Every finding on record at Allure of Prophetstown

Based on interview and record review, the facility failed to transfer a resident (R1) with a gait belt, and failed to supervise a resident (R1) during ambulation. These failures apply to 1 of 3 residents (R1) reviewed for safety & supervision in the sample of 4. These failures resulted in R1 obtaining a intertrochanteric fracture of her left hip and undergoing left femur intramedullary nailing. This past noncompliance occurred from July 23, 2026 to July 24, 2026. The findings include:R1's face sheet printed on 8/28/26 showed R1 has diagnoses including but not limited to displaced intertrochanteric fracture of left femur, generalized anxiety disorder, depression, unsteadiness on feet, lack of coordination, and dementia without behaviors.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, utilizes a walker, requires partial/moderate assistance to walk, and has had 1 fall since admission to the facility.R1's fall risk evaluation dated 5/11/26 showed R1 is at risk for falls.R1's care plan dated 5/20/26 showed, (R1) is at risk for falls related to confusion, gait/balance problems, unaware of safety needs.R1's local hospital records dated 7/30/26 showed, (R1) presented to the emergency room after sustaining a fall. Found to have a UTI (urinary tract infection) and intertrochanteric fracture of left hip and underwent left femur intramedullary nailing on 7/25.On 8/28/26 at 10:20 AM, V5 (Certified Nursing Assistant) stated, I was the aide working with (R1) when she fell. I was going to check on her for rounds, and I got her to stand up and she was holding her walker. I turned around to turn her bathroom light on and open her door and as soon as I went to turn around, she was mid-fall and I couldn't catch her. We would wake her up, partially help her sit up and sit on the edge of the bed and she would stand up to her walker and walk to the bathroom. She was more of a supervised walker because she walked well. She was wearing her slip-on shoes at the time of the fall. Depending on how weak she was, we would use a gait belt at times. Most of the time I would just hold onto the back of her pants or my arm under her arm. I probably would have had the bathroom light on and opened the door before I got her up to go to the bathroom, so I could've walked next to her and supervised her. I did receive some education on gait belts and supervision of residents. I should have used a gait belt and stayed with her to make sure she was safe. I didn't know she was a contact guard assist with ambulation.On 8/28/26 at 11:14 AM, V2 (Director of Nursing) stated, (R1) was care planned for contact guard assist so (V5) should have had a gait belt on her. I did educate him on that and that we use a gait belt at all times for any resident requiring assistance with ambulation.On 8/28/26 at 12:24 PM, V7 (Nurse Practitioner) stated, (R1) did require some assistance with ambulation. I would agree that she should have been wearing a gait belt and had staff next to her supervising her when she was up. This fall could have potentially been prevented had those interventions been in place.The facility's policy titled, Fall Prevention Program revised on 8/2025 showed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility's policy titled, Use of gait belt dated 2025 showed, It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.Prior to the survey date of 8/28/26, the facility took the following actions to correct the noncompliance on 7/24/26:1. Immediate corrective action for the resident identified in the deficiency. a. Increased supervision x 24 hours for immediate intervention. b. Resident added to the Falling Leaves Program. c. X-rays to left hip ordered and referred to physical therapy. d. Reviewed care plan/added revisions to reflect resident's current needs.2. Identifying other residents with potential for being affected and corrective action. a. All residents at risk for falls would be at risk , but no other concerns noted.3. Systemic changes to reasonably assure deficiency does not recur. a. The facility implemented the following system-wide improvements: i. Policy Review 1. Policies related to Fall Prevention Program, Gait Belt Use Policy, and Accidents and Supervision were reviewed and compared to current practices. ii. Staff Education 1. All clinical staff, including agency, will receive education regarding: a. Fall prevention procedures b. Accidents and supervision c. Gait Belt Use Policy4. How corrective actions will be monitored. a. Quality Assurance Study tools have been developed. i. Weekly audits will be completed for 3 months to verify: 1. Did resident have a fall 2. Was the policy and procedure followed by staff ii. Monthly QA review will evaluate: 1. Any falls during the month 2. Were policies and procedures followed by staff 3. Results will be reviewed during monthly QAPI meetings and corrective action will be implemented as needed.5. Administration will monitor for overall compliance.

Based on interview and record review, the facility failed to ensure a resident was free from missing narcotic medication for 1 of 3 residents (R1) reviewed for misappropriation of resident medication in the sample of 3. The past non-compliance occurred from 10/18/25- 10/20/25. The findings include:R1s October Summary Sheet shows she was admitted to the facility on [DATE] and was placed on hospice 10/13/25. The same sheet shows a 10/13/25 physician order for Morphine Sulfate 20 mg/5 ml- give 0.25ml every hour as needed for pain or shortness of breath. The individual controlled substance record shows on 10/14/25 the facility received a 5ml bottle of Morphine Sulfate for R1.The October Medication Administration Record (MAR) shows R1 did not receive any doses of Morphine and had no complaints of pain.On 12/21/25 at 8:53AM, V5, Licensed Practical Nurse (LPN), said R1 had passed away on hospice. She said when R1 was admitted to hospice, they sent a bottle of morphine for her. The bottle stood out to her as weird and the liquid in the bottle was a thick gel and pink in color. When she returned to work a few days later and saw the bottle was missing she began to search what happened to it. She said the medication sheet showed R1 took no doses, and the bottle and count sheet were gone, and it was not signed out on the master count sheet. V5 said she reported the missing bottle to V2, Director of Nursing.On 12/21/25 at 10:45 AM, V2 said V5 reported to her R1 was missing a bottle of Morphine. V2 said she conducted a search and determined the bottle and the count sheet were both missing. She found the count sheet in the shred bin located in the nurse's station, with no doses signed out, and the paper was still intact. V2 said while reviewing the video footage of nurses counting at change of shift, the bottle and count sheet were last seen on 12/18/25 during the morning count between V8, LPN, and V4, Registered Nurse (RN). She said the evening shift change was not conducted in plain view of the camera. But when she interviewed V7, LPN, who counted with V4, she did not recall seeing R1's bottle of Morphine. V2 said based on her findings, she determined V4 had taken the bottle of Morphine.The facility's undated policy for Abuse, Neglect and Exploitation 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. Definitions: Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.Prior to the survey date of 12/21/25, the facility had taken the following action to correct the noncompliance: During an emergency QAPI Quality Assurance and Performance Improvement meeting on 10/20/25:1. The current policies for Controlled Substances Administration and Accountability and Abuse, Neglect, Exploitation were reviewed.2. A root cause analysis was completed to determine how the Morphine was missing. It was determined the nurses were not doing the narcotic count correctly at the end of shift.3. R1's Morphine was immediately reordered.4. On 10/20/25, education with nursing staff was conducted by the Director of Nursing on 1) Abuse, Neglect and Exploitation policy; 2) Medication Administration; 3) Controlled Substance Administration and Accountability Policy.4. Checklists and monitoring tools were created to determine:1) Were the controlled substances counted correctly and documented at shift change2) Were the controlled substance sheets/papers counted correctly and documented at shift change3) Were there any missing controlled substances

Based on interview and record review, the facility failed to ensure controlled narcotic medications were counted by the nursing staff for 1 of 3 residents (R1) reviewed for narcotic medications in the sample of 3. The past non-compliance occurred from 10/18/25 to 10/20/25.The findings include: R1s October Summary Sheet shows she was admitted to the facility on [DATE] and was placed on hospice 10/13/25. The same sheet shows a 10/13/25 physician order for Morphine Sulfate 20 mg/5 ml- give 0.25ml every hour as needed for pain or shortness of breath. R1's individual controlled substance record shows on 10/14/25 the facility received a 5ml bottle of Morphine Sulfate.On 12/21/25 at 8:53AM, V5, Licensed Practical Nurse (LPN), said R1 had passed away on hospice. She said when R1 was admitted to hospice, they sent a bottle of morphine for her. The bottle stood out to her as weird and the liquid in the bottle was a thick gel and pink in color. When she returned to work a few days later and saw the bottle was missing she began to search what happened to it. She said the medication sheet showed R1 took no doses, and the bottle and count sheet were gone, and it was not signed out on the master count sheet. V5 said she reported the missing bottle to V2, Director of Nursing. V5 said the nurses have 2 medication carts. At each shift change the nurses count the controlled medication. She said the oncoming nurse will follow the count sheets while the outgoing nurse does the control cards, bottles and patches. Then both nurses sign the book showing the count was correct.On 12/21/25 at 9:06 AM, V6, Registered Nurse (RN), said, At each shift change, the nurses count the control cards and number of bottles; they are in a separate drawer. One by one we verify each item in the cart. The count sheet shows the total number of items in the cart. Both nurses sign the book when the count is correct. When we use something, it is subtracted out, and the next shift will reflect that in the count. V6 said when there is any discrepancy with the count, it is reported to V2, Director of Nursing.The October 2025 change of shift control count sheet for the 100 hall shows no count was recorded from the night shift of 10/16/25 until the night shift of 10/18/25. The count sheet was missing the number of cards and count sheets, and the number of miscellaneous items in the cart for 4 shift changes.On 12/21/25 at 10:45 AM, V2 said V5 reported to her on 10/20/25, R1 was missing a bottle of Morphine. V2 said she conducted a search and determined the bottle and the count sheet were both missing. She found the count sheet in the shred bin located in the nurse's station, with no doses signed out, and the paper was still intact. V2 said while reviewing the video footage of nurses counting at change of shift, the bottle and count sheet were last seen on 12/18/25 during the morning count between V8, LPN, and V4, Registered Nurse (RN). She said the evening shift change was not conducted in plain view of the camera. But when she interviewed V7, LPN, who counted with V4, she did not recall seeing R1's bottle of Morphine. V2 said based on her findings, she determined V4 had taken the bottle of Morphine. V2 said she did review the narcotic count sheets and there were some holes in the documentation. The count was not done at shift change as it was supposed to be done.The facility's undated policy for controlled Substance Administration & Accountability documents it is the policy of this facility to promote safe, high-quality patient care, compliant with the state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. 9. B. For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift.Prior to the survey date of 12/21/25, the facility had taken the following action to correct the noncompliance: During an emergency QAPI Quality Assurance and Performance Improvement meeting on 10/20/25:1. The current policy for Controlled Substances Administration and Accountability was reviewed.2. A root cause analysis was completed to determine how the Morphine was missing. It was determined the nurses were not doing the narcotic count correctly at the end of shift.3. R1s Morphine was immediately reordered.4. On 10/20/25, education with nursing staff was conducted by the Director of Nursing on 1) Abuse, Neglect and Exploitation policy; 2) Medication Administration; 3) Controlled Substance Administration and Accountability Policy.4. Checklists and monitoring tools were created to determine:1) Were the controlled substances counted correctly and documented at shift change2) Were the controlled substance sheets/papers counted correctly and documented at shift change3) Were there any missing controlled substances

Based on interview and record review, the facility failed to provide a safe transfer for R1. This failure resulted in a laceration to R1's leg on 10/31/25 that required 9 stitches at the local emergency room for 1 of 3 residents (R1) reviewed for safe transfers in the sample of four. This past noncompliance occurred from 10/31/25 to 11/3/25. The findings include: R1's Face Sheet, dated 11/13/25, showed diagnoses including metabolic encephalopathy, gastrointestinal hemorrhage, asthma, atrial fibrillation, pneumonia, bacteremia, bullous pemphigoid, gastroesophageal reflux disease, hypertension, and tinea unguium.R1's Minimum Data Set (MDS), dated [DATE], showed no cognitive impairment; chair/bed transfer - dependent; toilet transfer - dependent.R1's Care plan, dated 10/19/25, showed R1 has an activity of daily living self-care performance deficit, activity intolerance, and limited mobility. Transfer: The resident requires assistance of 2 staff members for a pivot transfer using a FWW (front wheeled walker) and gait belt. Restorative-Transfers. I will be able to transfer between surfaces using a 2-person pivot with a FWW and gait belt. Staff will provide gait belt and walker. Staff will also ensure to block my feet during the sit to stand part of my transfers. Staff will also provide verbal cues to assist due to visual deficits. Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.R1's Nurses Note, dated 11/1/25 at 2:41 AM, showed, Resident sitting in recliner and tells this nurse she has a cut on her leg. This nurse sees a washcloth taped over affected area, when washcloth removed there is a large, deep laceration below knee on upper part of lower leg. No active bleeding at this time, subcutaneous tissue showing, resident denies any pain to area. At 4:10 AM, Resident has returned from emergency room, 9 stitches to right lower extremity, dressing clean, dry, and intact.R1's Final Incident Investigation, dated 11/3/25, showed, on 11/1/25, V5, Certified Nursing Assistant, enters the room of R1 and observes a wound to the resident's right lower extremity, to which she immediately reports to the nurse, V6 Licensed Practical Nurse - LPN. Upon V6's assessment she notes a laceration. V6 reports that there was visible subcutaneous tissue, but no active bleed. V9, Nurse Practitioner, was notified of the newly acquired skin condition and gave the orders to send R1 to the emergency department for evaluation. V3, Assistant Director of Nursing - ADON, was notified. Power of attorney was notified. R1 later returned from the hospital with 9 stitches to her right lower extremity. V9 NP was notified of the resident's return and gave orders to monitor the wound for signs or symptom of infection before initiating antibiotic therapy, remove stitches in 10 days, and utilize as needed Tylenol for pain. R1 was interviewed and she stated that two aides came in to get her ready for bed. R1 reports they transferred her into a wheelchair around 9:00 PM and at that time she complained of her leg hurting but was not aware of any injury to her leg at that time. R1 described the staff as two black girls but did not know their names. V7, CNA, was interviewed. V7 stated when she entered R1's room, R1 said she had to use the bathroom and that she transferred with the sit to stand because her leg hurt. V7 stated she saw that R1's leg was bleeding so she covered the wound with a towel so she could continue toileting R1, and she forgot to notify the nurse because she had answered another light. It was also discovered during the investigation that there was blood on the foot pedal pegs on the wheelchair, believed to have caused the skin laceration.On 11/13/25 at 9:34 AM, V1, Administrator, stated the investigation into R1's incident was done by V2, Director of Nursing and V10, Regional Nurse. V3, Assistant Director of Nursing, was on call and was notified about a laceration on R1's leg. V3 looked at R1's wheelchair and found blood on the area where the foot pedals attach to the wheelchair. R1 was interviewed and said two girls transferred her and then her leg started to hurt, and she did not realize she had a laceration. R1 was being transferred to the recliner when the laceration occurred. V7, CNA, and V8, CNA, transferred R1 to her recliner They did not do a safe transfer.On 11/13/25 at 9:43 AM, V2, Director of Nursing/DON, stated she did the investigation for the laceration to R1's leg. V2 stated she watched the facility cameras to see if she could figure out what happened. V2 stated on 10/31/25 in the evening, she saw V7 go into R1's room and then she came out and V8 followed V7 back into R1's room. V2 stated on the camera she could see V7 grab a washcloth and go back into the room. V2 stated she then saw V8 take the stand lift into the room; a few minutes later they both left the room. V2 stated she saw V7 grab a roll of tape, go into R1's room and a few minutes later V7 left the room. V2 stated she called V7, and she said R1 was sitting in her recliner in just a brief when she went into the room and the wound was already there. V2 stated V7 told her she covered the laceration to stop the bleeding and then continued to transfer R1 to take her to the toilet. V2 stated V7 told her she got distracted answering call lights and forgot to tell the nurse. V2 stated after completion of the investigation she feels the injury to R1's leg occurred when V7 was caring for R1, that it occurred during a transfer, and she taped a washcloth over the top of it because she was afraid of getting in trouble. V2 stated V3 found blood on the pegs of R1's wheelchair where the footrests attach to the wheelchair. They think R1 received the laceration from that during a transfer. V2 stated what happened was an unsafe transfer. V2 stated what should have happened is they should have had a gait belt on R1. They should have made sure to go slow and steady with the transfer to prevent injury during a transfer.On 11/13/25 at 12:04 PM, V8, CNA, stated R1 was already like that when she went into her room. V8 said she just took the stand lift into the room and then left because she had her own people to take care of. V8 said she went into the room with V7 because R1 wanted to go to the bathroom. R1 said she could not be moved without the sit to stand, so that is why she got the sit to stand and then she left the room. V8 stated they did not transfer R1, she wouldn't let them, she refused to transfer with the gait belt. V8 stated V7 used the sit to stand lift by herself to take R1 to the bathroom.On 11/13/25 at 12:09 PM, V7, CNA, stated R1 was in her recliner with her call light on and she wanted to go to the bathroom. V7 said R1 told her to use the sit to stand on her. V7 stated she pulled R1's covers off and saw a wound to her leg. V7 took R1 to the bathroom and then put her in recliner. V7 stated she put a towel on her leg. V7 stated she was on her way to tell the nurse, but other call lights were going off. V7 stated she answered them and forgot to tell the nurse. V7 stated R1 already had that (laceration) when she came in. V7 stated she took R1 to the bathroom by herself using the sit to stand lift.On 11/13/25 at 12:29 PM, R1 stated it was around 8:00 PM and she had to go to the bathroom before going to bed. R1 stated she put her call light on and 2 ladies from and agency came in to help her. R1 stated she had never seen them before. R1 stated she told them she uses the chair lift to transfer. R1 stated the ladies told her no. R1 stated her wheelchair was quite a bit away from her, and they told her she could walk to her wheelchair. R1 stated she told them she couldn't walk that far, and they laughed at her. R1 stated they had her stand. One of them was behind her having her move forward and the other one was by the wheelchair. R1 stated she missed part of the seat of the wheelchair; she was half in and half out of the chair. R1 stated that is when she hurt her leg but did not know it was bleeding at the time. R1 said she hit her leg on the chair because of how she landed in the chair. R1 stated they did not have a gait belt around her and did not help her. R1 stated one of the ladies put a towel around her leg and told her it was bandaged and left the room. R1 stated she went to the hospital and had 9-10 stitches put in her leg. R1 stated she felt absolutely not safe during the incident. R1 stated she had never met them before but thinks they are a danger to frail people and any patients anywhere.On 11/13/25 at 2:17 PM, V9, Nurse Practitioner, stated she was notified R1 had a fall with laceration, so she was sent out for sutures. V9 stated the laceration should be reported right away as well as any complaints of pain. V9 stated staff should look and see why there are complaints of pain and follow up on it. V9 stated any type of fall or gliding into the wheelchair should be looked into and reported for the resident safety. The resident care plan should be followed for transfers and if staff are unable to transfer the resident as stated in the care plan, then the nurse should be notified. A gait belt should be used for a two person transfer every single time especially if the resident has any weakness; they need to use it for the safety of the resident. The facility's Safe Resident handling/Transfers policy (2024) showed, all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are safer alternative and should be used. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. Handling aids may include gait belts, transfer boards, and other devices. Two staff members must be utilized when transferring residents with a mechanical lift. Staff will be educated during transfers, to avoid contact with wheelchair, wheelchair foot pedals, or transfer devices, to prevent injury. Staff must ensure that there is appropriate clearance between the resident and the wheelchair, wheelchair foot pedals, or transfer devices, to avoid such contact.Prior to the date of 11/13/25, the facility had taken the following action to correct the noncompliance:The facility ensures resident's safety during transfers.I. Corrective action for residents identified in the deficiency.A. Resident was sent to the hospital for evaluation and received sutures for laceration to the leg.B. Padded leg sleeves were added to the resident's plan of care to protect legs from further injury.C. Agency CNAs involved will not be returning to the facility.II. Identifying other residents with potential for being affected and corrective action.Any resident that is care planned for transfers needing assistance have the potential to be affected but others were identified.III. Systemic changes to reasonably assure deficiency does not recur.A. In-service was conducted by the DON with nursing staff on November 3.2025 which included the facilities policy and procedure for safe resident transfers.IV. How corrective actions will be monitored.DON or designee will conduct QA study to determine:1. Does the resident require assistance with transfers?2. Did the staff complete transfer safely?The QA study will be completed 5 days a week for two weeks, twice weekly for 2 months, and weekly for 1 month. Audit results will be forwarded to the facility Quarterly QAPI committee for review. Any concerns identified will be immediately corrected.The Administrator is responsible for compliance.

Based on interview and record review, the Certified Nursing Assistant/CNA failed to notify the nurse when she saw a laceration to a resident's leg, which was a change in condition for 1 of 3 residents (R1) reviewed for change in condition in the sample of four. This past noncompliance occurred from 10/31/25 to 11/3/25. The findings include:R1's Face Sheet, dated 11/13/25, showed diagnoses including metabolic encephalopathy, gastrointestinal hemorrhage, asthma, atrial fibrillation, pneumonia, bacteremia, bullous pemphigoid, gastroesophageal reflux disease, hypertension, and tinea unguium.R1's Minimum Data Set (MDS), dated [DATE], showed no cognitive impairment; chair/bed transfer - dependent; toilet transfer - dependent.R1's Nurses Note, dated 11/1/25 at 2:41 AM, showed, Resident sitting in recliner and tells this nurse she has a cut on her leg. This nurse sees a washcloth taped over affected area, when washcloth removed there is a large, deep laceration below knee on upper part of lower leg. No active bleeding at this time, subcutaneous tissue showing, resident denies any pain to area. At 4:10 AM, Resident has returned from emergency room, 9 stitches to right lower extremity, dressing clean, dry, and intact.R1's Incident Investigation Final Report, dated 11/6/25, showed on 10/31/25, R1 was interviewed and she stated that two aides came in to get her ready for bed. R1 reports they transferred her into a wheelchair around 9:00 PM and at that time she complained of her leg hurting but was not aware of any injury to her leg. The night shift agency CNA (Certified Nursing Assistant) V7 was interviewed. V7's stated when she entered R1's room, R1 said she had to use the bathroom and that she transferred R1 with the sit to stand because R1's leg hurt. V7 stated she saw R1's leg was bleeding so she covered the wound with a towel so she could continue toileting R1. V7 stated she forgot to notify the nurse because she had answered another light.On 11/13/25 at 9:34 AM, V1, Administrator, stated the investigation into R1's incident was done by V2, Director of Nursing, and V10, Regional Nurse. R1 was interviewed and said two girls transferred her and then her leg started to hurt, and she did not realize she had a laceration. V7, Certified Nursing Assistant/ CNA, said she wrapped the towel around the laceration, took R1 to the bathroom, left the room after toileting R1, answered call lights, and forgot to tell the nurse. V1 stated it was after that another CNA (V5) answered R1's call light and saw the laceration to her leg. V7 should have immediately reported it to the nurse.On 11/13/25 at 9:43 AM, V2, Director of Nursing/DON, stated she did the investigation for the laceration to R1's leg. V2 stated she watched the facility cameras to see if she could figure out what happened. V2 stated on 10/31/25 in the evening, she saw V7 go into R1's room and then she came out, and V8 followed V7 back into R1's room. V2 stated on the camera she could see V7 grab a washcloth and go back into the room. V2 stated she then saw V8 take the stand lift into the room; a few minutes later they both left the room. V2 stated she saw V7 grab a roll of tape, go into R1's room and a few minutes later, V7 left the room. V2 stated she called V7, and she said R1 was sitting in her recliner in just a brief when she went into the room and the wound was already there. V2 stated V7 told her she covered the laceration to stop the bleeding and then continued to transfer R1 to take her to the toilet. V2 stated V7 told her she got distracted answering call lights and forgot to tell the nurse. V2 stated after completion of the investigation, she feels the injury to R1's leg occurred when V7 was caring for R1, that it occurred during a transfer, and she taped a washcloth over the top of it because she was afraid of getting in trouble. V2 stated V7 should have immediately notified the nurse so it could have been addressed right away.On 11/13/25 at 12:09 PM, V7, CNA, stated when she pulled the cover from R1 she saw a wound to her leg. V7 stated she took R1 to the bathroom, put her back in her recliner, put a towel on the laceration, and left R1's room. V7 stated she was going to tell the nurse but started answering call lights and forgot to tell her.On 11/13/25 at 2:17 PM, V9, Nurse Practitioner, stated she was notified R1 had a fall with laceration, so she was sent out for sutures. V9 stated the laceration should be reported right away as well as any complaints of pain. V9 stated staff should look and see why there are complaints of pain and follow up on it. The facility's Notification of Changes policy (2024) showed the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 1. Accidents: a. resulting in injury; b. potential to require physician intervention.Prior to the survey date of 11/13/25, the facility had taken the following action to correct the noncompliance:The facility ensures proper notification with resident condition changes.I. Corrective action for residents identified in the deficiency.A. Resident was sent to the hospital for evaluation and received sutures to the leg.B. Agency CNAs involved in the incident will not be returning to the facility.II. Identifying other residents with potential for being affected and corrective action.Any resident that has a change in condition have the potential to be affected, but none have been identified.III. Systemic changes to reasonably assure deficiency does not recur.A. In-service was conducted by the DON with nursing staff on 11/3/25 which included reporting changes in condition and safe resident handling.IV. How corrective actions will be monitored.DON or Designee will conduct QA study to determine:1. Was there a change in condition?2. Did staff notify all pertinent parties immediately?The QA study will be completed 5 days a week for two weeks, twice weekly for 2 months, and weekly for 1 month. Audit results will be forwarded to the facility Quarterly QAPI committee for review. Any concerns identified will be immediately corrected.The Administrator is responsible for compliance.

Based on interview and record review, the facility failed to ensure bedtime snacks were offered every evening for five residents (R22, R29, R31, R42, R59) of five residents in attendance in a group meeting in the sample of 41. Findings include:On 9/24/25 at 10am, five residents (R22, R29, R31, R42/Resident Council President, R59) attended a group meeting in the activity room.All five residents reported not consistently getting offered or getting snacks in the evening. R22 stated, They bring in a big bowl with different snacks we can pick from, but they're not always offered. On 9/24/25 at 2:45pm, V9, Evening Cook, stated Dietary staff pass out evening snacks every night around 6:30pm to the 200 and 300 units. V9 stated the Dietary staff document on a snack log if the resident actually takes the snack. V9 stated they don't document if the resident refused, Only document if the resident actually takes the snack.V9 stated the snack logs are kept in the kitchen, not in the resident record. On 9/24/25 at 3:10pm, V2, DON (Director of Nursing) stated CNA's (Certified Nursing Assistants) don't really have anything to do with passing the evening snacks, however, it's everyone's responsibility. V2 stated CNAs don't document (about the snacks) because they don't pass them out. Evening Snack Logs for 200 and 300 Units during July, August and September 2025 show inconsistent, incomplete documentation indicating entire days with no recordings of snacks taken or offered by residents. These omissions include R22, R29, R31, R42 and R59. Facility Policy - Offering/Serving Bedtime Snacks, dated 2024, documents:It is a practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis.Policy Explanation and Compliance Guidelines:The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preferences and requests on a daily basis.Nursing staff delivers and serves snacks to residents.Intake of bedtime snacks is documented on a resident snack sheet.

Based on observation, interview, and record review, the facility failed to prevent cross contamination by not ensuring staff wore the appropriate personal protective equipment (PPE) when entering the room of a covid positive resident (R34) and failed to perform hand hygiene after exiting R34's room or prior to entering other resident rooms on the unit. This failure affects 18 of 18 residents (R3, R4, R6, R12, R14, R16, R18, R23, R25, R34, R35, R37, R38, R46, R54, R57, R60, R61) reviewed for infection control in the sample of 41.The findings include:Facility provided Centers for Medicare and Medicaid Services-802 form dated 09/23/2025 that showed R3, R4, R6, R12, R14, R16, R18, R23, R25, R34, R35, R37, R38, R46, R54, R57, R60, R61 all reside on the 100 locked unit. Form also indicated under the section for infections, covid for R34.On 09/23/2025 at 09:45 AM, a contact precaution and a droplet precaution sign was posted on R34's room door, with a three-drawer clear plastic bin next to R34's room door that contained multiple yellow isolation gowns, a box of disposable (K95) respirator masks, and two boxes of latex gloves. At 09:46 am, R34 was sitting in a recliner chair in her room, asleep. On 09/23/2025 at 09:47 AM, V13 (CNA/Certified Nursing Assistant Coordinator) indicated R34 is on contact isolation because she is covid positive then said staff should wear K95 masks, a gown, and gloves when entering R3's room. R34's face sheet documented an admission date of 02/06/2025, with a past medical history not limited to Covid-19, dated 09/17/2025.R34's progress note, dated 09/17/2025, documented, resident has congestion, and states that she feels sick. This nurse performed a COVID test on the resident. The COVID test is positive. Verified by this nurse and the day shift nurse. [Director of Nursing] and Administrator notified. [Nurse Practitioner] notified. Nurse Practitioner ordered guaifenesin (Mucinex) 600 milligrams twice daily by mouth x 10 days, encourage fluids, and isolation. R34's active physician orders as of 09/25/2025 showed but not limited to: Covid 19 symptom evaluation assessment once daily every night shift related to Covid 19 for 11 days with start date of 09/17/2025; Covid 19 monitoring for loss of smell, fatigue, gastrointestinal (GI) upset, shortness of breath (SOB), cough and decreased appetite every day and night shift related to Covid 19 for 11 days with start date of 09/17/2025; strict isolation-droplet & contact for Covid 19 positive and is to receive all cares, treatments, activities and meals in their private room every day and night shift for 11 days.On 09/23/2025 at 11:50 AM, observed V6 (Laundry Aide) pushing a wheeled clothing rack down the hall on the locked 100 unit. V6 was wearing a surgical mask and was going from room to room distributing personal laundry items into resident rooms. At 11:53 AM, V6 entered R34's room without performing hand hygiene or applying a K95 mask, isolation gown or gloves. V6 hung some clothing items in R34's closet, then exited her room without changing his surgical mask or performing any hand hygiene. V6 then proceeded down the hall of the unit and entered in and out of several resident rooms distributing laundry items. On 09/23/2025 at 11:58 AM, V6 (Laundry Aide) said he was previously in-serviced on wearing PPE when entering isolation rooms, then indicated he didn't think he needed to apply PPE before entering R34's room because he was just going in and out of her room. On 09/25/2025 at 09:30 AM, V3 (Assistant Director of Nursing & Infection Preventionist) said since R34 is covid positive, which is airborne, staff should have on full PPE, which includes a gown, N/K95 mask and gloves, and should perform hand hygiene upon entering/exiting resident's room to prevent cross contamination.On 09/25/2025, V1 (Administrator) provided in-service training and attendance form, dated 09/25/2025, that educated on EBP (Enhanced Barrier Precautions)/ Covid donning and doffing. V6 was included on this training form. Contact Precautions sign provided by facility indicated that everyone must clean their hands before entering and leaving room, put on gloves before room entry and discard before room exit, put on gown before room entry and discard before room exit. Droplet Precautions sign provided by facility indicated that everyone must clean their hands before entering and leaving room, ensure eyes, nose and mouth are fully covered before room entry and remove face protection before room exit. Infection Control Policy and Procedure for Covid-19 policy (page 7) last revised 10/15/2024 reads in part: healthcare workers must use proper PPE when exposed to a resident with suspected or confirmed Covid-19.must wear and N95 respirator, eye protection, gown and gloves.Undated Transmission-Based (Isolation) Precautions policy reads in part: it is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. For training and quick references purposes, a summary of precautions is contained at the end of this policy. Contact precautions are intended to prevent transmission of pathogens that are spread by direct o indirect contact with the resident or resident's environment.donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission though environmental contamination. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing or talking). Airborne precautions prevent transmission of pathogens that remain infectious over long distances when suspended in the air. Recommendations for Personal Protective Equipment (PPE): contact-don gloves and gown upon room entry, droplet-don a mask upon room entry, airborne-wear a fit-tested NIOSH-approved N95 or higher-level respiratory protection upon room entry.SARS (Covid-19) precautions: droplet or airborne.

Based on observation, interview, and record review, the facility failed to adequately monitor daily meal and/or supplemental intakes for a resident (R3) with a significant weight loss. This failure affects 1 of 2 residents (R3) reviewed for nutrition in the sample of 41.The findings include:R3's face sheet documented an admission date of 12/02/2022, with a past medical history that included Parkinson's Disease, dementia, and mild-calorie protein malnutrition. Review of R3's documented weights for the last six months showed a weight of 98.6 lbs. on 03/10/2025 and a weight of 92.0 pounds (lbs.) on 09/10/2025 which is a -6.69% loss.R3's care plan last completed on 09/15/2025 reads: impaired nutrition risk related to impaired cognition and behavioral symptoms. R3 does what the voices tell her to do; she states that they allow her to eat or not.Appetite is poor to fair; risk for malnutrition.R3's care plan interventions included but not limited to assist with meals (feed/set-up) as needed; offer ensure provided by family when meals refused; consult occupational therapy for adaptive devices, per order; encourage intake of nutritional supplements between meals evaluate for signs of impaired swallowing. No therapy consults or evaluations were provided by facility.R3's Nutrition/Dietary Note, dated 09/16/2025 at 09:36 AM, documented by V8 (Registered Dietician) reads, weight warning, -5.0% change over 30 day(s). Res underweight. Significant weight loss x one month.Supplements/fortified foods in place due to varied meal intake. Staff to continue to encourage resident at meals, offer meal substitute if she does not prefer the main entree.On 09/23/2025 at 12:00 PM, R3 was observed sitting up in bed with a lunch plate in front of her on a bedside tray table, and a clear plastic cup of what appeared to be a shake next to the plate. R3 indicated she did not want to eat, and the plate appeared untouched. No staff were observed encouraging R3 to consume any food or drink and did not observe R3 attempt to feed herself. On 09/24/2025 at 09:05 AM, R3 was observed sitting up in bed with a breakfast plate in front of her on a bedside tray table, and a clear plastic cup of what appeared to be a shake next to the plate. R3 indicated she did not want to eat, and the plate appeared untouched. No yogurt was noted on tray table. No staff were observed encouraging R3 to consume any food or drink and did not observe R3 attempt to feed herself. On 09/24/2025 at 09:11 AM, when asked who assists R3 with meals, V13 (CNA/Certified Nursing Assistant Coordinator) said R3 feeds herself but usually won't eat because she hears voices that tell her not to eat. V13 did not indicate whether staff offer supplements or alternate food items to encourage R3 to eat.Review of R3's intake nutrition intakes from 07/23/2025 through 08/07/2025 documented R3 refused (code -98) or consumed 0-50% (code 1, 2) of a meal(s) from 07/23 - 07/30, 08/02 -08/05, and 08/07. No amount eaten is documented for the morning meal on 07/31 or the evening meal on 07/29. R3's intake log from 08/08/2025 through 08/23/2025 documented R3 refused (code -98) or consumed 0-50% (code 1, 2) of a meal(s) from 08/08, 08/11 - 08/12, 08/14 - 08/19, and 08/21 - 08/23. No amount eaten is documented for the evening meal on 08/08, 08/12, 08/17 - 08/18, 08/21, or 08/23. R3's intake log from 08/24/2025 through 09/08/2025 documented R3 refused (code -98) or consumed 0-50% (code 1, 2) of a meal(s) on 08/24 - 08/26, 08/28 - 09/08. No amount eaten is documented for the evening meal on 08/24, 08/26, 08/28, 09/02, and 09/07 - 09/08. R3's intake log from 09/09/2025 through 09/24/2025 documented R3 refused (code -98) or consumed 0-50% (code 1, 2) of a meal(s) on 09/09 - 09/16, 09/18, 09/21 - 09/24. No amount eaten is documented for the afternoon meal on 09/16 or 09/24 or for the evening meals on 09/12, 09/14 - 09/16, 09/21 - 09/24.R3's active physician orders as of 09/25/2025 showed but not limited to ready care 2.0 120 milliliters (ml) three times a day for supplement; chocolate pudding twice daily between meals for meal supplement; ice cream twice daily and offer yogurt at breakfast for supplement; super cereal at breakfast, power potatoes at lunch and dinner.On 09/25/2025 at 10:07 AM, V2 (Director of Nursing) said R3 was last assessed by V10 (Medical Director) on 09/21/2025 and was flagged for body mass index (BMI), with no further documentation provided from V10 by facility addressing R3's significant weight loss. V2 then indicated R3 hears voices and will not eat at times or take medications because of this. She added the aides should document all resident consumed meals daily and R3's yogurt, power potatoes, and super cereal come from Dietary, which the aides should document these intakes with their meal intakes. When asked how this surveyor could determine what percentage of R3's documented intakes were for the meals versus the provided supplements, V2 (DON) said, There's no clear-cut way to document or monitor what percentage of food was consumed over the amount of (R3's) supplement. V2 then said the nurses document R3's chocolate pudding and nutritional shake intake on medication administration record (MAR).On 09/25/2025 at 10:36 AM, V8 (Registered Dietician) said R3 triggered for significant weight loss in the last 30 days. V8 added R3 started multiple supplements over the last few months to increase caloric intake due to her medical history that are being documented. V8 then said R3 is on the nutrition at risk list, and she will meet weekly with management to discuss R3's plan of care. Undated Nutritional Management policy provided by facility on 09/25/2025 reads: the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.Undated Nutritional and Dietary Supplements policy provided by facility on 09/25/2025 reads: it is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and resident's highest practicable level of well-being. The facility will provide nutritional and dietary supplements to each resident, consistent with the resident's assessed needs.

Based on observation, interview, and record review, the facility failed to provide an adequate justification for the use of an antipsychotic medication in one resident (R2) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 41. Findings include:On 9/23/25 at 9:20am, R2 was sitting in a wheelchair next to her bed waiting for her medications. R2 appeared irritable and somnolent. On 9/23/25 at 12:20pm, R2 was in the hallway in her wheelchair, well-dressed with makeup on and initiated conversation. Mood appeared brighter with appropriate conversation. On 9/24/25 at 1:05pm, R2 was again sitting in the hallway, well-dressed, facial makeup, pleasant and easily engaged. Current Physician Order Summary Report indicates R2 has diagnoses that include Dementia with Psychotic Disturbance, General Anxiety Disorder and Major Depressive Disorder.Summary Report indicates R2 receives Quetiapine (antipsychotic) 50mg (milligrams) twice daily related to Dementia with Psychotic Disturbance. Psychotropic Informed Consent, dated 5/10/22, indicates consent was given for R2's Seroquel (Quetiapine) 50mg twice daily on that date. Medication Regimen Review Prescriber Recommendation, dated 11/8/24, indicates R2 is receiving Quetiapine 50mg twice daily for Schizoaffective. Recommendation indicates Gradual Dose Reductions (GDR's) are periodically recommended for all psychotropics. Alternatively, a prescriber note with clinical rationale for why an attempted dose reduction would impair function or cause psychiatric instability and exacerbate an underlying medical/psychiatric disorder is also recommended.Physician/Prescriber Response to Pharmacy Recommendation dated, 11/8/24, indicates (R2) is still disoriented at times insisting she needs to go to school or get kids; can be irritable at times and indicated to continue the Seroquel at the current dose. Psychiatric Services Note, dated 5/9/25, indicates, Based on clinical information and current presentation, the patient (R2) no longer meets criteria for Schizoaffective Disorder. While (R2) previously exhibited mood instability with psychotic features, her dominant clinical presentation now reflects dementia-related psychotic disturbance. R2's Behavior Monitoring Record, dated 8/27/25 to 9/25/25, indicates on 9/23/25 R2 displayed abusive language.All other days indicated No behaviors observed. R2's Current Care Plan did not include documentation related to R2 receiving Seroquel, any target behaviors or non- pharmacological interventions. On 9/25/25 at 9:15am V2, DON (Director Of Nursing) identified herself as managing the psychotropic medications for residents. V2 stated V11, Psychiatric Physician, is the one who decide R2 was no longer meeting criteria for Schizoaffective and was diagnosed with Dementia. V2 acknowledged R2's behaviors were not severe or prolonged.V2 stated V12, Care Plan Coordinator, is responsible for resident care plans and should have included the Seroquel on R2's Care Plan. Facility Policy/Use of Psychotropic Medication(s) dated 2025 documents:It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Adequate Indication for use refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and after any other treatments have been deemed clinically contraindicated. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Chemical Restraint refers to any drug used for discipline or that makes it more convenient (i.e., less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated, because they are less dangerous to a resident's health and safety. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medications(s) are beneficial to the resident, as demonstrated by monitoring and documentations of the resident's response to the medication(s). Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications.

Based on observation, interview, and record review the facility failed to ensure multidose medication vials were marked with expiration dates after opening which applies to 58 residents in the facility. The findings include: The CMS-671 form dated 8/5/24 showed the facility's census to be 58 residents. On 8/7/24 at 10:35 AM, V9 (Licensed Practical Nurse) opened the medication room and medication storage refrigerator. The 2 opened vials of Tuberculin testing solution were stored in the refrigerator. The first vial was almost empty, and the second vial was approximately half empty. Both vials had no written opened date or expiration date on them. On 8/7/24 at 10:40 AM, V9 stated when the vials are opened the nurse should write the date on them. The opened date will determine the expiration date. V9 stated Tuberculin is good for about a month after opened. On 8/7/24 at 12:00 PM, V2 (Director of Nursing) stated multidose vials need to have the date it was opened written on them. The facilities Medication Expired Dates and Storage Sheet (initialed 8/7/24) showed Aplisol/Tubersol-Tuberculin PPD/Mantoux Injection- Should be maintained according to manufacture recommendations in refrigerator. Expires 30 days after opening. Nurses write on the product the open and expire dates.

Based on observation, interview, and record review the facility failed to ensure water temperatures in resident bathrooms were maintained at a safe level and failed to ensure fall precautions were implemented for residents with a history of falling. These failures apply to 4 of 17 residents (R36, R31, R9, and R53) reviewed for safety and supervision in the sample of 17. The findings include: 1. On 8/5/24 at 10:57 AM, surveyor, using a calibrated thermometer, checked the water temperatures in R53's bathroom sink which was 123.8 degrees Fahrenheit (F). On 8/5/24 at 11:02 AM, R31's bathroom sink water temperature was 134.4 degrees F and on 8/5/24 at 2:05 PM, R9's bathroom water temperature was 125.1 degrees F. On 8/5/24 at 10:59 AM, V3 (Certified Nursing Assistant/CNA) said some resident bathroom water temperatures get so hot you can't even touch them. V3 said R31's bathroom was such a room. V3 said he has informed maintenance about the concern with no response. On 8/5/24 at 12:19 PM, V4 (Maintenance Director) said the water should be between 100 and 110 degrees F, no more and no less; anything greater than 110 degrees can be scalding. On 8/5/24 at 12:38 PM, V5 (Maintenance Assistant) was checking the water temperature in R31's room. As the water was running steam was visible. V5 said, I can see it's hot, I can't even hold my hand under it. V5 said the temperature is 136 (degrees F) and going up. The facility's Safe Water Temperatures Policy (undated) shows the following: It is the policy of this facility to maintain appropriate water temperatures in resident care areas. Water temperatures will be set to a temperature of no more than 100-110 degrees F. 2. On 8/5/24 at 10:37 AM, R53 propelled herself from the dining room to the bathroom in her room and transferred herself onto the commode. R53 had bare feet. On 8/5/24 at 10:43 AM, V11 (CNA) entered R53's bathroom, stood by R53 as R53 transferred back to her wheelchair. V11 did not use a gait belt to assist R53. R53's Admission Record dated 8/6/24 shows her diagnoses include, but are not limited to, lack of coordination, unsteadiness on feet, abnormalities of gait and mobility, need for assistance with personal care, and history of falling. R53's MDS (Minimum Data Set) dated 6/12/24 shows R53 has severe cognitive impairment and requires substantial/maximal assistance with sit to stand, chair/bed to chair transfer, and toilet transfer. R53's current care plan provided by the facility shows R53 has fallen six times in the last year. R53 needs staff assistance prior to transfers and staff are to ensure R53 wears non-skid footwear. 3. On 8/5/24 at 10:25 AM, R36 was in the dining room doing activities. R36 kept standing up on her own. V11 (CNA) walked with R36 out of the dining room. V11 did not use a gait belt when ambulating with R36. R36 had a shuffling, unsteady gait and her head was always looking down. At 10:29 AM, V11 walked back into the dining room with R36 and still no gait belt was being used. On 8/5/24 at 11:31 AM, R36 was walking around unassisted in the dining room. Activities staff, V12 (Wound Care Nurse), and V8 (Licensed Practical Nurse) all walked by R36 and no one intervened or assisted R36. R36's Admission Record dated 8/7/24 shows R36's diagnoses include, but are not limited to, dementia, unsteadiness on feet, lack of coordination, and weakness. R36's MDS dated [DATE] shows R36 requires partial/moderate assistance with sit to stand, chair/bed to chair transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet. R36's current care plan provided by the facility shows R36 is a fall risk and has fallen nine times in the past year. On 8/7/24 at 10:07 AM, V3 (CNA) said R36 ambulates by herself and does not need a gait belt. V3 said they sometimes use a gait belt when R53 transfers from her chair to the commode so they can hold onto it while they clean/wipe her, but R53 is independent with transfers. The facility's Use of Gait Belt Policy (undated) shows the following: It is the policy of this facility to use gait belts wit residents that cannot independently ambulate or transfer for the purpose of safety.

Based on observation, interview, and record review the facility failed to follow the pureed menu for 6 of 6 residents (R4, R6, R11, R23, R43 and R51) reviewed for dietary services in the sample of 17. The findings include: A facility provided list indicated R4, R6, R11, R23, R43, and R51 were on a pureed diet on 8/5/24. The menu for 8/5/24 showed pureed enchiladas were to be served and a number 6 scoop providing a 5.33 ounce (oz.) serving size was to be used to plate the enchiladas. On 8/5/24 11:26 AM, V7 (Cook) said there were 6 residents on a pureed diet. V7 started plating the pureed food. V7 used a spoodle with a green handle to plate the pureed enchilada. Written on the handle of the spoodle was 4 oz. V7 placed one 4 oz. scoop of the pureed enchiladas on the plates (1.33 oz. less than what the menue called for). On 8/5/24 at 12:08 PM, V7 said she was done plating the pureed food and used the 4 oz. spoodle to plate the pureed enchiladas. On 8/5/24 at 12:08 PM, after serving the pureed meals, there was pureed enchiladas in the serving container covering the bottom of the container. On 8/5/24 at 12:12 PM, V6 (Dietary Manager) said a number 6 scoop would provid 5.33 oz. and the menus should be followed.

Based on observation, interview, and record review the facility failed to identify, assess, and implement treatment for a pressure ulcer before developing into a stage three pressure ulcer for 1 of 6 residents (R6) reviewed for pressure ulcers in the sample of 17. The findings include: On 8/5/24 at 10:25 AM, V12 (Wound Licensed Practical Nurse) performed a dressing change to R6's pressure wound to her left buttock. V12 removed the dressing and R6 had a pressure ulcer present measuring 2.6 centimeters (cm) x 1.8 cm x 0.1 cm. R6's Weekly Skin assessment dated [DATE] shows that she has discolored excoriation to her left buttock area. R6's Shower Assessment Sheet dated 7/17/24 shows a circle around her buttock area and it documents, ointment on. On 8/7/24 at 9:07 AM, V15 (Certified Nursing Assistant/CNA) said that she was the CNA that filled out the shower sheet on 7/17/24. V15 said that she circled the buttocks area because there was a dressing on her buttock and wrote ointment on because there was redness around the dressing that she put ointment on. R6's Wound Observation Tool dated 7/19/24 shows that a stage 3 pressure ulcer on her left buttock was identified that measured 1.5 cm x 2 cm x 0.2 cm. No other assessment of the pressure wound were provided prior to 7/19/24. On 8/7/24 at 9:05 AM, V12 said that she saw the open pressure ulcer when she toileted R6 on 7/19/24. V12 said that when she saw it, it was a stage three open pressure ulcer. V12 said that the staff should have told her about the open wound once it happened but no one notified her. V12 said that when the wound was found, she asked the staff why no one reported it to her and she said that every one said that they thought that she already knew about it. The facility's undated Pressure Injury Prevention and Management Policy shows, Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record .Nursing assistants will inspect skin during bath and will report any concern to the resident's nurse immediately after the task.

Based on observation, interview, and record review the facility failed to ensure a resident's splints were applied to bilateral upper extremity contractures for 1 of 1 resident (R28) reviewed for splints in the sample of 17. The findings include: R28's Physician's Order Sheet printed on 8/6/24 shows an order dated 9/20/23 for: Resident to wear bilateral WHO's (Wrist Hand Orthotics) daily, on at AM and off at HS (bedtime). R28's Care Plan shows diagnoses of: spastic quadriplegic cerebral palsy, osteoarthritis and mild intellectual disability. R28's Minimum Data Set assessment dated [DATE] shows that she is dependent on staff for activities of daily living, has impairment to both sides of her upper and lower extremities and received no days of splint or brace assistance in the last 7 days. On 8/5/24 at 10:58 AM, R28 was sitting in the common area of the facility in a high back wheelchair. R28 had bilateral contractures to her hand, wrist and arm. At 11:05 AM, there was a blue hand splint laying on the floor near her garbage can in her room. At 1:16 PM, R28 did not have any splints on her upper extremities. On 8/6/24 at 9:20 AM and 1:26 PM, R28 was laying in bed. R28 did not have splints on her bilateral upper extremities. R28's blue splint was still laying on the floor next to her garbage can. On 8/6/24 at 1:26 PM, V17 (Restorative Certified Nursing Assistant) said that R28 does have bilateral hand splints that she uses. V17 said that she applies them daily if the resident wants them on but does not document their application, removal or refusal anywhere. R28's Care Plan does not address when splints should be applied. The facility's Prevention of Decline in Range of Motion Policy dated 7/1/23 shows, The facility will provide treatment and care in accordance with professional standards of practice. This includes .appropriate equipment (braces or splints) .Care Plan interventions will be developed and delivered through the facility's restorative program .Interventions will be documented on the resident's person centered care plan. Documentation should include, but not limited to: type of treatments, frequency and duration of treatments, measurable objectives, resident goals. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record.

Based on observation, interview, and record review the facility failed to ensure a resident received ice cream as ordered for 1 of 3 residents (R6) reviewed nutrition in the sample of 17. The findings include: R6's Face Sheet shows that she admitted to the facility on [DATE]. R6's Physician's Order Sheet printed on 8/7/24 shows an order dated 7/31/24 for ice cream at lunch and dinner for additional nutrition. R6's Vitals Summary shows that on 7/9/24 she was 116.8 pounds and on 7/30/24 she was 109.8 pounds. R6's Nutrition Note dated 7/31/24 shows, staff report poor appetite .try ice cream with lunch and dinner On 8/5/24 at 11:35 AM, R6's noon meal was delivered to the table. R6 had pureed enchiladas, potatoes, pureed carrots and pureed strawberry dessert. R6 was not provided ice cream. R6 did not consume any of her meal. R6 left the dining room at 11:52 AM. On 8/6/24 at 11:46 AM, R6 was seen leaving the dining room. V7 (Cook) said that R6 barely ate any of her meal and was not served ice cream. On 8/6/24 at 11:50 AM, V6 (Dietary Manager) said that R6 should be served ice cream with lunch and dinner and it is on her meal ticket. V13 (Cook) said that she just missed it today. On 8/6/24 at 12:18 PM, V14 (Dietitian) said that she likes to order ice cream or pudding for residents who are eating 50% or less and not maintaining weight to help reduce weight loss. V14 said that if ice cream is ordered to help with nutrition, it should be give with the meal and should be given at the ordered meal. R6's Care Plan shows that she has a nutritional problem or potential nutritional problem r/t (related to) anorexia with interventions to: Provide and serve supplements as ordered .Ice cream lunch and dinner . The facility's undated Weight Monitoring Policy shows, Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.

Based on observation, interview, and record review the facility failed to ensure the placement of a feeding tube was checked prior to administering medications and enteral feeding for 1 of 1 resident (R35) reviewed for tube feeding in the sample of 17. The findings include: R35's Hospital Notes dated 8/1/24 shows, [AGE] year old male with a history of dementia was recently hospitalized .had undergone G-tube placement on 7/26/24 .patient was seen in the emergency roiagnom on [DATE] after patient pulled out tube leading to the dislodged G-tube which was replaced in ED He was sent back to [emergency room ] again last night after he pulled the G-tube leading to dislodgment where the balloon was outside the gastric lumen based on the CT imaging On 8/6/24 at 9:00 AM, V18 (Registered Nurse) prepared R35's morning medications to administer via his Percutaneous Endoscopic Gastrostomy (PEG) tube. V18 entered R35's room, opened the feeding tube port, attached a syringe without a plunger into the tube feeding port and administered water, medications, and 8 ounces of enteral feeding. V18 did not check placement of the feeding tube prior to administering. On 8/6/24 at 2:21 PM, V2 (Director of Nursing) said that placement of a PEG tube should always be checked before administering any tube feeding or medications to ensure that the tube is in the correct place. V2 said that placement should be check by aspirating gastric content using a syringe. The facility's Enteral Tube Feeding via Gravity Bag Policy revised on 11/23 shows, Verify placement of feeding tube. If anything suggests improper tube positioning, do not administer feeding or medication .

Based on observation, interview, and record review the facility failed to ensure a resident's bilateral under arm pain was assessed, the physician notified, and treatment interventions implemented for 1 of 4 residents (R2) reviewed for pain in the sample of 17. The findings include: On 8/5/24 at 2:10 PM, R2 said that he has been having pain under both of his arms in his armpit area for about a week. At that time, V12 (Wound Licensed Practical Nurse) entered the room. R2 explained the pain to V12. V12 said that he probably had skin tags and she will have the nurse practitioner see him. On 8/6/24 at 1:49 PM, R2 said that he is still having the armpit pain and no one has done anything about it or even looked at them. R2's armpits were observed. There were no skin tags present or any redness observed. On 8/6/24 at 1:53 PM, V18 (Registered Nurse) was asked if she had heard anything about R2 having bilateral armpit pain. V18 said that R2 is always complaining about some type of pain but she had not heard that he was having armpit pain. R2's Progress Notes from 8/1/24-8/7/24 do not document any assessments of his bilateral armpit pain. R2's Medication Administration notes show that he received pain medication on 8/2/24 at 3:18 PM and 8/3/24 at 7:56 AM but did not document the location of the pain. On 8/6/24 at 2:21 PM, V2 (Director of Nursing) said that if a resident is complaining of pain, the nurse should go and assess the resident to identify where the pain is at, what makes it better, what makes it worse and do a visual assessment to see if there is any observable signs of an issues. V2 said that if it is a new pain for the resident, the physician should be notified and orders carried out if provided with new orders. V2 said that the nurse should document their assessment of the pain in the resident's medical record. The facility's undated Pain Management Policy shows, Based on professional standards of practice an assessment or evaluation of pain by the appropriate members of the interdisciplinary team may necessitate gathering the following information, as applicable to the resident: history of pain and its treatment .Identifying key characteristics of the pain: duration of pain, frequency, location, timing, pattern, radiation of pain . Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manager each individual resident's pain beginning at admission

Based on observation, interview and record review the facility failed to ensure a master count of controlled substances was maintained. This failure resulted in a resident's controlled medication to be missing for 1 of 3 residents (R1) reviewed for controlled medication counts. This past non-compliance occurred form 7/13/24 to 7/18/24. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including other chronic pain, and fibromyalgia. The 7/31/24 order summary sheet for R1 shows an order for hydrocodone-acetaminophen tablet 5-325 mg (Norco) , 1 tablet to be given every morning and at bedtime for pain. R1's progress notes show on 7/11/24 at 4:00 PM, she was sent out and admitted to the hospital and returned on 7/15/24 at 4:00 PM. On 7/31/24 at 10:50 AM, V4 LPN (Licensed Practical Nurse) said on 7/11/24 she gave R1 her morning dose of Norco and then later in the shift, sent her out to the hospital. The Norco was in the cart at the end of the shift count. She said when R1 returned from the hospital on 7/15/24, she noted the Norco missing from the medication cart. V4 said she was not sure what had happened to it, and followed up on 7/16/24 with the pharmacy and the DON (Director of Nursing) to see if the completed narcotic sheet had been turned into her. She said once she reported it, the medication room was searched and both medication carts and the Norco was no where to be found. She reported the missing medication to the administrator. V4 said, at the time of the missing Norco, there was no master count of the narcotics and the only way to know if a medication was missing would be the nurses knowing what should be in there. On 7/31/24 at 10:33 AM, V6 RN (Registered Nurse) said she worked on 7/11/24 and had punched out R1's medications on accident, after realizing R1 was in the hospital. She wasted the Norco with the other nurse on duty, so she knows the card was present and accounted for during her shift and reporting off on 7/12/24 at 6:00 AM. On 7/31/24 at 9:45 AM, V5 RN said R1 was on a scheduled Norco twice daily and should have had a card in the cart. V5 said R1 went to the hospital on 7/11/24 and was not working that day, but did notice on the narcotic count on 7/13/24, R1's Norco was not in the drawer. V5 said she asked V3 RN during the count about R1's card and she did not have any answer. V5 said V3 was an agency nurse and was not familiar with her. She noticed the Norco was gone along with the count sheet. V5 said R1 remained in the hospital, so she continued the count. When R1 returned on 7/15/24, there still was no Norco tablets. On 7/31/24 at 11:00 AM, V1 Administrator said it was reported to her R1 was missing Norco tablets. She said both medication carts and the medication room, and the pills were no where to be found. She said the pharmacy was contacted and it was determined R1 should have had about 10 pills left in her card. On 7/31/24 at 11:17 AM, V3 RN said she worked the night shift on 7/12/24 into the morning of 7/13/24. She said it was only her second time in the facility. She said the narcotic count was completed at the beginning of her shift. She did not recall giving any Norco during her shift, and did not recall seeing a card of Norco for R1. V3 said the facility had no master count on the cart, the total number of controlled substances on the medication cart. She said R1 was not in the facility during her shift. The facility's incident report details security camera footage on 7/12/24 at 6:23 PM, V4 counted narcotics with V3, and 15 pages were turned in the count book. On 7/13/24 at 6:22 AM, V3 counted narcotics with V5, and only 14 pages were turned in the book. On 7/31/24 at 11:00 AM, V1 said through her interviews and watching the camera footage she believed V3 took the Norco card and the count sheet. The facility's 2024 policy for compliance with reporting allegations of abuse/neglect/exploitation documents 4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: c. Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Prior to the survey date of 7/31/24, the facility had taken the following actions to correct the noncompliance: 1. On 7/18/24 the facility implemented a new master count procedure for controlled substances, with daily QA audits conducted by the DON for compliance for all medication carts. 2. On 7/18/24 all nurses were educated on the master count policy and procedure. The Medication Administration policy was updated. 3. On 7/18/24, Nurses, CNA's (Certified Nursing Assistants) were educated on Abuse, Neglect, and exploitation.

Based on observation, interview and record review the facility failed to document the administration of controlled medications for 1 of 3 residents (R3) reviewed for controlled medication in the sample of 3. The findings include: R3's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including dementia, Alzheimer's disease, and primary generalized osteoarthritis. On 3/12/24 a diagnosis of a fracture of the right femur was added. R1's order summary sheet shows a 3/12/24 order for one Norco tablet 5-325 mg to be given by mouth every 6 hours as needed for pain. R1's June 2024 MAR (Medication Administration Record) shows V9 LPN (Licensed Practical Nurse) gave one dose of Norco on 6/15/24 at 8:34 PM. No other doses were documented on the MAR. The controlled drug receipt record/disposition form documents between 6/1/24 and 6/26/24, a total of 9 pills were signed out by V9, with 8 doses not signed on the MAR. R1's July 2024 MAR shows only one doses given during the month on 7/21/24 at 2:32 AM. V9 documents the dose given as effective. No other doses were documented. The controlled drug receipt record/disposition form shows from 7/3/24 to 7/29/24, a total of 9 pills were signed out by V9 with only 1 dose documented. On 7/31/24 at 1:06 PM, V2 DON (Director of Nursing) said when a nurse is passing medications each pill should be documented after it is given. She said if the medication is a PRN (as needed) medication, the nurse should follow up to ensure it was effective and document the result on the MAR. On 7/31/24 at 1:25 PM, V9 said she gives R3 her Norco for complaints of back pain, knee pain and abdominal pain. She said R3 had hip surgery a few months ago. V9 said R3 is unable to assess her pain by a scale due to confusion. She said when giving a controlled medication is should be signed out, and documented on the MAR when given. She had no reason why she was not documenting the medication, just forgetting to do it. She said all of the doses signed out were given to R3. On 7/31/24 at 1:18 PM, R3 was observed sitting up in her wheelchair visiting with V10 (husband) in her room. She was alert, but unable to state where she had pain, or if she received pain medications at night. She said the nurse just knows to bring the medication to her. V3 was rubbing the tops of her thighs and looking at her feet. V10 stated (R3) had a recent fracture of her hip and probably takes the pain medications to help her sleep. The facility's 2024 policy for medication administration notes Medications ar administered by licensed nurses, or other staff who are legally authorized to do so in this state. Policy Explanation and compliance guidelines: 20. Sign MAR after administered.

Based on observation, interview and record review the facility failed to transfer a resident in a safe manner, failed to follow facilty's policy and procedures for 1 of 3 residents (R1) in the sample of 3. The findings include: R1's admission record documents she was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease and cognitive communication deficit. The 5/23/24 quarterly assessment of R1 shows she has severe cognitive impairment and is dependant on staff for chair/bed to chair transfers. The 6/19/24 300 hall resident information lists R1 as a transfer with a mechanical lift with 2 assist. On 6/20/24 at 9:50 AM, R1 was observed sitting up in her chair. She was alert, but non verbal. She had a mechanical lift sling underneath her. V5 and V6 CNA's (Certified Nursing Assistants) said a beige sling is used for R1, and the sling is crossed under her legs. V5 and V6 attached the sling hooks to the mechanical lift, and began to transfer R1. V6 was guiding R1 out of her chair and said there should always be 2 staff present for R1 as she tends to lean forward during transfers. In a written statement on 6/11/24, V3 CNA stated she hooked R1 up to the mechanical lift, her chair was between her bed and her room mates bed so when R1 was lifted her head would be right where it should lay in the bed. V3 lifted her up and everything was fine until she moved the lift over top of R1's chair, and R1 started to lean forward and V3 tried to grab her, and R1 went back into the sling but did not go back into position. She went to the left and head first out of the sling. V3 stated she tried to catch her but it all happened too fast, and R1 hit her head on the floor. On 6/20/24 at 10:00 AM, V8 CNA said she was working on the hallway with V3, and was not aware V3 was laying people down and did not ask her for assistance. She said R1 is a mechanical lift and requires 2 staff for a transfer. She said R1 is dangerous to transfer with 1 staff because she tends to lean forward in the sling. On 6/20/24 at 8:30 AM, V4 CNA said R1 is a mechanical lift, and will attempt to sit up during transfers with the mechanical lift, and there should always be 2 staff present during the transfer. On 6/20/24 at 9:30 AM, V7 RN (Registered Nurse) said V3 was yelling for assistance with R1. She found V3 holding a bloody rag to the back of R1's head. V7 said she immediately called 911. She said R1 says very little and is not able to follow commands. She said V3 was the only staff in the room at the time of her initial assessment, and V8 came in afterwards. The 6/11/24 emergency room nursing note document R1 arrived with reports of being dropped from a mechanical lift injuring back of head. R1 noted to have a small abrasion to the back of her head. On 6/20/24 at 8:50 AM, V2 DON (Director of Nursing) stated V3 was assigned to R1 on 6/11/24, and was putting her to bed. V3 was transferring R1 by herself when R1 fell . The facility's undated policy for safe resident handling/transfers documents it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guideline. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Compliance Guidelines: 10. Two staff member must be utilized when transferring residents with a mechanical lift.

Based on observation, interview, and record review, the facility failed to have a system in place to track or trend illnesses, failed to have a process in place to identify contagious residents, and failed to implement transmission-based precautions for resident exhibiting infectious illness. These failures resulted in 9 residents (R1,R8,R16,R22,R35,R45,R47,R54,R61) experiencing respiratory illness, 17 residents (R4,R10,R11,R13,R17,R18,R19,R21,R29,R33,R46,R50,R51,R53,R58,R59,R62) testing positive for COVID-19, and 3 residents (R4,R50,R58) being hospitalized for COVID-19. The Immediate Jeopardy began on 8/26/23 when R22 and R45 began having symptoms of body pains, increased cough, and elevated temperatures. V1 (Administrator) and V3 (Regional Nurse) were notified of the Immediate Jeopardy on 8/31/23 at 1:47PM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 9/1/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: Upon entrance to the facility on [DATE], no signage was posted indicating a respiratory outbreak in the facility. Staff and residents were not wearing masks. V1 (Administrator) stated no residents in the facility were currently on isolation. Residents were observed congregating in activity areas as well as participating in communal dining without face coverings. No personal protective equipment or isolation signs were observed at any resident rooms or doorways. A review of electronic medical records showed: On 8/26/23, R22 and R45 reported body pains and increased cough. R22 had a temperature of 99.7 degrees and R45's temperature was 102.3 degrees. On 8/27/23, R16 and R61 experienced body aches, malaise, and congestion. R47 experienced chest congestion and cough. R13 experienced body aches, malaise, and throat discomfort. R58 experienced a sore throat and cough. On 8/29/23, R35 experienced watery eyes and congestion. R1 experienced increased temperature and cough. R46 experienced a non-productive cough, increased drowsiness, congestion, and shortness of breath with exertion. R54 experienced a sore throat, productive cough with green phlegm, watery eyes, and a headache. R58 was sent to the local emergency room due to difficulty breathing and low oxygen saturations. R58 was diagnosed with COVID-19 in the emergency room . On 8/30/23, R62 experienced a cough with a sore throat. R50 experienced a loose, productive cough, increased shortness of breath, temperature 99.2 degrees, oxygen saturations 91% on 4 liters of oxygen, shaking, flush, and complaints of not feeling well. R50 was sent to the local emergency room and hospitalized with a diagnosis of COVID-19. On 8/31/23, R4 experienced increased lethargy, expiratory wheezing and crackles to all lung fields. R4 tested positive for COVID-19 and had a decline in respiratory status and was sent to the local emergency room and hospitalized . On 8/29/23 at 9:21AM, R61 stated she has had watery eyes, sore throat, plugged ears, chills, and a headache since 8/25/23. No isolation signs or personal protective equipment (PPE) was located outside of R61's door. Staff are observed not wearing face masks throughout the facility. On 8/29/23 at 11:23AM, R51 was in the dining room waiting for her meal to be served. R51 had a congested cough. R51 coughed up a moderate amount of phlegm in her hand and wiped it on her sweater. R51 was not wearing a mask and was participating in communal dining. (R51 tested positive for COVID-19 on 8/31/23) On 8/30/23 at 8:33AM, V6 (Licensed Practical Nurse) was administering medications to R54. V6 stated, Today is her first day of her antibiotic for her upper respiratory infection. We have not been COVID testing any residents with respiratory symptoms since I started working here in March. (V6 then entered R54's room with no mask on. R54 was not on any type of isolation and no PPE was located outside of her room). On 8/30/23, a list of all residents with current respiratory infections was provided to the survey team and showed 13 residents (R1,R8,R13,R16,R22,R35,R45,R46,R47,R50,R54,R61,R62) with current infections. The facility had not identified they were in outbreak status until the survey team requested this list. On 8/30/23 at 11:02AM, V3 (Regional Director of Operations) stated, I just called the local health department to report the outbreak. We put isolation bins outside all of the infected resident's rooms, and have started COVID testing all of the infected residents and so far they are negative. On 8/30/23 at 1:11PM, V2 (Director of Nursing/Infection Preventionist) stated, We just tested all of the residents who have respiratory symptoms for COVID-19 and they are all negative. The first resident who was sick was R45 I think and we COVID tested him right away because the doctor told us to. He was negative. We noticed different people (residents) coming up with respiratory symptoms and (V8-Nurse Practitioner) gave us standing orders for Robitussin, Azithromycin (antibiotic), and albuterol nebulizer treatments. Today is when I would have identified an outbreak, not before. (V1-Administrator) is the one who reports outbreaks to the health department when we have them. I would not have considered us to be in an outbreak until you pointed it out today. I didn't realize how many residents were ill. I have been keeping track of the illnesses but only jotting down notes. I don't have any official tracking form that I use. I can't use the facility floor plan either to identify trends because I can't read it. Up until today we were just encouraging any resident with respiratory symptoms to stay in their room and keep drinking fluids. If residents do come out of their room, they should be encouraged to wear a mask. If we have a resident test positive for COVID then they need isolate immediately and if they had a roommate that roommate should be tested on days 1, 3, and 5 and isolate until all tests come back negative. We definitely encourage good hand hygiene for residents and staff. Prior to today, nobody except (R45) had been tested . I should have started testing when residents were showing symptoms. I know that now and our corporate office informed me that I did not take the correct action nor did I track the illnesses in order to identify any trends in certain areas of the building. As soon as we had residents coming up with respiratory symptoms, I should have had the residents isolate to prevent the spread of the illnesses. On 8/30/23 at 2:45PM, R8,R13,R16,R19,R35,R45,R46,R47,R50,R54, and R61 had a sign posted on their door showing, Droplet Precautions: Everyone must clean their hands before entering and when leaving the room. No personal protective equipment was located outside any of the above resident's doors and staff were not wearing masks in the facility. Staff observed entering rooms showing Droplet Precautions were wearing surgical masks only. (Isolation was initiated 4 days after the first case of respiratory illness). On 8/30/23 at 3:30PM, a sign was posted on the entrance to the facility showing a respiratory outbreak within the facility. (4 days after the first resident experienced respiratory illness) On 8/30/23 at 3:09PM, V7 (Public Health Nurse) stated, I got an e-mail from (V1-Administrator) about 2 hours ago regarding the respiratory outbreak. In the past when we have had different respiratory outbreaks we have considered 2 or more an outbreak. The last time the facility reported any type of illness was in December 2022. What they are supposed to do is e-mail the infectious disease e-mail so that anyone in our department can respond to them. They should have COVID tested immediately and isolated residents. They should definitely be masking for everyone. This is very basic at this point and all facilities should know this. COVID-19 is making a comeback and is very much still prevalent and should have been on their radar. On 8/31/23 at 8:10AM, R50's door was closed and staff stated resident was sent to the hospital on 8/30 due to COVID+ status. Staff not wearing masks throughout facility, no PPE located outside infected resident rooms. On 8/31/23 at 8:16AM, V1 stated, (R50) was sent to the hospital last night and is now our second COVID positive case. (R58) was our first one on 8/29. We did not test anyone after the first positive and we didn't isolate or test (R58's) roommate. I guess I just didn't think about it because we haven't had to do this for so long. We haven't had a COVID positive in months. The health department did e-mail me back last night and told me to just keep doing what we are doing because they had already talked to (V3). We are going to test every resident on (R50's) hall this morning. On 8/31/23 at 9:04AM, V7 (Public Health Nurse) stated, I spoke with (V3) yesterday and the facility informed me they were doing increased monitoring for respiratory signs/symptoms, placed isolation buckets outside of the infected resident's rooms, and that staff were wearing gowns, masks, gloves in the isolation rooms. I recommended they keep doing that and I also spoke to her about RSV (Respiratory Syncytial Virus) and Influenza and she said that wouldn't really matter because they already started antibiotics. I informed her that these are viral so it would be beneficial to test. I recommended they do respiratory panels on all residents. They said they can't do that without a physician's order and I said okay. I did not tell them if they wanted to do it they could. It is highly recommended to do further testing if the COVID tests come back negative so we can identify exactly what illness we are dealing with. I would have expected to have been notified of their first positive COVID case so I could track it and keep in contact with the facility and help identify and trends or give recommendations to help slow the spread. I highly doubt the first COVID+ resident's symptoms started on 8/29/23 so the roommate should've been tested earlier than 8/30/23. (V3) reported to me that no residents have experienced a fever thus far. (At this time, 3 residents had reported increased temperature) On 8/31/23 at 12:05PM, V8 (Nurse Practitioner) stated, If residents are displaying respiratory symptoms, you definitely should isolate them until you know that symptoms are resolving to prevent spreading the illness. I would have thought with their nursing judgement that they would have done the antigen testing in house. As a matter of fact, when I was notified of the first COVID positive case I told the staff, I sure hope you're going to be testing the rest of the residents. I assumed they would have done that per their policy but apparently not. This definitely could have been less severe of an outbreak if they had isolated the residents and used personal protective equipment like they were supposed to. If you have a sign on the door that says droplet precautions then you have to have gowns, masks, and gloves outside the door, available for staff to put on PRIOR to entering the room or they are not protected against any illness that resident has. On 8/31/23 at 12:42PM, The facility completed their outbreak testing for COVID-19 on the entire facility and provided a list of 17 total residents (R4,R10,R11,R13,R17,R18,R19,R21,R29,R33,R46,R50,R51,R53, R58,R59,R62) who tested positive for COVID-19 in the facility. Two resident's (R50,R58) are currently hospitalized with COVID-19. On 9/1/23 at 9:42AM, V3 (Regional Director of Operations) stated, (R4) was sent to the hospital last night due to declining condition and was one of our COVID positive residents. The facility's policy titled, Infection Control Policy and Procedure for COVID-19 Facility Response Strategy dated 5/25/23 showed, COVID-19 testing is required for any of the following: Symptomatic residents or healthcare providers (HCP), even those with mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for COVID-19 as soon as possible. Implement recommended infection prevention and control practices when caring for a resident with suspected or confirmed COVID-19 infection. Asymptomatic residents and HCP with a close contact or higher-risk exposure are recommended to have a series of three viral tests for COVID-19 infection .Outbreak testing: A broad-based approach includes the unit, floor, or other specific area of the facility where the positive COVID-19 case was identified. The facility's policy titled, Infection Prevention and Control Program dated 5/1/23 showed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines .1. The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .9. COVID-19 testing: a. anyone with symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. The facility's policy titled, Transmission-Based (Isolation) precautions dated 2023 showed, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission .10. Droplet Precautions- e. healthcare personnel will wear a facemask for close contact with an infectious resident. F. based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. The Immediate Jeopardy that began on 8/26/23 was removed on 9/1/23 when the facility took the following actions to remove the Immediacy and correct the noncompliance. The facility implemented the following abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee held on 8/31/23 at 3:30PM. 1) Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. a. All residents has been tested for COVID. All residents who are listed as positive for covid are either in the hospital or have been placed on droplet isolation. The isolation rooms have the appropriate signs and PPE. b. All residents who have respiratory signs and symptoms have been placed on droplet precautions. The resident rooms have the appropriate signs and PPE. c. Health department notified of respiratory illness on 8/30/23 @ 3:38PM by (V3-Regional Director of Operations) d. Health department notified of COVID outbreak on 8/31/23 @ 9:48AM by (V1-Administrator). Ongoing communication has been conducted with the health department by (V1). e. All staff and residents will wear proper PPE and source control f. All current staff in the facility have been tested for covid. All staff that have not been tested for covid will be tested prior to their next shift. g. All communal dining and activities have been put on hold to prevent the spread of covid. h. All staff including agency staff will be in-serviced by (V3), (V1), (V2) on: covid policy, hand washing, PPE, testing residents for covid that have respiratory signs and symptoms, implementing transmission-based precautions. In-servicing will be conducted either via phone or in person prior to their shift. 2) How the facility will identify other residents having the potential to be affected by the safe deficient practice. a. All residents have the potential to be affected. All residents in the facility have been tested for covid. This was completed on 8/31/23. The QAPI meeting was conducted on 8/31/23 and reviewed: 1) Notifying the local health department to obtain guidance on illness outbreak 2) The facility discussed the local health department guidance on the illness outbreak 3) The facility discussed the plan for training all staff, including administration regarding response to illness outbreak 4) Review of IJ for F880 5) Review of facility abatement plan 6) Review of infection prevention control program policies 7) Review of covid policies 8) Review or PPE policies 9) Review of handwashing policies 10) All residents with respiratory signs and symptoms need to be tested for covid 11) The facility's policies on infection control 12) Transmission based precautions policy 13) When to implement isolation and transmission-based precautions. 3) The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. a. In-service training done by (V21-Chief Nursing Officer) with (V3) on 8/31/23 on covid policy, handwashing, ppe, testing residents for covid that have respiratory signs and symptoms, response to illness outbreak, policies and procedures regarding implementing transmission based precautions for residents actively displaying symptoms of respiratory illness, and the procedure on when to notify the local health department to obtain guidance on illness outbreak. b. In-service training done by (V3) with (V1) and (V2) on 8/31/23 on covid policy, handwashing, ppe, testing residents for covid that have respiratory signs and symptoms, response to illness outbreak, policies and procedures regarding implementing transmission based precautions for residents actively displaying symptoms of respiratory illness, and the procedure on when to notify the local health department to obtain guidance on illness outbreak. c. The facility completed in-service training for all staff by (V3), (V1), and (V2) on covid policy, handwashing, ppe, testing residents for covid that have respiratory signs and symptoms, response to illness outbreak, policies and procedures regarding implementing transmission based precautions for residents actively displaying symptoms of respiratory illness, and the procedure on when to notify the local health department to obtain guidance on illness outbreak. All staff will be educated in person or via telephone on 8/31/23 or prior to their next scheduled shift. All staff are expected to be in-service by 9/8/23. 4) Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent DON/ADON or designee will continue to conduct a QA study to determine: a) Does the resident exhibit respiratory symptoms, were they tested for COVID-19? b) Were proper precautions implemented for COVID positive residents and for residents actively displaying symptoms of respiratory illness? c) Was resident isolated per facility policies and procedures? d) Was local health department notified of covid positive residents and for residents actively displaying symptoms of respiratory illness for guidance, per facility policy? e) Was proper signage and equipment in isolation rooms? f) Did staff use proper PPE and hand hygiene? g) Did staff follow facility's policies pertaining to infection control and response to illness outbreak? The DON/ADON or designee will conduct the QA study at least 3 times per week for a period of 3 months with the facility created QA tool to maintain compliance with this regulation. The results of this tool will be reviewed during the facility's quarterly QA meetings. Any issues identified will be immediately corrected. Administrator or designee will monitor for overall compliance. On 9/1/23 at 11:00AM, a review of the facility's in-service record showed all staff working the remainder of the day on 8/31/23 and staff working on 9/1/23 were in-serviced on infection control procedures consisting of identifying and monitoring residents for symptoms, notification to the nurse for residents identified as having new symptoms, isolation of potentially contagious residents, hand hygiene, COVID-19 policy regarding symptoms and testing, and personal protective equipment. As of this time, 83% of the entire staff had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift.

Based on observation, interview, and record review the facility failed to prevent severe, unplanned weight loss (R59) and failed to implement a nutritional supplement (R1) for 2 of 2 residents reviewed for nutrition in the sample of 17. These failures resulted in R59 sustaining a 21.36 % weight loss over 5 months. The findings include: 1. R59's face sheet printed on 8/30/23 showed diagnoses including right sided hemiplegia (paralysis), expressive language disorder, metabolic encephalopathy, anxiety, dysphagia (difficulty swallowing), and unsteadiness on feet. R59's facility assessment dated [DATE] showed severe cognitive impairment and extensive to total staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use, and hygiene. The same assessment showed no or unknown regarding any loss of weight over 5% or more the last month or loss of 10% or more in the last 6 months. R59's August 2023 physician order report showed an order dated 6/22/23 for a low concentrated sweets diet, pureed texture, thin consistency. The report did not have any orders for any weight supplement or how often weights should be done. On 8/29/23 at 11:35 AM, R59 was seated in a high back wheelchair in the main dining room. R59's eyes were closed, and her mouth was a gap while V13 (Certified Nurse Aide) fed her a pureed textured meal. V13 was able to drink and swallow after cueing from V13. On 8/30/23 this surveyor reviewed R59's weights from 4/3/23 (date of admission) to 8/24/23 (last recorded weight). Results indicated at 21.36% weight loss in five months, a 9.16% weight loss in three months, and a 6.3% weight loss over the last one month. R59's progress notes were also reviewed. There were only two nutrition progress notes which were dated 4/29 and 6/25. Neither note had any indication of significant weight loss concerns. Both notes showed a plan to continue monitoring, follow with registered dietician for consult as needed, and continue to monitor weights as needed. On 8/31/23 at 12:06 PM, V1 (Administrator) stated she is the current acting dietary manager. V1 said resident weights are reviewed by V4 (Registered Dietician) and V2 (Director of Nurses). V1 said all residents are weighed on their once or twice a week shower day. V2 reviews the weights weekly and V4 reviews them monthly. Weights are reviewed and discussed weekly on Thursdays at the risk management meeting. Any resident with a big weight gain or decrease is discussed. V4 does the nutritional recommendation for residents with big weight decreases. The recommendation is approved by the physician and put on the order report. V1 said it is important for the recommendations to be on order as soon as possible to stop the weight loss. V1 said large weight losses can lead into other medical issues. V1 stated residents on a puree diet have an even greater risk of weight loss. V1 reviewed R59's weights in the electronic medical record and said there has been a gradual significant weight loss during R59's time here. V1 said she had no idea why it had not been noted earlier or why interventions had not been put in place sooner. On 8/31/23 at 12:50 PM, V4 (Registered Dietician) stated she reviews residents' weights monthly. V4 said the dietary manager left the facility around July 7 and she has been the one watching weights on a weekly basis since then. V4 said she charts weight changes if there is any change of 5 pounds or more. V4 said if there is nothing charted, then she did not have any problem with a resident's weight. V4 said she documents in the resident's nutritional notes any concerns and recommendations she has. The note is sent to the director of nurses to be approved by the physician or nurse practitioner. V4 said it is important to identify weight loss soon to avoid the potential for weakness, reduction in normal activities of daily living, or overall health. V4 said unchecked weight loss could exacerbate current medical conditions. V4 said nutritional recommendations need to be implemented sooner versus later to see if they are working or not. V4 defined a significant weight loss of 5% in one month, 7.5% in three months, and 10% in 6 months. V4 said yesterday (8/30) was the first time she had time to document R59's nutritional notes and did not have any dietary recommendations before then. V4 said yesterday was the first time she had recommended any dietary interventions in regard to R59's significant weight loss. R59's progress notes showed a nutritional note dated 8/30/23 at 3:11 PM (during the survey) for a recommendation to notify MD of 10.1-pound weight decrease in the last month, which indicates a significant weight loss. Add a health shake daily to aid in weight stability. R59's care plan also showed a newly added focus for an unplanned/unexpected weight loss start dated 8/31/23. All interventions were also start dated 8/31/23. The facility's undated Weight Monitoring policy states under the policy section: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The policy further states: 4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. 35175 2. R1's face sheet showed an [AGE] year-old female with diagnosis of mild protein calorie malnutrition. asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, dyspnea, dementia, kidney failure, type 2 diabetes, heart failure, and rheumatoid arthritis. R1's physician order sheet showed a 6/23/23 order for a health shake three times daily. On 08/29/23 at 12:05 PM, R1 was in the dining room in a wheelchair. R1 was feeding herself a grilled cheese sandwich and complained it was salty. On 08/30/23 at 07:42 AM, R1 was in the dining room feeding herself a toast and egg sandwich. On 08/31/23 at 09:13 AM, V2 Director of Nursing said (while reviewing R1's medical record) she doesn't find any evidence that a health shake was given as ordered until the end of June. V2 confirms R1's 5/14/23 physician order for a health shake to be given daily. V2 also confirmed a significant weight loss noted from May to June 2023. V2 said a health shake three times a day was ordered on 6/23/23. V2 said it is her expectation that residents receive dietary supplements as ordered. V2 said the May health shake order did not show up on her medication administration record (MAR). If they don't receive the supplements they may experience continued weight loss, wounds, an overall decline, and weakness. R1's weight record showed the following: 5/3/23 weight-192 pounds, 6/3/23 weight-174.4 pounds. A 9.17 % weight loss in one month. R1's 5/14/23 dietary note authored by V4 Dietician showed a significant weight loss of 6.1% in the last month. V4 recommended to add a health shake daily to aid in weight stability. R1's 6/17/23 dietary note authored by V4 showed another significant weight loss of 8.3% in the last month. V4 recommended to increase health shakes to three times daily. R1's May 2023 medication administration record (MAR) did not show the health shake order. R1's June 2023 MAR showed a health shake was given once a day on 6/21 and 6/22/23. R1's nutrition care plan has no intervention for a dietary supplement or mention of her significant weight loss. R1's 7/25/23 facility assessment showed moderate cognitive impairment and requiring extensive assistance for bed mobility, transfer, dressing, personal hygiene and bathing. This assessment showed weight loss while not on a physician prescribed weight-loss program.

Based on observation, interview and record review, the facility failed to assess, monitor, and document the assessments on 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 9. This failure resulted in R1 being sent out to a local emergency room the next morning, and being admitted to the hospital with diagnoses of urinary tract infection (UTI), pneumonia, and weakness. The findings include: R1's Admission Record. printed by the facility on 7/11/23, showed she had diagnoses including anemia in chronic kidney disease, hypertension, edema, major depressive disorder, weakness, and chronic, peripheral venous insufficiency. R1's facility assessment dated [DATE] showed she is cognitively intact and requires extensive assist of staff for activities of daily living. On 7/11/23 at 9:28 AM, R1 was in the dining room, finishing her breakfast meal. A staff member backed R1's wheelchair up and started propelling her back to her room. On the way to R1's room, two staff members told R1 that they were glad to see her back in the facility. R1 thanked them and said she was glad to be back. At 9:33 AM, R1 said she had been at the hospital. R1 said she was told that she had been having high blood pressure. R1 said she was also told that she was coming down with pneumonia. R1 said she does not remember the high blood pressures or if the nurses assessed her the night before she was sent out to the hospital. On 7/10/23 at 3:44 PM, V4 (CNA-former employee of the facility) said she worked the overnight shift on 7/4/23, from 6:00 PM-6:00 AM, the morning of 7/5/23. V4 said at the start of her shift, during the shift report, she was told that R1's blood pressure had been high. V4 said that night she was concerned about R1 because she had checked R1's blood pressure and it was high. V4 said she asked V17 (Licensed Practical Nurse-LPN) to check R1's blood pressure and V17 came in and tried to check R1's blood pressure, but was not able to get it. V4 said V17 threw the blood pressure cuff (wrist type) at her and said none of the blood pressure devices in the facility are working correctly. V4 said she checked R1's blood pressure after V17 threw the monitor at her and was able to obtain a reading. V4 said the first blood pressure reading obtained from R1 was 211/91 and R1's pulse was 41. V4 said that was using the wrist cuff. V4 said the second reading was 230/94, and was obtained manually using a blood pressure cuff and a sphygmomometer. V4 said she asked V17 if they should still give R1 her shower, because it was her scheduled shower night. V4 said V17 told her to give R1 her scheduled shower. V4 said R1's third blood pressure reading was 258/94 using the wrist blood pressure monitor, after R1's shower. V4 said she checked R1's blood pressure again right after getting that reading to compare it using the manual method, with a blood pressure cuff and sphygmomometer and it was 252/77. V4 said R1's pulse was 45 at that time. V4 said she checked R1's blood pressure again around midnight and it was 239/101 using the manual method. V4 said she could not get V17 to do an assessment on R1 and she was really concerned about her. V4 said she tried calling and texting V2 (Director of Nursing-DON), however, V2 did not answer. V4 said she was so upset and worried about R1 because she was not well. V4 said R1 was kind of delusional on her shift on 7/4/23, adding that she was talking to someone in her room and there was no one there. V4 said R1's speech was slowed. V4 said during the shift report at the beginning of her shift, she was informed that R1 had not been acting like herself recently and she may have had a mini stroke. V4 said when V17 was in R1's room attempting to get a blood pressure on her, she did not do any other assessment on R1, she just tried to get the blood pressure reading, and was not able to get it. V4 said neither one of the nurses were in R1's room after 10:00 PM on 7/4/23. V4 said she could not get either nurse to do an assessment on R1. On 7/11/23 at 10:16 AM, V5 (CNA) said she worked on 7/4/23 from 6:00 PM-6:00 AM shift. V5 said she was working a different hall, but all of the CNAs were kind of working together that night. V5 said V4 (CNA) was asking the other CNAs what to do. V5 said R1's blood pressure readings had been high all night. V5 said she was not in the room when V17 was trying to check R1's blood pressure. V5 identified V18 as the other CNA assigned to the hall R1 was on. V5 said after R1 had her shower, V16 (Licensed Practical Nurse-LPN, Agency Nurse) went into R1's room to check on R1, however she does not know if she assessed R1 or not. V5 said she did hear V16 tell V4 that she did not go to school for nursing and she did not know what she was talking about. V5 said both of the nurses that night were in and out of the building quite a bit that night. V5 said the nurses on duty were either outside or in the nurses station with the lights off a lot of the night. On 7/11/23 at 2:03 PM, V8 (LPN) said she worked the morning of 7/5/23. V4 said the Nurse giving shift report did not voice any concerns regarding R1 to her. V8 said the nurse did say that she was not able to obtain a blood pressure reading on R1. V8 said she went in to see R1 and she did not seem like herself. V8 said R1 was still alert, but slower to think. V8 said she had the CNAs get R1 up and bring her to the dining room. V8 said in the dining room, when R1 was brought down for breakfast, she noticed that something was not right with R1. V8 said R1 was definitely different and had a change in condition from 7/4/23-7/5/23. V8 said when monitoring a resident closely, she would expect to see some assessment documented in the resident's progress notes. V8 said by documenting an assessment, the Nurses working after that can get an idea of what the resident was like on the previous shifts versus what they are seeing at that time. On 7/11/23 at 1:19 PM, V2 (Director of Nursing-DON) said V4 (CNA) had sent her a text message around midnight on 7/4/23-7/5/23 saying she was concerned about R1's increased blood pressure. V2 said V4 also called her around 12:30-1:00 AM. V2 said she did not hear the call or the text. V2 said V16 and V17 called her later and they were both upset with V4, saying V4 was yelling at them and slamming the nurse's door. V2 said V16 and V17 told her that they checked on R1 and were assessing R1. On 7/11/23 at 4:48 PM, V9 (CNA) said she worked on 7/4/23 during the 6:00 PM-6:00 AM shift. V9 said she had checked R1's blood pressure before her shower and it was 211/91. V9 said V4 and V18 (CNA) asked V17 to assess R1 due to the high blood pressure. V9 said she was sitting out by R1's room when V17 went in to R1's room. V9 said V17 was not in R1's room very long at all. V9 said V17 came out of R1's room and said none of the blood pressure monitors in the facility were working. V9 said she asked V16 later to assess R1 and V16 did go down to R1's room, however, she did not assess R1. V9 said V16 just looked at R1 and said something to her, then left the room. V9 said V16 did not assess R1's blood pressure, hand grips, pupils, or any of the other assessments to assess for stroke. V9 said V16 just said something to R1 and then left the room. V9 said neither V16 or V17 went back in to check on R1 after that. V9 said V4 could have handled it better, but she thinks V4 was upset because she was concerned about R1 and her high blood pressure and she did not feel like the nurses were assessing R1. V9 said V4 wrote down all of the blood pressure readings she obtained during her shift that night and showed the readings to V13, one of the nurses that came in on the morning of 7/5/23. On 7/12/23 at 1:08 PM, V13 (LPN) said she arrived to work about 6:00 AM on the morning of 7/5/23. V13 said V4 told her about the concerns she had regarding R1's high blood pressures. V13 said she saw the paper that V4 had written R1's blood pressure readings on and R1's blood pressures were abnormally high and low. V13 said when she came in to work that day, V17 (LPN) was upset and said the CNA was trying to be a nurse and said the CNA was talking about increased blood pressures for R1. V13 said she asked V17 if she took R1's blood pressure reading and V17 told her that she was not able to obtain a blood pressure reading on R1. V13 said V17 did not mention any other assessment, she just said R1 was alright. V13 said she asked V17 if she went in and assessed R1 and V17 just ignored her question. V13 said if she were the nurse on duty the previous night, she would have done a full assessment on R1 and rechecked her blood pressure. V13 said she would have documented the assessment. V13 said it is important to do an assessment and document the assessment, so the facility nurses have a history of what is going on and to get a current picture of what is going on with the resident and see if further medical treatment is needed. V13 said with increased blood pressures like those that V4 (CNA) showed her, she (V13) would have assessed the resident and then notified the Nurse Practitioner or R1's Doctor. On 7/13/23 at 7:40 AM, V18 (CNA) returned this surveyor's call from 7/11/23 and 7/12/23. V18 said she worked on 7/4/23 during the 6:00 PM-6:00 AM shift. V18 said she was working the same hall as V4 that night. V18 said R1 was slow to respond and not her normal self that night. V18 said V17 came in and put the wrist type blood pressure monitor on R1's upper arm, instead of her wrist area, the first time she went to check it. V18 said then she put it down by R1's wrist but had the monitor turned around and it was not in the correct position, where you would check the pulse. V18 said she wanted to say something to V17, but V17 had already snapped at V4 and she was afraid to say anything to her. V18 said V17 was not able to obtain a blood pressure reading on R1 and did not do any further assessment on her. V18 said R1's blood pressure kept going up and she and V4 were concerned. V18 said V17 did not do any other checks/assessments on R1 that shift. V18 said V4 did get aggressive with V16 and V17 that night, but it was because she was concerned about R1. V18 said V16 had gone in one time to R1's room to check on her, after the CNAs asked her to. V18 said V16 went in and asked R1 how she was feeling. V18 said V16 did not do an assessment on R1, and did not check her blood pressure. V18 said V16 told her and V4 that if R1's blood pressure was that high, then she would be complaining about a headache. V18 said her and V4 were checking R1's blood pressure using both the wrist monitor and doing it manually. V18 said she worked on a cardiology unit for two years previously and she knows how to obtain a blood pressure. V18 said at one point, it looked like R1's mouth was sagging to the right. V18 said V16 told them R1 was okay. On 7/12/23 at 2:03 PM, V16 (LPN-Agency) said she worked on 7/4/23 on the night shift. V16 said one of the CNAs had concerns with a resident's blood pressures. V16 said she does not know the name of the CNA, or the name of the other nurse that was on duty on 7/4/23, or the resident's name that the CNA was concerned about. V16 said R1 was not her patient. V16 said the CNA complained that the resident's blood pressure was high. V16 said the other nurse was on break so she went and checked the resident's blood pressure. When asked what R1's blood pressure was, V16 said she was not sure what her blood pressure was, but she was not in distress. V16 said she is not sure if V17 assessed R1 or not because she had her own patients. On 7/12/23 at 3:06 PM, V17 (LPN-Agency) said the CNA (did not know her name) told her that R1's blood pressure was 300 over something. V17 said she manually checked R1's blood pressure and it was fine. When asked what R1's blood pressure was when she checked it, V17 said she did not recall what R1's blood pressure was, but it was within normal range. V17 said she even had V17 check R1's blood pressure too. V17 said R1 was fine and there was nothing out of the normal for R1. V17 said 7/4/23 was the first or second time she had worked at the facility. V17 said she assessed R1 on 7/4/23. When asked where she documented the assessment, V17 said she did not document an assessment because there was nothing wrong with R1. V17 said it was the CNA that was causing the problem. R1's electronic medical record was reviewed. No progress note or assessment of R1 was found in her electronic medical record for 7/4/23, except for a wound assessment on the day shift. R1's electronic vitals tab had no entry of blood pressure monitoring on 7/4/23. On 7/11/23 at 1:19 PM, V2 said she spoke with V16 and V17 on the phone during their shift on 7/4/23. V2 said V16 and V17 said they were assessing R1. V2 said there should have been documentation in R1's medical record showing that an assessment was done for R1. On 7/12/23 at 4:18 PM, V2 (Director of Nursing) said she did not see any assessment documented in R1's electronic medical record for 7/4/23, other than her wound assessment. V2 said she did not see any blood pressure readings documented in R1's medical record for 7/4/23. On 7/12/23 at 1:26 PM, V3 (FNP-Family Nurse Practitioner) said she saw R1 on 7/3/23. V3 said staff had reported that R1 was lethargic and leaning to the side. V3 said when she saw R1, her symptoms had pretty much resolved. V3 said she wrote in her notes that nursing staff would monitor closely. V3 said that means that they would monitor R1 for any change in condition, any symptoms, monitor her vital signs and blood pressure, and speak with her to see if her speech is clear. V3 said if blood pressure readings were high, like 200/100, she would expect the Nurse to increase the monitoring of R1's vitals and watch for any symptoms. V3 said the assessments should be documented in the resident's medical record. V3 said even if the assessment is normal, the nurse should be documenting the assessment in the resident's medical record. R1's Shower Assessment Sheet dated 7/4/23 showed a blood pressure reading of 211/91 and a pulse of 41. the shower sheet showed Couldn't log. No way to log on to point care. was written under R1's vitals on the shower sheet. R1's Health Status Note dated 7/5/23 at 10:45 AM showed Resident confused and unable to swallow medications due to confusion. Pocketing food in mouth at breakfast. Redirected to swallow and resident began to cry, upset with self related to the increased confusion. Complained of pain level of 4 out of 10 to left lower extremity, does have scheduled Tramadol however is unable to swallow medications this morning. Vital signs: Blood pressure 194/96, pulse 80, respirations 16, and temperature 97.6 tympanic. Equal grip with hands. At 9:10 AM, POA (power of attorney) updated on current status and is requesting resident be sent to ER for further evaluation and treatment. DON notified. Nurse Practitioner notified. The note showed 911 was called at 9:13 AM and left via stretcher with emergency medical services at 9:34 AM on 7/5/23. The Health Status Note dated 7/6/23 at 12:21 AM, the nurse on duty called the local hospital and was informed that R1 had been admitted to the hospital for pneumonia, UTI, and weakness. R1's 7/10/23 Medication Discharge Report from a local hospital showed Visit Reason: UTI, pneumonia, weakness. The report showed R1 was admitted to the local hospital on 7/5/23.

Based on observation, interview and record review, the facility failed to ensure a resident with dementia, wandering and aggressive behaviors, did not exit the building and obtain a metal rod, which he used as a weapon. The facility failed to develop a care plan addressing the resident's aggressive and wandering behaviors and put interventions in place to de-escalate a situation of aggression, and the facility failed to ensure a resident with dementia exhibiting wandering behaviors was supervised for 1 of 2 residents (R3) reviewed for abuse in the sample of 9. This failure resulted in R3 exiting the building into the back courtyard where he grabbed a metal rod, brandishing it as a weapon, chasing staff around the back courtyard. The police were notified, R3 was tazed, sustaining wounds to his bilateral hands and sent to a local hospital. R3's Admission Record, printed by the facility on 7/12/23, showed he had a diagnosis of unspecified moderate dementia, with other behavioral disturbance. R3's facility assessment dated [DATE] showed he had severe cognitive impairment. R3's care plan, initiated on 4/24/23, showed R3 had a history of criminal behavior, including battery in 1982 and domestic violence in 1984. The care plan showed Visually monitored for any agitation or behavior. Monitor and assess for signs of agitation. Reassure and redirect to quiet place in (R3's) room if agitated. R3's Cognitive deficit care plan, initiated on 4/24/23, showed R3 had impaired decision making. The care plan showed Offer verbal cues and reminders. Redirect as needed. R3's 4/20/23 Health Status Note showed R3 was admitted to the facility. Upon assessment R3 was moderately hard of hearing and had poor vision in both eyes. R3's Health Status Notes dated 5/5/23 at 5:23 AM, showed R3 was observed in the hallway urinating on the floor. The note showed R3 told staff Get him out of the bathroom or else I am going to kill him. Directed towards R3's roommate who was using the bathroom at the time. R3's Health Status Note dated 5/5/23 at 5:29 AM, showed R3 was observed in another resident's room, sitting on the bed, taking his shoes off. The note showed R3 was hard to redirect out of the other resident's room. The note showed the other resident was already in the bed. R3's electronic vitals tab showed his was 67 inches tall (5 foot 6 inches) on 4/19/23. The vitals tab showed R3 weighed 126.1 pounds on 5/5/23 and 120.2 pounds on 5/11/23. R3's Health Status Note dated 5/9/23, showed R3 was in the back courtyard stating, He is trying to kill us. The note showed V12 (Licensed Practical Nurse-LPN) was trying to redirect R3 to no avail. R3 grabbed a steel rod from the ground and began chasing V12 and two other CNAs (Certified Nursing Assistants) that were also out in the courtyard, trying to talk R3 into going back inside. R3 was charging at staff with the rod. The note showed V26 (Maintenance Supervisor) was called because V12 thought having a male present would help calm the situation, which it did not. R3 continued running after staff threatening them with the steel rod. The note showed V12 had also told V15 (LPN) on her walkie talkie to call 911 and V3 (Family Nurse Practitioner-FNP) for an order to send out to a local emergency room for evaluation and treatment. The note showed the police showed up and R3 ran at the police officers with the steel rod. The police officers asked R3 to stop and drop the weapon, R3 continued at them and the police tazed R3. R3 fell forward onto his stomach and immediately jumped up and continued fighting the police. The police told R3 to stop or they would taze him again. The note showed R3 received injuries to both hands. R3 was handcuffed and walked to the front of the building by the two police officers, where an ambulance was waiting. The police Incident Report #2300015, dated 5/9/23, showed V29 (Prophetstown Police Officer) was starting his shift when he heard dispatch notify V30 (Chief of Police, Prophetstown) that a patient at (the facility) was combative and attacking the staff. V29's report showed he notified dispatch that he was enroute as well. The report showed upon arrival V29 heard commotion coming from the courtyard as he was walking down the hall. I (V29) heard V30 yell repeatedly to drop the stick etc. The report showed V29 then pie'd the corner of the courtyard and V30 told him that R3 had a metal rod that he was swinging at people. The report showed V29 found R3 chasing after a nurse with the rod and told R3 to drop the rod. R3 refused. V29's report showed, At this time, I (V29) could see the rod was about 3-4 feet in length and was [NAME]. (R3) was swinging it around his head like a [NAME]. He (R3) then took about five steps and began to charge at me (V29). I then drew my taser and pointed it at (R3). I warned him that he was going to be tased. He (R3) still lunged at me. I then deployed my taser center mass at (R3's) chest. The taser locked up all major muscle groups causing him to fall thankfully into a flower bed/landscaping area. The report showed After taking the rod away, and securing (R3) into handcuffs, he was treated by (the facility's) nursing staff for skin tears incurred during the fall. During this time, (R3) was in an altered state of mind and kept seeing people that weren't there. We kept asking who was there, and he (R3) said the man who was trying to get everyone. We had to reassure him that no one was there. Once his initial injuries were taken care of, we walked (R3) to the ambulance where he was restrained with soft restraints. He was then transported to (a local hospital) without incident. R3's 5/9/23 Discharge Instructions and Summary of Visit documents showed a CT without contrast was performed on R3 due to decreased level of consciousness and bilateral hand x-rays were performed due to the fall. The Discharge summary showed a 12 lead EKG was also performed due to an altered level of consciousness. The discharge summary showed a urinalysis was collected as well as blood draws for lab work. The emergency department notes dated 5/9/23 showed R3 was noted to have some injury to his bilateral hands that was wrapped with rolled gauze in the field. The notes showed R3 arrived to the emergency department in two-point restraints and was noted to be calm and cooperative, but unable to provide a direct history. On 7/20/23 at 11:37 AM, V12 (LPN) said one of the CNAs came up to the nurse's room while she was receiving report at 6:15 in the morning on 5/9/23. V12 said she grabbed a shake and R3's medications and as soon as she opened the door to the memory care unit, she saw R3 going out the back door to the courtyard. V12 said herself and V23 (CNA) went out to the courtyard. R3 was heading left towards the 200-300-unit courtyard area. V12 said she told [NAME] to come talk to her that she had a shake for him. V12 said R3 was frantic to get out and was grabbing the fence and shaking it. V12 said she had not seen R3 like that before. V12 said this was R3's first major behavior outburst. V12 said she does not remember exactly when R3 got the rod, but the rod was sticking in the ground. V12 said once R3 grabbed the rod, the situation turned. He was holding it like like he was going to stick it into us. V12 said R3's vision is not the best. V12 said she called V2 (Director of Nursing) from the cell phone she had on her, and she had her walkie talkie radio in her other hand letting V15 (LPN) to notify V3 (FNP-Family Nurse Practitioner) to get an order to send R3 to the ER for eval and treatment and then to call 911. V12 said she was doing all of this while running from R3 and trying to protect the CNAs that were out there. V12 said she thought if there was a male involved, it would change the situation, so she used the radio to ask V26 (Maintenance Supervisor) to come out. V12 said V26 came out and tried to calm R3 down to no avail. V12 said R3 started chasing V26, and them (herself and the CNAs), if they were around him. V12 said R3 was chasing them for about 12-15 minutes and it was about 45 minutes from the time R3 went out the back door until he left in the ambulance. V12 said the police came and R3 was still chasing them around the courtyard. V12 said R3 came at the police and they told him to drop the weapon or he would get tased. V12 said R3 continued to charge at the police and they tased him. V12 said when R3 hit the ground, he popped back up, he did not have the rod at that time. V12 said the police told him to stop being combative or they would tase him again. V12 said the officers handcuffed R3 and she attempted to clean the wounds on his hands. V12 said there was quite a bit of blood, mostly on his right hand. At 4:24 PM, V12 said she works for the corporation's float pool. V12 said she had not received any training through the facility and had not received any dementia training through the corporation. V12 said she had worked dementia units prior to working at the facility. V12 said with increased aggression and agitation, 95% of it is approach. Most of the time you can turn a situation around with how you approach the resident. V12 said you do not want to crowd a resident with agitation. You do not want too many people or get too close to the resident or stand over them. V12 said sometimes two to three people may be too much. On 7/20/23 at 12:15 PM, V1 (Administrator) said she did not report the incident to the Illinois Department of Public Health because R3 was sent to the local hospital due to increased agitation and aggression. V1 said R3 did not receive any stitches or anything for the wounds on his hands. On 7/20/23 at 12:38 PM, V25 (CNA) said she worked on 5/9/23. V25 said R3 was already outside when she went out. V25 said R3 was holding the steel rod like a rifle. Anytime we got close or tried to calm him down, he would swing at us. V25 said V26 (Maintenance Supervisor) tried to calm R3 down. V25 said R3 would not put the rod down and nothing they tried was working. V25 said that when the police were called. V25 said V30 (Chief of Police) tried to talk with R3 calmly and calm him down. V25 said then V29 (police officer) came out and tried to do the same. V25 said R3 did not calm down. V25 said the police officers warned R3 to put the rod down quite a few times. V25 said she looked away for a second and was not sure if R3 had lunged at the officers. V25 said she turned back around and saw V29 tase R3. V25 said R3 got right back up an kept going. V25 said she thinks it was V29 that told R3 if he does not calm down he will tase him again. V25 said R3 said okay and the behaviors stopped. V25 said she does not know if R3 could have been subdued without being tased, adding, I know we could not get (R3) to calm down and drop the rod. V25 said R3 was not scared of anyone at that time and he was unpredictable. On 7/20/23 at 11:03 AM, V26 (Maintenance Supervisor) said he was in his shop at the facility when he was asked over the radio to go outside. V26 said he went outside and saw R3 chasing V12 and two other staff. V26 said R3 had a little 3/8-inch rod that was used to hold up tomato plants last summer. V26 said he asked (R3) what he was doing and then R3 turned and started chasing him for about five minutes before the police came. V26 said he ran because he could see himself getting stabbed with the rod if he tried taking it away from R3. V26 said R3 was holding the rod like a spear with a hand near both ends of the rod. V26 said V30 and V29 came out and saw R3 chasing him. They told R3 to put the rod down. They tried quite a few times to get R3 to put the rod down and then R3 lunged at the officer on his (V26's) right side so the officer tased him. V26 said R3 fell face down in the dirt and his hands must have slid across the concrete sidewalk. V26 said the officers got R3 up off the ground and he (V26) grabbed the steel rod off the ground. V26 said V29 and V30 handcuffed R3. At 11:14 AM, V26 showed this surveyor where the incident took place in the back courtyard. At 11:16 AM, V26 showed this surveyor the metal rod that R3 had brandished during the incident. The rod was approximately four feet long and 3/8-inch around. The ends of the rod were smooth. V26 said the rod was located in one of the flower boxes by the 200-300 halls courtyard. On 7/20/23 at 1:20 PM, V23 (CNA) said a little after 6:00 AM on 5/9/23, R3 exited the memory care unit into the courtyard. V23 said She tried to get him to come back in but he would not stop. V23 said R3 kept going towards the unlocked gate. V23 said R3 grabbed a rod out of the ground by the flower beds and started chasing them. V23 said R3 was holding the rod like it was a gun at times. V23 said V12 told V26 (Maintenance Supervisor) to come out. V26 came out and was not able to calm R3 down. V23 said R3 chased V12, her and V26 around for about 20 minutes. V23 said when the police arrived, R3 was still swinging the rod around and the police told him to drop it or he was going to get tased. V23 said R3 was still going towards the officers and they tased him. On 7/20/23 at 2:28 PM, V28 (CNA) said she has worked at the facility for one year. V28 said she worked on the memory care unit for the first-time last week. V28 said she has not had any in-person training for dementia; however, she has done some computer training for dementia care. V28 said she has not had any specific training on how to deal with a dementia resident exhibiting aggressive behaviors. On 7/20/243 at 2:03 PM, V21 (CNA) said she has worked at the facility for about two years. V21 said she has not had any training from the facility for dementia care. No in-service training, and no computer training for dementia. V21 said if a resident displays aggressive behaviors, they are supposed to report it to the nurse. V21 said It is hard because they just walk out the door and don't want to come in. I have never worked at a place with a door that goes outside on the dementia unit. V21 said she thinks it is very important to have dementia training especially for aggressive behaviors because the resident with dementia is confused and does not know wat is going on. On 7/20 23 at 2:13 PM, V10 (CNA) said she has worked at the facility since October 2022. V10 said she has not had any in-service training on dementia. V10 said she has done some computer training on dementia. V10 said the training covered different types of abuse and there was one on redirection. V10 said she thinks it is important to keep on dementia training, especially training for what to do when residents have behaviors, aggression, and agitation.V10 said she thinks there could be better, clear-cut procedures on how to handle residents with aggression. On 7/21/23 at 2:23 PM, V22 (LPN) said she is in the float pool and not an employee of the facility. V22 said she receives training through the corporation. It does include dementia training. V22 said you cannot de-escalate if a patient is that aggressive. V22 said she would report it to V2 (Director of Nursing) and stay with the resident, never leave them alone. V22 said she would have another staff member with her. V22 said she would have another nurse on duty call the doctor and see if the resident could be sent out for an evaluation. V22 said she would protect other residents during that time. On 7/20/23 at 1:57 PM, V8 (LPN) said she has done the dementia training online for CEU (continued education). V8 said she has not attended any in-service training for dementia that she can recall. V8 said when a resident with dementia has aggression, staff should diffuse the situation, lower their tone, make eye contact. If aggression increases, tap out and get someone else to help. On 7/20/23 at 3:13 PM, V2 (Director of Nursing) said on 5/9/23 staff tried to redirect , re-approach and use different staff. V2 said they had to have the police come. V2 said staff tried to get R3 to come back into the building and he would not do it. V2 said the facility staff cannot let a resident from the dementia unit be out back by themselves, adding, there is a river out back. V2 said if staff cannot get the resident to calm down, they call the police and send the resident out for a psychiatric evaluation. V2 said maybe there was too much stimulation, adding that it was the perfect storm; R3's brothers had recently visited, he had a roommate and the roommate's wife would come in with their dog. V2 said they let R3 go out back door now and watch him from afar. If he does not want to come back in, staff watch him from afar and let him cool down, and then he will usually come in. On 7/21/23 at 2:15 PM, V3 (FNP-Family Nurse Practitioner) said R3 needs a locked unit and he is on a locked unit. V3 said a code had to be entered into the back door to the courtyard, or it would not open because it was locked. This surveyor informed V3 that the door would still open, however, the alarm would sound. V3 said she was not aware of that. V3 said there should not be a steel rod, or anything that could endanger R3 or any other resident in the courtyard. V3 said it is important to ensure staff are knowledgeable on how to diffuse instances of aggression for residents with dementia. V3 said it is a good idea to develop a care plan that addresses a resident's aggressive and exit-seeking behaviors and list the interventions put in place to address those behaviors. On 7/11/23 at 9:06 AM, R3 was observed in the hallway, outside of his room. R3 was confused and did not know the door he was standing near was his room, even though R3's name was on the door. On 7/20/23 at 2:07 PM, R3 approached this surveyor and V21 (Certified Nursing Assistant-CNA). R3 asked How do you get out of this place? Someone needs to show me the way out. R3 was able to be redirected to the dining area for a snack without difficulty. R3 still had a wound on his right hand from the incident on 5/9/23. R3's [NAME] Initial Wound Evaluation and Management Summary dated 5/16/23 showed a non-pressure wound of the right hand, full-thickness, due to trauma/injury, measuring 12 cm (centimeters) x 8 cm x 0.3 cm with 40% thick adherent devitalized necrotic tissue (non-viable tissue), 25% slough (white or yellow, non-viable tissue), and 35% granulation tissue (red, beefy, viable tissue). The Wound Evaluation showed excisional debridement was performed to remove the non-viable tissue. R3's most recent Wound Evaluation and Management Summary dated 7/18/23 showed a non-pressure wound of the right hand, partial thickness measuring 3.3 cm x 2.2 cm x not measurable due to dried fibrinous exudate (scab). On 7/20/23 at 3:40 PM, V1 (Administrator) was asked about an assessment for R3's left hand. V1 said maybe an assessment for R3's left hand was not documented because the right hand was so bad and they were focusing on it. V1 said the wound on R3's left hand was just a small abrasion. V1 said maybe because R3 would not let the nurses remove the bandage and do the dressing change, that by the time they did take the bandage off, the left hand was healed. R3's care plans were reviewed. As of 7/20/23, the facility had not developed a care plan to address R3's wandering, exit-seeking, or aggressive behaviors. 2. On 7/10/23 at 3:44 PM, V4 (CNA) said she was working on 7/4/23 and was talking with other CNAs when one of them (she did not recall who said it) said R2 and R3 were found laying in bed together and R3's hand was under R2's clothes, in her private area. On 7/11/23 at 8:43 AM, V1 (Administrator) said she had not received any reports of sexual abuse. V1 said she had not received any report of R3 touching R2 inappropriately. On 7/11/23 at 8:55 AM, R2 was in her room, laying in bed. R2 said there had been a male in her room. R2 said the male did not do anything inappropriate to her, and has not touched her inappropriately. R2 said when the male came into her room, he just stood there for a minute and then walked back out. R2 said this has happened two times. R2 said if a male did come in and touch her inappropriately, she would tell staff right away. R2 said she has never been in any of the males rooms in the facility. On 7/11/23 at 8:48 AM, R3 was observed in the dining room, sitting at a table with 2 other males. At 9:06 AM, R3 was observed standing in the hall outside the dining room. R3 was asked by this surveyor if that was his room, and pointed to the room across the hall from the dining room, displaying R3's name on the door. R3 said no, it was not his room and asked this surveyor where his room was. This surveyor asked R3 if his name was (R3's name) and he said yes. This surveyor informed R3 that his name was on the door along with a picture of animals. R3 said well maybe that is my room. Upon entering R3's room, R3 recognized some of his belongings and said yes this is my room, I can tell now that I am in here. When asked if any of the female residents had ever been in his room. He said yes, my daughters come to see me and they have been in here. When asked if any of the women that live in the building have been in his room, R3 again said yes, my daughters have been in here. R3 appeared confused and was not able to comprehend what this surveyor was asking him. When asked if he had gone into any of the females rooms in the building, R3 said he has not been in any other resident's rooms. On 7/11/23 at 8:50 AM, V19 (Certified Nursing Assistant-CNA) said she has seen R2 and R3 in eachother's rooms and has redirected them. V19 said R2 and R3 hang out, walking down the hall. V19 said she has not seen, or heard about any inappropriate touching involving R3 and any other residents. On 7/11/23 at 9:00 AM, V7 (Licensed Practical Nurse-LPN) said she was not aware of any incident regarding R3 inappropriately touching any of the female residents. V7 said usually R3's behaviors are aggressive such as verbal aggression and raising his hand at staff. V7 said R3 has sundowners and tries to get out of the building sometimes. V7 said R2 also wanders and tries to get out of the building. V7 said she has not seen any inappropriate sexual behaviors and no one has reported any regarding R3. On 7/11/23 10:16 AM, V5 (CNA) said she is not aware of R3 being in R2's room. V5 said she knows that R2 and R3 thought they were husband and wife one day. V5 said V10 (CNA) told her during shift report one day that R2 and R3 were laying in bed together in R3's room, but to her knowledge, they were both fully clothed. V5 said V10 said they were being touchy-feely and they were split up. V5 said it only happened one time. On 7/11/23 at 10:43 AM, V10 (CNA) said she has seen R2 and R3 in R3's room, laying on the bed together a couple of times. V10 said it happened about a month prior. V10 was not able to identify the day it happened. V10 said the first time she saw them, they were both fully-dressed, laying in bed together. V10 said she redirected R2 out of R3's room. V10 said the next time (within two days of the first incident) she saw R2 and R3 laying in bed in R3's room, R3 had his hands down R2's pants. V10 said she redirected R2 out of R3's room and informed V12 (LPN). V10 said she informed V12 what she had seen and asked if residents on the dementia unit were able to give consent for sexual activity. V10 said V12 told her she was going to talk to V2 (Director of Nursing) about it. V10 said she was told to redirect R2 and R3 and to pass the information on to other staff. V10 said she has seen R2 and R3 go into eachother's room after that and staff would redirect them. V10 said R2 and R3 are both confused and seek out eachother. V10 said they thought they were married. On 7/12/23 at 9:50 AM, V10 said she has seen R3 go into other female resident's rooms. He will go in and talk to R7 sometimes. V10 said R3 wanders. He has dementia. V10 said R3 is easily redirected. V10 said she did not report the first time she saw R2 and R3 laying in bed together because she did not see anything inappropriate going on. On 7/11/23 at 1:31 PM, V12 (LPN) said she does not recall if one of the CNAs ever told her that R2 and R3 were laying in bed together in R3's room and R3 had his hands under R2's clothes. V12 said she cannot say one way or the other without looking at her nursing notes. V12 said she was in another state, on vacation at the time and did not have access to her nursing notes. When asked if that was something that you would probably recall being told, V12 said yes, you would think so, but I cannot say without looking at my notes. On 7/11/23 at 2:03 PM, V8 (LPN) said she has not been on the dementia unit since December of 2022. V8 said she had not heard anything about R2 and R3 laying in bed together and there being any inappropriate touching. On 7/12/23 at 9:37 AM, V14 (CNA) said R3 roams around a lot. V14 said R3 is easily redirected. V14 said she has not seen R3 exhibit any sexually inappropriate behaviors towards any residents or staff. V14 said she just heard about the incident involving R2 and R3 yesterday (7/11/23). On 7/12/23 at 11:55 AM, V11 (LPN) said R3 has general wandering behaviors. He will go in and come right back out. V11 said this past weekend is the first time she has seen a female in R3's room. V11 said her and V13 (LPN) were doing report and one of the CNAs came and said there was a female resident in R3's room. V11 said the female resident was laying on R3's bed and R3 was on the bed next to her, leaning back, propped up on his elbows. V11 said she did not see any inappropriate touching, or clothing messed up, or anything that would lead me to believe anything happened. V11 said staff intervened and they got R2 out of the bed. V11 said R3 was upset and combative and asked where are you taking her. V11 said they informed R3 that they were taking R2 back to her house. V11 said R3 did not say anything about R2 being his wife during that incident, but he was speaking very lovingly about her, saying don't you hurt her, and that's a good woman there. On 7/12/23 at 1:08 PM, V13 (LPN) said on 7/9/23 V20 (CNA) came up to the nurse's desk and asked if it is okay for R2 to be in R3's room. V13 said she and V11 went to R3's room to see what was happening. R2 was laying on her back in R3's bed and R3 was on his side next to her in the bed. V13 said she did not see any inappropriate touching during the encounter. V13 said she talked to R2 and redirected her out of R3's room. V13 said it took a minute to redirect her out of his room. V13 said R2 sat on R3's bed for a while before they were able to redirect her out of his room. V13 said R2 did not want to leave R3's room at first. V13 said R2 and R3 are both confused and she does not know if R3 realizes who R2 is. He was walking down the hall behind them yelling at staff. V13 said prior to the incident on 7/9/23, she was not aware of any incident involving R3 touching any female residents inappropriately. V13 said R2 has a tendency of migrating towards the new male residents, not sexually, just befriending them. On 7/12/23 at 1:34 PM, V15 (LPN) said she has had to redirect R2 out of R3's room before. V15 said she had not seen any inappropriate sexual behavior from R3 before. V15 said R3 has not acted sexually inappropriate with herself or any other staff, that she is aware of. V15 said R3 has not acted sexually inappropriate with any other female residents. R2's Admission Record, printed by the facility on 7/12/23, showed she had diagnoses including unspecified dementia with agitation, anxiety disorder, and visual hallucinations. R2's facility assessment dated ,d+[DATE], 2023 showed she had severe cognitive impairment, disorganized thinking and inattention. R2's care plans were reviewed. R2's Cognitive deficit care plan, with a revision date of 5/10/23, showed she has impaired decision making and a self-care deficit. The interventions in place were to encourage activity participation, remind and direct her to activity, and offer verbal cues, reminders and redirection as needed. Redirect when wandering or rummaging. R2's cognitive function/dementia care plan, with a revision date of 5/10/23, showed she has impaired cognitive function/dementia or impaired thought processes. The interventions include cue, reorient and supervise as needed. R2's care plan, with a revision date of 6/28/23 showed R2 uses anti-anxiety medications related to adjustment issues, anxiety disorder. Interventions include Monitor/record occurrence of for target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc., and document per facility protocol. The care plans do not address wandering into male resident's rooms, being found in a male resident's bed, inappropriate touching, or redirecting out of male resident's rooms. R2's progress notes from 4/8/23 - present do not document R2 being found laying in bed with a male resident or inappropriate touching. R3's Admission Record, printed by the facility on 7/12/23, showed he had diagnoses including unspecified dementia, moderate with other behavioral disturbance, and adjustment insomnia. R3's facility assessment dated [DATE] showed he had severe cognitive impairment. R3's cognitive deficit care plan, with a revision date of 5/15/23, showed he had impaired decision making, and a self-care deficit. The interventions in place included encourage activity participation, invite to group activities, Offer verbal cues and reminders, redirect as needed. R3's care plan, with a revision date of 6/20/23 showed R3 had a history of criminal behavior including batter in 1982 and domestic violence in 1984. The care plan showed R3 was evaluated by the State Police and considered high risk. The care plan showed R3 was placed in a private room, in high visually monitored area, to permit visual monitoring prior to analysis. The care plan interventions showed R3 had been referred to facility psychiatrist for evaluation monthly. R3's care plans do not address being found laying in bed with a female resident or inappropriate touching. R3's progress note dated 5/4/23 showed a CNA reported to the nurse that R3 had been passing another resident's room and the CNA heard the resident say to R3, come here and give me a kiss R3 went into that resident's room, leaned over, embraced the resident and gave her a kiss. The note showed the residents were redirected and V1 had been notified. R3's progress note dated 5/5/23 showed R3 was observed by a CNA in another resident's room, sitting on the bed, taking his shoes off, getting ready to lay down. The other resident was already in the bed. R3 was hard to redirect to get him out of the other resident's room. R3's progress note dated 5/9/23 showed R3 was in the back court yard stating he is trying to kill us. staff were trying to redirect R3 and he grabbed a steel rod from the ground and began chasing the nurse and two CNAs. The notes showed 911 was called and R3 was tazed by police when he started running towards the police with the steel rod in his hand. R3's progress note dated 5/11/23 showed he got into another resident's room across the hall from his and tried keeping the door shut, to keep staff from entering. One of the resident's in the room yelled at R3 to get out. Staff were able to get R3 out and back to his room. Progress note dated 5/17/23 showed res was observed going in and out of other resident rooms. R3 said I'm getting out of here and you can't stop me. R3's progress note dated 6/28/23 showed R3 was wandering hallway, searching for exit. R3's progress note dated 6/30/23 showed he was anxious and seeing images and people that were not there. Pacing up and down the hallway, going in and out of other rooms. Progress note dated 7/3/23 showed R3 was very agitated and hallucinating. R3's progress note dated 7/9/23 showed resident noted to be wandering in hall and entering other resident rooms at this time. The notes showed the nurse was able to get resident into bed to lay down. Resident then patted the bed and said Come on right here honey, followed by Man I sure hope your old man doesn't come home to this. On 7/12/23 at 11:55 AM, V11, the nurse who wrote the note on 7/9/23, said she thinks it may have been the way she worded Let's get into bed. when she was assisting him into bed. V11 said she did not feel uncomfortable or like he was trying to be sexually inappropriate with her. V11 [NAME][TRUNCATED]