and anus) and perianal skin tears, [DIAGNOSES REDACTED]tous (red and swollen)- small areas of excoriation skin tears at ("entioileus", sic., term not found and Z5, ER Manager, upon questioning, was not familiar with the term) and multiple small abrasions. (R2) unable to tolerate speculum insertion (a device used to open the vaginal vault to inspection). Rape kit was sealed. No labs resulted." E5, CNA, stated on 08/11/11 at 2:35 P.M. that E7, CNA, gave R2 a shower after the incident with R1 on 08/08/11. E5 explained that 08/08/11 was R2's "Shower day" and "(E7) said we (E5 and another CNA, E6) should give (R2) a shower 'cause we didn't know if (R1) got inside (R2) or not". On 08/15/11 at 2:30 P.M., E6, CNA, stated that R2 had been given a shower after the incident with R1 on 08/08/11. E6 denied being directed by any other staff to shower R2. E6 stated that R2 had earlier that day refused to take shower on R2's "Shower day, " and usually if R2 was instructed later to go take a shower, with staff leading, "(R2) would take her shower." E6 implied that after the incident with R1 she felt R2 would appreciate being cleaned up. E7, on 08/16/11 at 2:37 P.M., stated, in regards to giving R2 a shower on 08/08/11 after incident with R1, "I feel bad now, but it was (R2's) shower night. I didn't know anything about washing away evidence." E7 stated she could not remember ever receiving any training from the facility about any specialized care that needed to be provided to alleged sexual assault victims, "Not till I talked to the police (on 08/08/11)." These statements conflict with E7's statements that she had stood outside R1's doorway until the police arrived on 08/08/11. R1's Resident Admission Information sheet dated 06/02/11, indicates R1 was admitted on this same date. R1's Admission Assessment, dated 06/02/11, indicates his "Mental Status" as "Alert, Oriented (to) name, place and year." R1's Nurses' Notes dated 06/02/11 at 1 P.M. indicate that he "Ambulates with rolling walker." Another "Nurses' Note" dated 06/03/11 at 9:30 P.M. indicates that R1 is "Up ad lib (as per his own desire)." Yet another "Nurses' Note" dated 06/04/11 at 1:18 P.M. indicates that R1 "Walks/ambulates freely." R1's Psychosocial Assessment & Social History, dated 06/07/11 and completed by E17, Social Services Director, indicates that R1 was placed at the highest level ("Level 1") of mental functioning with "Modified independence" of decision making. R1's initial Minimum Data Sets (MDS), dated [DATE], indicates that R1 has no identified cognitive or behavior problems. E11, Certified Nurses Aide (CNA), on 08/11/11 at 12:05 P.M., described R1 as "Well oriented, could carry on a conversation." E11 further described an incident that occurred between her and R1 "The week-end before last," when R1 had attempted to hug E11 while she was providing nail care. E11 stated she had "Written it up as a behavior (incident) and informed the nurse," but could not recall which nurse that was. E12, CNA, stated on 08/11/11 at 12:20 P.M., "(R1), when he first came here, he seemed better oriented. Then he started complaining a lot about room mates and kept wanting room changes. (R1) Sat out in front (lobby) and greeted (staff) as we came into work. I now wonder, with his room changes, about how he seemed to be getting closer to the women's end of the hallway. (R1) started out at the end of the hall where there is all men residents." R2's Resident Admission Information sheet dated 05/06/11, indicates R2 was admitted on this same date. R2's Admission Assessment, dated 06/02/11, indicates her "Mental Status" as "Alert," but only "Oriented (to) name." This same area also includes that R2 was assessed as "Forgetful" and "Confused." R2's Nurses' Notes dated 05/06/11 at 5:30 P.M. indicate that she was "Oriented to staff and call light. (R2) Is able to use call light but does not always remember." Included in this same note is that R2's "Son states (R2) does not eat, bathe or change clothes at home. States (R2) will sleep for days at a time, Safety is a major concern at this time...Encouraged staff to check on (R2) frequently." R2's Psychosocial Assessment & Social History, dated 05/09/11 was completed by E17, Social Service Director. This form indicates that R2's memory and Cognitive skills are "Moderately impaired." R2's Assessment For Residents At Risk For Incidents, dated 05/10/11 and completed by E17, indicate that R2's admitting [DIAGNOSES REDACTED]. This assessment indicates that R2 was assessed as not being sexually active. This form further indicates that R2's mental status is "Confused" and places R2 at "Moderate Risk- can sometimes make needs known. Individual safety care plan needed at this time." R2's only two care plans (both dated 05/16/11) that address specific safety issues are: "Resident has exit seeking behaviors" and "Resident at risk for falls." None of R2's care plans have any specific time and frequency of when observations should be done other than listed approaches such as "Monitor and report changes in cognition" and "Close supervision." E4, Rehabilitation Assistant/Certified Nurses Aide (RA/CNA), stated on 08/11/11 at 11:50 A.M., that she knew R2 and verbally described her as "Very confused. A lot of the times (R2) needed re-direction, told what time of day it was, where the dining room was. (R2 is) Generally a quiet person. Mostly wanted to eat and go back to bed." E4 denied ever observing any sexual behavior from R2. E11, Certified Nurses Aide (CNA), on 08/11/11 at 12:05 P.M., described R2 as "Very confused." E11 stressed a vocal intonation on the word "Very." E11 went on to say, "We would wake (R2) up and she wouldn't know where she was, what time it was, who I was. (R2) Could take herself to the bathroom but had to be reminded to go. You could tell (R2) something and five minutes later you'd have to remind her again. (R2) was somewhat stand-offish (uncomfortable) with even having her pants pulled down when we (staff) were providing care." E12, CNA, stated on 08/11/11 at 12:20 P.M., "(R2) was nice, confused- didn't know where her own room was, didn't know which way to go. I do not believe (R2) could make any good decisions, just too confused." E8, Nurse Manager, stated on 08/11/11 at 12:30 P.M., that (R2) was "Alert but was confused. (R2) Needed a lot of directing." E14, Licensed Practical Nurse (LPN), stated on 08/11/11 at 2:10 P.M. that she knew of, and had interacted with, R2 and that, "(R2) Was confused. Could be sitting in Dining room asking what time it was and when breakfast was, even when her breakfast tray was on the table. (R2) roamed the halls at times looking for her 'apartment,' had to be physically re-directed often." E10, Registered Nurse (RN), stated on 08/15/11 at 12:32 P.M. that she knew R2 "Very well." E10 described R2 as "Totally confused. Always asked where the dining room was, always after eating wanted to go back to her room but couldn't remember how (to get there) or what her room number was. (R2) Always asked on a daily basis what medications she was receiving. (R2) was very sweet, very passive. A perfect victim, actually." On 08/11/11 at 1:15 P.M. R2 stated she did not know where she was or how long she had been at that particular facility. R2 stated she did not remember why she was in the current facility. R2 stated she did not remember any incident involving a man on 08/08/11 and stated, "I don't remember any part of that." R2 did not remember going to or being in the hospital emergency roiagnom on [DATE], "For anything." R2 was unable to state time of day or what day it was. R2 was soft-spoken, smiled frequently and was pleasantly mannered. On 08/22/11 at 10:39 A.M., E18, Assistant Administrator, provided a resident roster identifying nineteen residents as female and confused (R5, R7, R8 through R24). On 08/17/11 at 9 A.M., E18, Assistant Administrator, stated that the facility had contracted with residents who wished to be able to participate in consensual sexual behavior in the past. E18 stated that residents could sign an agreement of this sort through Social Services department. E18 stated that there were no residents with a consensual sexual behavior contract during the time of the incident between R1 and R2 on 08/08/11. E18 stated that she couldn't remember a contract having been done, except one, "A long time ago." E18 stated that staff would be made aware of any residents with a consensual sexual behavior contract through shift reports if any were done. When asked for a copy of the facility's policy on consensual sexual behavior contracts and procedure for informing staff, E18 stated, "I don't think there is one." The facility did not provide such, either. Z1, Detective with the local police municipality, stated that R1 was arrested on 08/08/11 at the facility and taken to jail. Z1 further stated that R1 was to be charged with both Criminal Sexual Abuse, "A felony class charge.," and "Aggravated Sexual Abuse of a female over [AGE] years old." This failure resulted in an Immediate Jeopardy situation. The Immediate Jeopardy situation was identified on 08/17/11. The Immediate Jeopardy was determined to have begun on 08/08/11, when the facility failed to immediately stop an observed, non-consensual sex act between R1 and R2 as it was occurring. Both E1, Administrator, and E18, Assistant Administrator, were informed of the Immediate Jeopardy on 08/17/11 at 9:02 A.M. The immediacy of the Immediate Jeopardy was removed on 08/17/11when all staff completed in-service training. The surveyor confirmed though interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Effective 08/08/11, R1 was escorted by the local police from the facility. This was confirmed by police documents provided by Z1 on 08/11/11. 2. R2 was transferred to a local emergency roiagnom on [DATE] for physical evaluation after alleged sexual abuse had occurred. 3. On 08/17/11, the facility provided In-Service training to all facility staff in the following: 1. The facility's Abuse policy, 2. The requirements of reporting abuse, 3. The requirements of protecting the resident and the threat immediately., 4. The seven types of abuse, 5. How to identify abuse, and 6. Responsibilities when abuse is alleged. 4. On 08/17/11 the facility completed a audit of all alert and oriented residents and found no other complaints of inappropriate behavior. Confused or non-verbal residents were observed for signs of unexplained bruising, new peculiar behaviors and fearful expressions. No examples were noted in this category of residents.

Based on observation, interview, and record review, the facility failed to identify a resident, failed to administer medications as ordered, and failed to insure a resident took a medication in 3 of 14 residents sampled. These failures resulted in a significant medication error for 3 of 14 residents sampled (R1, R3, and R4). R4 had a drop in blood pressure, nausea and vomiting requiring R4 to be sent to the emergency room and to receive IV (intravenous fluids) for 2 days following the medication error. R1 was hospitalized at the end of 3 days for behavior manifestations. Findings include: 1. The POS (Physicians Order Sheet) for R4 dated 11/01/10 documents the following Diagnoses: [REDACTED]. Facility Medication Occurrence Report for R4 dated 10/27/10 documents the following: "A new nurse being oriented (and) passed medications to the wrong person." The same Medication Occurrence Report for R4 documents that the following medications intended for another resident were given to R4: [MEDICATION NAME] 25mg (milligrams) which is an anti-psychotic medication used in the treatment of [REDACTED]. The same report also states that R4 was also given R4's regular medications which included: [MEDICATION NAME] 0.5mg, used to treat anxiety; and [MEDICATION NAME] 25mg, an anti-psychotic used in the treatment of [REDACTED]. The nurses notes for R4 dated 10/27/10 at 9:30AM document the following: "Medication error made by orientating nurse. Will notify family." The same nurses notes for R4 on 10/27/10 at 1:30PM document the following: "Doctor notified. Resident experiencing emesis of clear liquid. Order received at 11:20AM to send to the emergency room . The nurses note for R4 dated 10/17/10 at 4:00PM document the following: "Call from hospital requesting copy of (R4's) liver function panel from 09/09/10. On 10/27/10 at 4:15pm nurses notes for R4 document the following: "Resident arrived at facility with family, daughter and husband. Resident's blood pressure is to be taken every 2 hours for the next 12 hours. Hold [MEDICATION NAME] and [MEDICATION NAME] tonight. If systolic blood pressure is below 85 or heart rate is below 60 return resident to the emergency room ." The nurses notes for R4 dated 10/28/10 at 2:30PM document the following: "Family requesting blood pressure be taken. Stated (R4) was lethargic. Blood pressure 78/40. Doctor notified. New order received for Normal Saline IV (Intravenously) at 80cc (cubic centimeters) an hour for 2 days. 4:15PM- IV started in right antecubital area. 3:30 PM Blood pressure was 78/40. A 5:30PM blood pressure was 128/58. At 7:30PM blood pressure was 122/68." The nurses notes for R4 dated 10/29/10 document the following: Doctor here to see resident. New order to discontinue Simvastin. Physicians Progress note for R4 dated 10/29/10 documents the following: "Med (medication) Error. Patient given nine meds of other patient by mistake. Was sent to ER (emergency room ) for evaluation and [MEDICAL CONDITION]. Sleeping in bed today. Blood pressure 110/50. Discussed with daughter to hold [MEDICATION NAME] and [MEDICATION NAME] for 2 days (48 hours), discontinue Simvastin, IV fluids for 2 days." On 11/12/10 at 1PM Z1 (R4's daughter) stated, "We visited (R4) again the next day. I thought she was really lethargic. I asked the nurse (E4) to look at (R4). E4 LPN (Licensed Practical Nurse) told us that (R4) looked ok and didn't need an assessment. I then decided to get another nurse to look at (R4). When the other nurse checked (R4's ) blood pressure she noticed it was low. That's when they called the doctor and he ordered IV fluids for a couple of days." On 11/17/10 at 2:30PM Z4 (nurse for R4's attending physician) stated, "I remember doctor being called about this resident getting the wrong medications. That combination would have caused a lowering of blood pressure in someone who does not take any antihypertensive medications." On 11/12/10 at 1:20PM E6 (LPN) stated, " I was orientating. It was my first day on that side of the building. The other nurse wanted me to go alone. I asked the other nurse who (R5) was. I thought she pointed to (R4) so I went to the table and gave the medications to (R4). (R4) is confused and would not have given a name. There was no picture of (R5) in the MAR (medication administration record) and (R4) was on the other unit." Facility Medication Administration Policy received on 11/13/10 from E5 (LPN) documents the following: "The resident must be identified before administering any medication." The same policy does not document what procedure is used to identify the resident. On 11/12/10 at 1:30PM E5 (LPN) stated, "All residents are to have a picture on the MAR indicated [REDACTED]." On 11/12/10 at 1:45PM E3 (ADON/Assistant Director of Nursing) stated, "Our main way of identifying residents during medication pass is to refer to their picture on the MAR. We try to update those every 6 months. Its a 3 step system. First the nurse is to look at the picture. Second the nurse is to ask another staff member or the resident if they are alert. Third the nurse is to check the identification bracelet on the resident." On 11/12/01 at 12:05PM E7 (LPN) stated, "I'm new. I just started a couple weeks ago. I received 3 days orientation with another nurse then was on my own. When there is no picture on the MAR indicated [REDACTED]." On 11/12/10 at 2:00PM facility census was 67. MAR's (Medication Administration Records) for all 67 residents were reviewed. 8 of 67 residents had no picture in the MAR. 2. The POS (Physicians Order Sheet) for R1 dated 10/01/10 documents the following Diagnosis: [REDACTED]. The nurses notes for R1 dated 10/20/10 at 3:45PM documents the following: "readmitted to facility from mental health facility after psychiatric evaluation. Alert to own name. Accompanied by spouse." Discharge instructions for R4 from mental health facility dated 10/20/10 at 2:27PM document the following medication: [MEDICATION NAME] 25mg (milligrams) twice daily at 8AM and 5PM. The POS for R1 dated 10/20/10 documents the following: Quetiapine [MEDICATION NAME] ([MEDICATION NAME] generic name) 25mg BID (twice daily). The MAR (Medication Administration Record) for R1 dated 10/20/10 documents the following: Quentiapine [MEDICATION NAME] 25mg 1 BID. The same MAR for this medication has no initials of staff indicating the medication was administered from 10/20/10 through 10/25/10. The nurses notes for R1 dated 10/23/10 at 3:00AM documents the following: Resident very anxious. Hands and feet active. Can't seem to keep them still. Almost hyperventilating." The nurses notes for R1 dated 10/23/10 at 2PM document the following: Was told by 1st shift nurse resident was taken to emergency room at mental health facility by spouse because of behavior shown by resident. 8:00PM Resident returned by ambulance from mental health hospital. Appears a little anxious but smiled at staff. " The POS for R1 dated 10/25/10 documents the [MEDICATION NAME] orders received on that date. The MAR for R1 dated 10/25/10 documents the [MEDICATION NAME] orders received for R1 on that date. No initials of staff were entered onto the MAR for 10/25/10 to indicate that the medication was given. The nurses notes for R1 dated 10/25/10 at 6:00AM document the following: "Resident very agitated. Arms and legs constantly moving. Call placed to psychiatrist. 1:10PM Resident throwing self off toilet, sliding on and off wheelchair. Call placed to psychiatrist. 2:30PM- New order for [MEDICATION NAME] 50mg 1 every morning, 25mg at 5:00PM, and 100mg at bedtime." The nurses notes for R1 dated 10/25/10 at 3:45PM document the following: Hold [MEDICATION NAME] 50mg, 25mg, and 100mg. Give [MEDICATION NAME] 12.5 mg BID (twice daily). 4:15PM Called about [MEDICATION NAME] 12.5 order. New order to discontinue and give [MEDICATION NAME] 25mg BID. 4:26PM- Resident in front of nurses station flailing around and all at once resident slid down in wheelchair. 5:15PM- Resident went down hall in wheelchair flailing arm and legs all over. Stopped and evaluated. Residents eyes open but not responsive for 10 seconds then came to and was very anxious. 5:40PM-Ambulance arrived. Resident again non responsive for 3 seconds. Loaded on stretcher and taken to hospital." On 11/10/10 at 1:30PM E2 (DON/Director of Nursing) stated, "(R1) was sent to the hospital initially due to increased combativeness. While there the doctor prescribed [MEDICATION NAME]. The pharmacy refused to fill this because they said his insurance cancelled it. I found out the pharmacy didn't fill this because the insurance denied it. On (10/25/10) I called the pharmacist and he said it was a too soon refill which is why the resident didn't get the [MEDICATION NAME]." Facility Medication Occurrence Report for R1 dated 10/25/10 and signed by E2 (DON) documents the following: Insurance cancelled medication ([MEDICATION NAME]) per pharmacy. Resident not given medication for 2 days." On 11/10/10 at 2:05PM Z2 (facility pharmacist) stated, "On 10/25/10 there was a fax from the facility for [MEDICATION NAME] 50mg in the morning, 25mg in the afternoon and 100mg at bedtime. My dispense log shows that the medication was dispensed to the facility that day. They were sent a 2 day supply because their exchange was due to take place in 2 days and the 30 day supply would come when the exchange happened. This resident was dual eligible for Medicaid and Medicare Part D so coverage of this medication was not a problem. On 10/25/10 our delivery manifest shows that the facility nurse signed for the [MEDICATION NAME], indicating that it was delivered." On 11/10/25 IDPH regional office received a fax from facility pharmacy. Fax received documents that [MEDICATION NAME] was dispensed to the facility on [DATE] and signed for by E9 (LPN/Licensed Practical Nurse). 3. The POS (Physicians Order Sheet) for R3 dated 11/01/10 documents the following Diagnoses: [REDACTED]. The same POS for R3 documents the following order: [MEDICATION NAME] 20mg (milligrams) daily at 8:00AM. Facility Medication Administration Policy received on 11/13/10 from E5 (LPN) documents the following: "The nurse is to stay with the resident until all medications have been taken." On 11/10/10 at 11:10AM R3 was lying in bed with head of bed elevated. R3 had an overbed table across the bed with breakfast tray sitting on it. Sitting on the breakfast tray was a paper medication cup with a small white pill in it. R3 was sleeping. On 11/10/10 at 11:16AM E4 (LPN) went into R3's room. E4 looked at the medication cup on R3's breakfast tray and stated, "Oh, you forgot to take your [MEDICATION NAME]. I brought it in here when (R3) got breakfast around 9:00AM." E4 (LPN) then took the breakfast tray out of R3's room, went to get fresh water and administered the [MEDICATION NAME] to R3 at 11:30AM. On 11/10/10 at 2:30PM E2 (DON) stated, "Nurses are not to leave medications unattended and are supposed to stay with the residents until all the medications have been taken.

Based on observation, interview and record review, the facility failed to ensure that one of fifteen residents on the sample (R3) and two of twelve residents on the supplemental sample (R17 and R34) were provided nursing care free from verbal and mental abuse by nurse E8. The facility also failed to ensure that one resident of fifteen residents on the sample (R1) and one resident of twelve on the supplemental sample (R35) were cared for in a manner free of rough handling by nurse aide E10. Findings include: 1. R3 stated on 9/24/10 at 11:20 AM that nurse E8 talks "sassy" to R3, and that E8 often makes R3 wait before E8 will give R3 a pain pill. R3 further stated on 10/5/10 at 11:30 AM that R3 does not think that E8 "likes" R3. R3 said that one day last week, E8 cussed at R3 when R3 asked E8 a question concerning the late serving of food to R3's roommate. R3 said that E8 told R3 at the time that it was none of her "d--- business." R3 said that the next day, R3 reported it to the staff person who drove R3 to an appointment in the van. R34 stated on 9/28/10 at 10:25 AM that about a month ago, the afternoon nurse E8 told R34 "in a mean way" that R34 would have to wait for her pill. R34 said that this happened again yesterday. R34 said that all the other nurses give R34 her medicine when she asks for it. R34 also said that R34 does not understand why E8 treats R34 that way, but thinks it must be because R34 is Hispanic. E4 (Social Service Designee) stated at 10:15 AM on 9/24/10 that R34 has complained twice that E8 was rude to R34 and would not give R34 a "nerve pill" when R34 asked for it. E4 said that she knows that E2 (Director of Nursing) has "talked" to E8 about the matter. E2 stated at 9/24/10 at 10:30 AM that she has talked with E8 about passing medications to R34 when R34 asks for them, so as to reduce R34's stress level. E5 (Activity Director) stated on 9/28/10 at 12:40 PM that residents come to E5 with problems regularly, and that complaints regarding E8's demeanor are not uncommon. E5 said that E8 has a loud voice, and residents feel that E8 "screams" at them and "talks down to them." E8 stated on 9/29/10 at 1 PM that often R3 and R34 come up to her and want medication when E8 is in the middle of doing blood sugar testing and passing medications to the diabetics. E8 said that she will tell them to wait for the medications until E8 is done with the residents who have diabetes. The facility's Complaint Log for the months of July, August and September 2010 indicated the following staff-related allegations: 1. 9/13/10 and 9/16/10 - R34 reported that the nurse was rude to her. 2. 9/22/10 - R35 reported that a nurse aide had upset her. The logs indicated under the "Actions Taken" column that either staff were "talked to," inservices were held for staff, or the Nursing Department or Administrator was notified of the allegations. Facility Concern/Complaint forms indicated the following: 1. 9/13/10 - R34 alleged that nurse E8 was rude to her and did not give R34 her medication timely. The form also stated that when E8 did pass the medication, E8 threw it at R34. The form also stated that the nurse was educated on resident rights and was given a "write-up." 2. 9/16/10 - R34 alleged that a nurse was rude to the resident while R6 asked for her medication. R6 also alleged that she asked for the medication at 4 PM, but the nurse did not pass it until 7:15 PM. The form further stated that the staff member would be educated on resident rights. E1 stated on 9/27/10 at 1:15 PM that corrective actions have been taken regarding these allegations made pertaining to E8, and can be found in E8's personnel file. E8's personnel file contained a Facility Corrective Action Notification form dated 5/21/10 indicated that on 5/20/10, E8 was overheard telling a former resident (R17) to "shut up." The form indicated that E8 was given a verbal warning. E8's file also contained a Facility Corrective Action Notification form dated 9/7/10 that stated on 9/6/10, E8 was heard "screaming and arguing with a resident (R17) for over five minutes." The form indicated that E8's behavior caused R17 to cry. The form also stated that E8 was given a written warning for the matter. A statement dated 9/6/10, written by E26 (Evening Receptionist) who witnessed E8's behavior toward former resident R17 on 9/6/10, was attached to this Corrective Action form. The statement, which was addressed to E4 (Social Service), documented that E26 believed that E8 was "just ridiculous" in the way that E8 talks and yells at the residents. E26 stated that E8 screamed and argued with R17 for 5 minutes, and that this was not the first time E26 had seen this behavior of E8's. E26 stated that she has discussed this situation with E1 in the past, and that E26 could not understand why E8 "still has a job." E26 stated that E26 had "NEVER heard anyone be more disrespectful or inconsiderate." A facility Concern/Complaint form dated 9/29/10 indicated R3 reported that E8 (nurse) cursed at the resident when R3 asked a question about R3's roommate. The report stated that E8 told R3, "It is none of your d--- business." The accompanying investigation report completed by E1 indicated that R3, E8 and one other staff member, to whom R3 initially reported the matter, were interviewed. The report stated that E8 refused to provide a statement regarding the matter, and was given a three day suspension. E8 was currently working at the facility during the survey on the week of 10/4/10, and conducted medication passes, one of which was observed. 2. E2 (Director of Nursing) stated on 9/24/10 at 10:30 AM that she has recently received separate complaints of rough handling on the part of nurse aide E10 from R1 and R35. E2 said that upon investigation of the allegations, E10 has and will be again "written up" for roughness. E2 said that if another allegation is received, E10's employment will be terminated. E4 (Social Service Designee) stated on 9/24/10 at 10:15 AM that a couple months ago, R1 complained that aide E10 was rough when repositioning R1. E4 said that recently R35 complained that E10 was rough with R35 as well. R1 stated on 9/24/10 at 11 AM that some aides have been rough with her when turning her in bed. R1 said that when her left arm is pulled by staff to turn her, it hurts. R1 said that E2 is working on the problem, and staff are getting better about it. R35 stated on 9/28/10 at 10 AM that she has only been at the facility a few weeks, and that a couple nurse aides, names unknown, have been "mean, abrupt, or plain rude." A facility Concern/Complaint form dated 7/6/10 indicated that R1 made a complaint that E10 was too rough with the resident, who no longer wanted E10 to take care of her. The form indicated that E2 then "talked to" E10. A Concern/Complaint form dated 9/6/10 indicated that R1 made a complaint that aides, including E10, were rough with her when being turned. Another Concern/Complaint form dated 9/22/10 indicated that R35 complained that E10 was "very rude and rough" with the resident. The form documented that E10 lifted the resident's bad leg, causing R35 to yell out. R35 also reported that at that point, E10 then "ripped" the pillow out from underneath her leg. The form also documented R35 stated E10's bedside manners were "really bad." E1 stated on 9/27/10 at 1:15 PM that corrective actions have been taken regarding these allegations made pertaining to E10, and can be found in E10's personnel file. E10's personnel file contained a Corrective Action form dated 7/21/10 which stated that several residents had reported that E10 was handling them roughly. The form further documented that this issue had been addressed before with E10 "off the record," but that reports of E10's roughness had increased. The form indicated that E10 was provided "staff education" as a corrective action. E10's file also contained two Corrective Action forms dated 9/24/10. One of the forms documented further resident reports of rough handling and a "short temper" on the part of E10. This form indicated that a verbal warning was the corrective action taken. The other form documented that on 9/23/10, the facility received another report of rough handling on E10's part. The form indicated that E10 was given a written warning. E1, Administrator stated at approximately 10 AM on 10/4/10 E10's employment had been terminated.

Surveyor: McDorman, Pat Based on interview and record review, the facility failed to develop and implement a system to collect and analyze data related to the number and frequency of falls, identify patterns and assess the root cause of the falls. The facility failed to develop a plan of care with interventions to meet the specific needs of residents to prevent falls for R4, R5, R21 (3 of 3 residents with repeated falls with injury in the sample of thirteen ). R4 sustained a fractured wrist and head lacerations. R5 sustained a laceration to the right eyebrow. R21 sustained a abrasion and hematoma of the right neck and laceration to left eyebrow. Findings include: 1. The physician's orders [REDACTED]. The admission Minimum (MDS) data set [DATE] rates R4 as modified independence for cognitive skills for daily decision making (some difficulty in new situations only). According to this MDS, R4 is independent with all activities of daily living (ADLs) except for dressing and bathing which R4 needs setup help and supervision. This MDS documents that R4 has no falls or fractures prior to admission to this facility. The quarterly MDS dated [DATE] documents that R4's cognitive skills have declined to: moderately impaired (makes poor decisions, cues/supervision required), but R4 still remains independent with all ADL's except for bathing and dressing. This quarterly MDS documents that R4 has had no accidents while at this facility. The nurses notes of 5/30/10 and the incident report of 5/30/10 document that R4 was found sitting on the floor against the wall. The Incident Reports document that R4 was found sitting on the floor against the wall across from her door on 5/30/10 at 2:15 am, was sent to hospital at 615 AM with a fractured wrist, fell to the floor in her room at 1045 PM on 8/15/10, on 9/16/10 at 5:00 AM R4 was found on floor in room, on 9/18/10 at 8:08 AM R4 was found on floor in her room with a laceration on right side of head and a skin tear on right hand and wrist. R4 was sent to hospital by ambulance. R4's care plan dated 5/7/10 does not identify falls as a problem or document any approaches in the antipsychotic medication/antianxiety medication care plan to prevent falling. The antipsychotic approach documents to monitor for over sedation/hypotension with slurred speech, staggered gait, fainting, falling, decreased blood pressure and lethargy. There is no evidence in the clinical record that monitoring was being done, with no approaches to prevent falls. E2, Director of Nursing stated on 10/4/10 at 10:00 AM, that the department heads discuss who has fallen in the morning meeting. The care plan person is responsible for providing interventions. At present there in no care plan person working at this facility. E2 stated that no one tracks the falls by trends and patterns and critically analyzes the data in order to develop new approaches to prevent further falls. E2 stated that the care plan books are kept in the care plan office and she has a separate fall careplan book in her office. On 10/7/10 at 10:15 AM, E30 (Certified Nurse Aide) stated that there is a black book at the nursing desk that documents each residents care needs: transferring, eating, dressing and bathing(assist or independent). There is nothing in the black book about approaches to prevent falls, how to approach aggressive residents or likes and dislikes of the residents. According to E30, there is a care plan book in the care plan office, but CNA's don't have time to hunt it down and read it. No one tells them about new approaches to prevent further falls. 2. The physician's orders [REDACTED]. R5 was admitted to this facility from home on 5/18/09 with no history of falling according to Z7(wife). The fall risk assessment documents that R5 scores as a high risk for falls and a prevention protocol should be initiated immediately and documented on the care plan. The Minimum (MDS) data set [DATE] documents that R5 has fallen in the past 30 days. The Resident Assessment Protocol Summary for this MDS documents that a decision to care plan falls. This same MDS documents that R5's cognitive skills are severely impaired(never/rarely made decisions.) R5 was independent with all activities of daily living (transferring, walking and eating.) R5 needed assistance with dressing, toileting and bathing. On 5/28/10, a Significant Change MDS was done for R5. This MDS documented R5's cognitive skills as being moderately impaired -decisions poor cues/supervision required. It documents that R5 has fallen in the past 30 days and the past 31- 180 days. No RAP summary was completed for this MDS according to E23(Nurse consultant). The current care plan which is kept in the care plan book in the care plan office does not have a specific "fall" care plan with interventions to prevent further falls. The physical Restraint care plan documents that R5 requires use of restraints due to potential for frequent falls and injury. The approaches listed to prevent further falls are: continuous use of lap restraint while in wheel chair. Assess every month for possible restraint reduction, restorative ambulation program. E2 provided a Fall care plan dated 9/2/09 and updated every quarter through 3/30/10 that she said she keeps in her office. This care plan documents that R5 is at risk for falls related to self mobility impairment, poor decision making ability and decreased judgement and safety awareness, recent history of falls and currently taking Haldol and Paxil daily. The approaches are: bed alarm, low bed, ask if he needs help when heading to his room, toilet routinely to reduce the risk of self transfer. It lists each fall dates (31 falls from admission until present with no new specific approaches to prevent further falls.) There is no documentation in this care plan to indicate that these falls were reviewed for trends and patterns with new interventions after each fall to prevent further falls. E2 stated that the facility department heads discuss resident falls daily and the care plan coordinator is supposed to update the care plan. E2 stated that there is no care plan person at this time. E2 stated that they don't discuss any trends and patterns or brain storm to provide approaches to coincide with the time and location of the falls. On 10/7/10 at 10:30 AM, E 31 was interviewed regarding R5's falls. E31 stated that no one tells the CNA's about any new interventions to prevent further falls. E31 stated that the previous shift CNA's tell her shift if anyone fell during there shift. E31 stated that the care plan book is kept in the care plan office(not easily accessible) to the CNA's. E31 stated that R5 has bed alarms, chair alarms and a lap restraint while up in the wheel chair because of his falls. The incidents provided for review from 3/19/10 - 10/2/10 document that R5 had 31 falls during this time period- 11 on 3rd shift with 6 in the bedroom, 15 on days in the dining room and the A and B halls, and 5 on 2nd shift mostly in the dining area. R5 has had abrasions to his elbows, knees and nose on at least 7 of these falls according to these incident reports. R5 takes Haldol daily which places R5 at risk for falls. The antipsychotic medication care plan approaches documents to monitor for the adverse side effect, Akathisia(extreme desire to move shown by constant pacing or leg movements) but gives no direction of what to do if observed. R5 was diagnosed with [REDACTED]. On this same care plan, it is documented to monitor for over sedation/hypotension ,staggered gait, fainting, falling, decreased blood pressure, confusion lethargy or daytime sedation with no direction of what to do if observed. 3. The current physician's orders [REDACTED]. The annual Minimum (MDS) data set [DATE] documents that R21's cognition is severely impaired(never/rarely made decisions.) It documents that R21 has fallen in the past 30 days and the past 31-180 days. There is no Resident Assessment Protocol Summary filled out with a decision to proceed to the care plan with falls as a problem. The Fall Risk assessment dated [DATE] documents that R21 is at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The current care plan which is kept in the care plan office documents that R21 needs assist with all activities of daily living. The current care plan dated 12/2/09 identifies R21 as being a fall risk related to self mobility impairment, poor decision making ability and decreased judgement and safety awareness, recent history of falls. The approaches/interventions are the normal interventions- bed in low position, toilet routinely, stand by assist with gait belt, call light in reach, wander guard at all times, pressure alarm while in wheelchair. There are no specific interventions to prevent R21 from falling while in room unsupervised or in the dining room. The Incident Reports from 2/22/10 - 9/11/10 document that R21 fell 22 times during this period with a laceration to Left eye on 6/22/10, bruise to Left eye on 3/26/10 and right neck abrasion and hematoma on 3/1/10. Eleven of these falls were unwitnessed in R21's room. Five were in the dining room and the rest in the A hall way. The Incident Listing for R21 also document that R21 fell nine times from 2/18/09 - 10/6/09 The care plan approaches after each fall repeat the approaches already tried. There are no specific interventions for where, when or how the falls occur in order to prevent further falls.