Every finding on record at Allure of Sterling

Based on observations, interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 3.The findings include:R1's electronic face sheet show R1 has diagnoses that include right leg amputee, diabetes, morbid obesity and hypertension.R1's facility assessment dated [DATE] shows R1 has a BIMS of 15, no cognitive impairment.On 8/7/26 at 9AM, R1 stated almost a month ago, her and R2 were both in their wheelchairs, sitting at the front of the 300 hallway when V4 (Certified Nursing Assistant-CNA) yelled at them and said we must move because [R3] was going to her room and we were in R3's way. R1 said she did not move right away because R3 was still far. R1 said while she was sitting in her wheelchair, and without letting her know, V4 (CNA) went behind her, grabbed her wheelchair forcefully backwards, and turned the wheelchair around quickly. It jerked her, and she almost fell face forward. R1 said she's an amputee; she used her left leg to steady herself in the wheelchair and caused pain to her right stump. V4 then in a rude and mean manner said, Go to your room.! As the day went on, R1 said no one talked to her or asked her what happened. She could hear V4 talking about her to other staff, of what happened. R1 said she informed V1 (Administrator), that V4 pulled her in her wheelchair backwards forcefully, then turned her around so fast she almost fell out of her wheelchair. R1 said that was abuse, no one should be treated that way. R1 said V1 responded that there were always two sides of a story and there were surveillance cameras in the 300 hallway that can show what really happened that day. V1 also said that she will investigate the incident. R1 said up to now, no one had gotten back to her to let her know the result of the investigation.On 8/7/26 at 9:45 AM, R2 with (BIMS of 15 dated 7/17/26) said he was with R1, when the incident happened. Both him and R1 were sitting in their wheelchairs at the entrance of 300 wing. V4 (CNA) told them to move. R2 said he moved but V4 did not give R1 enough time to move. V4 went behind R1, pulled R1 backwards and turned R1 around in her wheelchair too fast. R1 almost hit the wall. R1 had to put her foot down to stop the wheelchair from moving fast. When V4 let go of R1's wheelchair, it bumped into V4's side accidentally. R2 said the way V4 treated R1 bothered him. R2 said he told V2 (Director of Nursing) what happened, R2 said he wanted V2 to look into the situation. On 8/7/26 at 1 PM, V4 (CNA) said she cannot recall the exact date. That day, R3 was on her way to her room, R1 was in the way so she told R1 to move out of the way. V4 said she was not sure if she moved R1 in her wheelchair. V4 said she thought she guided R1 in her wheelchair. V4 said she recalled R1's wheelchair hitting her side. V4 said no one had spoken to her about the incident except today (8/7/26). V4 said she was told she was being suspended today pending the investigation.On 8/7/26 at 1:30 PM, V7 (License Practical Nurse-LPN) said he was R1, R2 and R3's Nurse on 7/17/26. V7 (LPN) said he did not witness the incident, but he heard V4 (CNA) telling R1 and R2 to move out of the way so R3 can go to her room. V7 said V4 had a normal tone of voice. Then he heard R1 used the b---- word, which R1 does use that language at times. V7 said he documented the incident and instructed V4 to stay away from R1.R1's progress notes dated 7/17/26 by V7 shows, [R1] had behavior towards (V4). R1 was in hall and was asked to move so another resident (R3) could go inside their room. R1 refused to move and flipped out on (V4). Called her a derogatory name. R1 was calmed down and aid V4 had to be moved to another hall.On 8/7/26 at 11:40 AM, V2 (Director of Nursing-DON) said R2 spoke to her about R1 and V4 but unable to recall the date or specific time of their conversation. R2 said V4 went behind R1 who was in her wheelchair and moved R1 and in the process R1 almost fell. R1 put her foot down and R1's wheelchair accidentally hit V4. V2 said she did not talk to R1 regarding the incident. V2 said she also did not speak to the alleged CNA (V4), and she did not speak to the Nurse (V7) working that shift. V2 said she did not document when R2 spoke to her or what R2 reported to her. V2 said she reported the allegation to V1. V2 said again V2 cannot recall the day and time when she reported this to V1. On 8/7/26 at 11:50 AM, V1 (Administrator) provided this surveyor with a document identified as a soft file dated 8/3/26. It documented her conversation with R1 regarding the allegation involving CNA (V4), that she pulled R1 in her wheelchair backwards. The document showed she was informed of the situation and stated she would look into the matter. The soft file did not contain documentation of any interviews with other residents or staff. The document did not show any review of the camera footage and did not contain any follow up investigation conducted after V1 was informed of the allegation. On 8/7/26 at 12 PM, V1 said last Monday 8/3/26, R1 spoke to her about V4 (CNA) R1 did not like that V4 went behind her and moved her in her wheelchair without letting her know first. V1 said she did not do any investigation yet and only documented the conversation in a soft file. V1 said she had not spoken to the CNA (V4) or to the Nurse. V1 said the cameras in the hallways can only go back so far. V1 said the investigation will start today. (8/7/26). The facility policy entitled Abuse, Neglect and Exploitation (undated) shows, it is the policy of this facility to provide protection for the health welfare and rights of its resident by developing and implementing written policies and procedures that prohibit and prevent abuse neglect exploitation and misappropriation of residence property. Investigation of alleged abuse neglect and exploitation and immediate investigation is warranted when suspicion of abuse neglect or exploitation or reports of abuse neglect or of exploitation occur. 4. Identifying, interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations.

Based on interview and record review the facility failed to accurately enter a medication order and failed to weigh a heart failure resident as ordered. This applies to 1 of 5 residents (R1) reviewed for nursing care in the sample of 5. The findings include: R1's admission Record (Face Sheet) showed an original admission date of 12/6/24 with diagnoses to include but not limited to diabetes type II, acute respiratory failure, congestive heart failure (CHF, decreased heart efficiency often manifested as swelling and shortness of breath related to fluid retention), acute kidney failure, anxiety, and depression.R1's April 2026 Medication Administration Record (MAR) showed an order for weekly weights on Monday due to Congestive Heart Failure (CHF). R1's weekly weight for 4/6/26 and 4/13/26 showed the nurse documented NA. R1's Progress Notes for 4/6/26 and 4/13/26 showed no documentation related to R1's weights. R1's Weights and Vitals section of her Electronic Health Record (EHR) showed a documented weight on 4/1/26 of 257.8 pounds and the next documented weight was not until 4/20/26 at 260.6 pounds.On 7/21/26 at 10:52 AM, V5 (Licensed Practical Nurse/LPN) stated the initials for the weekly weight documentation on 4/6/26 and 4/13/26 were hers. V5 stated she does not know what she meant by NA; however, she believed it most likely represented an inability to assess R1's weight due to R1 not getting out of bed. V5 stated she would or should have passed on to the next shift the need to obtain R1's weight. V5 stated the importance for the increased frequency of weight monitoring for CHF residents is due to their risk of fluid retention and shortness of breath. On 7/21/26 at 2:18 PM, V3 (Assistant Director of Nursing/ADON) stated V2 Director of Nursing was not at the facility and she was not available. V3 stated the increased weight measurement frequency for CHF residents is to identify possible fluid retention prior to it affecting the resident's breathing. V3 stated the nurse on 4/6/26 and 4/13/26 should have passed on to the next nurse that R1's weight was not measured, and it should be done the next morning. V3 stated physicians prefer morning weights for CHF residents due to it being the most consistent. V3 stated the nurse also should have documented the reason for not measuring R1's weekly weight.R1's Health Status Note from 4/25/26 at 2:12 PM showed, Lab called in about a critical high lab. BNP 3000 [B-type natriuretic peptide, a hormone released by the heart to control blood flow, higher levels can indicate heart failure, normal range is less than 100. Individuals with CHF can have chronic high levels.] Community Physicians notified. Awaiting orders.R1's Health Status Note from 4/25/26 at 2:25 PM showed, [Nurse Practitioner] called back she ordered Bumetanide [diuretic] increase from BID [twice daily] to TID [three times daily] for three days.R1's April 2026 MAR showed R1 had been taking two tablets of one milligram (mg) each of Bumetanide twice daily since June 2025 until the increase was ordered on 4/25/26. R1's MAR showed the increased frequency order on 4/25/26 was entered as one tablet of 1 milligram three times a day (not two milligrams three times a day).R1's Nurse Practitioner note from 4/27/26 at 11:15 AM showed, She [R1] had lab work done on 4/24/2026 that showed.and a BNP of 3000. The on-call provider was notified over the weekend and her [Bumetanide] dose was to be increased to 3 times daily through the weekend. However, she is typically on [Bumetanide] 2 mg PO [by mouth] twice daily, and the order was entered as 1 mg PO 3 times daily, so the patient was actually receiving less [Bumetanide] over the weekend. The patient has no lower extremity edema [swelling] today. (Authored by V6)On 7/21/26 at 1:22 PM, V6 (Nurse Practitioner) stated Bumetanide, on 4/25/26, should have been increased to two milligrams three times a day. V6 stated the elevated BNP value could indicate worsening CHF. V6 stated it is common for CHF residents to be weighed daily or weekly to monitor them for fluid retention.

Based on observation, interviews and record review, the facility failed to notify a resident's physician regarding an injury sustained when a mechanical sling lift tipped and hit the resident on the top of the head for 1 of 4 residents (R4) reviewed for improper nursing care in the sample of 8. The findings include:R4's face sheet, provided by the facility on 4/21/26, showed she had diagnoses including, but not limited to ulcerative colitis, fracture of right clavicle, pain in right shoulder, low back pain, pain in unspecified right knee, benign neoplasms of ascending, descending and transverse colon, post-hemorrhagic anemia, complete intestinal obstruction, colostomy, restless legs syndrome, muscle weakness, lack of coordination, unilateral primary osteoarthritis left hip, and gastrointestinal hemorrhage.R4's facility assessment dated [DATE] showed she was cognitively intact, had no behaviors, used a wheelchair for mobility, and was dependent on staff for toileting, bathing, dressing, bed mobility and transfers. R4's ADL (activities of daily living) care plan, initiated on 9/2/25, showed she had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and limited mobility. The care plan showed that R4 requires a Mechanical Lift with two staff assistance for transfers.On 4/16/26 at 9:00 AM, R4 said a newer CNA (Certified Nursing Assistant) (V14) transferred her with a mechanical sling lift and the mechanical sling lift hit her on top of the head when she was being lowered into her wheelchair. R4 said her head was bleeding and it hurt a lot at first. R4 said she was crying when it happened. R4 lowered her head, so this surveyor could see the injury. R4 had about an inch long, dark, purplish-colored scab on the top of her head. On 4/21/26 at 9:48 AM, V3 (Licensed Practical Nurse-LPN/Wound Nurse) said she does not know if the nurse called R4's doctor to inform him about the incident on 3/10/26. V3 said she did not update R4's doctor. On 4/21/26 at 10:45 AM V8 said she did not notify R4's doctor after the incident occurred on 3/10/26. V8 stated, I was just supposed to be passing meds that day. Of course, you want to deal with any resident issue that comes up. (V9) and (V10) (LPNs) took over because she was leaving at 10:00 AM. V8 said she documented in the incident report that V21 (R4's doctor) was updated but she does not know who updated the doctor.On 4/21/26 at 12:19 PM, V9 (LPN) said she did not notify R4's doctor or assist in any way for the incident involving R4.On 4/21/26 at 12:34 PM, V10 (LPN) said she is not aware who updated the doctor regarding R4's incident on 3/10/26, adding it was not her (V10). On 4/21/26 at 11:59 am, V21 (R4's previous physician and the facility's medical director at the time of the incident) said he does not recall the facility notifying him about the mechanical sling lift hitting R4 on the head.On 4/21/26 at 1:55 PM, V2 (Director of Nursing/DON) said she asked V3 (Wound Nurse) to assist V8 (RN) with the assessment and documentation. V2 said she believed V21 was R4's doctor at that time. V2 said V21 did not have a nurse practitioner. V2 said she was not sure which nurse would have notified the doctor. V2 said she just said R4's wound looks like it does not need to be treated. V2 said she was not implying that she did not need to be sent out, just that it did not look like she needed stitches.R4's initial incident report dated 3/10/26 showed during transfer the top of (R4's) scalp was scraped by the mechanical lift. Pressure applied to scalp. Neuro checks initiated. Wound care provided. Skin check completed. The incident report showed injuries observed at the time of the report were an abrasion to the top of the scalp. Level of pain 10. The report showed injuries report post incident: No injuries observed post incident. The report showed V8 was the one that documented the report. V8 documented that V21 was notified of the incident.

Based on observation, interviews and record review, the facility failed to do a thorough assessment of a resident's injury, failed to document an assessment of the injury in the resident's electronic medical record, and failed to initiate a treatment for 1 of 4 residents (R4) reviewed for improper nursing care in the sample of 8.The findings include:R4's face sheet, provided by the facility on 4/21/26, showed she had diagnoses including, but not limited to ulcerative colitis, fracture of right clavicle, pain in right shoulder, low back pain, pain in unspecified right knee, benign neoplasms of ascending, descending and transverse colon, post-hemorrhagic anemia, complete intestinal obstruction, colostomy, restless legs syndrome, muscle weakness, lack of coordination, unilateral primary osteoarthritis left hip, and gastrointestinal hemorrhage.R4's facility assessment dated [DATE] showed she was cognitively intact, had no behaviors, used a wheelchair for mobility, and was dependent on staff for toileting, bathing, dressing, bed mobility and transfers. R4's ADL (activities of daily living) care plan, initiated on 9/2/25, showed she had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and limited mobility. The care plan showed that R4 requires a Mechanical Lift with two staff assistance for transfers.On 4/16/26 at 9:00 AM, R4 said a newer CNA (Certified Nursing Assistant) (V14) transferred her with a mechanical sling lift and the mechanical sling lift hit her on top of the head when she was being lowered into her wheelchair. R4 lowered her head, so this surveyor could see the injury. R4 had about an inch long, dark, purplish-colored scab on the top of her head. R4 said no treatment was started and they did not measure the injury on the top of her head. On 4/21/26 at 9:48 AM, V3 (Licensed Practical Nurse-LPN/Wound Nurse) said did assess R4 the morning that the mechanical sling lift fell on her. V3 said V10 asked her to look at R4. V3 said V10 looked at it too. V3 said she did not do a full assessment of R4's wound. She looked at it and recommended they call the doctor because R4 may need to be sent out. V3 said V2 (Director of Nursing) went down to assess R4 and said it looked fine, and no treatment was needed. V3 said she did not document an assessment for the wound on R4's head. V3 said she measured the wound and wrote it down on paper but did not document an assessment in R4's electronic medical record. V3 said no treatment was initiated for R4's injury. At 9:58 AM V3 went with this surveyor to measure the wound on top of R4's head. It measured 1.9 centimeters (cm) x 0.2 cm x 0.0 cm. R4 was asked by this surveyor how often they measure the wound. R4 said today is the first time they have measured it. At 10:20 AM R4 said V3 would come in and look at it to see how it was doing, but there were no measurements done until today, and no treatment was put in place for it. V3 was asked to provide this surveyor with any documentation that she had regarding the wound on R4's head.On 4/21/26 at 10:45 AM V8 (Registered Nurse/RN) said she was working the day the incident happened with R4. V8 said she looked at R4's injury quickly then went to get the equipment to take her vitals. V8 said V9 and V10 (LPNs) went down to see R4. V8 said V10 said the wound just looked like an abrasion. V8 said V9 and V10 took over the care for R4. V8 said she did not do an assessment of the wound or document an assessment of the wound. V8 said she was not sure what the aftercare treatment was. On 4/21/26 at 12:19 PM, V9 (LPN) said she was working on a different hall the day of the incident. V9 said she did not see R4's wound or do an assessment of the wound or assist in any way. V9 said it looked like they had enough people in R4's room to handle the situation so she went back to her area.On 4/21/26 at 12:34 PM, V10 (LPN) said she was working on a different hall the day R4 got hit by the mechanical lift. V10 said V9 got R4's vitals. V10 said she was up at the desk and V9 asked her to look at R4. V10 said the wound looked superficial from what she could see. V10 said she did not do an assessment of the wound or document any assessment. She said she went back to her hall.On 4/21/26 at 1:55 PM, V2 (Director of Nursing/DON) said she went down to look at R4 that morning after the mechanical lift hit her head. She was up in the chair and there was maybe an inch abrasion on her head that was already starting to form a scab. V2 said the wound was no longer bleeding. V2 said she asked V3 (Wound Nurse) to assist V8 (RN) with the assessment and documentation. V2 said she just said it looks like R4's wound does not need to be treated. V2 said she was not implying that R4 did not need to be sent out, just that it did not look like she needed stitches. V2 said R4 was not bleeding at that time. V2 said R4 said she was not going anywhere right then. V2 said she let R4 know if she had any headaches, to let staff know and the doctor could be updated and decide if she needed to be sent out. V2 said she did not have any assessments from V4 for the wound on top of R4's head. V2 said V3 said she had one. V2 said an injury assessment should include a description of the wound, a full description of the skin issue, the appearance, including measurements, and any pain associated with the wound. V2 said it should all be in the initial incident report; however, it was not in the initial incident report. V2 said she has not seen any measurements or descriptions of the wound other than the next day on 3/11/26 when V10 (LPN) documented abrasion to top of scalp is closed. No drainage. No redness or swelling. The resident had no complaint of pain or discomfort. V2 said that is not an acceptable assessment of the wound either. V2 said no treatment was initiated. V2 said R4 still has a scab on her head, and it has been over a month.R4's initial incident report dated 3/10/26 showed during transfer the top of (R4's) scalp was scraped by the mechanical lift. Pressure applied to scalp. Neuro checks initiated. Wound care provided. Skin check completed. The incident report showed injuries observed at the time of the report were an abrasion to the top of the scalp. Level of pain 10. The report showed injuries report post incident: No injuries observed post incident. The report showed V8 was the one that documented the report.R4's electronic medical record showed no Weekly Skin Assessment for R4 on the day of the incident (3/10/26). The next Weekly Skin Assessment was dated 3/16/26. The assessment dated [DATE] only showed abrasion to top of scalp. No documentation of the size or appearance of R4's wound to her head was documented in the assessment. R4's progress notes showed R4 was not seen by her facility physician (V21) or the Nurse Practitioner until 4/6/26.

Based on observation, interview and record review, the facility failed to ensure the safety of a resident during a mechanical sling lift transfer for 1 of 4 residents (R4) reviewed for improper nursing care in the sample of 8. The findings include: R4's face sheet, provided by the facility on 4/21/26, showed she had diagnoses including, but not limited to ulcerative colitis, fracture of right clavicle, pain in right shoulder, low back pain, pain in unspecified right knee, benign neoplasms of ascending, descending and transverse colon, post-hemorrhagic anemia, complete intestinal obstruction, colostomy, restless legs syndrome, muscle weakness, lack of coordination, unilateral primary osteoarthritis left hip, and gastrointestinal hemorrhage.R4's facility assessment dated [DATE] showed she was cognitively intact, had no behaviors, used a wheelchair for mobility, and was dependent on staff for toileting, bathing, dressing, bed mobility and transfers. R4's ADL (activities of daily living) care plan, initiated on 9/2/25, showed she had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, and limited mobility. The care plan showed that R4 requires a Mechanical Lift with two staff assistance for transfers.On 4/16/26 at 9:00 AM, R4 said a newer CNA (Certified Nursing Assistant) (V14) transferred her with a mechanical sling lift and the mechanical sling lift hit her on top of the head when she was being lowered into her wheelchair. R4 said V14 could not find anyone to help her, so she transferred her from her bed to her wheelchair by herself. R4 said her head was bleeding and it hurt a lot at first. R4 said she was crying when it happened. R4 lowered her head, so this surveyor could see the injury. R4 had about an inch long, dark, purplish-colored scab on the top of her head. On 4/16/26 at 4:00 PM, V1 (Administrator) was asked about the injury on R4's head. V1 said the injury was caused by the mechanical sling lift during a transfer. V1 said it was a single staff transfer. V1 said there should have been two staff doing the transfer. V1 said she provided staff education on proper transfers, adding, it is in my file. This surveyor requested all assessments and documents V1 had on the incident.On 4/21/26 at 9:48 AM, V3 (Licensed Practical Nurse-LPN/Wound Nurse) said the day the mechanical lift fell on R4's head, V10 asked her to look at R4. V3 said R4's wound was bleeding, but not a lot. V3 said there was a dime-sized amount of blood on the gauze. There was some blood in her hair. V3 said R4 could have already been cleaned up. V3 said R4 was upset when the incident happened and had pain when she (V3) cleaned it. It was very sensitive and sore. V3 said R4 still has a scab on it (over a month later). At 9:58 AM, V3 and this surveyor went to R4's room and measured the wound on top of R4's head. It measured 1.9 cm x 0.2 cm x 0.0 cm. At 10:04 AM, V3 said for the first three weeks R4's wound on the top of her head was sensitive and painful when touched.On 4/21/26 at 1:22 PM, V14 (CNA) said she started working at the facility in mid-January of 2025. V14 said she tried to get help transferring R4 when she went to bring the mechanical sling lift into R4's room but did not see any other CNAs down the other halls. V14 said she got R4 changed, got her ready to be transferred, and told R4 she would get her hooked up to the mechanical sling lift. V14 said R4 had told her before the day the incident happened that she was terrified of the mechanical sling lift. V14 said she started transferring R4 from her bed to the wheelchair. V14 said she hooked the sling to the mechanical lift and lifted R4 off the bed. V14 said she tried to get R4 aligned with the wheelchair, she (V14) was trying to adjust the sling to line her up with the chair when the mechanical sling lift tipped. V14 said R4 plopped down into the wheelchair and the mechanical lift hit her on top of the head. V14 said she felt terrible. V14 said R4 cried and screamed out that it hurt. V14 said she imagined it did hurt. V14 said she called the nurse to come check on her. V14 said R4's head had blood on it, at least at the site. V14 said she and another CNA cleaned the blood from the side of R1's head. There was blood on R4's shirt, she thinks it may have been from R4 wiping her hand on it. V14 said R4 complained of it hurting when she went back in later to check on R4 during the day. V14 said when the incident happened, she transferred R4 by herself. V14 said there should be two staff for mechanical sling lift transfers.On 4/21/26, V8 (LPN) said she was the nurse working on 3/10/26 when the mechanical lift hit R4 on the head. V8 said a CNA notified her that while transferring R4 with the mechanical sling lift, something slipped, and the mechanical lift hit R4 on the top of the head. V8 said there was only 1 CNA doing the mechanical lift transfer and she believes, according to the facility policy, there should have been 2 CNAs. V8 said when she went into R4's room R4 was sitting in her wheelchair with a wet cloth to her head. V8 said R4 was actively bleeding on top of her head. V8 said she looked at it quickly then went to get the equipment to take R4's vitals. V8 said V9 and V10 (LPNs) came to look at R4, then V8 and V9 took over the incident. V8 said she documented the incident report. On 4/21/26 at 12:19 PM, V9 (LPN) said she was assigned to a different hall and heard the mechanical lift hit R4's head. V9 said she thought V3, and a CNA were cleaning it up when she went to R4's room to look at her. V9 said she did not see R4's wound. V9 said she does not recall who all was in the room at the time, but it looked like they had enough people in there to take care of the situation, so she went back to her hall.On 4/21/26 at 12:34 PM, V10 (LPN) said she was working another hall the day R4 got hit by the mechanical lift. V10 said V9 got R4's vitals. V10 said she was up at the nurses' desk and V9 asked her to look at R4. V10 said from what she could see, the wound looked superficial. V10 said V9 tried to clean it up and the blood was starting to coagulate. V10 said after looking at R4's wound, she went back to her hall.On 4/21/26 at 1:55 PM, V2 (Director of Nursing/DON) said she went down to look at R4 after the mechanical lift hit her head. R4 was up in the chair and there was maybe an inch abrasion on her head that was already starting to form a scab. V2 said it was that morning that I went in to look at R4. V2 said the wound was no longer bleeding. R4's progress note showed 3/10/2026 10:13 During transfer, top of Resident's scalp scraped by (mechanical sling lift). Pressure applied to scalp; Neuros initiated; wound care provided; skin check completed. MD and POA notified.R4's care plan initiated on 9/2/25 showed R4 requires Mechanical Lift with two staff assistance for transfers.The facility's 2025 policy and procedure titled Safe Resident Handling/Transfers showed It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy showed 3. Mechanical lifting equipment or other approved transferring aids will be used based on the resident's needs to prevent manual lifting except in medical emergencies.10. Two staff members must be utilized when transferring residents with a mechanical lift.12. Staff members are expected to maintain compliance with safe handling/transfer practices.13. Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on interview and record review, the facility failed to supervise residents in a manner that prevented resident injury for one of six residents (R1) reviewed for safety/supervision in the sample of six. This failure resulted in R1 obtaining a large skin tear that required sutures at the local hospital emergency room and increased pain. This past noncompliance occurred from January 1, 2026-January 2, 2026.The findings include:R1's admission Record dated January 7, 2026 shows that she was admitted to the facility on [DATE] with diagnoses including heart disease, long term use of anticoagulants, diabetes mellitus, major depressive disorder, anxiety disorder, morbid obesity, need for assistance with personal care, history of falling, and muscle wasting. R1's Care Plan initiated September 29, 2021 shows, The resident has potential/actual impairment to skin integrity related to fragile skin, long term use of anticoagulants, diabetes mellitus, major depressive disorder, impaired mobility, and weakness. R1's Care Plan revised on March 18, 2022 shows, The resident needs assistance/escort to activity functions.R1's Progress Notes dated January 1, 2026 shows, This nurse was called to the 400 hallway. [R1] was bleeding all over the floor and on her hand. Cleansed with normal saline and observed skin tear/laceration. Unable to approximate some edges with steri strips and some areas on the right hand were deeper than others. The laceration/skin tear goes from the middle finger at the knuckles all the way up in between 2nd and middle finger to her wrist. Resident transported to local emergency room via ambulance.R1's hospital records dated January 1, 2026 shows, Right hand with significant multilayer laceration exposing extensor tendons over the second metacarpal and phalange as well as the third metacarpal. Assessment and plan: Upon evaluation she had a pretty extensive deep laceration that measured proximately 12 cm X 6 cm. She was dressed with a nonstick dressing and put in a splint to promote adequate healing and to prevent disruption of the sutures to the back of her hand.R1's Progress Notes dated January 2, 2026 at 1:36 AM shows that R1 received 19 sutures and is on an antibiotic for infection prevention.R1's Progress Notes dated January 2, 2026 at 5:34 PM shows that R1 received a new order for narcotic pain medications due to right hand injury.R1's Progress Notes dated January 3, 2026 at 2:17 PM shows it was apparent during the breakfast meal that R1 needed increased assistance for meal and obtaining items that may or may not be too heavy. R1 voiced complaints of pain to her hand.R1's Progress Note dated January 4, 2026 at 2:50 AM shows R1 was three days post right hand injury. R1 was having a hard time with day-to-day function, including self-feeding.R1's Progress Note dated January 6, 2026 at 6:23 AM shows R1 has a right-hand laceration and is in pain frequently which is being controlled with scheduled pain medication.R1's Progress Note dated January 7, 2026 at 3:44 AM shows R1 was in pain and rating her pain at seven out of ten scale.The facility's Root Cause Analysis shows R1 received a laceration on top of her right hand when she became entangled in the food cart. R6 (who utilizes an electric wheelchair) went to help R1 by moving the food cart out of the way when he accidentally bumped his controller causing his wheelchair to move. R1's hand got caught under R6's wheelchair controller causing the laceration. On January 7, 2026 at 11:00 AM, R1 was in her recliner in her room. R1's right hand was covered in an ace bandage. R1 said she had pain to her right hand. R1 said that staff put her at the nurses' station and left her there. R1 said she was tired and decided to take herself back to her room when she became caught on a food tray. R1 said she cut her hand on the meal cart when she got tangled in it. R1 said she is having a hard time feeding herself now because she is right-handed. At 11:33 AM, R6 was sitting in a motorized wheelchair in his room. R6 said R1 got stuck in the metal tray cart and he did not want the metal tray cart to tip onto R1, so he tried to help R1 get unstuck. R6 said there was no staff in the hallway. R6 said he must have bumped the controller on his wheelchair and his chair moved and scratched R1's hand. R6 said he felt horrible it happened.On January 7, 2026 at 11:14 AM, V4 Licensed Practical Nurse (LPN) said R1 was pretty good with her activities of daily living prior to her injury to her hand. V4 said R1 now has difficulties with eating because she is right-handed. V4 said she had to write something down for R1 because R1 couldn't write since she is right-handed. V4 said R1 also experiences more pain than she did before.On January 7, 2026 at 1:07 PM, V2 Director of Nursing (DON) said she believed staff were in the process of picking up meal trays during the incident with R1's hand and R6. V2 said no staff saw that R1 was stuck in the tray cart. V2 said staff usually push R1 in her wheelchair back to her room after meals. V2 said staff placed R1 at the nurses' station and got called in a different direction. V2 said she expects staff to transport residents back to their rooms when they are done eating and their call lights are given to them.The facility's Accidents and Supervision policy dated 2025 shows, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. All staff are to be involved in observing and identifying potential hazards in the environment. The facility will provide adequate supervision to prevent accidents.Prior to the survey date of January 7, 2026, the facility had taken the following action to correct the noncompliance:On January 2, 2026, the facility held an emergency quality assurance performance meeting to discuss the facility's incident and accident policy and come up with a plan of correction.On January 2, 2026, R6's motorized wheelchair was evaluation for any safety concerns-none were found.On January 2, 2026, all food trays were evaluated with no concerns identified.R6 was re-evaluated for his motorized wheelchair safety.On January 2, 2026, all staff were in serviced on accidents/supervision and placement of meal carts.The administrator or designee will ensure the food tray cart is placed in the nutrition room to avoid further incidents.

Based on interview and record review, the facility failed to ensure a registered nurse was scheduled for eight consecutive hours a day, seven days each week. This failure has the potential to affect all residents in the facility. The findings include:The facility's CMS 671 form dated 12/16/25 showed 84 residents reside in the building. The facility's December 2025 nurse schedule was reviewed from 12/1/25 to 12/16/25. The working schedule showed no RN (Registered Nurse) coverage on 12/6 and 12/13. The facility was unable to provide documentation of an RN working either day. On 12/18 25 at 12:19 PM, V2 (Director of Nurses) said. We did not have RN coverage on those days. We need to have a RN here at least eight consecutive hours each day. We missed both of those Saturdays. The facility's undated Nursing Services and Sufficient Staff policy states: 8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

Based on interview and record review, the facility failed to post daily nursing staff information and failed to maintain a minimum of 18 months of the daily postings. This failure has the potential to affect all residents in the facility. The findings include: The facility's CMS 671 form dated 12/16/25 showed 84 residents reside in the building. On 12/18/25 at 10:20 AM, the facility's posted direct care staff daily report was dated 12/16/25. At 11:31, V8 (Regional Nurse Consultant) said there are no other daily reports after 7/31/25 (over four months). The prior director of nurses kept copies of the daily posted reports, but the current director of nurses does not. At 12:05 PM, V1 (Administrator) said it is important to post daily staffing numbers, so we know who is working and to ensure there is appropriate staffing for the day. The facility's undated Nursing Services and Sufficient Staff policy states: The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The personnel types showed licensed nurses and nurse aides.

Based on interview and record review the facility failed to offer snacks at bedtime. This failure has the potential to affect all residents in the facility. The findings include:The CMS 671 form dated 12/16/25 showed 84 residents residing in the facility. On 12/17/25 at 10:19 AM residents and the facility's ombudsman were present for a group meeting. Residents stated they don't get bedtime snacks unless they ask for one. Staff don't offer them or pass them out room to room. Residents stated bedtime snacks were offered in the past, but it was stopped because staff were sneaking them for themselves. Residents stated it stopped a long time ago. If we want a snack after dinner, we have to bring something back from lunch. Then keep it in our room until the evening time. The facility assessments were reviewed for the residents present at the group meeting. There was no resident with cognitive impairment. On 12/17/25 at 2:00 PM, V10 (Dietary Manager) stated kitchen staff take a snack cart down to the resident units each day. It gets placed in the nutrition room on the long-term care unit. The CNAs (Certified Nurse Aides) are responsible for passing the snacks, not the dietary staff. On 12/18/25 at 12:27 PM the nutrition room on the unit was noted to have a number coded locking system on it. Residents could not access the room to get a snack without staff assistance. On 12/18/25 at 12:30 PM, V2 (Director of Nurses) stated CNAs should be offering bedtime snacks during the water pass. It is important so residents have substance between the evening meal and the next morning meal. The facility's undated Offering/Serving Bedtime Snacks policy states: 1. The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preferences and request on a daily basis.

Based on observation, interview, and record review, the facility failed to ensure a resident's (R9, R24) wound care was performed to avoid cross contamination and the risk of wound infection; failed to ensure staff wore appropriate personal protective equipment for a resident on contact isolation (R68) and enhanced barrier precautions (R24, R50). This failure affects 4 of 4 residents reviewed for infection control in the sample size of 34.The findings include: 1.On 12/17/2025 at 09:56 AM, R9's wound care was performed by V4 (Wound Care Nurse) and observed by another surveyor. V4 indicated R9 admitted with wound to her sacrum and has a wound to the coccyx area that is newer and comes and goes. V4 applied wound cleanser to a gauze pad then proceeded to cleanse the sacral wound then the coccyx wound. V4 removed her gloves and performed hand hygiene. V4 applied a new pair of gloves, then proceeded to apply skin prep to the sacral wound then to the coccyx wound. V4 then applied a small piece of mesalt (sodium chloride debridement, dry absorbent wound dressing) to the sacral wound then to the coccyx wound. V4 applied a bordered foam dressing to R9's buttocks that covered both the sacral wound and the coccyx wound. When asked if R9's wounds are considered two separate wounds, V4 said, yes they are now. V4 added that R9's wounds are both measured and assessed separately but she does cleanse and treat both areas at the same time. On 12/18/2025, R9's medical records were reviewed with the following noted: R9's face sheet documented admission date of 12/06/2024 with a past medical history not limited to morbid obesity, type 2 diabetes mellitus, urinary tract infection and hypertension. Minimum Data Set Section M - Skin Conditions dated 09/22/2025 indicated R9 has one or more unhealed pressure ulcers/injuries that both require the application of ointments/medications and nonsurgical dressings. Review of R9's care plan on 12/18/2025 reads in part: resident has a history of requiring antibiotic therapy related to urinary tract infection (UTI) and wound infection last revised on 01/06/2025; has potential/actual impairment to skin integrity related to fragile skin, impaired mobility, type 2 diabetes mellitus, obesity, weakness, deconditioning. Resident has a stage four pressure wound to sacrum, and stage two pressure wound to coccyx last revised on 12/02/2025. R9's care plan interventions included but not limited to follow facility protocols for treatment of injury. Date Initiated 12/09/2024. R9's active orders as of 12/18/2025 showed treatments to cleanse coccyx with wound cleanser, apply skin prep to peri wound, apply mesalt sheet and cover with border foam once daily and as needed (PRN) if saturated, soiled, dislodged; cleanse sacrum cleanse with wound cleanser, apply skin prep to peri wound, apply mesalt sheet and cover with border foam once daily and PRN every day shift for wound care. Review of R9's December 2025 treatment administration record (TAR) showed individual treatment orders to sacrum and coccyx, both with start dates of 12/10/2025. R9's most recent wound evaluation and management summary dated 12/16/2025 reads in part: focused wound exam (site 1) indicated a stage four pressure wound to sacrum with wound size of 2.7 x 0.5 x 0.3 (cm) centimeters (length x width x depth) and focused wound exam (site 8) stage three pressure wound to coccyx with wound size of 0.9 x 0.4 x 0.2 cm (length x width x depth). On 12/18/2025 at 08:40 AM, V3 (Assistant Director of Nursing & Infection Preventionist) said when providing wound care to a resident with multiple wounds, each wound should be cleansed, treated and covered individually, starting with the cleanest to the dirtiest wound to avoid cross contamination and prevent infection. Undated Wound Treatment Management Policy reads in part; to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. The facility will follow specific physician orders for providing wound care. **On 12/18/2025, healthcare worker background check was conducted, and it was noted that V4 (Wound Nurse) did not have a current nursing license. Look up detail view provided by facility and dated 12/18/2025 08:57 AM showed V4's license status as not renewed. First effective date showed 06/08/2024 with expiration date pf 02/28/2025. (See citation 300.661) ** 2. On 12/18/2025 at 10:47 AM, V13 LPN gathered the supplies to perform R24s wound dressing changes. He entered the room, donned gloves, no gown, and moved R24s catheter bag to the opposite side of the bed. He removed the blankets and then removed the soiled dressing from R24s left leg. Without changing gloves, he cleansed the wound and applied skin prep to the skin surrounding the wound. V13 then applied her treatment and covered the wound with a new bandage. He did not change his gloves at any time during the treatment. V13 removed his gloves and gathered supplies for R24s next dressing. He stated he made a mistake and should have had a gown on during the dressing change. He put on a gown and gloves for her next wound care treatment. After rolling R24 onto her left side, he removed the dressing from the right upper back. The dressing had dark tan drainage. Without changing gloves, he cleansed the wound and applied skin prep to the wound edges. R24 needed repositioning and he moved her legs and rolled her back over before removing his soiled gloves. With clean gloves, V13 removed the packing from a wound on R24s lower buttocks, and without changing gloves he cleansed the wound and applies skin prep around the wound bed. He opened packages and used his scissors with the same soiled gloves and re-packed the wound before removing his gloves. V13 said he thought he only had to change his gloves between wounds. The facility's undated policy for Personal Protective Equipment documents this facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitor, and other staff. Definitions: Personal Protective Equipment (PPE) refers to a variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. It includes gloves, gowns, face protection (facemasks, goggles, and face shields), and respiratory protection. Gloves: iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. B. Gowns. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. 3. On 12/17/2025 at 8:46 AM, V4 Wound Nurse put on gloves, went into R50's room, provided a dressing change and treatment to his diabetic foot ulcer. V4 was not wearing a gown. After the dressing change was completed, V4 stated R50 was on enhanced barrier precautions – EBP and she should have worn a gown. The EBP sign on R50's door showed, enhanced barrier precautions; everyone must: wear gown and gloves for the following high contact care activities - dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. On 12/17/25 at 1:45 PM, V2 Director of Nursing stated enhanced barrier precautions are followed whenever care is given. Gowns and gloves should be worn to stop the transmission of everything. The Face Sheet dated 12/17/25 for R50 showed diagnoses including type 2 diabetes mellitus with foot ulcer, hypertension, benign prostatic hyperplasia, obstructive sleep apnea, adjustment disorder with mixed anxiety, and vascular dementia. The Physician Order Summary Report dated 12/17/25 for R50 showed an order dated 5/1/25 for enhanced barrier precautions. The Care Plan dated 9/16/25 for R50 showed resident is on enhanced barrier precautions related to skin integrity issues. PPE is for enhanced barrier precaution-only necessary when performing contact care activities. The facility's Enhanced Barrier precautions policy (2025) showed, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. High-contact resident care activities include h. Wound care: any skin opening requiring a dressing 4. R68's face sheet dated 12/18/25 showed diagnosis including but not limited to diabetes mellitus foot ulcers, absence of left leg below the knee amputation, chronic ulcer of right foot and ankle, and peripheral vascular disease. R68's December 2025 physician order report showed an order start dated 12/15/25 for contact isolation every shift for ESBL (extended-spectrum beta-lactamases) infection in the right lower extremity wound. On 12/16/25 at 9:45 AM, a yellow sign was posted on the door of R68's room. The sign stated, STOP contact precautions. The sign showed gloves and gowns required before room entry. At 9:50 AM, V9 (CNA) entered the room and dropped off bed sheets inside. V9 was not wearing a gown or gloves. At 2:24 PM, V11 (Social Services) stated gowns and gloves are not necessary unless direct resident care is being provided. At 2:31 PM, R68 was seated in a recliner in his room. R68's right lower leg was wrapped in a white gauze dressing. The dressing did not cover his toes. R68's second toe was visible and had bright red blood fully exposed. At 2:34 PM, V9 (CNA) was observed entering R68's room a second time and not wearing a gown or gloves. At 2:39 PM, V12 (Licensed Practical Nurse) said gowns and gloves are needed regardless if care is being done or not. On 12/17/25 at 2:25 PM V3 (Infection Control Preventionist) stated R68 is on contact isolation because of the infection in his right leg wound. Staff need to wear gowns and gloves before entering the room, just like the sign shows. Proper PPE is needed to keep germs off the staff and reduces the potential for them carrying it to another resident. All staff are educated, including non-nursing personnel like housekeeping, social services, and dietary, about correct PPE use in isolation rooms. The facility's undated Transmission-Based (Isolation) Precautions policy states under the contact precautions section: c. Healthcare personnel caring for resident on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. The policy states: f. Contact precautions will be used .when a resident has wounds, secretions, or excretions that are unable to be covered or contained.

Based on observation, interview, and record review, the facility failed to ensure a female resident (R29) was properly groomed by not removing facial hair from her chin area. This failure affects 1 of 3 residents reviewed for activities of daily living (ADL's) in the sample size of 34.The findings include:On 12/16/2025 at 09:51 AM, R29 was observed in her room in a wheelchair next to bed. Resident was dressed appropriately and appeared clean with course facial hair visible to chin area that was approximately 1-2 inches in length. At 01:10 PM, R9 was observed on the 300 hall and remained unshaved.On 12/17/2025 at 10:03 AM, R29 was observed in her wheelchair near the 300 unit nurse's station. Resident was dressed appropriately and appeared clean with course facial hair visible to chin area that was approximately 1-2 inches in length. At 12:30 PM, R9 was observed in the dining room near the 300 unit and remained unshaved. On 12/17/2025, R29's medical records were reviewed with the following noted:R29's face sheet documented admission date of 01/16/2023 with a past medical history not limited to osteoarthritis, muscle weakness, lack of coordination and hypertension.Minimum Data Set (MDS) Section GG - Functional Abilities dated 11/25/2025 indicated that R29 is dependent on staff to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands.R9's care plan last completed on 11/26/2025 reads in part: resident has an ADL self-care performance deficit related to impaired balance.currently in restorative programming for dressing and grooming and bed mobility. Date initiated 01/18/2023. Last revision on 06/09/2025.Care plan interventions include but not limited to, bathing/showering: R9 requires limited to extensive assistance by one staff with bathing/showering routinely, and as necessary. Date initiated 07/27/2023.Review of progress notes for last 30 days showed no refusal of care notes documented.On 12/18/2025 at 08:40 AM, V3 (Assistant Director of Nursing & Infection Preventionist) said most residents are showered twice weekly, sometimes if requested. V3 added that residents are typically groomed/shaved on their shower days by the aides (provide most of grooming) but should be offered anytime its needed. V3 then said female residents should not have facial/chin hair and if care/grooming/shaving is refused, it should it be charted.Facility provided R29's shower sheets for the last three months on 12/18/2025 that showed resident shower days are on Wednesdays and Sundays and staff are to indicate whether facial hair was removed on the shower sheet. Five shower sheets were received dated 12/03/2025, 11/12/2025, 11/09/2025, 11/02/2025, and 10/26/2025 that showed R29 was not shaved on 11/09/26 and 10/26. No shower sheets were received for R29's scheduled shower days on 12/07, 12/10, 12/14 or 12/17. Undated Grooming a Resident's Facial Hair policy reads in part, it is the practice of this facility to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice.

Based on observation, interview and record review the facility failed to have weekly measurements and complete assessments of a resident's diabetic ulcer for 1 of 4 residents (R50) reviewed for wounds in the sample of 34.The findings include: On 12/17/25 at 8:46 AM, R50 was sitting in a chair in his room for wound care to his right foot. V4 Wound Care Nurse removed the dressing to the bottom of R50's foot. R50 had a large, round, dark colored area to the ball of his foot, below his right big toe. The edges of the wound were raised. V4 stated R50 is supposed to have surgery to remove a bone in his foot that is pushing downward. V4 stated the wound was a diabetic ulcer. V4 stated R50 goes out to the podiatrist for wound care. V4 stated she did not have any wound notes/assessments for R50 and if there are any from the podiatrist V3 Assistant Director of Nursing - ADON would know where the notes are located. On 12/17/2025 at 9:55 AM, V3 ADON stated the wound documentation for R50 should be scanned into miscellaneous in the electronic medical record. V3 stated staff should be monitoring the wound; there should be documentation. V3 has a diabetic ulcer and that is to be monitored weekly with the wound observation tool. V3 stated it was probably a mistake that there wasn't any documentation of the assessment and monitoring of the ulcer and there should be documentation. V3 stated she would contact the podiatrist for the assessments of R50's ulcer. The facility Weekly Skin Assessments dated 9/15/25, 9/22/25, 9/29/25, 10/6/25, 10/13/25, 10/20/25, 10/27/25, 11/3/25, 11/10/25, 11/17/25. 11/24/25, 12/1/25, 12/8/25, and 12/15/25 showed R50 is being followed by the doctor for a diabetic wound to the right plantar foot, treatment order in place. The assessment does not include the measurement or description of the wound.On 12/17/2025 at 11:17 AM, V3 ADON brought in notes for R50 from the podiatrist and stated the notes are dated 11/6/25; they are the last notes that they received. V3 stated it is a diabetic ulcer. V3 stated the doctor did measurements and showed them and description of the area on the resident foot. V3 stated that the facility should be doing that as well and doesn't know why it isn't being done.The Podiatrist note dated 11/6/25 that was sent to the facility on [DATE] showed, R50 presented to the doctor's office for evaluation of a foot ulcer. R50 has an ulcer and callus on the bottom of his foot due to the deformity on his right side, where the big toe goes up and the first metatarsal goes down, causing pressure on sesamoid bone. Assessment: diabetic neuropathic ulcer. The note showed a full thickness wound that measured post debridement of nonviable skin slough as 3/5 cm x 4 cm x 0.2 cm. The Face Sheet dated 12/17/25 for R50 showed diagnoses including type 2 diabetes mellitus with foot ulcer, hypertension, benign prostatic hyperplasia, obstructive sleep apnea, adjustment disorder with mixed anxiety, and vascular dementia. The Physician Orders for R50 showed an order dated 11/3/25 to apply betadine to the right plantar foot and cover with gauze daily and as needed. On 8/6/25 an order was placed for a post-op to shoe to be worn when in chair and ambulating as tolerated by resident. The Care Plan dated 11/24/25 for R50 showed the resident has potential/actual impairment to skin integrity related to cellulitis, type 2 diabetes mellitus. Resident has a diabetic wound to right plantar foot. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc. to doctor. Post op shoe per physician order as tolerated by resident. The Minimum Data Set- MDS dated [DATE] for R50 showed moderate cognitive impairment. The facility's Wound Treatment Management policy (2025) showed, the effectiveness of treatments will be monitored through ongoing assessment of wound. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. Characteristics of wound: Pressure injury stage (or level of tissue destruction if not pressure injury). Size - including shape, depth, and presence of tunneling and/or undermining. Volume and characteristics of exudate. Presence of pain. Presence of infection or need to address bacterial bioburden. Condition of tissue in the wound bed. Condition of the peri-wound skin. Location of wound. Treatment decisions will be based on etiology of wound.

Based on observation, interview, and record review, the facility failed to effectively implement a fall intervention and provide a safe mechanical lift transfer for 1 of 5 residents (R13) reviewed for safety in the sample of 34.The findings include: On 12/17/2025 8:37 AM, R13 was sitting at the dining room at table eating breakfast. R13 was dressed and had slipper socks on that were worn on the bottom and the heels appeared to have holes. R13 was sitting forward in her chair and her butt wasn't at the back of her chair. At 8:44 AM, V6 Certified Nursing Assistant - CNA told R13 to scoot back in her chair, that she is too far forward, and can fit her arm behind her. V6 stated R13 can stand and walk but refuses too. V6 stated R13 got mad about something last week and stood up on her own. V6 stated they used to transfer her with a stand lift, and she would raise her arms up. V6 stated it was dangerous, so they use the full mechanical lift to transfer R13. On 12/17/2025 at 9:17 AM the surveyor had V6 check R13's slipper socks. V6 stated the socks used to have grips on the bottom but they were worn off and should probably have different ones on. V6 stated it would be safer for R13 to have socks on with grips. V6 removed R13's slipper socks and they were worn on the bottom with holes forming and very few grip dots left. The Fall Risk assessment dated [DATE] for R13 showed a score of 15 - high risk for falls. On 12/17/25 at 1:45 PM, V2 Director of Nursing - DON stated for fall prevention residents have an assessment completed. The assessment gives a fall risk which determines the resident's location in the building and interventions that need to be put in place. If a resident has a score over 10, that puts them at high risk for falls. V2 stated interventions that are specific to the resident are put in place and are on the care plan. V2 stated the resident's care plan should be followed. The Care Plan dated 12/17/25 for R13 showed, the resident is at risk for falls related to deconditioning, and dementia. Nonslip footwear to be worn as tolerated as residents allows. Follow facility fall protocol. On 12/18/25 the facility did not have a fall prevention policy. The facility had an Incidents and Accidents policy for after an incident has occurred that V1 Administrator submitted as the facility fall protocol. On 12/17/2025 9:27 AM, V5 CNA and V7 CNA took R13 to her room to provide incontinence care. R13 was sitting in her wheelchair and had a mechanical lift sling under her. V5 and V7 attached the sling to the mechanical lift. V7 went into R13's bathroom. V5 transferred R13 from her chair to her bed without any assistance. After the transfer, R7 came out of the bathroom with wet washcloths and a towel for incontinence care. V5 stated it is the policy to have two people transfer a resident with the mechanical lift. V5 stated they use two people for safety. V5 stated she transferred R13 with the lift when V7 was in the bathroom, and she probably shouldn't have done that. On 12/17/2025 at 1:45 PM, V2 DON stated the mechanical lift policy is to have two people for the transfer with the lift for safety. One person to maneuver the lift and the other person to watch the resident and guide them. The Face Sheet dated12/17/25 for R13 showed diagnoses including dementia, lack of coordination, Alzheimer's disease, depression. Anxiety disorder, hyperlipidemia, hypertension, hypothyroidism, and sepsis. The Minimum Data Set, dated [DATE] for R13 showed severe cognitive impairment; substantial/maximal assistance for rolling in bed; dependent for transfers. The Care Plan dated 12/17/25 for R13 showed, R13 has an activity of daily living-ADL self-care performance deficit related to dementia. R13 is a 1-2 assist with ADL's. Transfer: The resident requires assistance by 2 staff to move between surfaces. R13 uses a mechanical lift for transfers. The facility Safe Resident Handling/Transfers policy (2025) showed 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 guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the 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 a safer alternative and should be used. Two staff members must be utilized when transferring residents with a mechanical lift.

Based on interview, and record review the facility failed to ensure a resident (R1) was not sexually abused by another resident (R2) for 1 of 3 residents reviewed for sexual abuse in the sample of 5.This failure resulted in an Immediate Jeopardy.The Immediate Jeopardy began on 11/19/25 when facility staff failed to ensure R2 did not enter R1's room and have sexual activity with R1. Both R1 and R2 have cognitive impairment and lack the ability to consent for sexual activity. V1 Administrator was notified of the Immediate Jeopardy on 12/3/25 at 8:15 AM. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on 12/3/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.The findings include:The Face Sheet dated 11/27/25 for R1 showed diagnoses including dementia, sleep disorder, general anxiety disorder, emphysema, chronic obstructive pulmonary disease, trigeminal neuralgia, hypertension, hyperlipidemia, osteoporosis, and urinary tract infection.The Nurse Practitioner (NP) note dated 11/11/25 for R1 showed she was being seen for a scheduled psychiatric follow up. R1 demonstrated behaviors consistent with her ongoing neurocognitive decline but was attentive and responded appropriately to all inquiries. Alerted and oriented X1 (person). Recent and remote memory: poor. Attention span and concentration: poor.The Minimum Data Set - MDS dated [DATE] for R1 showed severe cognitive impairment.On 11/27/25 at 9:09 AM, V1 Administrator stated R1 and R2 are two residents that are close. They were in R1's room together. V9 CNA (Certified Nursing Assistant) walked into R1's room and R1 and R2 were naked. R2 was standing over R1with his right hand on the wall and left hand under R1's shoulder. R1 was leaning back. V9 stated she saw R2's buttocks and asked them what they were doing. V9 told R2 to leave the room. V1 stated V9 got V8 the nurse. V1 stated V10 (R1's daughter) was notified when this happened. V1 stated this incident occurred on 11/19/25 and was not reported to the state. V1 stated she did an investigation and since no intercourse happened, she did not report it. V1 stated she asked V9 if R2 had an erection when he turned around and she said he didn't. They were not on top of each other. V1 stated there wasn't any sexual act going on; they were just naked. V1 stated she did an abuse investigation and did not report it because no sexual intercourse happened.On 11/27/25 at 10:10 AM, V1 stated V8 Licensed Practical Nurse - LPN called her the night it happened and V1 directed her to interview R1 and do a skin check. V1 stated it is not documented in R1's chart and she does not know why it wasn't. V1 stated she did not know why V8 did not do a risk assessment and put it into the chart. V1 stated normally a risk assessment is done and entered in the resident's chart so they have all the details. V1 stated it should be documented in the chart that the family was notified. V1 stated she notified R1's family on 11/19/25 so the lack of documentation is on her for that.On 12/1/25 at 9:14 AM, V10 (R1's daughter/Power of Attorney - POA) stated I was called on Wednesday (11/19/25) night when she was sleeping. V10 stated she talked to V1 Administrator Thursday (11/20/25). V1 at first said that there was sexual contact with R2 and R1. V1 said she still needed to talk to the CNA to get more information and then would talk to V10. V1 called V10 back and said both were naked. R1 was sitting on the bed in front of R2 giving him oral sex. R2 wasn't erect but R1 was performing oral sex. V1 had told V11 (R1's son) when she talked to him that R1 was laying down and R2 was leaning over her; R1 was giving R2 oral sex, so the story had changed. V10 stated that bothered them. V10 stated V2 Director of Nursing - DON called and said she would like to get consent for medication for R1 in case she had any anxiety. V10 stated if they need permission for R1 to have the medication, have V10 present to read to R1 what she is signing, and go over the papers, then why do they think R1 can consent to this? V10 stated she did not think R1 has the ability to consent. V10 stated when she went to the facility for a meeting on Tuesday (11/25/25) she was told R2 was leaning over R1, he had her head in his hand and was holding her head there. V10 stated there were so many different stories. V10 stated on Saturday (11/29/25) when she went to see her, R1 told her that R2 raped her. V10 stated she told the facility what R1 said; she told the facility that R1 said R2 raped her. V10 stated R1 doesn't remember exactly what happened but said he raped her. V10 said she dislikes R2 and doesn't have anything good to say about him. V10 stated she did a video/audio recording on her phone of R1 telling her she was raped. On 12/1/25 at 11:14 AM, V10 and R1 were sitting in chairs in the dining room with the door closed and no other residents or staff present for the interview. R1 identified the person at the table with her as V10 her daughter. R1 was asked if anyone there had made any sexual advances and /or touched her in a sexual way. R1 stated, he raped me. R1 stated she couldn't think of the man's name. R1 stated she was watching TV; the man came into her room and raped her. R1 stated the man got down next to her and was playing with her; he wasn't there long. R1 stated she told her boyfriend what happened because she was crying, and her boyfriend got mad. R1 was asked if the man was R2 or R3. R1 stated R2 was the one that raped her, and she was called into an office and questioned about it. R1 stated R2 had forced her to have oral sex, and she did not want to, but she didn't have a choice. R1 stated R3 is her boyfriend, and they are getting married. R1 stated she has been with R3 for a long time and has not had sex with him. V10 played a recording on her phone of R1 that was done on 11/28/25 at 3:47 PM and in the video R1 stated she was raped. R1 confirmed that R2 was the man's name and stated, I never want to see that bastard again. On 12/1/25 at 11:38 AM, R2 was sitting in a wheelchair in his room and was interviewed at that time. R2 stated his daughter put him in this place. R2 stated he is not in a relationship with anyone here. R2 stated he knew of R1 but did not really know her. R2 stated he went into R1's room one time. R2 stated he did not know what happened when he went into R1's room. R2 denied having sex with R1. R2 denied having his clothes off in R1's room. R2 stated he was in a room at the end of the hall, and they moved him to this room. R2 stated R1's room is somewhere down there (down the hall). On 12/1/25 at 11:49 AM, R1 and R3 were in the dining room sitting at a table together. R3 was facing across from R1 and they were talking. R2 entered the dining room and R1 looked at him and told him to leave. R1 and R3 were asked who R2 was and R3 stated he (R2) used to be his friend but wasn't anymore. R3 said R1 told him that R2 raped her, and she could not get up. R3 stated he felt so bad that it happened. R3 stated he did not have any part in what R2 was doing and wouldn't do something like that. R3 stated he was beyond mad at what happened and felt bad because there was nothing, he could do to protect R1. R3 stated he has never done anything like that in his life and doesn't know what R2 was thinking. R3 stated they stay away from R2 the best that they can. On 12/1/25 at 12:45 PM, V9 CNA stated on 11/19/25 at around 8:30 PM she went to R1's room, knocked on her door, and was told to wait a minute. V9 stated she entered the room and saw R2 naked with his buttocks facing her and he was thrusting. V9 stated R1 was laying at an angle with her back/torso area on the bed and her bottom half was half on and half off the bed. R2 had his right hand on the wall and his left hand on R1's shoulder. R2 was leaning in on R1 and was thrusting. V9 stated she couldn't really see R2's penis because it was dark and due to his body shape, she said she couldn't tell if he had an erection or not. V9 stated she couldn't tell if he was in R1's vagina or not and stated R1 and R2 were skin to skin, and he was thrusting. V9 stated when she told R2 to stop it seemed like he did not want to and wanted her to wait until he was finished. V9 stated she separated R1 and R2 and got the nurse right away. V9 stated V8 Licensed Practical Nurse - LPN contacted V1 Administrator and assessed R1. V9 stated she talked to V1 also. V9 stated R1 seemed like she was fine that evening and did not appear distraught. V9 tried to clean R1 up and R1 was giving her a hard time. V9 said, It was a big protest to get her (R1) dressed. V9 stated R1 acts like that at times normally. V9 stated R1 is confused and has a false reality. R1 thinks she has 8 kids at home that she must take care of and talks about seeing her mother. V9 stated what happened was serious in nature so it had to be reported. V9 stated she was in shock and was not aware of anything like this happening before and she has worked at the facility a total of four years; 2 years in housekeeping and 2 years as a CNA. V9 stated in her opinion she thought this was sexual abuse. V9 stated R2 seems more consciously aware of what he is doing more than R1 does. V9 CNA stated there are 2 CNAs from 6 PM to 10 PM and then she is working alone on the unit. V9 stated if she is in a resident room providing care such as incontinence care she could be in a room for 20 - 30 minutes so there is no one to check/monitor the other residents. V9 stated there needs to be 2 aides on the unit so one can do rounds, and the other one can check and monitor residents. On 12/1/25 at 1:18 PM, V3 Assistant Director of Nursing - ADON stated she was left out of the November 2025 incident between R1 and R2. V3 stated a night shift CNA, and the nurse spoke with V1 about the instance of R2 going into R1's room. V3 stated she has heard a couple of different stories about what happened. V3 stated the next day R1 told V15 CNA that she was raped; and V15 told V13 LPN who then reported it to V2 Director of Nursing and V1 Administrator. V1 went down immediately to talk to R1 and V19 regional Corporate Nurse did some questioning. V3 looked in her phone and stated it was on 11/21/25 that the rape was reported. V3 stated V20 Psychiatrist does not come into the facility; V14 Psychiatric Nurse Practitioner is the one that currently comes in. On 12/1/25 at 1:44 PM, V13 LPN stated she was doing morning medication pass on the dementia unit and V15 CNA told her that R1 went into R3's room and told him she was raped by R2. V13 stated she told V15 to tell V1 Administrator now. V15 came back and said she wasn't able to talk to V1 because she was in a meeting. V13 stated she went herself first to V2 DON who asked why she was she reporting this to her (V2) and to go and report it to V1. V13 stated she was going to go to V1's office when V1 walked by so she told V1 and V1 went to the unit to talk to R1. R1 and R2 are confused but R2 is more with it than R1 who is confused and forgetful. V13 stated she doubted that R1 had the ability to consent to sex. They have to call V10 for everything; R1 is not quite with it. On 12/1/25 at 1:59 PM, V14 Psychiatric Nurse Practitioner - NP stated she sees R1 for psychiatric services and R1 has dementia with moments of clarity, but it depends on the day. Some days R1 is more alert than others; there are moments when she is confused and moments when she is with it. V14 stated there is no way to tell if R1 can or can't consent but what she could say is when she has seen R1 she is alert and oriented x 1 (to herself). On 12/1/25 at 2:09 PM, V15 CNA/Activities stated R1 and R3 were walking in the hall and R3 told me that I V15) needed to talk to R1. V15 stated she talked to R1 and R1 said she was raped, R1 did not know his name, and pointed R2 out. V15 stated she reported it to V13 LPN who then reported it to V1. V15 stated V1 talked to them. On 12/1/25 at 4:00 PM V4 Medical Director stated, R1 is on a memory care unit for a reason. R1 cannot consent for herself. R1 and R2 are both in the memory care unit. V4 stated they are not capable of making sound decisions. V4 stated he was notified that there may have been a sexual encounter between R1 and R2. The residents were separated. V4 stated that later R1 accused the other resident of rape. V4 stated he doesn't know if a rape occurred. V4 stated the facility's policies and procedures should be followed. V4 stated what happened should be recorded/documented. V4 stated R1 was not sent out for examination because it probably was not wanted by the family. On 12/2/25 at 7:29 AM, V23 Sexual Assault Nurse Examiner stated R1 was seen at the hospital on [DATE] and V10 stated the state was looking into a sexual assault for R1. V23 stated she was just checking so she did not make a duplicate report. V23 stated V10 told her that this was reported at the facility right away, but nothing was done until they were told they had options. V23 stated it was two weeks past when this happened, so there won't be any evidence left but swabs were completed. V23 stated there wasn't any visible signs of trauma and no discharge was present, but it was hard to tell if anything happened because 2 weeks have elapsed since it happened. V23 stated R1 told her she was watching TV; a guy came into her room looking for her fiance and raped her. V23 stated V10 was there and said R1 was forced to have oral sex so there were two different stories about what happened. V23 stated R1's clothes could not be collected for any evidence because they did not know what she had been wearing, and her clothes have been washed. V23 stated she documented everything in the hospital record. On 12/2/25 at 10:08 AM V8 LPN stated she did not remember the day the incident happened between R1 and R2. V8 stated the CNA told her she knocked on R1's door, went into the room, and R2 was on top of R1 having sex. V8 stated when she went to R1's room they were no longer having sex. V8 stated she texted V2 DON who told her to contact V1 Administrator who told her to put 15-minute checks in place, make sure room doors were open, and have the aide sit outside of R2's room door. V8 stated she assessed R1 and did not find anything. R1 at first stated she didn't remember what happened then R1 told her she did want sex and wasn't forced. V8 stated R2 would not allow her to assess him. V8 stated she was told not to document anything or notify the families because V1 stated she would do that. V8 stated she knows things have happened in the past, her coworkers have charted them and then the charting disappears, and she doesn't know how that can happen. V8 stated in her opinion R1 and R2 can't consent to sex. V8 stated she reported what happened because she felt it was sexual abuse and is required to report it. V8 stated they put the 15-minute checks in place but there is only one aide and when that aide is providing care there is no way for her to monitor the other residents and do checks and complete her work. V8 stated there needs to be two aides on the hall at all times to watch everyone. The MDS dated [DATE] for R2 showed moderate cognitive impairment.The Face Sheet dated 11/27/25 for R2 showed diagnoses including dementia, adjustment disorder with mixed anxiety and depressed mood, type 2 diabetes mellitus, and hypertension.The Nurse Practitioner Note dated 11/25/25 for R2 showed he is alert and oriented x 2; he is able to explain why he is here and what his current health status is like. R2's recent and remote memory: fair. Attention span and concentration: fair.The facility's Abuse, Neglect, and Exploitation policy (2025) showed sexual abuse is non-consensual sexual contact of any type with a resident. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.The Immediate Jeopardy that began on 11/19/25, was removed on 12/3/25 when the facility took the following actions to remove the immediacy: Facility actions to remove immediacy include:1) Identification of Residents Affected or Likely to be Affected:R1 and R2 were immediately assessed for injury, changes in condition and psychosocial impact. R1 and R2 POAs, Police and MD were notified of the incident. R1 was sent to the ER (emergency room) for evaluation. R1 and R2 care plans were updated to reflect enhanced safety interventions. R1 and R2 had the Abuse, Neglect and Trauma assessment and Trauma Informed Care Assessment / PTSD was completed. The Social Services Director interviewed/assessed all residents with BIMS (brief interview mental status) scores of 8 and above for potential abuse. All residents with a BIMs score of 7 or less, will be assessed using the Abuse Screening Adapted for Cognitive Impairment form. Concerns were not identified during the interviews. The following actions were taken to prevent Sexual Abuse in the Memory Care Unit.A hall monitor was added to the memory care unit to ensure no resident enters another resident's room on 12/2/2025 to ensure the safety of all residents. The Hall Monitor is a dedicated staff member and will have no other duties.R2 was immediately placed on a 1:1 until hall monitor was established on 12/2/2025.2) Actions to Prevent Occurrence/Recurrence:Abuse investigation procedure and documentation process were reviewed.DON, ADON, and Administrator re-educated all staff on facility abuse policies.DON, ADON, and Administrator educated all staff on the Intimate Resident Behavior, Privacy and Relationships policy updated on 12/2/2025 to reflect residents within the memory care unit do not have the capacity to consent to sexual relationships.In the event of any future resident to resident sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.DON, ADON, and Administrator educated staff on the Hall Monitor duties and responsibilities and that the Hall Monitor is a dedicated individual with no other responsibilities.Administrator was educated by Regional Nurse on abuse policy which includes thorough investigation immediately upon receiving report or allegation of abuse.3) Quality Assurance Plans to monitor facility performance to ensure that corrective actions are achieved and are permanent:Emergency QAPI meeting was held on 12/1/2025 where the abuse policy and intimate relations policy were reviewed along with incident and root cause analysis.The Social Services Director or designee will continue to interview residents with BIMs score of 8 or higher on a monthly basis to ensure they have not experienced abuse. All residents with a BIMs score of 7 or less, will be assessed using the Abuse Screening Adapted for Cognitive Impairment form.Any reports of abuse will be immediately reported and investigated. The finding to be presented to the Quarterly QAA Committee.Date Facility Asserts Likelihood for Serious Harm No Longer Exists: December 3, 2025.

Based on interview and record review the facility failed to investigate an allegation of abuse in June 2025 for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:The Social Service Note dated 6/9/25 at 4:08 PM for R1 showed, this writer was informed by CNA that resident was interested romantically in another resident in the memory care unit. This writer spoke with both R1 and the other resident (R3) and educated them to utilize public spaces to spend time together. This writer asked them not to spend any time together in each other's rooms. R1 and peer both agreed and stated they want to take it slow. Medical Director in facility and notified. No new orders. Voicemail left for V10 to notify. Requested call back.On 12/1/25 at 9:14 AM, V10 (R1's daughter/power of attorney - POA) stated there was an incident in June 2025 with R1 and R3 but there wasn't any documentation about what happened. V10 stated she found out recently from a CNA that R1 was in R3's bed and R3 had his pants down. V10 stated they were split up before anything happened.On 12/1/25 at 1:18 PM, V3 Assistant Director of Nursing -ADON stated the only thing she knew about the incident in June 2025 between R1 and R3 is that there was an episode reported by V15 CNA. V3 stated V16 previous Social Services and V17 previous Administrator handled the situation. V3 stated she heard R1 and R3 were found in bed together naked. V3 stated V18 LPN was the nurse for the June incident. V3 stated she assumed the incident was reported because with the BIMS (Brief Interview of Mental Status) that the residents involved have, they cannot consent to sex. V3 stated she does not know why it was not reported.On 12/1/25 at 2:58 PM, V16 previous Social Services stated she no longer works at the facility and doesn't remember much without her notes in front of her. V16 stated R1 and R3 were on a memory care unit, and they were close friends. V16 stated R1 and R3 wanted to be boyfriend and girlfriend. V16 stated she spoke to V22 (R3's POA). V16 could not remember if she spoke to V10 (R1's POA) or left a message for her. V16 stated she was not aware of anything else between R1 and R3. V16 stated she was not aware of R1 and R3 being in each other's room, being in each other's beds, or being naked together.On 12/1/25 at 4:00 PM, V4 Medical Director stated R1 is on a memory care unit for a reason. R1 cannot consent for herself. V4 stated the facility's policies and procedures should be followed.On 12/3/25 at 8:15 AM, V1 Administrator stated, V1 stated she does not know anything about what happened in June 2025 between R1 and R3. V1 stated she was not at this facility at that time. V17 was the Administrator, and she is no longer with the company. V1 stated there isn't an investigation for anything in June and there is no abuse investigation in the last six months except now they have one for R1 and R2 because of what happened recently.On 12/3/25 at 8:26 AM, V12 Certified Nursing Assistant - CNA stated in June she was working on the memory care unit and went to do her rounds. V12 went past R3's room and his door was shut, so she knocked on the door, and went into the room. V12 stated R3's bed was the farthest bed and the curtain was drawn. V12 stated she was going to leave but she saw R1's walker in the room. V12 stated R3 was standing up next to the bed, had a white t-shirt on and underwear. R1 was laying on R3's bed but had her clothes on. V12 stated she escorted R1 out of the room and then reported it to the nurse. V12 stated she told the nurse.On 12/3/25 at 8:47 AM, V18 Licensed Practical Nurse - LPN stated on a day at the beginning of June around 5:00 PM a CNA came and told her that R1 and R3 were in bed together but had their clothes on. The CNA said she separated them and then came to get her. V18 stated she reported it to V17 previous Administrator who told her not to put anything in the notes in the resident's charts. V17 told her that V16 previous Social Services would take care of it. V12 stated she thought the nurse contacted the Administrator at the time. V12 stated no one from management talked to her about what happened. V12 stated she was taught that anything like this has to be reported immediately so she reported it.On 11/27/25 the facility did not have any Abuse Investigations in the last 6 months.The Face Sheet dated 11/27/25 for R1 showed diagnoses including dementia, sleep disorder, general anxiety disorder, emphysema, chronic obstructive pulmonary disease, trigeminal neuralgia, hypertension, hyperlipidemia, osteoporosis, and urinary tract infection.The Nurse Practitioner note dated 11/11/25 for R1 showed she was being see for a scheduled psychiatric follow up. R1 demonstrated behaviors consistent with her ongoing neurocognitive decline but was attentive and responded appropriately to all inquiries. Alerted and oriented X1 (person). Recent and remote memory: poor. Attention span and concentration: poor.The Minimum Data Set - MDS dated [DATE] for R1 showed severe cognitive impairment.The Face Sheet dated 11/27/25 for R3 showed diagnoses including dementia without behavioral disturbance, hypertension, morbid obesity, hypokalemia, adjustment disorder, and anxiety disorder.The MDS dated [DATE] for R3 showed moderate cognitive impairment.The facility's Abuse, Neglect, and Exploitation policy (2025) showed, an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of allegations; Provide complete and thorough documentation of the investigation.

Based on interview and record review the facility failed to ensure resident medical records contained complete and accurate information for 1 of 3 residents (R1) reviewed for medical records in the sample of 5.The findings include: The Social Service Note dated 6/9/25 at 4:08 PM for R1 showed, this writer was informed by CNA that resident was interested romantically in another resident in the memory care unit. This writer spoke with both R1 and the other resident (R3) and educated them to utilize public spaces to spend time together. This writer asked them not to spend any time together in each other's rooms. R1 and peer both agreed and stated they want to take it slow. Medical Director in facility and notified. No new orders. Voicemail left for V10 to notify. Requested call back.On 12/1/25 at 9:14 AM, V10 (R1's daughter/power of attorney - POA) stated there was an incident in June 2025 with R1 and R3 but there wasn't any documentation about what happened. V10 stated she found out recently from a CNA that R1 was in R3's bed and R3 had his pants down. V10 stated they were split up before anything happened.On 12/1/25 at 1:18 PM, V3 Assistant Director of Nursing -ADON stated the only thing she knew about the incident in June 2025 between R1 and R3 is that there was an episode reported by V15 CNA. V3 stated V16 previous Social Services and V17 previous Administrator handled the situation. V3 stated she heard R1 and R3 were found in bed together naked. V3 stated V18 LPN was the nurse for the June incident. V3 stated she assumed the incident was reported because with the BIMS (Brief Interview of Mental Status) that the residents involved have, they cannot consent to sex. V3 stated she does not know why it was not reported. V3 stated the note entered into R1's chart doesn't match the story of what happened. The note states so and so wanted a relationship and not that they were found in bed together.On 12/1/25 at 2:58 PM, V16 previous Social Services stated she no longer works at the facility and doesn't remember much without her notes in front of her. V16 stated R1 and R3 were on a memory care unit, and they were close friends. V16 stated R1 and R3 wanted to be boyfriend and girlfriend. V16 stated she spoke to V22 (R3's POA). V16 could not remember if she spoke to V10 (R1's POA) or left a message for her. V16 stated she was not aware of anything else between R1 and R3.On 12/1/25 at 4:00 PM, V4 Medical Director stated R1 is on a memory care unit for a reason. R1 cannot consent for herself. V4 stated the facility's policies and procedures should be followed. V4 stated what happens should be recorded/documented.On 12/3/25 at 8:47 AM, V18 Licensed Practical Nurse - LPN stated on a day at the beginning of June around 5:00 PM a CNA came and told her that R1 and R3 were in bed together but had their clothes on. The CNA said she separated them and then came to get her. V18 stated she reported it to V17 previous Administrator who told her not to put anything in the notes in the resident's charts. V17 told her that V16 previous Social Services would take care of it.The facility's Documentation in Medical Record policy (2025) showed, licensed staff and interdisciplinary team members shall document all assessments, observations, provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be factual, objective, and resident centered. False information shall not be documented. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.

Based on interview, and record review the facility failed to report an allegation of sexual abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:1) A statement dated 11/19/25 by V9 Certified Nursing Assistant - CNA showed she went to R1's room around 8:30 PM to assist her to bed. V9 knocked on the door, stated who she was and walked in. V9 observed R1 on her bed. R1's right foot was on the floor; her left leg was half on the bed and half on the floor. R2 had his right hand on the wall, and his left hand was under R1's right shoulder. R2 was standing with his back to V9; she saw his butt. R2 was not laying on top of R1.A written statement (no date) by V8 Licensed Practical Nurse showed, R1 stated to her that she did not know who wanted the information .and stated they had sex.The facility did not have any paperwork to show Illinois Department of Public Health was contacted with an initial allegation of abuse or a final investigation.On 11/27/25 at 9:09 AM, V1 Administrator was interviewed regarding any allegations of sexual abuse at the facility. V1 stated R1 and R2 are two residents that are close. They were in R1's room together. V9 CNA walked into R1's room and R1 and R2 were naked. R2 was standing over R1with his right hand on the wall and left hand under R1's shoulder. R1 was leaning back. V9 stated she saw R2's butt and asked them what they were doing. V9 told R2 to leave the room. V1 stated V9 got V8 the nurse. V1 stated this incident occurred on 11/19/25 and was not reported to the state. V1 stated she did an investigation and since no intercourse happened, she did not report it. V1 stated it was a team decision. V1 stated she should have reported it. V1 stated it 'ate at her' to not report it. V1 stated any allegation is to be reported and then investigated.The Face Sheet dated 11/27/25 for R1 showed diagnoses including dementia, sleep disorder, general anxiety disorder, emphysema, chronic obstructive pulmonary disease, trigeminal neuralgia, hypertension, hyperlipidemia, osteoporosis, and urinary tract infection.The Nurse Practitioner note dated 11/11/25 for R1 showed she was being seen for a scheduled psychiatric follow up. R1 demonstrated behaviors consistent with her ongoing neurocognitive decline but was attentive and responded appropriately to all inquiries. Alerted and oriented X1 (person). Recent and remote memory: poor. Attention span and concentration: poor.The Minimum Data Set - MDS dated [DATE] for R1 showed severe cognitive impairment.The MDS dated [DATE] for R2 showed moderate cognitive impairment.The Face Sheet dated 11/27/25 for R2 showed diagnoses including dementia, adjustment disorder with mixed anxiety and depressed mood, type 2 diabetes mellitus, and hypertension.The Nurse Practitioner Note dated 11/25/25 for R2 showed he is alert and oriented x 2; he is able to explain why he is here and what his current health status is like. R2's recent and remote memory: fair. Attention span and concentration: fair.The facility's Abuse, Neglect, and Exploitation policy (2025) showed, reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.2) The Social Service Note dated 6/9/25 at 4:08 PM for R1 showed, this writer was informed by CNA that resident was interested romantically in another resident in the memory care unit. This writer spoke with both R1 and the other resident (R3) and educated them to utilize public spaces to spend time together. This writer asked them not to spend any time together in each other's rooms. R1 and peer both agreed and stated they want to take it slow. Medical Director in facility and notified. No new orders. Voicemail left for V10 to notify. Requested call back.On 12/1/25 at 9:14 AM, V10 (R1's daughter/power of attorney - POA) stated there was an incident in June 2025 with R1 and R3 but there wasn't any documentation about what happened. V10 stated she found out recently from a CNA that R1 was in R3's bed and R3 had his pants down. V10 stated they were split up before anything happened.On 12/1/25 at 1:18 PM, V3 Assistant Director of Nursing -ADON stated the only thing she knew about the incident in June 2025 between R1 and R3 is that there was an episode reported by V15 CNA. V3 stated V16 previous Social Services and V17 previous Administrator handled the situation. V3 stated she heard R1 and R3 were found in bed together naked. V3 stated V18 LPN was the nurse for the June incident. V3 stated she assumed the incident was reported because with the BIMS (Brief Interview of Mental Status) that the residents involved have, they cannot consent to sex. V3 stated she does not know why it was not reported.On 12/1/25 at 2:58 PM, V16 previous Social Services stated she no longer works at the facility and doesn't remember much without her notes in front of her. V16 stated R1 and R3 were on a memory care unit, and they were close friends. V16 stated R1 and R3 wanted to be boyfriend and girlfriend. V16 stated she spoke to V22 (R3's POA). V16 could not remember if she spoke to V10 (R1's POA) or left a message for her. V16 stated she was not aware of anything else between R1 and R3. V16 stated she was not aware of R1 and R3 being in each other's room, being in each other's beds, or being naked together.On 12/1/25 at 4:00 PM, V4 Medical Director stated R1 is on a memory care unit for a reason. R1 cannot consent for herself. V4 stated the facility's policies and procedures should be followed.On 12/3/25 at 8:15 AM, V1 Administrator stated, V1 stated she does not know anything about what happened in June 2025 between R1 and R3. V1 stated she was not at this facility at that time. V17 was the Administrator, and she is no longer with the company. V1 stated there isn't an investigation for anything in June and there is no abuse investigation in the last six months except now they have one for R1 and R2 because of what happened recently.On 12/3/25 at 8:26 AM, V12 Certified Nursing Assistant - CNA stated in June she was working on the memory care unit and went to do her rounds. V12 went past R3's room and his door was shut, so she knocked on the door, and went into the room. V12 stated R3's bed was the farthest bed and the curtain was drawn. V12 stated she was going to leave but she saw R1's walker in the room. V12 stated R3 was standing up next to the bed, had a white t-shirt on and underwear. R1 was laying on R3's bed but had her clothes on. V12 stated she escorted R1 out of the room and then reported it to the nurse. V12 stated she told the nurse.On 12/3/25 at 8:47 AM, V18 Licensed Practical Nurse - LPN stated on a day at the beginning of June around 5:00 PM a CNA came and told her that R1 and R3 were in bed together but had their clothes on. The CNA said she separated them and then came to get her. V18 stated she reported it to V17 previous Administrator who told her not to put anything in the notes in the resident's charts. V17 told her that V16 previous Social Services would take care of it.On 11/27/25 the facility did not have any Abuse Investigations in the last 6 months.The Face Sheet dated 11/27/25 for R1 showed diagnoses including dementia, sleep disorder, general anxiety disorder, emphysema, chronic obstructive pulmonary disease, trigeminal neuralgia, hypertension, hyperlipidemia, osteoporosis, and urinary tract infection.The Nurse Practitioner note dated 11/11/25 for R1 showed she was being see for a scheduled psychiatric follow up. R1 demonstrated behaviors consistent with her ongoing neurocognitive decline but was attentive and responded appropriately to all inquiries. Alerted and oriented X1 (person). Recent and remote memory: poor. Attention span and concentration: poor.The Minimum Data Set - MDS dated [DATE] for R1 showed severe cognitive impairment.The Face Sheet dated 11/27/25 for R3 showed diagnoses including dementia without behavioral disturbance, hypertension, morbid obesity, hypokalemia, adjustment disorder, and anxiety disorder.The MDS dated [DATE] for R3 showed moderate cognitive impairment.The facility's Abuse, Neglect, and Exploitation policy (2025) showed, reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interview and record review the facility failed to ensure a resident at risk for elopement was supervised for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 3.The findings include:R3's admission record documents he was admitted on [DATE] with a diabetic foot ulcer and cellulitis. R3's elopement evaluation of 8/5/25 shows he had a history of elopement or attempted elopement while at home. Scoring a 1 for risk of elopement. No risk factors for elopement were identified, and no clinical suggestions or interventions were checked on the form.On 8/9/25 at 8:50 AM, V6 Licensed Practical Nurse (LPN) said on 8/5/25 R3 was observed going to the front door asking for family members to give him a ride. V6 said V8 Registered Nurse placed a wander guard bracelet on him so if he was attempting to go outside the alarm would sound. V6 did not recall where the wander guard came from or who gave it to V8 to put it on him. V6 said the next day on 8/6/25, R3 went to the front door in his wheelchair and had removed the wander guard so the alarm would not sound, and he left the facility. V6 said he was located at the gas station down the road. On 8/9/25, a message was left for V8, but no return call was received.On 8/9/25 at 8:55 AM, R3 said he was admitted to the facility for an infection to his foot, and he was on the other side of the facility for therapy. R3 stated the following: R3 can walk on his own but uses his wheelchair for longer distances. R3 was not happy his kids put him in the facility, so he left and was going to his friend's house. R3 did not tell anyone he was leaving; he just took off. R3 removed the wander guard because it would have made the door squeal when he left. R3 headed towards route 40 and made it to the gas station. R3 said he waited at the crosswalk to go across the highway. R3 said at the gas station he was put into a car and returned to the facility. R3 denied any falls, or injury and walked the entire distance without any issues. During the interview R3 was ambulating without assistance in his room. R3 had no visible injuries and spoke clearly of the event.On 8/9/25 at 1:00 PM, V9 LPN said R3 resided on the 200 wing and did not have any exit seeking behaviors. V9 said V12 CNA came to inform her R3 was asking family members to give him a ride. V9 said she completed the task she was doing and went to speak with R3, but he was not in his room or in the lobby. She said his wheelchair was by the front door and his wander guard was on the floor. V9 said she informed V6 to announce a missing resident, and all staff began to search for him. V9 said she left out the front door and went towards the east and the rest of the staff went west. Once she turned, she could see him down the road. R3 had a sack with him and was talking to a couple that were on the road. V9 said the couple assisted R3 across the highway to the gas station. Once at the gas station, V10 CNA arrived with the facility van, and V12 arrived with her mother in a private vehicle to assist with getting R3 back to the facility. V9 said R3 refused to get into the facility van but would get into the car. V9 said R3 was out of the facility for about 10 minutes total and had no injury noted upon assessment. On 8/9/25 at 2:25 PM, V1 Administrator said she was notified of the elopement around 6:00 PM, it was shift change. V1 was advised R3s wheelchair was found by the front door, and he had removed a wander guard. V1 said she was not aware R3 had a wander guard and could not determine who ordered it or placed it on R3. V1 said there is a process for placing a resident on such a device. It should have an assessment, care planning and orders.The facility's 4/16/21 policy for elopements and wandering residents the facility ensures that residents who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

Based on observation, interview, and record review the facility failed to prevent resident to resident physical abuse for one resident (R3) of three residents reviewed for abuse in the sample of 3. The Findings include: Comprehensive Cognitive Assessment indicates R3 is moderately impaired and has diagnosis of Mild Intellectual Disabilities. Incident Investigation Report dated 6/6/25 at 2:45pm indicates R3 was asked if someone hit her and R3 responded, Yes. My Roommate. Incident Investigation Report dated 6/6/25 at 2:45pm indicates R2 denied hitting R3 and stated that if she did, she didn't mean to. On 6/6/25 at 2pm, R3 was lying in bed and when asked if her previous roommate (R2) had ever hit her. R3 responded Yes. When asked where she was hit, R3 made eye contact and stated, All over. R3 denied being physically hurt. According to resident Census/Room assignments, both R2 and R3 were roommates until 5/28/25 when R2 was moved to another room on the same hall. R3 did not have another roommate after 5/28/25. Current Comprehensive Assessment indicates R2 is independent with mobility. Current Care Plan indicates R2 prefers to have a private room and has been manipulative and rude to past roommates (Revised 10/4/24). Current Comprehensive Assessment indicates R3 is total assist with transfers via mechanical lift and only has limited use of her right arm; Hemiplegia/Hemiparesis affecting left side. Social Service Progress Note dated 5/28/25 at 9:38am indicates R2 and guardian were notified and in agreement with the room move due to roommate preferences. Progress Note dated 5/29/25 at 2:48pm indicates R2 was noted to have behaviors of delusional thinking regarding their roommate. Intervention added of room move. Social Service Progress Note dated 5/28/25 at 9:41am indicates R3 and POA (Power of Attorney) notified of room move due to resident preference for window side of room. On 6/10/25 at 3pm V7, LPN (Licensed Practical Nurse) stated I don't remember who told me. I did hear (R2) was on (R3's) bed and that (R2) hit (R3). V7 stated she heard it as gossip and stated she didn't know if it was true or not. V7 stated, I heard in passing that's why (R3) was moved. On 6/10/25 at 2:45pm V2, ADON (Assistant Director of Nursing) stated she heard R2 was on R3's side of the room before they were moved. On 6/11/25 at 7:15pm V8, LPN stated R2 was found on R3's side of the room insisting it was R2's side. On 6/6/25 at 3:25pm V3, SSD (Social Service Director) denied R2 was moved to another room due to the alleged altercation of R2 and R3. Progress Notes did not include any documentation regarding a potential physical altercation between R2 and R3 or that R2 was insisting R3 was on the wrong side of the room. Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents: It is the policy of this facility to provide protections for the heath, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking.

Based on interview and record review the facility failed to report allegations of abuse to the Abuse Coordinator for three residents (R1, R2, R3) of three residents reviewed for abuse in the sample of 3. Findings include: Comprehensive Cognitive Assessment indicates R1 is moderately impaired and has diagnosis of Mild Intellectual Disabilities. On 6/5/25 at 1:15pm R1 stated (with V1, Administrator present) that [female staff member name] threw her up against the wall and she hit the left side of her head. R1 stated it hurt, but she didn't cry and there was no bump or anything. R1 identified [female staff member name] as a night shift CNA (Certified Nurse Assistant). R1 was unable to state the day/date of this incident. On 6/6/25 at 11:30am R1 stated (with V5, Hospice RN/Registered Nurse present) that [female staff member name] got her dressed for bed one night and then threw her against the wall getting her into bed. R1 stated that she hit the left side of her head It didn't hurt, I didn't cry but it made me mad. R1 stated that [female staff member name] does not have the temperament for the job and has a bad attitude. R1 stated that she told V7, LPN (Licensed Practical Nurse) the nurse who comes in the morning and stated V7 told R1 she would report her concerns. On 6/10/25 at 10:45am V9, CNA stated that about two weeks ago she was getting R1 out of bed in the morning and R1 told V9 Thank God it's you, because last night [female staff member name] threw me in the bed. V9 stated she was pretty sure there wasn't any staff by the name of [female staff member name] and (R1) talks all the time. V9 stated while she was still assisting R1 - V5, Hospice Nurse came into the room and V9 asked V5 if she knew who [female staff member name] was and if she had ever heard R1 talk about her. V5 told V9 that (V5) knew about R1's allegations and that (V5) was handling it. V9 stated she did not tell V1, Administrator or any other facility staff about R1's allegations. V9 acknowledged even if someone is cognitively impaired their allegations should be reported to their supervisor or to V1, Administrator. On 6/5/25 at 3:45pm V5, Hospice RN stated that R1 did tell her that a CNA named [female staff member name] had been rough while helping her to bed About 3-4 weeks ago and she reported R1's allegations to V2, ADON (Assistant Director of Nursing) at that time. V5 stated that she believed R1 was referring to V12, CNA who was usually R1's CNA on night shift. V5 stated she was told that R1 sometimes refers to V12 as [female staff member name] although that is not V12's name. On 6/6/25 at 2pm V7, LPN stated she also heard R1 calls V12 by [female staff member name] On 6/5/25 and again on 6/10/25 V2, ADON denied V5 reported any allegations of abuse to her regarding R1 or any other resident. R1 was consistent in her reporting of allegations throughout the investigation. Internal reporting of an allegation of abuse was not implemented until reported to the V1, Administrator by the State Agency surveyor on 6/5/25. 2) Current Comprehensive Assessment indicates R2 is independent with mobility. Current Comprehensive Assessment indicates R3 is total assist with transfers via mechanical lift and only has limited use of her right arm; Hemiplegia/Hemiparesis affecting left side. According to resident Census/Room assignments - both R2 and R3 were roommates until 5/28/25 when R2 was moved to another room on the same hall. Social Service Progress Note dated 5/28/25 at 9:38am indicates R2 and guardian notified and in agreement with room move due to roommate preferences. Progress Note dated 5/29/25 at 2:48pm indicates R2 noted to have behaviors of delusional thinking regarding roommate. Intervention added of room move. Social Service Progress Note dated 5/28/25 at 9:41am indicates R3 and POA (Power of Attorney) notified of room move due to resident preference for window side of room. On 6/10/25 at 3pm V7, LPN stated, I don't remember who told me - I did hear (R2) was on (R3's) bed and that (R2) hit (R3). V7 stated she heard it as Gossip and stated she didn't know if it was true or not. V7 stated, I heard in passing, that's why (R3) was moved. On 6/10/25 at 2:45pm V2, ADON stated that she did hear that R2 was on R3's side of the room before they were moved. On 6/6/25 at 2pm, R3 was lying in bed and when asked if her previous roommate (R2) had ever hit her - R3 responded Yes. When asked where she was hit, R3 stated, All over. R3 denied being physically hurt. Progress Notes did not include any documentation regarding a potential physical altercation between R2 and R3. No internal reporting of R2 being physically aggressive with R3 was made until 6/6/25 when State Agency surveyor reported the allegation to V13, Regional Nurse Consultant. Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation resident property. The facility will have written procedures that include: Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframe's: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

Based on observation, interview, and record review, the facility failed to identify a pressure injury prior to be becoming a Stage 3, failed to assess a new pressure injury, and failed to implement pressure relieving interventions after a new wound was found for 1 of 6 of residents (R82) reviewed for pressure in the sample of 19. These failures resulted in R82 having a Stage 3 pressure injury for a week before an assessment was done, pressure relieving interventions were put into place and the pressure care plan interventions were updated. The findings include: R82's face sheet showed a [AGE] year-old female with diagnosis of mild protein calorie malnutrition, conversion disorder with seizures, intellectual disabilities, hypertension, dysphagia, malignant neoplasm of the uterus, and cognitive communication deficit. On 9/24/24 at 10:23 AM, R82 was in the hallway in a wheelchair. R82 was self-propelling the chair and leaned to the left. On 9/24/24 and 9/25/24, R82 was seen in her wheelchair and consistently leaned to the left. On 9/26/24 at 7:41 AM, V8 (Wound Doctor) said he expects a wound to be assessed by the nurse at the time it is found. V8 said, They shouldn't wait a week for me to look at it. The wound could deteriorate. [R82's] left mid back wound is a Stage 3 pressure injury. V8 measured the back wound as 3.0 centimeters (cm) X 2.5 cm X 0.1 cm. The wound had a reddened circumference, darkened center, and was circular in shape. V8 ran his finger on R82's back to show the staff present the wound was over the posterior rib cage. V8 told the staff, You don't want it to get any worse. It's right over the chest. V8 debrided the wound at the bedside. V6 (Licensed Practical Nurse) showed V8 R82's wheelchair and said she believed R82's back rubbed on the metal bar on the left side of the wheelchair as she usually leans that way. V8 asked V6 to have therapy apply a pad to the back of the chair to pad the area and alleviate pressure from the bar. V8 said the facility definitely should have implemented interventions to relive pressure to R82's back. V8 said, A cushion or something to provide pressure relief. An initial assessment is important to know if the treatment is doing the job or not. Is it getting better or worse? It helps you decide on the treatment. On 9/26/24 at 8:07 AM, V2 Director of Nursing (DON) said when a wound is found the nurse should do an assessment and document the assessment. V2 said, Documentation could be done in the progress note. Not every wound has a wound observation tool. There should be a wound note on the date the wound is found, and I don't see one for [R82's] wound. V2 was unable to show any care plan interventions initiated after finding the wound to R82's back. V2 said R82 is only in bed at night. R82's 5/22/24 admission skin assessment showed no open areas. R82's physician order sheet showed a 9/19/24 order that she may see the wound care services. Another order dated 9/18/24 showed wound treatment orders to the mid back wound to start 9/19/24 (wound present 9/18/24). R82's wound doctor notes showed no mention or assessment of the left mid back wound. R82's pressure care plan interventions have had no updates since 5/2024. R82's 8/23/24 facility assessment showed moderate cognitive impairment. The facility's 1/3/22 Pressure Injury Prevention and Management Policy showed: The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; and modifying the interventions as appropriate. Licensed nurses will conduct a full body skin assessment on all residents after any newly identified pressure injury. Assessments of pressure injuries will be performed by a licensed nurse and documented on the____________ (left blank). After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment. Evidence based interventions for prevention will be implemented for all residents who have a pressure injury present. Interventions on a resident's care plan will be modified as needed. Considerations for needed modifications include new onset or recurrent pressure injury development.

Based on observation, interview, and record review the facility failed to ensure coffee was served at a safe temperature to a resident. This failure resulted in R3 sustaining a full thickness (third degree) burn to her right thigh from hot coffee. The facility failed to ensure needles were safely disposed of. This applies to 2 of 18 residents (R3, R32) reviewed for safety in the sample of 18. The findings include: 1. On 08/29/22 at 09:43 AM, V14 Hospice Nurse said R3 has a burn on outer right thigh from coffee she spilt on herself last week. On 08/29/22 at 11:42 AM, V4 Dietary Manager stated, we had a resident get burned last week with coffee. It was too hot. The resident who got burned was served coffee that was above 155 degrees. We got a new coffee machine at the beginning of the year and now we are recording the temperature before it goes out to the dining room. On 08/30/22 at 11:15 AM, V3 Assistant Director of Nursing (ADON)/ Wound Nurse said R3 has a burn to her right posterior thigh from hot coffee. V3 stated R3 spilled coffee on herself, it happened on the weekend on 8/20/22. The original wound had blisters on the area touched by the hot liquid, and then it was reddened around the blisters. It measured 19 centimeters (cm) by 15 cm by 0.1 cm. There was fluid filled blisters. The treatment orders were [MEDICATION(S)] cream with xeroform gauze dressing and gauze wrap in case the blister drained. On 08/30/22 at 01:17 PM, V3 exposed R3's right leg. R3 had an undated dressing on her right thigh. The dressing was saturated with yellow fluid and the edges of the dressing were slightly rolled. R3 had a large area of dark redness that appeared wet/raw looking with yellow/cream colored skin pieces flattened to the wound bed surrounded by an area of slightly less reddened skin. There were smaller reddened areas (down from the large area) closer to R3's knee. The blisters appeared to have drained (flattened). On 08/31/22 at 950 AM, V8 Licensed Practical Nurse (LPN) stated It happened on a Saturday morning. R3 asked a new Certified Nursing Assistant (CNA) for coffee. The CNA went to kitchen to get it and then handed it to R3. R3 was sitting up in her chair in her room and R3 spilled it in her lap. I was in another room, and I heard hollering out. The CNA came and got me. The CNA was first in the room, and she removed R3's pants and put cool cloths on it. We got R3 in bed and situated with cool cloths. I called the on-call doctor and I let the doctor know it was a pretty large red area. I called the wound doctor and got orders for [MEDICATION(S)] and Vaseline gauze. I left R3 in bed and gave her [MEDICATION(S)]. It was a big red area. I frequently checked on her, there were no blisters at the time I left on Saturday evening. Sunday morning when I checked on her, there was big fluid filled blisters. R3 would say she was in pain when asked and I would give her [MEDICATION(S)]. R3 is also on scheduled for Tylenol which helps her. It (the coffee) was obviously too hot if it burned her. I let the aid know to not give coffee that's too hot. R3's Burn Incident Report dated 8/20/22 shows, Resident spilled coffee on her lap. Resident states I burned my leg .burn to right posterior thigh resident will be monitored when having coffee at meal and other times . R3's Wound Evaluation and Management Summary dated 8/25/22 shows burn wound to the right, posterior, lateral thigh full thickness Wound size 19 cm x 15 cm x 0.1 cm. The facility's Coffee and Drink Cart Check list shows coffee is to be temped and recorded before each meal .must be 155 degrees or lower before leaving the kitchen 2. On 08/29/22 at 09:46 AM, R32 was up in her wheelchair next to the bed. On the bed next to R32 was a used blood draw needle within reach of R32. On 08/29/22 at 09:49 AM, V8 LPN saw the used blood draw needle and stated yes they left that. That's a safety concern. That's terrible. R3 could reach that if she tried, she's not alert. I'll talk to the lab girl, she should not have left that, it needs to be in a sharps container. R32's Facesheet shows R32 has a diagnosis of unspecified dementia. R32's Minimum Data Set, dated dated dated [DATE] shows R32 is cognitively impaired.

Based on interview and record review the facility failed to ensure a resident with skin tears was monitored for signs and symptoms of infection, failed to assess and document an initial wound assessment and weekly wound assessments for a skin tear, and failed to ensure treatment orders were obtained for a skin tear for 1 of 3 residents (R1) reviewed for skin tears in the sample of 3. This failure resulted in R1 being transferred to an acute care hospital on 9/12/21 and requiring debridement of her left lower extremity and intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility assessment dated [DATE] showed R1 had severe cognitive impairment and required the physical assistance of two staff members for cares. R1's nursing progress note dated 9/12/21 showed, Resident in recliner after lunch and received a phone call. She was speaking to her son and wasn't making sense as she normally does. Assessment completed, paged [On Call NP] .Received order to send to ER (emergency room ). Notified 911. R1's acute care hospital Infection Disease Consultation dated 9/13/21 showed, . She was noticed to have change in mental status with fever yesterday. Therefore, she was brought to the emergency room . In the emergency room , temperature was 102.6 degrees Her left lower extremity showed big bullae [large fluid filled blister] from her malleolus [bone on ankle] up to almost the middle of her leg. There is tenderness in that area . There is redness and bluish discoloration . Assessment/Recommendations: 1. [CONDITION(S)]. Patient presented with fever and leukocytosis. Source will be her bacteremia and [CONDITION(S)]. 2. [CONDITION(S)] change in her left lower extremity with big bullae with Group A Strep and [CONDITION(S)]. This is highly compatible with [CONDITION(S)]. Patient needs to be seen soon by surgery service . In the meantime, I am going to change her antibiotic to [MEDICATION(S)]-G 4 million units every 4 hours, in addition to [MEDICATION(S)] 900 mg IV (intravenous) every 6 hours. 3. Group A Strep bacteremia. Source will be her left lower extremity . 4. Bilateral pleural effusion probably related to her [CONDITION(S)] Please note that I called her son, [V5 R1's Power of Attorney] and I updated him about my assessment and plan. He is in agreement to do surgery tonight . R1's Incident Note dated 9/7/21 at 12:40 AM showed, reported to this nurse that resident had obtained a skin tear to left outer leg while residents' legs were being put back up on the bed . R1's September 2021 Treatment Administration Record showed no documentation of monitoring R1's left lower leg skin tear. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation found in R1's medical record of initial measurements of R1's skin tear or an initial assessment of R1's skin tear. R1's care plan initiated on 7/26/21 showed, Skin Tear/Potential for skin tear . Interventions: . If skin tear occurs, treat per facility protocol and notify MD, family. On 9/28/21 at 1:20 PM, V3 (Wound Care Nurse) said the nurses let her know if there is a new wound and she completes the weekly wound evaluations. V3 said if there is a skin issue such as a tear or a blister it would be documented on those wound assessments. V3 said if there is a skin tear the nurses document where the skin tear is located. V3 said skin tears are measured by the nurses when it is identified and then it starts the weekly wound assessment form. V3 said skin tears are measured throughout the healing. V3 said if a skin tear occurs the nurses notify the doctor and get orders for treatment. V3 said the purpose of monitoring skin tears is to watch for any signs and symptoms of infections and to make sure the treatment is working. At 2:30 PM, V3 said there are no wound assessments in R1's record for the left lower leg skin tear. V3 said when a skin tear is identified an assessment should be done, it should be measured, and entered in the medical record. V3 said she does not know why this process was not done for R1's left leg wound. On 9/28/21 at 2:11 PM, V2 DON (Director of Nursing) said she was unable to find any monitoring of the left lower leg skin tear or treatments. V2 said the measurements were never documented for the left lower leg skin tear and R1 was sent to the hospital before her first weekly wound assessment would have been due. V2 said the initial assessment should include measurements and then that would trigger the weekly wound assessment to be done. V2 said all wounds are monitored for signs and symptoms of worsening condition, infection, and pain control and overall healing. V2 said the physician should be notified immediately if there are any changes to the wound. At 4:13 PM, V2 said, If a wound is not monitored it could become infected, worsen, and cause pain. The facility's undated policy titled Skin Integrity - Skin Tears showed, Policy: It is the policy of this facility to provide proper treatment and care to maintain skin integrity. This policy pertains to the prevention and management of skin tears. Policy Explanation and Compliance Guidelines: 1. The facility will utilize a systemic approach for the prevention and management of skin tears including assessment, care planning, monitoring, and modification of interventions as appropriate. 2. Assessment; a. Licensed nurses will conduct skin assessments in accordance with facility policy . c. When a skin tear is discovered, the nurse shall complete an incident report. The following information shall be recorded: i. The resident's name, ii. The name of the employee discovering the skin tear, iii. The site and description of the skin tear . 3. Interventions for Prevention and to Promote Healing; b. Topical treatments in accordance with current standards of practice will be provided for all residents who have a skin tear . 4. Monitoring . b. RNs and LPNs will participate in the management of skin tears and medical conditions by following physician orders, assessment of residents, and reporting changes in condition to the residents' physicians . 5. Modification of Interventions; a. The attending physician will be notified of the presence, progression towards healing, or lack of healing of any skin tears, or any changes in the resident's medical condition. b. Interventions will be modified in a resident's plan of care as needed. Considerations for needed modifications include: i. Changes in medical condition or factors affecting the risk for skin tears. ii. New onset or recurrent skin tear. iii. Lack of progression towards healing . The facility's undated policy for Wound Treatment Management showed, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: . 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include a. Lack of progression towards healing. b. Changes in the characteristics of the wound .

Based on interview and record review the facility failed to immediately notify R2's physician for a resident (R2) with a history of brain bleeds and blood thinning medication use when he (R2) fell and hit his head on the floor. This failure resulted in R2 requiring emergency treatment. R2 sustained bilateral subdural hematomas (brain bleeds) and was hospitalized . R2 expired five days later as a result of his injuries. This applies to 1 of 3 residents (R2) reviewed for physician notification in the sample of 10. The findings include: The hospital discharge summary dated (MONTH) 20, 2019 showed R2 was transferred from the facility to a local hospital on (MONTH) 11, 2019 following a fall and subsequently expired on (MONTH) 16, 2019. Facility's incident report dated (MONTH) 11, 2019 states on (MONTH) 11, 2019 at 7:00 AM, R2 was observed lying on the floor next to bed by Certified Nursing Assistant (CNA). R2 was laying on right side of body with no visible head injury noted, including assessment of head. R2 denied pain, vital signs, neurological checks, and mental status remained within normal limits until approximately 11:00 AM when wife, who was visiting, informed nurse of change in condition. Nurse assessed and observed acute change in neurological status. 911 immediately notified, physician notified, and Power of Attorney (POA) at bedside. Transferred to hospital for evaluation. Computed tomography (CT) of head results indicate acute Subdural Hematoma. Resident admitted to hospital. R2's electronic face sheet dated (MONTH) 5, 2019 showed R2 had [DIAGNOSES REDACTED]. R2's history and physical from (MONTH) 11, 2019 showed [DIAGNOSES REDACTED]. R2's physician's orders [REDACTED]. On (MONTH) 6, 2019 at 10:05 AM, V16 Nurse Practitioner who was covering on-call for R2's primary physician stated she received a call from V17 Licensed Practical Nurse at 11:13 AM (Four hours after R2 fell ) on (MONTH) 11, 2019 and returned her call at 11:15 AM. V17 reported R2 was having [MEDICAL CONDITION] activity and had sustained a fall earlier in the morning. V16 gave orders to send R2 to the emergency room immediately for evaluation. V16 stated if she had been called four hours earlier when the fall occurred, she would have immediately sent him to the emergency room . V16 confirmed on her pager and computer system that she did not receive any calls from the facility on (MONTH) 11, 2019 until 11:13 AM. V16 also confirmed she was the only person on call for the facility from the evening of (MONTH) 10, 2019 thru the morning of (MONTH) 13, 2019. (V16 was not notified of the 7:00AM fall incident until 11:15 AM). On (MONTH) 6, 2019 at 9:19 AM, V18 Physician covering for primary physician stated (R2) was a candidate for surgical intervention. V18 stated the four hour delay in emergency treatment affected the outcome in this case. Timing is paramount with a subdural hematoma. V18 stated (R2's) fall directly contributed to his death as he bled from trauma to the head. The use of [MEDICATION NAME], Aspirin and (R2's) history of subdural bleeds made him a very high risk patient and this was a very unfortunate case. On (MONTH) 5, 2019 at 11:54 AM, V9 Primary Physician for R2 stated if a resident had an unwitnessed fall and took blood thinners he would advise staff to send the resident to the emergency room for immediate evaluation. V9 stated the cause of death for (R2) was intracranial bleed, dementia and pneumonitis. On (MONTH) 5, 2019 at 1:20 PM, V7 Certified Nursing Assistant (CNA) stated on (MONTH) 11, 2019 at approximately 7:00 AM she walked past (R2's) room and noticed him on the floor on his right side with his head on the floor between the recliner and bed. V7 stated I'm pretty sure he hit his head. V7 called for V17 Licensed Practical Nurse (LPN) to assess (R2). On (MONTH) 5, 2019 at 10:33 AM, V17 stated V7 notified her on (MONTH) 11, 2019 at approximately 7:00 AM that R2 was on the floor in his room. V17 stated at 8:45 AM, she attempted to notify V16 Nurse Practitioner of R2's fall. V17 stated at 9:00 AM, V19 R2's wife came to visit and she notified her of R2's fall at this time. V17 said V19 alerted her at approximately 10:30 AM that R2 was not acting right and V17 observed (R2) having [MEDICAL CONDITION] activity. V17 stated she notified V16 Nurse Practitioner to report the change in condition. V16 ordered to send (R2) to the hospital for evaluation. On (MONTH) 5, 2019 at 12:18 PM, V15 LPN stated she assisted V17 with initial assessment of (R2). Upon entering the room, (R2) was laying on his right side with his head behind the recliner. Staff then assisted (R2) to the side of his bed and then into his chair. On (MONTH) 6, 2019 at 8:58 AM, V2 Director of Nursing stated [MEDICATION NAME] and Aspirin are anti-platelets, not anti-coagulants so residents on these medications are not automatically sent for evaluation following an unwitnessed fall. If a resident had a fall, developed bruising and was on blood thinning medications the physician should be notified. On (MONTH) 7, 2019 at 10:42 AM, V7 stated (R2's) baseline functional status was one to two assist transfer and could use a walker for short distances. At approximately 10:45am (R2) was pale, wouldn't pick up his feet, his eyes were half open, he was not talking, his mouth was half open and he was spacing out. V7 stated at this time (R2) required assistance of two staff members to transfer him into bed. On (MONTH) 7, 2019 at 10:50 AM, V2 stated if a resident is experiencing an acute situation ([MEDICAL CONDITION] activity) the nurses know to notify 911 before attempting to call the physician. All of the nurses are aware they can do that. In (R2's) situation, 911 should have been called before the physician because R2 was at his baseline health condition right before the wife notified the nurse that the acute change occurred. On (MONTH) 7 2019 at 11:20 AM, V9 stated If a resident has a change in condition, the nurses should send them to the emergency room for evaluation immediately. They do not need to wait for a physician's orders [REDACTED]. On (MONTH) 7, 2019 at 11:32 AM, V17 stated her initial call to report R2's fall to a physician was at 9:00 AM and did not receive a call back. V17 called V16 at 10:45 AM to report R2's change in condition. V17 stated there was nothing unusual with his behavior or vital signs so she did not feel it was urgent to immediately notify on call physician. V17 stated there was a delay in notification because she was doing medication pass. On (MONTH) 11, 2019 at 1:22 PM, V20 Communications Specialist stated Initial call from the facility to the switchboard was received at 11:10 AM. Local hospital attendant picked up the phone call at 11:11 AM. V16 was paged at 11:13 AM. Record review of telephone log from local hospital showed the only phone call received from facility to local hospital switchboard occurred on (MONTH) 11, 2019 at 11:10 AM. The facility's Post Fall Assessment policy dated (MONTH) 1, (YEAR) states 5. The physician and responsible party will be notified of the fall and findings from the assessment. The facility's Change in Condition policy dated (MONTH) 1, (YEAR) states 5. The Resident/Physician/Family/Responsible party will be notified when there has been: a. an accident or incident involving the resident .6. In the event of an emergency situation, 911 will be called immediately and the Physician/Family/Responsible party will be notified as soon as possible . The facility's Abuse and Prevention policy revised on (MONTH) 25, (YEAR) states Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On (MONTH) 6, 2019 at 1:30 PM, V1 stated the facility has no policies regarding emergency care, physician notification or unwitnessed fall for a resident on blood thinning medication.

Based on interview and record review the facility neglected to implement bed rails and alarms for a resident (R2) at high risk for falls. The facility neglected to identify that a resident was on two blood thinning medications and at high risk for bleeding after a fall with head trauma. This failure resulted in a delay from the time of the fall to the time that (R2) was transferred to the hospital for evaluation. Resident admitted to the hospital with [REDACTED]. This applies to 1 of 3 residents (R2) reviewed for neglect in the sample of 10. The findings include: The hospital discharge summary dated (MONTH) 20, 2019 showed R2 was transferred from the facility to a local hospital on (MONTH) 11, 2019 following a fall and subsequently expired on (MONTH) 16, 2019. R2's electronic face sheet dated (MONTH) 5, 2019 showed R2 had [DIAGNOSES REDACTED]. R2's history and physical from (MONTH) 11, 2019 showed [DIAGNOSES REDACTED]. R2's physician's orders [REDACTED]. R2's care plan dated (MONTH) 22, (YEAR) stated I (R2) am at risk for falls due to poor safety awareness, confusion, forgetfulness, dementia, weakness, difficulty in walking, anti-hypertensive medications, narcotics and history of falls. R2's care plan goal dated (MONTH) 7, (YEAR) stated (R2) will continue to utilize a pressure alarm. R2's care plan dated (MONTH) 6, (YEAR) states (R2) prefers the use of bilateral ½ padded side rails on my bed for turning and repositioning, helping me transfer to and from bed safely, provides stabilization while sitting on the side of my bed, and it promotes safety while I receive activities of daily living (ADL) care from staff. On (MONTH) 5, (YEAR) at 10:33 AM, V17 Licensed Practical Nurse stated V7 Certified Nursing Assistant reported to her on (MONTH) 11, 2019 at 7:00 AM that (R2) was laying on the floor in his room. (R2's) bed alarm was not sounding when V7 found (R2) on the floor. On (MONTH) 5, 2019 at 1:20 PM, V7 stated R2 normally had two side rails up when in bed but when V7 found R2 his side rail was down. V7 stated R2 was not able to lower the side rails on his own. V7 stated (R2's) pressure alarm was on his bed but was not sounding when she found R2 on the floor. The facility's Fall Prevention and Risk Assessment policy dated (MONTH) 1, (YEAR) states 4. Risk factors and fall prevention measures for individual residents will be documented on the resident's comprehensive care plan and communicated to the direct care staff for implementation. The facility's Resident Alarm policy dated (MONTH) 1, (YEAR) states 2. The use of alarms do not eliminate the need for adequate supervision of the resident .b. When alarms are utilized, additional monitoring shall be provided, including but not limited to: ii. Verifying alarms are working properly. The facility's Fall Prevention and Risk Assessment policy dated (MONTH) 1, (YEAR) states 6. Any resident who falls will be immediately assessed for potential injury, and treated as necessary. On (MONTH) 6, 2019 at 8:58 AM, V2 Director of Nursing stated If a resident develops bruising after a fall and is on blood thinning medication, you should notify the physician. I'm not sure if we have a policy on that but it is standard nursing knowledge that is what should be done. In an emergency a nurse may send a resident to the emergency room and notify the physician after. If a resident cannot tell us if they fell and hit their head and had an unwitnessed fall, we assume that they hit their head. Nursing notes from (MONTH) 11, 2019 at 7:00 AM state V17 noted two small areas of blue discoloration to top of right hand. On (MONTH) 5, 2019 at 11:54 AM, V9 Physician stated if a resident had an unwitnessed fall on blood thinners he would advise the facility to send them to the emergency room . On (MONTH) 6, 2019 at 10:05 AM, V16 Nurse Practitioner stated if a resident is receiving blood thinning medications and has an unwitnessed fall, she would recommend immediate evaluation at the emergency room . On (MONTH) 5, 2019 at 10:33 AM, V17 stated Resident's that are on blood thinners are monitored for bruises. The fall already happened so we just did neurological checks. The facility's Change in Condition policy dated (MONTH) 1, (YEAR) states 6. In the event of an emergency situation, 911 will be called immediately . On (MONTH) 4, 2019 at 3:05 PM, V19 (R2's) wife stated she notified staff on (MONTH) 11, 2019 at 10:30 AM that something wasn't right and R2 was white and shaking. R2 was in his wheelchair in his room. On (MONTH) 7, 2019 at 10:42 AM, V7 stated at 10:45 AM R2 was pale and wouldn't pick up his feet for V19 to push him in the wheelchair. (R2's) eyes were half open, mouth was half open and he was spacing out. (R2) was a two person transfer instead of a one person transfer to his bed and was not responding. On (MONTH) 7, 2019 at 11:32 AM, V17 stated at 10:45 AM (R2) was experiencing unusual behaviors and [MEDICAL CONDITION] activity. Nursing notes from (MONTH) 11, 2019 at 11:00 AM state (R2) visiting with wife and she noted he was drooping and slurring to left side [MEDICAL CONDITION] activity. On (MONTH) 7 2019 at 11:20 AM, V9 stated If a resident has a change in condition, the nurses should send them to the emergency room for evaluation immediately. They do not need to wait for a physician's orders [REDACTED]. On (MONTH) 7 2019 at 10:50 AM, V2 stated if there is an acute situation ([MEDICAL CONDITION] activity, loss of consciousness or acute change in vital signs) the nurse would notify 911. In this situation, 911 should have been called before the physician because (R2) was at his baseline right before V19 notified V17 that the acute change occurred. (R2) had altered mental status, mainly unresponsive. On (MONTH) 7 2019 at 11:32 AM, V17 stated When someone is unresponsive, not coming out of a [MEDICAL CONDITION] (R2) you should call 911 prior to calling the physician. On (MONTH) 7, 2019 at 11:32 AM, V17 stated she notified V16 of R2's change in condition at 11:00 AM after she had notified Emergency Medical Services. Local ambulance run report dated (MONTH) 11, 2019 shows the local dispatcher was notified by facility at 11:19 AM of request for assistance for R2. On (MONTH) 6, 2019 at 10:05 AM, V16 stated she received a call from the facility on (MONTH) 11, 2019 at 11:13 AM and returned the call at 11:15 AM. At this time, she was notified of (R2's) change in condition. The facility's Abuse and Prevention policy revised on (MONTH) 25, (YEAR) states Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On (MONTH) 6, 2019 at 1:30 PM, V1 stated the facility has no policies regarding emergency care, physician notification or unwitnessed fall for a resident on blood thinning medication.

Based on interview and record review the facility failed to protect residents from unwanted sexual advances that include sexually inappropriate touching and making sexually inappropriate comments towards 3 of 4 residents (R6, R7, and R8) reviewed for abuse in the sample of 20. This failure resulted in R6, R7, and R8 being very upset, anxious, fearful, and becoming increasingly afraid. The Findings include: R1 was admitted to the facility on (MONTH) 12, (YEAR) with a [DIAGNOSES REDACTED]. R1 was discharged from the facility on (MONTH) 5, (YEAR). On (MONTH) 14, (YEAR) at 10:00 AM, R13 who was the roommate to R1 at admission said R1 was rude and had no respect for anyone else. R13 said R1 would yell and cuss at him and he felt like he had done something wrong. On (MONTH) 15, (YEAR) at 1:15 PM, R11 and R12 who are roommates and across the hall from R1's first room in the facility said R1 would sit in their doorway and stare at them. R11 and R12 said it made them feel scared and very uncomfortable. R11 and R12 said they did tell some staff about it. R11 and R12 both said they are glad R1 is gone. On (MONTH) 14, (YEAR) at 9:50 AM, V13 LPN and V16 LPN said R1 was rude and demanding to staff and residents, would make inappropriate sexual comments to residents and have inappropriate touching to female residents. V16 said R1 would be placed on 15 minute checks for better supervision but no staff were assigned to do this, we just keep an eye on him. On (MONTH) 14, (YEAR) at 9:55 AM, V19 CNA said R1 would cuss at the staff and residents when he did not get his way and make inappropriate comments to the other residents. We were told to keep an eye on him. V19 said she was not aware he was on 15 minute checks. On (MONTH) 14, (YEAR), at 9:56 AM V18 CNA said R1 would make sexual remarks to staff and residents. V18 said there was no direct order to supervise any closer. On (MONTH) 14, (YEAR) at 9:20 AM, V17 CNA said R1 would get agitated with the other residents if he did not get his way. R1 would make sexual comments to the staff and residents. V17 said they were told to just keep an eye on him. On (MONTH) 14, (YEAR) at 3:15 PM, V3 Social worker said R1 was sexually inappropriate with the other residents almost immediately after being admitted to the facility. The facility provided the abuse allegations dated (MONTH) 1, (YEAR) to (MONTH) 14, (YEAR) which includes: R1initiated 4/26/18 to R8, 5/5/18 to R7 and 8/5/18 to R6. On (MONTH) 14, (YEAR) at 11:05 AM, R8 said R1 touched her breast as they were going into the dining room. R8 said R1 was behind her and asked where she was going. R8 said the next thing she knew his hand was on her breast. R8 said she went right away to a staff person at the front desk and said what happened. R8 said this made her very upset and was glad the facility moved him to another dining room so she did not have to see him in there anymore. R8 also said when she went to talk to the nurse about R1, she was told he was confused and R8 felt like no one really cared about the trouble R1 was causing. R8 said she is glad R1 is gone now from the facility. On (MONTH) 15, (YEAR) at 2:20 PM, V1 Administrator said she would consider getting the breast touched sexual abuse. V1 said she spoke with both R1 and R8 after the incident and she believed R1's story that the incident was an accident. The MDS (Minimum Data Set Assessment) for R1 dated (MONTH) 23, (YEAR) shows he has severe cognitive impairment. The MDS for R8 dated (MONTH) 13, (YEAR) shows her to be cognitively intact. The investigation was labeled other rather than sexual assault and only R1 and R8 were interviewed. On (MONTH) 14, (YEAR) at 11:00 AM, R7 said R1 touched her thigh and her breast. R7 said she was headed to her room at the end of the hall and R1 was sitting outside his door which was next to hers. R7 said R1 asked her to see what you got then touched her breast and her thigh. R7 said she was afraid of him and went to the nurse's station to report what had happened and just stayed there until R1 was moved to another room. R7 said she is glad he is gone from the facility. On (MONTH) 15, (YEAR) at 2:20 PM, V1 said R1 was moved to another room in the facility after this incident. V1 said she does not know why R1 was not sent out for an evaluation after this incident. The MDS for R7 dated (MONTH) 25, (YEAR) shows her to be cognitively intact. The facility abuse investigation and report shows an interview with R7. No interviews with staff or other residents about the behavior of R1 was documented. On (MONTH) 14, (YEAR) at 1:45 PM, R6 said R1 tried several times to grab her hand and put it on his crotch and would rub her back or shoulders. R6 said R1 was always causing trouble. On (MONTH) 15, (YEAR) at 1:05 PM, R10 (former resident on same hall as R1) said he was in the dining room and saw R1 roll up behind R6 and rub her back. R10 said he heard R6 say, I don't like people talking dirty to me. R10 said he told the CNA (Certified Nursing Assistant) later that night about what he had seen. R10 felt it was very inappropriate for R1 to do that. On (MONTH) 16, (YEAR) at 1:05 PM, V21 CNA said R10 told her that he saw R1 rubbing R6's back and heard R6 say she did not like people talking dirty to her. V21 said she went and told the nurse right away. On (MONTH) 14, (YEAR) at 2:00PM, V24 LPN (Licensed Practical Nurse) said she spoke with R6 after hearing of the allegation. V24 said R6 told her about the rubbing and that she would never let a man talk to her that way again. V24 said she told the administrator about the incident the next morning and was told it would be taken care of. The nursing progress note dated (MONTH) 23, (YEAR) shows R6 telling V24 that R1 took her hand and tried to place it on his genitals. R6 stated she pulled her hand away and did not want to touch it and R1 told her it would feel good. On (MONTH) 14, (YEAR) at 1:50 PM, V22 and V23 (R6's daughters) said they were never notified of this happening. On (MONTH) 15, (YEAR) at 2:20 PM, V1 said she was never given a report of this happening. There is no abuse investigation into this incident, even after reported to administrator by this surveyor. On (MONTH) 14, (YEAR) at 1:05 PM, R6 said she was sitting at the dining room table when R1 rolled up to her and sat very close to her. R6 said she told R1 to move over and he touched my leg and moved his hand up to her crotch. R6 said she yelled at him and slapped R1 in the face. R6 said she was so mad and just reacted. The MDS dated (MONTH) 19, (YEAR) for R6 shows her to be cognitively intact. On (MONTH) 14, (YEAR) at 9:23 AM, V4 RN (Registered Nurse) said she was the nurse on duty the day R6 and R1 had their altercation. V4 said she had her back to the dining room and did not see what happened but heard a staff member say what are you doing very loudly. She turned and saw R6 standing up and yelling He grabbed my crotch. V4 said R1 was sent to the hospital that day for his behavior. V4 also said if R1 was out of his room she knew to keep an eye on him as he was not always on 15 minute checks. On (MONTH) 14, (YEAR) at 3:15 PM, V3 (Social Service) said R1 was transferred to the hospital for a psychiatric evaluation that day because something needed to change with his behavior as he was putting other residents at risk. On (MONTH) 15, (YEAR) at 2:20 PM, V1 said R1 was sent to the hospital that day and not after the previous incidents, because R6 slapped him back and someone could get hurt. The behavior notes for R1 dated: (MONTH) 1, (YEAR), (MONTH) 4, (YEAR), (MONTH) 6, (YEAR), (MONTH) 18, (YEAR), and (MONTH) 19, (YEAR) shows R1's continued reports of aggression towards other residents, taking himself into other female resident's rooms while they are dressing, using foul language towards fell ow residents and making sexually inappropriate comments to female peers. The COMS (R) Long Term Care Evaluation dated (MONTH) 20, (YEAR) documented by V14 LPN shows, residents are becoming increasingly scared of him and social services was told that one resident does not want to be near him at all. On (MONTH) 16, (YEAR) at 1:38 PM, V14 said she left a voice mail for the social service department regarding the resident's concerns with R1. V14 said R19 was immobile due to [MEDICAL CONDITION] and was always fearful he would come after her. On (MONTH) 16, (YEAR) at 1:55 PM, R19 said she was afraid of him, If he blew his cool, I would be a magnet, I can't defend myself. R19 also said she was happy R1 was no longer in the facility. The facility provided the criminal history background check completed on (MONTH) 10, (YEAR) which came back with hits to include aggravated battery. R1 was admitted to the facility on (MONTH) 12, (YEAR). On (MONTH) 15, (YEAR) at 3:00 PM, V1 said in her experience background checks are done before a resident is admitted to the facility. V1 said she does not ever check them and is unsure what the dates mean. V1 said the facility should know if a resident is an identified offender but she is not the facility. V1 said, I guess we obviously were not managing him well. The care plan for R1's sexually inappropriate towards peers and staff shows the intervention provide constant supervision when resident is not in room. This intervention was initiated on (MONTH) 16, (YEAR) and created on (MONTH) 31, (YEAR). A resolved date of (MONTH) 14, (YEAR) was present on the care plan but R1 was discharged (MONTH) 5, (YEAR). There is no record of a 1 to 1 observation being done. The 15 minute logs for R1 were reviewed and no consistency was shown in when they were completed or why. The facility said they do not have a policy for 1 to 1 observations or 15 minute checks.

Based on observation, interview, and record review the facility failed to safely toilet residents by leaving two residents with a high risk of falls unattended on the toilet which resulted in one resident suffering a nasal fracture and required sutures on her forehead. This applies to 2 of 11 residents (R1 and R5) reviewed for safety in the sample of 16. The findings include: 1. R5's electronic [DIAGNOSES REDACTED]. R5's August 4, 2017 Minimum Data Set (MDS) assessment documents R5 requires extensive assistance from staff for toileting and has severely impaired cognitive skills for daily decision making. On November 13, 2017 at 7:35 PM, R5 had bruises under both eyes extending down past her cheek bones and bruising across the bridge of her nose. A bandage was on the right side of R5's forehead. R5's fall reports show she has had seven falls since February 1, 2017 through November 13, 2017. The February 2, 2017 fall report shows E14 (Certified Nursing Assistant-CNA) took R5 to the bathroom and stepped out of the room to help another resident. When E14 returned to the room, R5 was on the floor. The report shows R5 received an abrasion to the right scapula and a bruise on her face. The report shows staff was provided verbal education to not leave resident unattended on toilet and to apply proper footwear prior to transfers. The fall report from November 09, 2017 shows E23 was taking R5 to the bathroom. E23 left to get clothes for R5 and R5 stood up and lost balance, landing on the floor. R5 was bleeding from her nose and had a laceration under her right eye. 911 was called and an ambulance transported R5 to a local hospital. The November 9, 2017 consultation reports from the local hospital show R5 had a traumatic fall in the bathroom of the nursing facility causing facial trauma, nasal fracture, and epistaxis. The report shows R5 had an abrasion on her forehead which was sutured in the hospital. The report also shows R5 was on a blood thinner. The November 9, 2017 history and physical from the local hospital shows R5 was evaluated in the emergency room and in view of the fact that she had a nasal fracture and she is on a blood thinner, placement in observation was recommended by the emergency room . The computertography (CT) report of the facial bones shows slightly displaced bilateral nasal bone fracture and nondisplaced nasal septum fracture. The hospital plan of care shows the patient was placed in observation to monitor closely in view of the head trauma in a patient on a blood thinner. On November 15, 2017 at 8:32 AM, E14 (CNA) said R5 should not be left unattended on the toilet because R5 is a fall risk. At 9:12 AM, E19 (CNA) said if a resident is a fall risk they should not be left unattended on the toilet. The Morse Fall Scale (a scale that measures a resident's risk for falls) for December 5, 2016, July 25, 2017, and November 3, 2017 all show R5 had a high risk for falling. R5's Fall care plan shows on February 2, 2017 staff provided verbal education to not leave resident unattended on toilet. 2. R1's electronic [DIAGNOSES REDACTED]. R1's June 15, 2017 MDS shows she requires extensive assistance of two staff members for toileting. R1's August 26, 2017 falls incident report shows R1 was on the toilet. Staff told R1 they needed to help a coworker transfer R1's roommate and to wait until she returned to get her off the toilet. R1 proceeded to get off the toilet, R1 lost balance and fell . R1's July 21, 2017 Morse fall scale shows R1 has a high risk of falling. On November 15, 2017 at 8:55 AM, E2 (Director of Nursing-DON) said R5 and R1 should not be left unattended on the toilet because they are both at risk for falls. E2 said staff should use the call light or find a way to communicate a need for supplies without leaving the resident's side. On November 14, 2017 E18 (Restorative Nurse-RN who oversees falls) said any resident who is a fall risk should not be left on the toilet unattended.

Based on interview and record review, the facility failed to provide specialized services by not administering prescribed medications to manage a resident's behavior due to mental illness. This applies to 1 of 3 residents (R1) reviewed for behavior management in the the sample of 6. The findings include: R1's physician progress notes [REDACTED]. R1's admission assessment dated [DATE] at 1530 (3:30 PM) shows "No recent changes in mental status...Orientation x 3...mood- cheerful, pleasant...changes in mood - None..." R1's Nurse Note dated [DATE] at 8:00 PM shows "pt assisted to restroom at 1130 pm and demanded to sit on the floor because she thought the staff member assisting her was going have a baby and she needed to be on the floor in order to catch it. Pt. was told that there was no baby to be delivered and she then pushed the staff member and said "you stupid girl move so I can catch your bloody baby". She then sat down on the floor...pt has been crying at times this shift and when asked what is wrong she will talk about family members passing away. She stated that her husband and daughter are both deceased after they both came to visit her this shift and she also spoke to them both on the phone..." R1's [DATE] at 8:30 AM nursing assessment shows "disoriented, confused, short term memory loss...repetitive behavior, disruptive behavior, Became more agitated as the day progressed and became verbally and physically aggressive with a CNA (Certified Nurse Assistant). R1's Narrative Nursing Note dated [DATE] documents "spilled a cup of coffee on her lap at supper time..." R1's [DATE] Narrative Nursing Noted dated [DATE] at 5:49 AM shows "Pt. combative with staff and speaking with an elevated voice. Pt. made frequent attempts to get out of w/c (wheelchair) unassisted and was oriented to person only. Pt spoke about seeing bugs crawling out of the walls and mice on the floor. Doctor contacted regarding behaviors and new orders for PRN [MEDICATION NAME] and and [MEDICATION NAME] were received. ..." R1's [DATE] Narrative Note at 9:00 AM shows "Resident spilled a cup of coffee on her lap. Appeared to be intentional and attention-seeking behavior..." R1's [DATE] at 2:26 AM nurse note shows "Pt out and about this tour. Wanders around the facility, freq looking out doors and windows. Pt states that she had 4 doctors at her previous facility and that they all fought over what was wrong with her. Pt tells that the doctors then went down into the basement and had rockets they were fighting over as well, in the end the doctors were peeing on each other with rocket fuel...pt dials her phone repeatedly throughout this tour, says she is calling her husband to see if his "side treat' is there or not...Attempted several times to explain to pt that it is midnight and he will not be here for several hours (husband). pt states that the new time system here is totally confusing and with the way we figure out time she will never catch on. She is pleasant, occ tearful when she talks about her husband... R1's [DATE] at 10:42 PM documentation shows "945 PM, res. had woke up from a little nap and thought she was in different facility. This made her anxious and she was stating that she had to get back to were she was or her daughter would have her locked up at "sing sing". Then she was asking to see the baby... R1's [DATE] Nurse note shows "Pt exited unit from the north hall door. Alarm sounded and this writer responded immediately. Pt is walking in the grass with her winter coat and hat on, using a cane...CNA requested please call for assistance in getting pt back in. Pt walked around the building and through the front parking lot. Then began to walk toward the building...pt turned towards the street and walked through the ditch and onto road...pt crossed the road and then began walking in the ditch...veering into the corn field several times...patient states she is going to (law office) because she needs a lawyer...425 am Police officer accompanied pt up the driveway and into the facility... R1's [DATE] Nurse note shows "heard screams from the hallway. Returned to see this pt striking (visitor) on her head several times with a cane. Moved pt back inter her room and removed the cane. Pt states there are dead people all over. And she has to get them out wit the cane. Placed call to 911 to report violent pt. Pt remained in her room for several minutes then began walking toward the doors to main hallway. Stood in front of pt and told her that she could not go out at this time, pt then punched this writer in the mouth, causing my lip to bleed and attempted hit me in the head with a remote that she was holding. prevented being struck by grabbing her swinging arm and then removed the remote from her other hand...She told the officers about the dead people and that this writer had given her shot with a 4 (inch) needle. And that is why she punched me. This pt has recd no meds from the today...Police requested ambulance assist, pt enroute to (medical center). R1's [DATE] at 9:15 AM Nurse noted shows "Addendum to previous note: When placing pt back on her bed after striking the girl in the hallway pt laid down on her bed and began swinging fists at staff and kicked this writer in the head..." R1's physician progress notes [REDACTED]. Alternate accommodations being sought for her". R1's physician progress notes [REDACTED]. R1's facility "Medication Incident/Error Report" dated [DATE] shows "Orders for [MEDICATION NAME] and [MEDICATION NAME] written on [DATE] were not transcribed to the MAR's and not given until today ([DATE])." R1's Medication Record shows the first dose of [MEDICATION NAME] 200 mg was not given until [DATE]. This record shows the first dose of [MEDICATION NAME] 0.5 mg was not given until [DATE] (5 days after the order was written). On [DATE] at 10:45 AM, E11 (Licensed Practical Nurse- LPN) said she took the orders for R1's [MEDICATION NAME] and [MEDICATION NAME] out of the chart and faxed them to the pharmacy on [DATE]. E11 said the chart then went back to the physician so he could talk to the family before the orders got put on the MAR. E11 said she did not see the chart when it came back from the physician. E11 said the order was missed and did not get processed until [DATE]. E11 said after the order is faxed to pharmacy it should be transcribed onto the MAR, and also put on a clipboard at the nurse's station so the nurses are aware of any new resident orders. On [DATE] at 9:00 AM, E3 (Regional Consultant) said the [MEDICATION NAME] and [MEDICATION NAME] were not transcribed from the physician's orders [REDACTED]. E3 said "it was our fault the meds were not given, not the pharmacy's". E3 said the order was written on [DATE], and the first dose was not given until [DATE]. E3 said the meds were delivered on [DATE] to the facility and were placed in the bottom drawer of the med cart. E3 said when the nurse did not see the medications on the R1's MAR, she should have checked the physician's orders [REDACTED]. On [DATE] at 4:45 AM, E1 (Administrator) said R1 was sent to the emergency roiagnom on [DATE] because she was a danger to other residents, and to herself. E1 said the facility was unable to manage R1's behaviors and had already told the family if any other incidents occurred, R1 would have to be transferred to another facility. On [DATE] at 9:00 AM, E3 (Regional Consultant) said R1 was sent to the Emergency Department for evaluation because she "was a safety hazard to herself, the other residents, and staff members". On [DATE] at 11:30 AM, E2 (Director of Nursing) said at the time of R1's discharge to the hospital ([DATE]), R1 "was a danger to herself, had attacked staff members, punched a nurse in the face, and hurt a visitor". E2 said R1 had dangerous behaviors that worsened during night hours, and seemed to become more severe since admission to the facility. On [DATE] at 12:00 PM, Z1 (Physician) said the [MEDICATION NAME] and [MEDICATION NAME] were ordered to treat R1's [MEDICAL CONDITION] Disorder, and Anxiety Disorder. Z1 said [MEDICATION NAME] has a quick onset and the medication could start helping R1's behaviors the same day it was started. Z1 said the facility notified him R1's medications was ordered on [DATE] but it was not started until [DATE] due to a nursing error.

A. Based on interview and record review the facility failed to administer an enema or remove impacted stool when a resident had no/ small or moderate bowel movements. This failure resulted in R40 being sent to the emergency department for digital disimpaction. This is for 1 (R40) of 3 residents reviewed for routine elimination habits in the sample of 41. The findings include: R40's [DIAGNOSES REDACTED]. An Interim Care Plan shows that the resident has alteration in bowel continence. A Resident Transfer Form of [DATE] shows that the resident was sent to the Emergency Department for agitation and fecal impaction. The Emergency Department (ED) record documents that the resident was "digitally disimpacted...removed chunks of stool". An abdominal Xray was done. The impression states "fecal materia throughout the colon". The resident was also given an enema in the ED. On [DATE] at 12:00 noon, Z5 said that R40 had results from the enema, in the ED. R40's medications include [MEDICATION NAME] 50mg every 4 hours as needed for pain, Calcium with D twice daily, and [MEDICATION NAME] 20 mg daily. The Nursing 2011 Drug Handbook shows that all 3 of these medications can have the side effect of constipation. R40's Bowel Function Flow Sheet was reviewed for [DATE] - 17, 2011. The form shows that the following: ,[DATE] - no bowel movement (BM) ,[DATE] - 1 small and 1 medium size BM ,[DATE] - no BM ,[DATE] - 1 medium BM ,[DATE] - 1 medium BM ,[DATE] - 1 small BM ,[DATE] - 1 small BM Review of the resident's careplans does not identify the resident as having potential problems with constipation. On [DATE] at 3:35 PM, E9 (Licensed Practical Nurse - LPN) writes, "Date of last BM [DATE]. Digital rectal check reveals hard formed stool within rectal vault. [MEDICATION NAME] suppository given." The documentation does not state if the resident's abdomen is soft, distended, or painful. The notes show that after lunch the resident became very agitated and resistive to care, telling people to get out of his room. On [DATE] at 12:28 PM, E9 document the resident is extremely confused and resistive to care, pushing away staff and food. She notes that the resident's family called requesting he be given an enema. The family said that he needs to have daily BM's. Review of the resident's ,[DATE] POS shows that the resident has an order for [REDACTED]. The Mosby's Medical, Nursing, & Allied Health Dictionary, 4th Edition, defines fecal impaction, "An accumulation of hardened or inspissated feces in the rectum or sigmoid colon that the individual is unable to move...Treatment includes oil and cleansing enemas and manual breaking up and removal of the stool by a gloved finger. Persons who are dehydrated, nutritionally depleted, on long periods of bedrest, receiving constipation medications, such as iron or opiates,...are at risk of developing fecal impaction." B. Based on Record Review and Interview the facility failed to ensure that a resident (R2) with chronic hip pain did not run out of his pain medication. This applies to1 (R2) of 3 residents reviewed for pain in the sample of 41. The findings include: R2's Minimum Data Set (MDS) of [DATE] shows the resident has no cognitive deficits. The MDS documents the resident has frequent pain that limits his daily activities. R2's [DIAGNOSES REDACTED]. The POS shows that the resident receives a [MEDICATION NAME] every 72 hours, which delivers 100 micrograms per hour for pain. The Medication Administration Record (MAR) shows that the resident was to receive a new patch [DATE]. Written on the MAR is "N/A" showing the resident did not receive the medication as ordered. Nurse's Notes of [DATE] written at 6:55 AM states, "Resident asked earlier in the shift if he was going to have a new [MEDICATION NAME] this evening. RN checked the MAR and stated that he would be getting a new patch tonight. RN asked resident if he had pain at this time, 10:00 PM and resident said 'a little bit' ...RN was not able to give new [MEDICATION NAME] as resident was out. RN called pharmacy about the patches. Pharmacy stated they hadn't received a refill order...RN informed resident that he was out of patches but they would be coming in Sunday afternoon ([DATE]). Resident became very anxious and wanted an [MEDICATION NAME] began complaining of pain continuously...". On [DATE] at 8:40 AM, E1 (Administrator) and E2 (Director of Nursing) said they had a problem with R2 not receiving his [MEDICATION NAME]. They said the resident had run out of them and they were not available in the Emergency Medication Box. They said the pain patch was due to be changed Sunday AM ([DATE]). The medication was not available until Monday AM ([DATE]). The resident went without the pain medication for 20 hours. The facility could not show evidence that the pain medication was ordered. E1 said they have an agreement with a local pharmacy for emergency medication orders when the medication is not available in the Emergency Box. The facility did not contact the emergency pharmacy. On [DATE] at 1:00 PM, R2 said, "I went without my pain patch last weekend, the facility ran out. I called my daughter. She brought in old ones from home. They were not the same dose, they were less. I don't know if the facility knows about it." The facility's Management of Pain states, "Our mission is to facilitate independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement." C. Based on Interview and Record Review the facility failed to ensure that a resident's DNR (Do Not Resuscitate) status was known to [MEDICAL TREATMENT] staff when receiving treatment at a local [MEDICAL TREATMENT] center. This applies to 1 (R1) of 3 residents reviewed for [MEDICAL TREATMENT] in the sample of 41 residents. The findings include: R1 is a resident who was receiving [MEDICAL TREATMENT] at an off campus site. Her ,[DATE] POS shows that her [DIAGNOSES REDACTED]. Nurse's Notes document on [DATE] at 3:10 PM, the [MEDICAL TREATMENT] center called the facility stating that R1 was not responding. The notes state, "They ([MEDICAL TREATMENT] center) want DNR faxed over...they said they did not receive it...3:35 PM received call from [MEDICAL TREATMENT] center that patient has passed away...". On [DATE] at 12:05 PM, E16 (Social Service) said that sometimes she is the fill-in transport person. E16 said, "When I transport residents, I don't ever take any paper work with me." She said she took the resident to her [MEDICAL TREATMENT] appointment at 10:45 AM and went back to pick her up at about 3:00 PM. E16 said, "The resident was seated in her geriatric chair. My first thought was 'oh my God, she's dead'. She did not respond to me. I got the attention of the [MEDICAL TREATMENT] staff. The resident was still unresponsive. The staff asked me what her DNR status was because they did not have it. I called back to our facility, they told me that she's a DNR and faxed the order to the [MEDICAL TREATMENT] center. While all of this was taking place, emergency medical services (EMS) had been called and arrived at the center. When EMS arrived, they initiated Cardiopulmonary Resuscitation (CPR). I waited at the fax machine for the DNR. When it arrived at the center, I gave it to the EMT's (Emergency Medical Technicians) and they stopped CPR." On [DATE] at 2:35 PM, Z3 ([MEDICAL TREATMENT] director) said they did not have the residents DNR status on file. She said, "The resident just returned from the hospital. The facility has never given us a copy of the DNR." On [DATE] at 3:40 PM, E1 said they don't ever send a resident's DNR order/paperwork with them when they leave the facility to go to appointments. The facility's Managing Code Status Policy and Procedure (undated) states, "It is the policy of this facility to respect the resident's choice in regard to treatment as set forth per the advanced directive documented by the resident, legal guardian, health-care proxy, or representative (sponsor). This choice regarding treatment options includes, but is not limited to Do Not Resuscitate directives. It is furthermore the policy of this facility to respect this choice whether the respiratory or [MEDICAL CONDITION] is witnessed or unwitnessed. The facility will make every effort to coordinate a plan of care between the resident, the responsible party and the physician to ensure that the treatment choices are implemented as directed."